pediatric neurologic disorders
TRANSCRIPT
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Pediatric Neurologic Disorders
Ma. Tosca Cybil A. Torres, RN, MAN
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Hydrocephalus
An excess of CSF in the ventricles or in the
subarachnoid space
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Classification
1. Obstructive/ intraventricular• caused by a block in the passage of fluid.
2. Communicating/ extraventricular• fluid passes between the ventricles and
spinal cord
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Assessment
1. Widened fontanelles
2. Separates suture lines in the skull
3. Enlarged head diameter
4. Shiny scalp
5. Prominent scalp veins
6. “Bossing” of forehead
7. Shrill cry
8. Sunset eyes
9. s/sx of increased ICP
10.Hyperactive reflexes
11.Strabismus
12.Optic atrophy
13.Irritable
14.Lethargic
15.Failure to thrive
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Diagnostics
• Sonogram • CT scan • MRI • Skull X-ray• Transillumination
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Therapeutic Management
• Ventricular endoscopy• Ventriculoperitoneal Shunt
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Nursing Diagnoses
• Risk for injury • Risk of infection • Risk for ineffective cerebral tissue perfusion• Risk for impaired skin integrity • Risk for imbalanced nutrition: less than body
requirements • Impaired family processes
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Nursing interventions
• Assess infant’s neurologic status closely. Watch for increasing irritability or lethargy.
• Measure and record head circumference every 4H. Assess anterior fontanelle for tenseness and bulging.
• Position infant with the head if the bed elevated 15º to 30° and maintain in neutral position.
• Monitor V/S q2H• Administer O2 as ordered.• Monitor I and O. Administer diuretics as ordered. • Encourage mother to breast-feed. Position properly with head
supported. Avoid flexion or hyperextension. • If vomiting occurs, encourage mother to attempt to refeed the
infant. If vomiting persists, anticipate the need for enteral or parenteral nutrition.
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Nursing interventions
• Wash head daily with repositioning q 2H• Encourage parents to verbalize feelings. • Teach parents signs and symptoms of
increasing ICP.
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Post operative nursing care
• Elevate head of bed to 30°• Infants are not turned to lie on the side of the
shunt• Assess for signs of increasing ICP • Assess for signs of infection • Keep NGT in place. • Introduce fluids gradually after NGT is removed. • Observe for constipation
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Neural Tube Defects
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Anencephaly
Absence of the cerebral
hemispheres.
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Anencephaly
• Occurs when the upper end of the neural tube fails to close in early uterine life
• Diagnosed by elevated AFP in maternal serum or on amniocentesis
• Confirmed by sonogram.
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Anencephaly
100% mortality rate.
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Microcephaly • Disorder in which brain growth
is so slow that it fails more than three standard deviations below normal on growth charts.
• Causes: • Intrauterine infection (rubella,
cytomegalovirus, toxoplasmosis) • Severe malnutrition or anoxia in
infancy
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Spina bifida ("split spine")
• a developmental birth defect involving the neural tube: incomplete closure of the embryonic neural tube results in an incompletely formed spinal cord.
• the vertebrae overlying the open portion of the spinal cord do not fully form and remain unfused and open
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Spina bifida
Categories: 1. spina bifida occulta2. spina bifida cystica (myelomeningocele)3. meningocele
• The most common location of the malformations is the lumbar and sacral areas of the spinal cord
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Assessment:• varying degrees of paralysis • absence of skin sensation• poor or absent bowel and/or bladder
control• curvature of the spine (scoliosis) • most cases there are cognitive
problems • hydrocephalus
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Types
Spina bifida occulta• Occulta is Latin for "hidden." • no opening of the back, but the outer part of
some of the vertebrae are not completely closed
• The skin at the site of the lesion may be normal, or it may have some hair growing from it; there may be a dimple in the skin, or a birthmark
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Spina bifida cystica (myelomeningocele)
• most serious and common form • the unfused portion of the spinal column allows the spinal cord to
protrude through an opening in the overlying vertebrae
• meningeal membranes that cover the spinal cord may or may not form a sac enclosing the spinal elements
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Meningocele
• least common form• Meninges covering the spinal cord herniate through
the unformed vertebrae• Protrusion may be covered with a layer or skin just
the clear dura
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Encephalocele
Cranial meningocele or myelomeningocele. Most often occur in the occipital area
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Medical-Surgical Treatment
• no cure for nerve damage• Closure of the opening on the back • if spina bifida is detected during
pregnancy, then open fetal surgery can be performed
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Nursing diagnoses
• Risk for infection • Risk for impaired cerebral tissue perfusion • Risk for impaired skin integrity • Impaired physical mobility
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Pre-operative care
• Place infant in supine • If in side lying, place a towel or pillow in between the
infant’s legs• Place a piece of plastic below the meningocele on the
child’s back like an apron and secure it with a tape• Apply a sterile wet compress of saline, antiseptic, or
antibiotic gauze over the lesion • Keep infant warm assess for seepage of any clear liquid
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Post operative care
• Place infant in supine until the skin incision is healed
• Same careful precautions are observed. • Assess for signs of increased ICP
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Cerebral Palsy
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Cerebral Palsy
A group of nonprogressive
disorders of upper motor neuron impairment that
result in motor dysfunction.
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Cerebral Palsy
• Cause is UNKNOWN.• Associated with low birth weight, prebirth,
or birth injury • Intrauterine anoxia and direct birth injury
may contribute to the development of CP• Occurs in 2:1000 births
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Types of Cerebral Palsy
Spastic S/Sx:
• Hypertonic muscles• Abnormal clonus• Exaggerated DTRs• Abnormal reflexes (eg. Babinski)• When held in ventral position, arching of back and abnormal
extension of arms and legs are observed• Failure to demonstrate parachute reflex when lowered
suddenly • Scissor’s gait • Hemiplegia, tetraplegia or paraplegia • astereognosis
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Types of Cerebral Palsy
Dyskinetic or Athetoid S/Sx:
• Abnormal involuntary movement • Athetoid means “wormlike” • Early in life, child is limp and flaccid. Later, in
place of voluntary movements, the child makes slow, writhing motions.
• Drooling• Speech impairment • Choreoid movements • Disordered muscle tone (dyskinetic)
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Types of Cerebral Palsy
AtaxicS/Sx:
• Awkward, wide based gait• Unable to perform finger-to-nose exam or perform
rapid, repetitive movements or fine coordinated motions.
Mixed
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Assessment
• History• PE-all forms of CP may have sensory
alterations• Strabismus• visual perception problems• Visual field defects• Speech problems • deafness
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25% to 75% of children with CP are cognitively
challenged. 50% have recurrent
seizures.
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Physical findings that suggest CP
• Delayed motor development • Abnormal head circumference • Abnormal postures • Abnormal reflexes• Abnormal muscle performance or tone
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Nursing Diagnoses
• Deficient Knowledge • Risk for disuse syndrome• Risk for delayed growth and development • Risk for imbalanced nutrition: less than body
requirements• Risk for self-care deficit • Impaired verbal communication
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Nursing Intervention
Help parents understand their child’s condition
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Nursing Intervention
Assist in ambulation.
Prevent contractures.
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Choose toys and activities appropriate to the child’s
intellectual, developmental, and motor levels, NOT
chronologic age.
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Ensure adequate nutrition.
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Provide alternative form of communication
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SPINAL CORD INJURY
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Causes:
• Trauma• Tumor• Ischemia• Developmental disorders• Neurodegenerative diseases• Transverse myelitis• Vascular malformations
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SPINAL CORD INJURY
Effects are less severe the lower the injury.
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Manifestations
• C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete dependency for ADLs.C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.
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Diagnostic:
1. Clinical evaluation: absence of reflexes, flaccidity, loss of sensation below injury level
2. Spinal x-ray: vertebral fractures, bony overgrowth
3. CT scans/MRI: evidence of cord compression and edema or tumor formation
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SPINAL CORD SYNDROME
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Central Cord Syndrome
• Central cord syndrome is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs.
• This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.
• This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord
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Anterior cord syndrome
• an incomplete spinal cord injury. • Below the injury, motor function, pain sensation,
and temperature sensation is lost; touch, proprioception and vibration sense remain intact..
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Brown-Séquard Syndrome
• usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injur, there is a loss of motor function, vibration, and light touch. Contralaterally, there is a loss of pain, temperature, and deep touch sensations.
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Assessment
ACTIVITY/REST
May exhibit: Paralysis of muscles (flaccid during spinal shock) at/below level of lesionMuscle/generalized weakness (cord contusion and compression)
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Assessment
CIRCULATIONMay report: PalpitationsDizziness with position changesMay exhibit: Low BP, postural BP changes, bradycardiaCool, pale extremitiesAbsence of perspiration in affected area
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Assessment
ELIMINATION
May exhibit: Incontinence of bladder and bowelUrinary retentionAbdominal distension; loss of bowel soundsMelena, coffee-ground emesis/hematemesis
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Assessment
EGO INTEGRITY
May report: Denial, disbelief, sadness, angerMay exhibit: Fear, anxiety, irritability, withdrawal
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Assessment
FOOD/FLUID
May exhibit: Abdominal distension; loss of bowel sounds (paralytic ileus)
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Assessment
HYGIENE
May exhibit: Variable level of dependence in ADLs
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Assessment NEUROSENSORY
May report: Absence of sensation below area of injury, or opposite side sensationNumbness, tingling, burning, twitching of arms/legsMay exhibit: Flaccid paralysis (spasticity may develop as spinal shock resolves, depending on area of cord involvement)Loss of sensation (varying degrees may return after spinal shock resolves)Loss of muscle/vasomotor toneLoss of/asymmetrical reflexes, including deep tendon reflexesChanges in pupil reaction, ptosis of upper eyelidLoss of sweating in affected area
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Assessment
PAIN/DISCOMFORT
May report: Pain/tenderness in musclesHyperesthesia immediately above level of injuryMay exhibit: Vertebral tenderness, deformity
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Assessment
RESPIRATION
May report: Shortness of breath, “air hunger,” inability to breatheMay exhibit: Shallow/labored respirations; periods of apneaDiminished breath sounds, rhonchiPallor, cyanosis
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Assessment
SAFETYMay exhibit: Temperature fluctuations (taking on temperature of environment)SEXUALITYMay report: Expressions of concern about return to normal functioningMay exhibit: Uncontrolled erection (priapism)Menstrual irregularities
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Nursing Diagnoses
• Ineffective breathing pattern • High risk for disuse syndrome• Impaired physical mobility • Altered sensory perception• Risk for infection • Altered elimination• Risk for impaired skin integrity • Ineffective individual coping• Powerlessness
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NURSING PRIORITIES
1. Maximize respiratory function.2. Prevent further injury to spinal cord.3. Promote mobility/independence.4. Prevent or minimize complications.5. Support psychological adjustment of patient/SO.6. Provide information about injury, prognosis and expectations, treatment needs, possible and preventable complications.
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Therapeutic management:
a. Surgery- laminectomy or fusion for decompression and stabilization, wound debridement, placement of cervical tongs or halo traction for stabilization, tracheotomy for mechanical ventilation as needed
b. medications: massive corticosteroid therapy to improve outcome, vasopressors for shock, prophylactic antibiotics for open wounds, analgesics for pain, anticoagulants to prevent emboli and thrombus formation, anti anxiety to reduce emotional stress.
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Therapeutic management
c. General:a. initial:
1. spinal stabilization with backboard or cervical collar on initial transport
2. MV if necessary 3. monitor cardiac status, blood gases, neuro V/S, I&O, V/S4. maintain skeletal traction and body alignment 5. reposition and turn every 2hrs6. passive ROM7. monitor bowel and bladder function, skin integrity and
avoid extreme temperatures
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Therapeutic management
b. Long term
1. bowel training
2. bladder training
3. PT to diminish orthostatic hypotension, increase strength and endurance, decrease muscle spasticity, prevent contractures
4. OT to aid adaptation of ADLs
5. respiratory therapy
6. recreational therapy
7. speech therapy
8. case mgt for needed resources
9. long term medical ff up
10. counseling of individual and family support adaptation
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Prevention and promotion:
1. Daily skin inspections
2. Diligent use of bowel and bladder programs to prevent bowel obstruction and UTI
3. Influenza and pneumonia vaccines to prevent respiratory complications
4. Early recognition and treatment of urinary tract and respiratory problems
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DISCHARGE GOALS
1. Ventilatory effort adequate for individual needs.2. Spinal injury stabilized.3. Complications prevented/controlled.4. Self-care needs met by self/with assistance, depending on specific situation.5. Beginning to cope with current situation and planning for future.6. Condition/prognosis, therapeutic regimen, and possible complications understood.7. Plan in place to meet needs after discharge.
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Infection of the CNS
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Bacterial Meningitis
Infection of the cerebral meninges
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Causes:
• RTI• Lumbar puncture• Skull fracture • Meningocele• Myelomeningocele
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Assessment
• History • S/Sx:
• Irritable • Headache• Seizure/shock• Brudzinski’s sign • Kernig’s sign• Opisthotonos• Cranial nerve paralysis (III & VI)• Papilledema
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Neonate
• Bulging and tense fontanelles• Poor sucking • Weak cry • Lethargy • Apnea• Seizures
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Diagnostics
• Lumbar tap with CSF analysis• Blood culture • Ct scan • MRI • Ultrasound
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Therapeutic management
• Antibiotic therapy (IV/intrathecal) • Corticosteroid • Osmotic diuretic
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Nursing diagnoses
• Pain • Risk for ineffective cerebral tissue
perfusion• Altered sensory perception
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Nursing interventions
• Position in supine without pillows• Place in isolation • Ensure strict medication compliance• Observe for signs and symptoms of increasing
ICP • Monitor I and O with specific gravity of urine • Assess senses
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Encephalitis
Inflammation of the brain tissue and possibly the meninges as well
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Assessment
S/Sx
Symptoms begin gradually or suddenly • Headache • Fever • Nuchal rigidity((+) brudzinski’s and Kernig’s sign) • Ataxia • Muscle weakness or paralysis • Diplopia • Confusion • Irritability
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Therapeuic Management
• Treatment is primarily supportive• Antipyretic • Antibiotic therapy• Corticosteroid • Osmotic diuretic
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Reye’s Syndrome• Acute encephalitis with accompanying fatty infiltration of the
liver, heart, lungs, pancreas, and skeletal muscle. • Occurs in children 1-18 years of age • Both sex are equally susceptible • Cause Unknown but generally occurs after a viral infection
such as varicella and influenza• If child was treated with salicylate such as acetylsalicylic acid
(aspirin) during the viral infection
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Neurologic Diseases that result from viral infections or neurotoxins
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Postpoliomyelitis Syndrome
• Complication of previous poliomyelitis virus (epidemic occurred in USA during 1940’s and 1950’s); persons who recovered are re-experiencing manifestation of acute illness in their advanced age
• Pathophysiology: Process is unknown• Manifestations: Fatigue, muscle and joint weakness, loss of muscle
mass, respiratory difficulties, and pain• Diagnosis: By history and physical examination• Treatment: Involves physical therapy and pulmonary rehabilitation• Nursing Care: Involves emotional support and interventions to deal with
dysfunction; ADL, safety are including in interventions
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Rabies Rhabovirus infection of CNS transmitted by
infected saliva that enters the body through bite or open wound
• Critical illness almost always fatal• Source often is bite of infected domestic or wild
animal• Incubation is 10 days to years
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Rabies
Manifestations occur in stages• Prodromal: wound is painful, various paresthesias,
general signs of infection; increased sensitivity to light, sound, and skin temperature changes
• Excitement stage: periods of excitement and quiet; develops laryngospasm and is afraid to drink (hydrophobia), convulsions, muscle spasms and death usually due to respiratory failure
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Rabies
Collaborative Care• Animal that bit person is held under observation
for 7 – 10 days to detect rabies• Sick animal are killed and their brains are tests
for presence of rabies virus• Blood of client may be tested for rabies
antibodies
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Rabies
Post-exposure treatment• Rabies immune globulin (RIG) is administered for passive
immunization• Client often has local and mild systemic reaction;
treatment is over 30 daysTreatment of client with rabies: involves intensive care
treatmentHealth Promotion• Vaccination of pets• Avoid wild animals, especially those appearing ill• Follow up care for any bites
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Tetanus (lockjaw)
Disorder of nervous system caused by neurotoxin from Clostridium tetani, anaerobic bacillus present in the soil
• Contract disease from open wound contaminated with dirt, debris• Has high mortality rateIncubation is usually 8 – 12 daysManifestations • Stiffness of jaw and neck and dysphagia• Spasms of jaw and facial muscles• Develops generalized seizures and painful body muscle spasms• Death occurs from respiratory and cardiac complications
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Tetanus (lockjaw)Diagnosis is made on clinical manifestationsClients with disease are treated in intensive care with
antibiotics, chlorpromazine (Thorazine) and diazepam (Valium ) for muscles spasms
Health Promotion• Active immunization with boosters given at time of
exposure• Passive immunization is given to persons who are not
adequately immunized
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Botulism Food poisoning caused by ingestion of food contaminated
with toxin from Clostridium botulinum, anaerobic bacteria found in soil
• Contracted by eating contaminated foods usually improperly canned or cooked
• Untreated death rate is highPathophysiology: Bacteria produce a toxin, which blocks
release of acetylcholine from nerve endings causing respiratory failure by paralysis of muscles
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BotulismManifestations• Visual disturbances• Gastrointestinal symptoms• Paralysis of all muscle groups• Effecting respirationDiagnosis • Based on clinical picture• Verified by laboratory analysis of client’s serum
and stool• Testing the suspected food
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Botulism
Treatment• Administration of antitoxin• Supportive treatment including mechanical ventilation
and systemic support in intensive care unit
Health Promotion• Teaching clients to process foods properly when home
canning• Boiling foods for 10 minutes which destroys the toxin• Not eating spoiled foods
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End of Concept