Cathy Cartwright

Endoscopic strip craniectomy: a minimally invasive treatment for early correction of craniosynostosis.

&NA; Traditionally, surgical correction of craniosynostosis involves calvarial remodeling, large blood losses necessitating transfusions, hospital stays of several days, and less‐than‐satisfactory results. In this study, outcomes from a minimally invasive technique called endoscopic strip craniectomy, along with a postoperative molding helmet, to correct craniosynostosis in young infants were evaluated. The endoscopic strip craniectomy was performed on 185 patients with clinical signs of craniosynostosis, with the following distribution: 107 sagittal, 42 coronal, 37 metopic, and 7 lambdoid, for a total of 198 sutures. The mean blood loss was 29.4 cc, and only two patients underwent intraoperative blood transfusion. Fourteen patients underwent postoperative blood transfusion; none was life‐threatening. There were no deaths, complications, neurological injuries, or infections. All but six patients were discharged on the first postoperative day. A majority of the patients achieved or approached normocephaly, and there were no complications. Neuroscience nurses need to be aware of this technique when they discuss treatment options with the families of infants with craniosynostosis.

Lumbar Puncture Opening Pressure Is Not a Reliable Measure of Intracranial Pressure in Children

There is very little data correlating lumbar puncture pressures to formal intracranial pressure monitoring despite the widespread use of both procedures. The hypothesis was that lumbar puncture is a single-point measurement and hence it may not be a reliable evaluation of intracranial pressure. The study was therefore carried out to compare lumbar puncture opening pressures with the Camino® bolt intracranial pressure monitor in children. Twelve children with a mean age of 8.5 years who had both lumbar puncture and intracranial pressure monitoring were analyzed. The mean lumbar puncture opening pressure was 22.4 mm Hg versus a mean Camino bolt intracranial pressure of 7.8 mm Hg (P < .0001). Lumbar puncture therefore significantly overestimates the intracranial pressure in children. There were no complications from the intracranial pressure monitoring, and the procedure changed the treatment of all 12 children avoiding invasive operative procedures in most of the patients.

Primary tethered cord syndrome: diagnosis and treatment of an insidious defect.

&NA; Failure to recognize the signs and symptoms of tethered cord syndrome in patients with spina bifida occulta can result in tragic consequences. Of patients with tethered spinal cord, 35% have bowel and/or bladder dysfunction.14 Scoliosis, foot or leg length discrepancies, pes cavus, and varus or valgus deformities also can occur. Early assessment and intervention by the neuroscience nurse who is familiar with theses clinical signs can help prevent significant deformities and irreversible neurological deficits.

American association of neuroscience nurses scope and standards of practice for neuroscience advanced practice nurses

Background Specialization in nursing arose as a way to enhance quality of care and improve access to care, in the face of increasing knowledge and technological advances. A nursing specialty is characterized by a unique body of knowledge and skill set, with nurses providing care focused on phenomena unique to the practice. Neuroscience nursing is a unique nursing discipline that addresses the needs of individuals with biopsychosocial alterations because of nervous system dysfunction (Webb, 2000). Recognition of neuroscience nursing as a practice specialty began in the 1960s and resulted in the formation of the American Association of Neurosurgical Nurses in 1968. To reflect the broader practice of its members, the association was renamed the American Association of Neuroscience Nurses in 1983. As neuroscience nursing evolved as a specialty, so did opportunities for advanced practice. The nursing shortage, the need to improve quality of care, restricted residency hours, and promotion of costeffective care have led to increasing use of advanced practice nurses (APNs). The number of APNs in neuroscience nursing has grown in recent decades, reflecting the complexity and diversity of the field. Through education and certification, the neuroscience APN demonstrates basic competency in the role. Neuroscience APNs include clinical nurse specialists (CNSs) and nurse practitioners (NPs). Neuroscience APNs work in a variety of settings, demonstrate specific competencies unique to neuroscience nursing, and have a broad scope of responsibilities. This document provides a framework for the neuroscience APN to practice, addressing the four requirements necessary for regulation of the advanced practice role: licensure, accreditation, certification, and education. Although neuroscience advanced practice nursing roles are defined, procedures and activities that may be performed are not defined because those are subject to individual collaborative practice as guided by state law and institutional or practice policy (Herrmann & Zabramski, 2005). There are many diverse statutes (state, federal, and community) and institutional guidelines that govern APN practice, and the Scope of Practice for Neuroscience Advanced Practice Nurses does not supersede those statutes or guidelines. For those APNs who are required to practice within a contractual agreement, protocols may be collaboratively developed that address specific responsibilities and expectations. The ability to perform specific clinical tasks is a multifaceted process involving APN competency, collaborative agreement with the physician or institution (if required), and state statutes. As practice evolves and statutes change, updates to this document may be necessary to reflect developments in the practice environment.

Pediatric athletic concussion.

Ifirst became interested in pediatric athletic concussion when my youngest son played high school football in the late ‘90s. The day after a game he told me about one of his team mates who received a hard hit during the game and couldn’t remember driving home. At that time getting your ‘‘bell rung’’ was an accepted consequence of the sport and you were expected to ‘‘buck up’’ and get back in the game. After all, that’s what you saw the pro athletes do. Now we know there are more serious consequences of athletic concussion, particularly for children and adolescents because of their growing brains. The media is full of stories of the long term effects of concussion and the devastating effects of second impact syndrome. According to the consensus statement from the 4th International Conference on Concussion in Sport held in Zurich in 2012, a concussion is ‘‘a brain injury defined as a complex physiological process affecting the brain, induced by biomechanical forces’’ (McCrory et al., 2013). A concussion may be caused by a blow to the head, or elsewhere on the body and the force transmitted to the head. It may involve loss of consciousness although less than 10% of concussions involve loss of consciousness. Confusion, foggy or fuzzy thinking and being slow to react or speak can all be signs of a concussion. Young athletes may not recognize they have a concussion or they may be reluctant to report their symptoms for fear of being held out of the game. If a concussion is suspected the athlete should not return to play the same day. When in doubt, sit them out. Conventional neuroimaging such as CT and MRI detect hemorrhage and cerebral contusions, but may be normal in a concussed athlete because a concussion is a functional rather than a structural brain injury. Both physical and cognitive rest are recommended for the symptomatic athlete. This may include limiting or restricting TV, video games, cell phones, texting, school work and school attendance, as well as driving and athletic activities. Return to play guidelines are tailored for each individual. No athlete should return to play if symptomatic at rest or on exertion. Althoughmost (80%Y90%) of concussions resolve in 7Y10 days, some may have symptoms that persist, particularly in children and adolescents. Once the athlete is asymptomatic at rest, he or she progresses in a step-wise fashion with each step every 24 hours so that it takes approximately one week to progress through the protocol and return to play, according to the recommendations from the 4th International Conference on Concussion. Neuroscience nurses need to be aware of the signs and symptoms of concussion as well as the long-term effects. Seek opportunities to educate parents, coaches and youth athletes about concussion. Encourage parents to speak to their child’s coach about concussion and return to play guidelines. Resources are available for parents and coaches at the Centers forDisease Control and PreventionHeadsUp Toolkit for High School Sports: www.cdc.gov/concussion/ HeadsUp/high_school.html. We can play an important role in limiting the long term consequences of pediatric athletic concussion.

Craniosynostosis and Plagiocephaly

Craniosynostosis is the premature closure of one or more cranial sutures and can occur in 1 in 2,100 children. Using numerous illustrations, this chapter discusses the pathophysiology of craniosynostosis, specific suture involvement, diagnosis, surgical treatment options, and nursing care. Positional plagiocephaly, often confused with craniosynostosis, is caused by deformational forces such as the mother’s pelvis prenatally or a firm surface such as a mattress postnatally. Since the 1992 Back to Sleep Campaign, there has been an increase in positional plagiocephaly. Techniques to prevent or improve plagiocephaly are presented as well as how to differentiate this skull deformity from craniosynostosis. Parents share their stories of how they felt when they learned their child had craniosynostosis and surgical correction.

“mock Herniations” to Assess Nurses’ Response Times and Accuracy in Setting Up Ventriculostomies in the Pediatric Intensive Care Unit

ABSTRACT When an emergent ventriculostomy is required for relief of increased intracranial pressure, it is critical that participating physicians and nurses work as an efficient team for optimal outcomes. From our experience, problems in ventriculostomy insertion have occurred because of delays in obtaining correct supplies and lack of skill in assembling the drainage system. The goals of this study were to (a) decrease the response time and (b) increase competency for successful insertion and setup of a ventriculostomy by using a “mock herniation” scenario. Three different nursing shifts in the pediatric intensive care unit at the University of Missouri Health Care were presented with a mock scenario of a child with increased intracranial pressure and impending herniation. Each group was timed on its ability to gather the correct supplies and scored on accuracy in setting up the drainage system. Subsequently, all pediatric intensive care unit nurses underwent skills laboratory training on correct assembly of the drainage system. After training, three different groups of nurses were tested again using the mock herniation scenario. This time, there was improvement in all areas tested, particularly in the mean time taken for accurate assembly and setup of the emergency ventriculostomy drainage system. We conclude that skills laboratory training reinforced by periodic mock herniations significantly decreases response time and increases accuracy of assembling supplies and setting up the drainage system for ventriculostomy insertion.