Final N173 Part 1
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What is hip dysplasia?
at birth the hip joint is mainly cartilage, and as ossification occurs the head of the femur must be properly situated in the acetabulum for correct hip development
development of dysplasia occurs when lax ligaments around the femoral head allow the femoral head to dislocate
S/S of hip dysplasia
- unstable hip
- unequal thigh/buttock skin folds
- limited abduction of affected side
- unequal knee height
How do you treat hip dysplasia in an infant....
ideally dx before 2 mo.
Put in a Pavlik Harness which will maintain the femur head in the acetabulum and legs will be flexed and abducted at 70 degrees
Problems with Pavlik Harness for infants
it is worn continuously for 3-6 months
watch for skin irritation....can be difficult with feeding, holding, playing car seat securing and development support.
How do you treat hip dysplasia in toddlers/children?
cast or surgery
Problems with correcting hip dysplasia in toddlers/children.....
- watch for muscle contractures
- skin breakdown
- bowel and bladder issues....keeping cast clean, incontinence, constipation and privacy
What are the development issues in a toddler/child with hip dysplasia?
- toilet training
How do you dx juvenile rheumatoid arthritis?
- Comprehensive H&P
- Persistent joint swelling that lasts longer than 6 weeks
- stiff, swollen, warm to the touch
- limited ROM
- anti CCP
Complication of juvenile arthritis
- check with a slit lamp eye exam....vision loss
Nursing management for juvenile arthritis
- Promote G&D
- Prevent deformity with PT/OT/ROM
- **want to avoid contractures**
How do you manage pain during exacerbations of juvenile arthritis?
- pain meds
- heat/cold packs
- neutral positions
Meds for juvenile arthritis
- (Naproxen, Ibuprofen)
Slipped Capital Femoral Epiphysis
S/S of SCFE
- Pain in the:
- Limp when ambulating
What is SCFE
slippage of the epiphysis of the femur due to a growth spurt...seen in adolesence
Kids with SCFE are usually sent to the school nurse why?
poor participation in PE activities due to pain
Over time what happens with SCFE?
- the hip loses flexibility
- leg shortens
- cant bend over and tie shoes or put socks on
Assessment findings for a kid with SCFE
- limb length discrepency
- atrophy of thigh muscle
- decreased ROM of hip
Surgery performed for SCFE
Percutaneous Pinning.....pain is inserted across the growth plate to secure the femoral head and prevent further slippage
Pre op and post op care for a child with SCFE
Pre Op-no weight bearing and immobilize till surgery....immediately put in hospital
Post Op-CMS checks, fluids, pain man, change position, monitor for infection, crutches for 4-6 weeks
Complications of SCFE after surgery....
avascular necrosis....if not caught in time the child can have permanent growth retardation of affected limb (one leg shorter than the other)
causes pain and will need hip replacement later in life
When are screws removed after SCFE surgery?
several years later
Patient teaching for SCFE
- isometric exercise
- crutch walking
- if overweight then refer to a nutritionist
DX of SCFE
xrays of patient in a frog leg position
S/S of Leg Calf Perthes
- Persistent pain of the hip that worsens with movement
- Limited ROM
- Loss of internal hip rotation and limited abduction
Serious complication of Leg Calf Perthes
if the femoral head protrudes outside the acetabulum and the healing process within the femoral head is incomplete, the femoral head will flatten over time and take a misshapen appearance
Dx of Leg Calf Perthes
x ray of femoral head
Goal of therapeutic management of Leg Calf Perthes
prevention of deformity of the hip and delay the onset of arthritis and degenerative joint disease
Initial treatment of Leg Calf Perthes
If kid with leg calf perthes doesn't get better after 7-10 days of NSAIDS, bed rest and ROM exercises....then what?
- Petrie Casts
- Abduction brace
How do you know a kid isn't getting better from treatments for Leg Calf Perthes?
cant abduct the hip
In a kid with Leg Calf Perthes what indicates collapse of the femoral head?
shortening of the extremities on the affected side
Management of Leg Calf Perthes problems
activity restrictions can be frustrating and cause non compliance
*work with the school and teachers to help child to stay involved
Teaching for a child with Leg Calf Perthes
- Most treatment is done at home.....sooo
- teach parents to perform neurovascular assess
- ID skin and safety issues in relation to mobility and brace use
- PT/OT appts
What is Osgood Schlatter's
bilateral knee pain that occurs with running, jumping or climbing stairs.
It is associated with growth and is more common in boys
S/S of Osgood schlatters
- swelling and pain in the tibial tubercle
- limping after activities
Clinical management of Osgood schlatters
- RICE-rest, ice, compression, elevate
- NSAIDS for pain
- knee mobilizer (maybe)
- PT for stretching and lengthening
Patient teaching for kid with Osgood schlatters
rest and be a couch potato!!
S/S of club foot
- rigid mid foot Cavus (high arch)
- Forefoot ADDUCTION
- heel varus (inward angulation)
- ankle Equinos (cave)
Goal for treatment of a club foot
- reduce or eliminate all of the components of the deformity so the child has a
- pain free foot
Secondary goals for club foot treatment
- satisfactory appearance
- ability to wear normal shoes
- avoidance of unnecessary or prolonged treatment
Two best treatment for a club foot
- Ponseti casting
- French physiotherapy
French physiotherapy for club foot
- PT's do
- daily sequential stretching, strengthening and mobilization of the foot
- followed by taping and splinting to allow for gradual correction of the deformity
See results by 3 months and fixed by 5 mo
Parent teaching for French Physiotherapy for a child with a club foot
parents are taught the exercises and how to splint cuz this is done till the child is 2-3 years old
Ponseti Casting for a kid with a club foot
Gold standard of treatment
- weekly gently stretches
- manipulation of misaligned bones
- followed by application of a well molded long leg plaster cast
deformity is corrected within 6-8 weeks
Nursing care for a child with a club foot no matter the extent or how it is corrected....
- education and anticipatory guidance
- reduction of discomfort and pain
- patient advocacy
Anticipatory guidance for a baby with a club foot
- give info about treatment protocol to reduce anxiety and guilt
- prepare families for disruption in childs care, such as difficulty with dressing, sleep and playing during bracings
But kids will adapt
Parent teaching for a baby with club foot
- proper neurovascular checks
- skin care...while in casts
- pain management
- How to bathe the child and
How do you reduce discomfort or pain in a child with a club foot during therapies?
- must have the infant relaxed during manipulation.
- encourage baby to feed during manipulation as a distractor
Patient advocate for a child with a club foot
- help patients stay on board with treatments/castings/
- call home to check on parent and support
Assessments for a person with a cast
- Assess circulation
- Place pads on pressure friction areas
- Raise extremity...and/or ice for swelling
- Reposition q 2h
What are casts used for?
maintenance and support of a bone in an anatomic position to heal and injured bone or correct a defect
2 different types of casts....describe
Plaster-heavy, cant get wet, takes a long time to dry but is cheap
Fiberglass-lighter and can be made with a water proof liner
Cyanotic vs. Acyanotic Heart Disease
Cyanotic-problem with the heart is causing not enough oxygen to be present in the blood
Acyanotic-the blood contains enough oxygen but it is pumped abnormally around the body
S/S of cyanotic heart disease
- blue finger, toes and lips
S/S of acyanotic heart disease
may be born without symptoms...but will cause problems
The pressure of the blood will be abnormally high, making the heart need to work harder to pump the blood. This can weaken the heart and increase it's risk of failure
- Pressure in the lungs is too high...pulmonary htn, which will damage the lungs causing
Congenital heart defects that are cyanotic
- Pulmonary Stenosis
- Tetralogy of Fallot
Congenital Heart defects that are acyanotic
- Coarctation of Aorta
Clinical Assessment findings for pulmonary stenosis
- Asymptomatic-born blue, dusky, tired
- s/s during exercise
- systolic ejection murmur
- rt side chf
- lg liver
What is pulmonary stenosis
a narrowing of the entrance to the pulmonary artery at the valve
Result of pulmonary stenosis
RV hypertrophy....cuz all of the blood isn't getting out of the right ventricle in to the left atria
decreased flow from the R ventricle
How is the foramen ovale involved in pulmonary stenosis?
an increase in RV pressure causes blood to regurg in the the RA which can cause the foramen ovale to open allowing blood to flow from the R to the L side of the heart
Important to do what for kids with pulmonary stenosis?
pre medicate with antibiotics before going to the dentist
If you have a severe case of pulmonary stenosis what will you be given and why?
PGE1 to keep the ductus arteriosis open so blood can be oxygenated
2 surgical treatments for pulmonary stenosis...describe
Balloon valvuloplasty...dilation of the valve to decrease pressure
Surgical Valvuloplasty....shunt from aorta to pulmonary artery to open it up
Where is the problem with pulmonary stenosis?
Problem with TGV / TGA
- Aorta arises from the right ventricle
- Pulmonary artery arises from the left ventricle
(supposed to be opposite of that)
If a baby has TGV/TGA what is necessary for them to survive while waiting for surgery?
How do you accomplish this?
PDA, ASD, VSD
If a baby has TGV or TGA what do we assess for later in life?
S/S of TGV/TGA
- cyanosis at birth...increases dramatically as PDA closes
- Hypoxemia despite O2 admin
- Decreased CO
- Progressive desat and acidosis
- heart failure
What's the problem with TGV/TGA?
both oxygen saturated and unsaturated blood are going out to the body....if PDA closes NO OXYGEN SATURATED BLOOD going out
4 defects with tetralogy of fallot
- pulmonary stenosis
- ventricular septal defect
- overriding aorta
- hypertrophy of RV
Whats an overriding aorta?
aorta is located over ventricular septal defect
Assessment of a kid with Tetralogy of fallot
- squatting position
- CHF with dry lungs
- activity intolerance
How does tetralogy of fallot have both a left to right and a right to left shunt?
Normally it is left to right cuz of VSD....but when having a TET spell it is a R to L shunt
S/S of a TET spell
- R to L shunt across VSSD
- increasing cyanosis
- decreased LOC
What causes a TET spell
- pushing during a BM
How do you manage a TET spell?
- put their knees in to chest (increases blood flow to lungs)
- moriphine to calm
- decrease tachypnea
- decrease peripheral vasodilation
A child with TOF has ventricular septal defect...what does this cause?
Rt. Ventricle hypertrophy
Result of an overriding aorta in a child with TOF
causes the heart to shoot out both oxygenated and non oxygenated blood
Typical sats for a kid with TOF
You will see kids in the ED who have TOF for what? S/S
- even lower sats
- dusky color
- burgundy cyanosis around mouth
- cool skin
How do you treat TGV/TGA?
surgical repair switching the pulmonary artery and aorta back to where they should be
What is the problem with coarctation of aorta?
narrowing of an area somewhere along the aorta
result-decreased flow from the left ventricles
Details about where the coarctation of aorta is and results....
before the arteries= decreased perfusion to the brain so they will have headaches and distended neck veins, nose bleeds
after the arteries=decreased pulses in lower extremities, decreased blood pressure in lower extremities, dusky LE, tingly, weak, cramping LE
Assessment findings for coarctation of aorta
- UE with higher BP than LE
- dusky lower extremities
- slow cap refill on extremities
How do you dx coarctation of aorta
measure BP in upper and lower extremities....lower will be lower.
Heart rate with COA
HR is the same in upper and lower extremities, but the lower extremities wont be as full or strong
3 ways to fix COA
- Balloon angioplasty
- End to end anastamosis
Meds to give a person with COA
- PGE 1....opens ductus arteriosis
Pressures and COA
Pressure will be high behind the narrowing and low after it
What is VSD?
an opening between the lft and rt ventricle causing RV hypertrophy
Results of VSD
- RV hypertrophy
- Pulmonary HTN
Assessment findings of VSD
- asymptomatic and may not be dx till older
- cyanosis while eating or exercising
- Murmur in mid/low chest that is loud and harsh
systolic and diastolic murmur
How do you treat VSD?
- treat pulmonary htn with meds and O2
- hope for spontaneous closure
- IF NOT and it's a big hole....
- Dacron patch to seal it closed
If a person has a lg hole with VSD what will I see?
- signs of HF
- sweating while eating
opening between the LA and RA causing a left to right shunt
Result of ASD
- RA hypertrophy
- Systolic murmur
- Pulm. HTN
Assessment findings for ASD
- asymptomatic till adult
- Systolic Murmur
- SOB on exertion
- Recurrent respiratory infections
- Mitral valve regurg
When would a person with ASD turn cyanotic?
exercise and eating
Why is a person with ASD at risk for a stroke?
because the hole may impede the electrical current causing dysrhythmias...or A fib which causes you to throw a clot....stroke
when the ductur arteriosus doesn't close withing 24-72 hours after birth
Where is the ductus arteriosis?
it is an opening between the pulmonary artery and aorta
Why wouldn't the ductus arteriosis close?
- too little prostaglandins
- decrease in BP in lumen
Who has the highest risk of getting PDA
Where will you hear the murmur if they have PDA?
- Upper left chest....off the aorta
- sounds like a machine
Assessment findings of a baby with PDA
- Widened pulse pressure
- Bounding pulses
- Enlarged heart
- Pulmonary congestion
3 ways to treat PDA
- Surgical Ligation
Meds to treat PDA
- Indomethacin-a PG inhibitor that constricts the ductus
- IV Ibuprofen to cleave prostaglandin
Describe the angiography PDA closure device for PDA
it is a coil that tissue grows over and provides a permanent occlusion
Describe surgical ligation for PDA
via a L thoracotomy and done within 1st year of life
Patho of Kawasakis
acute fever with a triggering of an immune response that affects the coronary arteries
S/S of Kawasakis
- High fever for 5+ days
- Strawberry tongue
- cracked lips
- Erythema on soles of feet and palms....then induration...then peeling
Labs that will be increased with Kawasakis
Complication of Kawasakis
Sign that you are in the convalescent/final stage of Kawasaki
Bue line on the nails
Clinical management of Kawasakis
- Antipyretics for fever (Tylenol, Ibuprofen)
- Maintain hydration
- Soft, bland diet
- Encourage fluids
- Mouth care
Why is it important to encourage bland, soft foods and maintain hydration for a kid with Kawasakis
cuz their mouth has sores and it is hard to eat.
Want them to eat popsicles and high calorie/protein liquids like milk shakes for calories
How do prevent the risk of coronary damage in a patient with Kawasakis?
- baseline ECHO at 3 weeks/1 mo. later
- watch HR and BP closely
- Assess for CHF
- Assess for chest pain
- Watch coloring and activity level
Meds given to kids with Kawasakis at dx
- IVIG-2G/kg over 10-12 hrs
- Aspirin 80-100mg/kg/day till fever resolves then 3-5mg/kg/day for 6-8 weeks or indefinitely if there is coronary artery involvement
When giving IVIG infusion for Kawasakis what do I watch?
- VS...especially BP
- Looking for:
- tight chest
When will the child have a coronary aneurysm when they have an active Kawasakis infection?
- 2nd stage....day 11-25 when they are still irritable
- hands and feet are peeling
- increased platelet count
Parent teaching for a kid with Kawasakis
s/s of cardiac compromise and the need for cardiac follow up due to risk of aneurysm
What does Digoxin do?
helps the heart pump blood more effectively, thereby improving the circulation of the blood and promoting the normal elimination of excess fluid
When do you give digoxin and how?
in the am and at night 20-30 before eating
What do you measure the digoxin in? And what if you miss a dose?
- give the dose when you remember it
Hold Digoxin if HR is what?
less than 100
How do you give a "loading dose" with digoxin....then what?
give then a greater than normal dose then taper down
2 things to watch for with digoxin
- watch for hypokalemia...this can make the dig toxic
- watch dig levels for toxicity >2.4
S/S of dig toxicity
- irregular pulse
- loss of appetite
- Vision changes
If a person has Dig Toxicity what do I do?
- May need to do CPR
- Activated Charcoal
- Gastric Lavage
- DONT INDUCE VOMITING
Patient ed for digitalis...
- take apical pulse for 1 full minute and hold if
- <70-85 for children
- <90-100 for infants
What's the difference btwn primary and secondary htn?
- primary is from obesity
- secondary is due to something else like renal issues that cause htn
How fast to you push diuretics? What happens if it is too fast?
over 5 min....ototoxicity
Blockage at the pulmonary artery or vein will lead to
Increased flow to the pulmonary artery or vein will lead to
Important assessments to make on a child with heart problems
- are they doing activities typical of kids their age and hitting milestones
- hows their growth...especially weight
- VS-HR, rhythm and BP IN ALL 4 Extremities
- Precordium quiet or bounding?
- delayed cap refill
- compare pulses rt to left and upper to lower
- Increased work of breathing? SOB retractions
- Sweating with eating
- Adventitious lung sounds
- O2 sats
When looking at a childs O2 sats who has heart issues what is important....
- know their norm
- and what it should be based on problem
Heme issues with heart problems
polycythemia....increased risk for clotting
How will you see a coronary aneurysm?
echochardiogram or angiogram
What causes a Tet spell?
decreased ventricular outflow....happens with crying and pooping
How do you decrease peripheral vasodilation during a TET spell
How do you minimize complications from CHF
- chunk activities
- high calorie foods, soft nipple, feed upright
- low flow O2
- Elevate HOB 30-45
Meds for CHF
- Ace Inhibitors
What do diuretics do for CHF
decreases circulating volume
What do ACE inhibitors do for CHF
decreases vasoconstriction through ACE I and ACE II which decreases sodium retention and afterload
Therapeutic level for Dig
When do you draw dig levels?
6-8 hrs after previous dose
What do you monitor on a patient taking dig?
potassium and renal function
Meds given for endocarditis
Penicillin or Cephalosporin
What do I watch for when giving PGE prostaglanding?
apnea....so be ready to intubate
What are the dx tests available to determine a congenital defect?
- cardiac cath
How do you dx endocarditis
Nursing care after a child has a cardiac cath
apply pressure with a pressure bandage
Prior to a person having an angiogram....
make sure they are not allergic to dye or shell fish
What are the 2 dx procedures that are non invasive
echo and ekg
Parent education important for meds
- side effects
Always make sure you teach parents when possible about....
- importance of immunizations
- appropriate activities
- s/s of worsening hf
s/s of worsening HF
- excessive sweating
- increased wob
- decreased urine output
- feeding intolerance
- weight gain or loss
Teaching for a parent with a kid with endocarditis
how to admin IV antibiotics at home
Teaching for a parent with a kid with kawasaki
- give ASA
- follow up with cardiologist and have repeat echo
What would you like to do?
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