Final N173 Part 1

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

• unstable hip
• unequal thigh/buttock skin folds
• limited abduction of affected side
• unequal knee height

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

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.

cast or surgery

• watch for muscle contractures
• skin breakdown
• bowel and bladder issues....keeping cast clean, incontinence, constipation and privacy

• regression
• toilet training
• fear
• discomfort

• Comprehensive H&P
• Persistent joint swelling that lasts longer than 6 weeks
• stiff, swollen, warm to the touch
• limited ROM

• Labs
• RF
• ANA
• HLA
• anti CCP
• CBC
• ESR
• CRP

• Uveitis
• check with a slit lamp eye exam....vision loss

• Promote G&D
• Prevent deformity with PT/OT/ROM
• Exercise
• **want to avoid contractures**

• pain meds
• heat/cold packs
• splinting
• neutral positions

• NSAIDS
• (Naproxen, Ibuprofen)

Slipped Capital Femoral Epiphysis

• Pain in the:
• Hip
• Thigh
• Groin
• Knee
• Limp when ambulating

slippage of the epiphysis of the femur due to a growth spurt...seen in adolesence

poor participation in PE activities due to pain

• the hip loses flexibility
• leg shortens
• cant bend over and tie shoes or put socks on

• limb length discrepency
• atrophy of thigh muscle
• decreased ROM of hip

Percutaneous Pinning.....pain is inserted across the growth plate to secure the femoral head and prevent further slippage

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

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

several years later

• isometric exercise
• crutch walking
• if overweight then refer to a nutritionist

xrays of patient in a frog leg position

• Persistent pain of the hip that worsens with movement
• Limp
• Limited ROM
• Loss of internal hip rotation and limited abduction

permanent deformity

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

x ray of femoral head

prevention of deformity of the hip and delay the onset of arthritis and degenerative joint disease

• Ibuprofen
• ROM
• Bed rest

• Traction
• Petrie Casts
• Abduction brace

cant abduct the hip

shortening of the extremities on the affected side

activity restrictions can be frustrating and cause non compliance

*work with the school and teachers to help child to stay involved

• 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

bilateral knee pain that occurs with running, jumping or climbing stairs.

It is associated with growth and is more common in boys

• swelling and pain in the tibial tubercle
• limping after activities

• RICE-rest, ice, compression, elevate
• NSAIDS for pain
• knee mobilizer (maybe)
• PT for stretching and lengthening

rest and be a couch potato!!

• rigid mid foot Cavus (high arch)
• Forefoot ADDUCTION
• heel varus (inward angulation)
• ankle Equinos (cave)

• reduce or eliminate all of the components of the deformity so the child has a
• functional
• structural
• mobile
• pain free foot

• satisfactory appearance
• ability to wear normal shoes
• avoidance of unnecessary or prolonged treatment

• Ponseti casting
• French physiotherapy

• 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

parents are taught the exercises and how to splint cuz this is done till the child is 2-3 years old

Prevents recurrence

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

• education and anticipatory guidance
• reduction of discomfort and pain
• patient advocacy

• 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

• proper neurovascular checks
• skin care...while in casts
• pain management
• How to bathe the child and

• must have the infant relaxed during manipulation.
• encourage baby to feed during manipulation as a distractor

• help patients stay on board with treatments/castings/
• call home to check on parent and support

• 5P's
• pain
• pallor
• pulselessness
• paresthesia
• paralysis

• Assess circulation
• Place pads on pressure friction areas
• Raise extremity...and/or ice for swelling
• Reposition q 2h

maintenance and support of a bone in an anatomic position to heal and injured bone or correct a defect

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-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

• blue finger, toes and lips
• SOB
• Fainting
• Fatigue

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
• breathlessness
• fatigue
• dizziness
• fainting

• Pulmonary Stenosis
• TGV/TGA
• Tetralogy of Fallot

• Coarctation of Aorta
• VSD
• ASD
• PDA

• Asymptomatic-born blue, dusky, tired
• s/s during exercise
• systolic ejection murmur
• rt side chf
• lg liver

a narrowing of the entrance to the pulmonary artery at the valve

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

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

pre medicate with antibiotics before going to the dentist

PGE1 to keep the ductus arteriosis open so blood can be oxygenated

Balloon valvuloplasty...dilation of the valve to decrease pressure

Surgical Valvuloplasty....shunt from aorta to pulmonary artery to open it up

pulmonary artery

• Aorta arises from the right ventricle
• Pulmonary artery arises from the left ventricle

(supposed to be opposite of that)

PDA, ASD, VSD

Admin. PGE

coronary stenosis

• cyanosis at birth...increases dramatically as PDA closes
• Hypoxemia despite O2 admin
• Decreased CO
• Progressive desat and acidosis
• heart failure

both oxygen saturated and unsaturated blood are going out to the body....if PDA closes NO OXYGEN SATURATED BLOOD going out

• pulmonary stenosis
• ventricular septal defect
• overriding aorta
• hypertrophy of RV

aorta is located over ventricular septal defect

• squatting position
• CHF with dry lungs
• activity intolerance
• FTT

Normally it is left to right cuz of VSD....but when having a TET spell it is a  R to L shunt

• R to L shunt across VSSD
• desat
• increasing cyanosis
• tachypnea
• decreased LOC

• crying
• pushing during a BM

• put their knees in to chest (increases blood flow to lungs)
• oxygen
• moriphine to calm
• decrease tachypnea
• decrease peripheral vasodilation

Rt. Ventricle hypertrophy

causes the heart to shoot out both oxygenated and non oxygenated blood

80's

• PNA
• tachypenia
• even lower sats
• small/short
• clubbing
• dusky color
• burgundy cyanosis around mouth
• cool skin

surgical repair switching the pulmonary artery and aorta back to where they should be

• PA-RV
• Aorta-LV

narrowing of an area somewhere along the aorta

result-decreased flow from the left ventricles

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

• UE with higher BP than LE
• dusky lower extremities
• slow cap refill on extremities

measure BP in upper and lower extremities....lower will be lower.

HR is the same in upper and lower extremities, but the lower extremities wont be as full or strong

• Meds
• Balloon angioplasty
• End to end anastamosis

• Digoxin
• PGE 1....opens ductus arteriosis

Pressure will be high behind the narrowing and low after it

an opening between the lft and rt ventricle causing RV hypertrophy

• RV hypertrophy
• Pulmonary HTN

• 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

• 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

• signs of HF
• edema
• crackles
• SOB
• tachypnea
• FTT
• sweating while eating

opening between the LA and RA causing a left to right shunt

• RA hypertrophy
• Systolic murmur
• Pulm. HTN

• asymptomatic till adult
• Systolic Murmur
• fatigue
• SOB on exertion
• Palpitations
• dysrhythmias
• Recurrent respiratory infections
• Mitral valve regurg

exercise and eating

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

it is an opening between the pulmonary artery and aorta

• too little prostaglandins
• decrease in BP in lumen

premies

• Upper left chest....off the aorta
• sounds like a machine

• Murmur
• Widened pulse pressure
• Bounding pulses
• Enlarged heart
• Pulmonary congestion

• Meds
• Angiography
• Surgical Ligation

• Indomethacin-a PG inhibitor that constricts the ductus
• IV Ibuprofen to cleave prostaglandin

it is a coil that tissue grows over and provides a permanent occlusion

via a L thoracotomy and done within 1st year of life

• TOF
• ASD
• VSD
• PDA

acute fever with a triggering of an immune response that affects the coronary arteries

• High fever for 5+ days
• Conjunctivitis
• Strawberry tongue
• cracked lips
• Erythema on soles of feet and palms....then induration...then peeling

• ESR
• WBC
• CRP
• Platelets

Coronary aneurysm

Bue line on the nails

• Antipyretics for fever (Tylenol, Ibuprofen)
• Maintain hydration
• Soft, bland diet
• Encourage fluids
• Mouth care

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

• 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

• 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

• VS...especially BP
• Looking for:
• hypotension
• flushing
• tight chest
• n/v
• diaphoresis
• chills

• 2nd stage....day 11-25 when they are still irritable
• anorexia
• hands and feet are peeling
• arthritis
• increased platelet count

s/s of cardiac compromise and the need for cardiac follow up due to risk of aneurysm

helps the heart pump blood more effectively, thereby improving the circulation of the blood and promoting the normal elimination of excess fluid

in the am and at night 20-30 before eating

• syringe
• give the dose when you remember it

less than 100

give then a greater than normal dose then taper down

• watch for hypokalemia...this can make the dig toxic
• watch dig levels for toxicity >2.4

• confusion
• irregular pulse
• loss of appetite
• N/V/D
• Palpitations
• Vision changes

• May need to do CPR
• Activated Charcoal
• Gastric Lavage
• DONT INDUCE VOMITING

• take apical pulse for 1 full minute and hold if 
• <70-85 for children
• <90-100 for infants

• primary is from obesity
• secondary is due to something else like renal issues that cause htn

over 5 min....ototoxicity

cyanosis

wet lungs...CHF

• 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
• Murmurs
• Precordium quiet or bounding?
• Clubbing?
• Cyanosis
• delayed cap refill
• edema
• compare pulses rt to left and upper to lower
• Increased work of breathing? SOB retractions
• Sweating with eating
• Adventitious lung sounds
• O2 sats
• Hepato/splenomegaly
• UO

• know their norm
• and what it should be based on problem

polycythemia....increased risk for clotting

echochardiogram or angiogram

decreased ventricular outflow....happens with crying and pooping

give phenylephrine

• chunk activities
• high calorie foods, soft nipple, feed upright
• low flow O2
• Elevate HOB 30-45

• Diuretics
• Ace Inhibitors
• Digoxin

decreases circulating volume

decreases vasoconstriction through ACE I and ACE II which decreases sodium retention and afterload

monitor K

0.5-2 ng/mL

6-8 hrs after previous dose

potassium and renal function

Penicillin or Cephalosporin

apnea....so be ready to intubate

• echo
• cxr
• ekg
• cbc
• cardiac cath

blood culture

apply pressure with a pressure bandage

make sure they are not allergic to dye or shell fish

echo and ekg

• frequency
• dose
• purpose
• side effects

• meds
• foods/feeding
• importance of immunizations
• appropriate activities
• s/s of worsening hf

• excessive sweating
• increased wob
• decreased urine output
• fatigue
• feeding intolerance
• weight gain or loss

how to admin IV antibiotics at home

• give ASA
• follow up with cardiologist and have repeat echo