Nursing Care of the Child with a Musculoskeletal Disorder

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Nursing Care of the Child with a Musculoskeletal Disorder
2014-11-12 23:26:51

taking care of the children
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  1. Assessment Overview
    Skeleton disorder usually present with specific localized signs and symptoms. 

    Muscular or joint disorders may present insidiously over time

    Limp is never normal. Always observe gait- it could be u stump toe or something more serious...always follow ur patients and watch them walk

    Observe for signs and symptoms of abuse

    • Nurses Diagnoses:
    • Pain- fracture, chronic inflammation in joint
    • Impaired physical mobility- cast/broken
    • situational low self-esteem- not able to do the things they used to do. feel like they don't like  their peers- back brace

    • red flag for abuse
    • bruises on back
    • multiple fracture
    • always observe
    • having problems with muscles can be indicative of a respiratory problem cause u need oxygen
  2. Assessment of body
    • Ptosis- drooping eyelids; cranial nerve Muscle dystrophy (muscles are wasting away)
    • poor sucking- cerebral palsy
    • muscle weakness- muscle dystrophy
    • spinal curvature-scolosis
    • repeated fracture- abuse, osteogensis imperfecta (genetic problem)
    • stiffiness and swollen- rheumatoid arthritis
    • Wobbling gait- seen in preschool who has muscular dystrophy
    • limb- injury or some othe problems congential
    • wide gait- CP (cerebral palsy)

    If u see any of these symptoms u def want to let the MD know...
  3. Bones and Bone Growth
    in children we need to focus on the growth plate this is where the bone grows- cartilage 

    Epiphyseal plate (growth plate): disk of cartilage between metaphysis and epiphysis of immature long bones allows growth in length

    • this is where the bones are going 
    • bones grow at the ends and if there is injury to epiphyseal plate child can have some disformity.
  4. Diagnostics
    • X-ray
    • - confirm or rule out pathology (injury)

    • Bone scan
    • - identify condition not clearly seen on x-ray- identify tumors and septic arthritis 

    • Computed tomography (CT)
    • - cross sectional picture of bones and surrounding structures and radiation exposure- u have to be careful with children having CT protect the child from radiation expore

    • MRI
    • brain, spine, soft tissue injury, ligament tendons and there is no radiation
  5. Common Medical Treatment
    • Traction- for some injury and scolosis- reduce a scolosis spine so when md go to do surgery it will be straighter 
    • Casting- injury, also used for deformities that some children are born with like club foot
    • Splint
    • cold therapy- constricts vessels which will reduce swollen 
    • Crutches
    • Orthotics- braces (on legs to prevent foot drop)
    • Physical therapy- regain strength and mobility
    • Medication
  6. Nursing care of the child in a Cast:

    • Treats fractures, weakness, paralysis or spasticity
    • used following corrective orthopedic surgery
    • made of plaster, fiberglass (most of the time use this) or plastic, air cast
    • drying time depends on material used (7 minutes- 2days) no weight bearing until dry
    • some cast can go into water some cant
    • put nothing in the cast u can use a dryer 
    • if pt wants to take shower bag cast and tell pt to keep out of water. 
    •   if waters gets in- can cause skin breakdown on infection
  7. Child in cast
    • explain the procedure to family answer all questions to reduce anxiety - answer child question
    • After cast care is completed neurovascular checks
    • - assess q 30min for the next few hours (2-3hr)
    • - then every hr for 24 hours
    • - then every 4 hr for 48 hours
    • - checking for pain or incre pain, ed
    • Note wound drainage under the cast
    • assess for skin breakdown skin breakdown at cast edges and provide skin care
    • contact provider immediately for signs of compromise or the cast develops cracks
  8. Neurovascular check
    • Pain- pain should not increase
    • edema- distal to the injury down below the injury
    • color- pink no pale or blue
    • warmth- bilaterally 
    • ask about numbness and tingling
    • movement
    • cap refill less than 2-3 sec
    • pulse strength- distal to where the injury is..bilateral
    • temp (fever)
    • skin
    • Drainage

    any problems need to be reported to md right away...we don't want to cut of circulation because that extremity could die
  9. Call HCP Immediately for
    • extremity is cool to touch
    • pt cannot move fingers and toes
    • numbness or tingling persist
    • increase drainage or foul odor
    • fever greater than 101.5 > 24hrs (with inflammation our temp can go up but it should not stay up if fever last longer that could mean an infection)
    • skin edges are red, swollen or shows s/s of skin break down
    • cast gets wet , softens cracks and splits

  10. Pt education: home care cast
    • position elevate - extremity
    • ice for the first 24 hr- 20min on 20-1hr off
    • assess for swollen warmth color and movement
    • never put anything down their cast- can use blow dryer because it gets itchy
    • protect from wetness
    • teach splinting or crutch walking if necessary
  11. Cast removal
    • Cast remains in place for 4-6 weeks
    • removed with electric cast cutter- kids would be scared
    • can be scary so provide reassurance that it will not cut their skin
    • skin under cast is dirty and macerated- provide skin hygiene smelly too
  12. Sprain
    • result from twisting, turning motion
    • - tendons and ligaments stretch excessively (may tear)
    • - uncommon in young children
    • - most common in ankle and knee

    swollen black and blue
  13. Management: sprain
    • RICE:
    • rest- extremity
    • ice- 20 min 
    • compression- wrap it ace bandage
    • elevated- so we can inhibit swollen

    • splints or cast
    • crutches
    • wheelchair
    • activity restrictions- because u have to rest extremity
    • PT
  14. Mediation
    • Acetaminophen
    • NSAIDS take with food
    • Benzodiazepines- relax pt- treat muscle spasm associated with casting or trachion- monitor sedation level
    • Narcotic analgesic- take VS for baseline before u give this- N/V sedation, constipation (increase fluids)
  15. Skeletal Injury: Fracture
    • Definition: break in the structure of the bone. long bone fracture most common. other common sites include wrist, fingers, toes, and skull
    • fractures in children growth plate fracture epiphyseal line- usually unintentional
    • Pathophysiology: commonly occur during sports activity, accidents child abuse, bone tumors or metabolic disease
  16. Common fracture in children
    Bend- microscopic fracture don't cross the bones can bend 45 degrees before they break

    Buckle fracture- tension side of bone due to compression of the bone- caused a raised area

    green stick- bone not broken all the way thru- incomplete fracture

    complete- bone broken all the way thru
  17. Fractures in children
    • S/s of fracture
    • sudden sharp pain at the fracture site
    • pain increase with movement and limited motion
    • swelling bruising discoloration obvious deformity or abnormal positioning of the affected part
    • diagnostics:
    • - x-rays: definitive diagnosis of fracture
    • serial x-ray to monitor healing and alignment
  18. 5 P's assessing fractures
    • Pain and point tenderness (u can point directly to the site)
    • Pallor
    • Pulse loss-distal to the fracture
    • Paralysis- weakness
    • other assessment findings; crepitus, open fracture - where bone as come thru skin
  19. Fractures in skin complication
    • infection
    • fat embolism- rare fat is released from the bone which goes into the blood and causes a clot- cause emobolism which can go to the lungs and cause clot
    • fracture at growth plate or epiphyseal plate can interrupt or alter growth of the bone
  20. Fracture in children Salter Harris Classification system
    • used to determined severity of the injury at the epiphyseal plate
    • Type I usually no effect on growth plate (no fracture)
    • Type II most common growth plate not involved (facture not on the growth
    • Injuries or Type III or above require intervention to prevent future dysfunction in the bone and affect body part
    •  IV interfers with normal bone growth
    • V is compression of the bone- often times we don't catch this fast enough
    • Treatment: reduce or realign the bone into proper placement. Allows it to heal. closed or open reduction.
    • sometimes the kids will be sedation and then the ortho surgeon will try to realign but if they can;t the child will have to go into surgery]]

    Closed reduction try to manipulate without openning the skin.

    open reduction- cut thru tissue and go right to that bone and realign
  21. What should the nurse do now??
    • Nursing interventions of the with a fracture
    • frequent neurovascular checks
    • teach pt and family about casting procedure
    • s/p cast care
    • provide support to help with anxiety and fear
    • encourage movement distal to injury
    • watch for complication such as shock, encourage movement, family

    assess respiratory status- because of fat embolism
  22. Congenital defect: talipes equinovarus (club foot)
    • definition: ankle-foot deformity, occurs in utero in approximately 1:1000 live births. increase risk for boys.
    • usually unilateral (could be on both). single birth defect or associated with syndromes (multiple defects). in true clubfoot cannot properly align the foot without intervention

    pseudo-talipes deformity: positional, looks turned in but can align foot straight 

    cause: mechanical factors, prenatal exposure to drugs/infections, inherited factor

    when baby is born the nurse should try to align the foot in the right position and if u cant get it there then it is a true club foot
  23. Congenital defect: clubfoot
    • Pathophysiology: abnormal muscles, joints and contractures of soft tissue results in nonfunctional position of the foot and ankle
    • s/sx: foot inverted everted, clublike appearance 
    • diagnostics: deformity obvious at birth. x-ray to confirm 
    • complications: chronic impairment
  24. Congenital defect: clubfoot: therapeutic management nursing intervention
    Therapeutic management: start in newborn period. serial casting and splinting (change cast every 1-3 wks bc babies grow super fast). passive stretching exercise. PT after foot goes into normal position

    • Nursing interventions:
    • physical assessment: look at feet and attempt to straighten midline
    • frequent diaper changes (cause you don't want to get cast wet)
    • serial casting - cast removed after 6 weeks)
    • emotional support
    • if this does not work then they would have to do surgery
  25. Club foot cast care reminders:
    • frequent neurovascular checks
    • monitor skin and toe movement
    • monitor for bleeding if surgery
    • monitor VS if a discolored area appears on the cast, circle it and record the time. continue to monitor closely and notify provider. 
  26. Congenital club foot (educations
    • Patient/parent education:
    • teach parents skin care and how to assess circulation status when casted
    • teach passive stretching exercises several times daily for several months
    • infant may have to sleep in Denis Brown splint or high top shoes for a few months to maintain proper position. 
    • prognosis good
  27. Congenital defects: development hip dysplasia
    definition: improper formation and function of the hip socket. three forms: dysplasoa, subluxation and dislocation of the head of the femur. 1:1000 births incr in girls

    • cause unknown, possibly inherited or interauterine position-breech, joint laxity, maternal hormones
    • Pathophysiology: the acetabulum (hip socket) of the pelvis is flatten or shallow which allows the head of femur to ride ip or dislocate in the socket
  28. dysplasia, sublux, dislocation
    Dyplasia- the hip socket is flat- the head of the femur cant sit

    Sublux- the hip socket is bend but the head of the femur can still move

    dislocation- really flatten totally outside of the hip socket-- not even near each other
  29. Development hip dysplasia s/s complication
    s/s limited hip abduction (way from the body), Galeazzi sign (leg looks shorter), asymmetrical skin folds, hip instability

    Dx: Barlow and Ortolani test, x-ray, sonogram. MRI

    • Complication: 
    • delayed treatment- possible lifelong waling difficulties 
    • back problems
    • degenerative hip changes
    • lordosis, joint malformation, sciatic nerve injury, necrosis of femoral head, soft tissue damage, permanent disability
  30. hip dysplasia therapeutic manage/ nursing intervention
    Therapeutic management: depends on severity, how early dx and age of child. includes Pavlik harness (helps to keep legs open) keep on for 23 hrs a day up to 6 months, spica cast (babies older than 6 months), surgical correction (if that doesnt work up to 18 months then this). 
  31. Hip dysplasia pt education
    • patient/parent 
    • teach how to apply harness correctly
    • avoid double or triple diapering
    • encourage parents to hold their child and to turn frequently, encourage play
    • teach signs of vascular compromise and how to check CSM for signs child is outgrowing cast, and when to call the healthcare provider
  32. Skeletal structure disorder: Scoliosis
    • Scoliosis
    • definition: spinal deformity with a lateral S curve spine > 10 degrees. involves rotation of vertbrae- happens mostly in girls it progresses with growth and when child stops growing it becomes more stable
    • around 5th grade school assess for this
    • classification: nonstructural (poor posture, pain, leg length discrepancies, appendicitis) or structural (could be caused by polo, muscle dystrophy, CP, tumors, infection)

    • Incidence: > 8 yrs with peak in puberty, incr in adolescent girls espcially with positive FH.
    • incidence 
  33. Scoliosis assessment
    • inspect back by having child bend over
    • all adolescent should be assessed- early detection is essential and is best for management
    • dx spine x-ray for further eval. if positive xray refer to ortho 
  34. Scoliosis complication
    • complication: worsen with severity of the curve
    • - lung capacity and restrictive lung disease
    • - tachyapnea and hypoxia, pain, arthritic change in spine
    • - shorten lifespan if the curve > 60 degrees
    • - neurological sequelae and paralysis or infection as complication due to corrective surgery
  35. Scoliosis thera. management
    • goal- maintain spinal stability and prevent progression of curve
    • < 20 degrees: close observation until age 18
    • > 20 degrees: non surgical body brace or traction, surgery or combination of both
    • > 40 degrees: surgery with spinal fusion
  36. Scoliosis Brace
    • child needs to wear TSLO brace 23 hr a day
    • < 40 degrees 
  37. Neuromuscular disorder: Cerebral Palsy
    • def: group of non specific symptoms caused by abnormal brain function. lifelong, most common of physical disability of children
    •   incidence 2.5:1000 live births, higher in premature and twins

    cause: damage to one or more specific areas of the brain. most causes occur before or during delivery and are associated with anoxia or oxygen deprivation to the brain. often no specific cause
  38. CP Classification 4 types
    • spastic and athetoid : 75% cases 
    • ataxic and mixed- 25 %

    • Spastic: 40% of cases, child will have excessive tone in voluntary muscles. spasms often occur with movement. invovles damage to the brain cortex
    • s/s:
    • hypertonic muscles
    • abnormal clonus- push on extremity then it will shake
    • incr DTR 3/4+ 
    • abnormal reflexes
    • neonatal reflexes will persist ie tonic neck and babinski well after 2 yrs
    • hemiplegia anf quadplegia 
  39. CP Athetoid 
    • about 20%
    • s/s athetosis or wormlike slow writhing movements in all extremities. movements are involuntary purposeless and interfere with normal motion (slow movement) 
    • may see drooling, facial grimace poor swallow
    • involves damage to the basal nuclei ganglion
    • asso with hyperbilrubiemia and kernicterus
  40. CP other s/s
    • unsteady wide gait appears as child begins to walk
    • appears clumsy
    • delated gross motor development eat, drinking, difficult to suck and swallow
    • spascity of hip muscles and lower extremities makes diapering difficult
    • posture abnormalities at rest
    • mental retardation, seizures, sensory deficits
  41. CP complications
    • convulsions, seizure
    • deficits in speech, sight and hearing
    • mental impairments
    • growth problems
    • abnormal sensation or perception
    • hydrocephalus 
    • decr quality of life
  42. CP assessment
    Suspect a baby may have CP when the child isnt feeding right. when develop

    • muscle weakness or convulsions
    • Nx Dx impaired physical mobility, compromised family coping, delayed growth and development
  43. CP medication
    • bacolfen pump
    • muscle relaxants
    • anticonvulsants
    • ortho surgery
    • braces/splints
  44. CP goals nursing care treatment
    • Goals
    • assist them in making the most of the assets
    • guide them to be well adjusted adults
    • meet their maximum potential
    • High calorie diet
    • ROM excercise
    • assist with communication, movement, and education
    • realistic short and long term goals
    • parental support

    to prevent contractures- ROM excer, hand rolls, high top shoes, leg brace
  45. Neuromuscular disorder (muscular dystrophies)
    def: inherited condition, results in progressive muscle weakness and wasting 

    • 3 types
    • congenital myotonic dystrophy
    • fasioscapulohumeral muscular dystrophy
    • pseudohypertrophic muscular dystrophy (duchenne which is the focus)
  46. Duchenne's muscular dystrophy
    • inherited from mom to her boys
    • Assessment: 
    • begin to show signs of muscle weakness around age 3
    • s/s waddling gait, difficulty climbing stairs, rise up off the floor by rolling onto stomach and then pushes themselves to their knees
    • to stand the child will press their hands against their ankles and their knees and then thighs as they walk up their front (Gower sign)
    • toe walking, scoliosis, fractures of long bones tachycardia, enlarged heart, pneumonia, death from heart failure around the age of 20- heart and respiratory failure
  47. Duchenne's muscular dys. (dx)
    • based on history and physical
    • muscle biopsy- fibrous degeneration and fat deposits
    • EMG- show decreased muscular activity
    • Labs: incr serum creatine phosphokinase CK- enzme found in cardiac and skeltoal muscle and brain
  48. Duchennes Nursing mana
    • encourage to remain ambulatory as much as possible
    • active and passive ROM every day
    • splinting or braces extremities to prevent contractures
    • high fiber, incr fluids, low calories, high protein diet to avoid constipation and obesity
    • provide emotional support and education to assist with coping
    • muscular dystrophy association