1102 Test 2 Child With Musculoskeletal Dysfunction

Front 1

Fractures

Back 1

Break in the bone
S&S: pain, abnormal positioning, edema, immobility or decreased ROM, ecchymosis, guarding, crepitus

DX: x-ray

TX: immobilization
Internal reduction: pins, screws, wires

External reduction: casts, traction, splinting

Front 2

Bone Healing

Back 2

Inflammation
Cellular Proliferation
Callus Formation
Ossification
Remodeling
Healing starts at

Hematoma at fracture site. Can take up to several months to year for remodeling kids are better than adults.

Front 3

Types of fractures:

Back 3

1796

Front 4

Epiphyseal injuries:

Back 4

weakest point of long bones

Special problems in determining whether or not bone growth will be affected
Early and correct assessment is essential
Severe break in Ephysis can change stature. (Knees elbows and shoulders)

CREG-closed reduction external fixation-Immobilize-cast

Reduce-open reduction internal fixation-pins screws

Front 5

Greenstick

Back 5

bend on one side and break on the other. (most common) incomplete break

Front 6

Transverse-

Back 6

straight across break

Front 7

Comminuted-

Back 7

break and fragments (to fix gather fragments of bone external fixator)

Front 8

Spiral break-

Back 8

twist and break (common in child abuse)

Front 9

Casts

Back 9

Plaster of paris or synthetic material

Before Casting: observe for injuries or constrictive items
After Plaster of Paris: turn q2hr; elevate part; uncover; support on pillow; handle only with palm of hand; NVs checks q2hr (5Ps: pain, pallor, pulselessness. Paresthesias, paralysis); hot spots; teach

Plaster of Paris-comes in rolls of plaster. Dump in water let it get thru roll pick it up squeeze apply to patient. Physicians job to apply to patient. As casts is being applied it gets hot for patient. First apply stockenett, put it on length of bone.24-48 hours for plaster to dry. While drying called green cast. Be sure entire cast drys turning patient every 2 hours leaving part exposed to air. Insert Pillows so green cast is not touching end of bed or any other surface. Work with palms of hands instead of fingers.
Teach patient-plaster can’t get wet. Synthetic-shower every other day. Tightness-fingers width patient stands up blood rushes to heart. Nothing goes down the cast!! Cast material smells. Teach crutch walking.
Feel cast for warmth-hot spot cut a window in cast to see severity for skin integrity.
If extremities look white-serious blue-venous extremities. Should be able to get pulse.
Synthetic-run water thru material physician forms to patient takes 20 minutes to dry. Lighter than plaster of paris, drys quickly.
Whether plaster or synthetic-When applying cast documenting part and documenting whats left in the wound.

Front 10

Casts

discharge planning

Back 10

Teach parents how to dry the cast, check for tightness, DO NOT allow anything to be put in the cast, use of crutches appropriately, administer analgesics and muscle relaxants, observe for infection

Hot spots-signs of infections
Plaster Paris-crumble wet more than once. Teach children not to remove stockenet. Explain to mom smells put lemon juice on it until smell wears off.
Muscle atrophy –isometric exercises.
White toes-elevate above heart then call doc
Blue-color caused by vaso constriction on top vaso dilation on bottom.

Front 11

Traction

Back 11

To reduce or realign a fracture site
Purposes: realign body fragments, provide rest for an extremity, help prevent or improve contractures or deformities; treat dislocation; allow pre-op or post-op positioning and alignment; provide immobilization; and reduce muscle spasms

Traction-reduce muscle spasms.

Front 12

Skin traction –

Bucks:

Russell's traction:

Back 12

Buck’s traction, Russell’s traction, weights pull one direction and the body pulls another

Buck’s traction-lower extremity. Used as preoperative stabilation IE-fractured femur use bucks for muscle spasm to weaken can wait til next day.

Russell’s-upper extremity traction. Weight hangs off elbow.


Skin-traction applied to skin.

Front 13

Skeletal traction:

Back 13

significant pulls in two directions. Insertion of pins or wire, Balanced Suspension Traction

Balanced suspension Traction-Skeletal traction requires more weight weight on pin site and weight on counter traction site. Leg is suspended and slightly flexed, relax hip and hamstring in sling, weights pull in both direction.
Weights must hang freely, NEVER adjust with Dr order, assess for tightness, exudate, weakness and contracture
Bryant’s traction-no congenital heart defects.
Skin Integrity-tilt them q2 hours, head of bed cannot be raised to full sitting position. 40-45 degrees cannot do 90 degrees.
Tissue Perfusion-
Risk for Injury-high top tennis shoes, boot, ROM q 2 hours. Active ROM No powder or corn starch.
Risk for Elimination-
External Fixator

Front 14

Bryant’s traction-

Back 14

no congenital heart defects

Front 15

Osteomyelitis

What meds:

What organisms:

Back 15

Infection of the bone
Usually staph aureus or hemophilus influenza
S&S: pain and tenderness with swelling in the affected area, decreased mobility of the affected joint, fever, and guarding or unwillingness to move
Findings: +blood culture, leukocytosis, elevated ESR and C-reactive protein

Culture and sensitivities-culture exudate from area from bone 24 hours preliminary report with set of sensitivities.

Vancomycin IV route

Blood work-make sure monocytes are working. When xraying extremity looks like moths have been eating away.

Front 16

Osteomyelitis

Nursing Management:

Pain Management:

Back 16

Nursing Management: Alteration in comfort
Assess the site for pain with movement
Use age-appropriate pain scales
Assess V/S
Administer appropriate antibiotics
Immobilize limb
Apply warm compresses to the affected area
Provide age appropriate diversional activities

Complete bed rest, possible IND
Give diladed, morphiene, phentynol,
Age appropriate diversion-vital signs q4 hours, then q2 hours, elevate extremity, apply warm compresses, don’t apply cold want to promote blood flow, use heat.
Contact Isolation
Diet=High Protein, high fiber, high vitamin

Front 17

Osteomyalitis:

NANDAs:

Back 17

Risk for injury
Hyperthermia
Impaired physical mobility
Parental health seeking behaviors
Diversional activity deficit

Front 18

Polydactyl-

Back 18

many digits

Front 19

Syndactyl –

Back 19

digits fused

Front 20

Clubfoot

Back 20

Foot is twisted out of its normal shape or position. Talipes

Front 21

Talipes Varus –

Back 21

an inversion or a bending inward

Front 22

Talipes Valgus –

Back 22

An eversion or bending outward

Front 23

Talipes Equinus –

Back 23

plantar flexion in which the toes are lower than the heel

Front 24

Talipes Calcaneous –

Back 24

dorsiflexion, in which the toes are higher than the heel

Front 25

Talipes Equinovarus –

Back 25

foot in pointed downward and inward in varying degrees

TX: correction of the deformity; maintenance of the correction until normal muscle balance is regained; F/U; observation of avert recurrence

Overcorrection because when cast is removed will revert hopefully to correct position.

Manipulation and the successive application of a series of casts until marked overcorrection occurs
Teach parents: overall treatment plan; importance of regular cast changes; and role they plan in long-term effectiveness

Cast is changed every week 1-2 weeks lasts 6 to 12 weeks. Parents need to be taught to keep Dr. Appointments and casts are changed.,how to take care of cast. Do not put anything in cast.

Front 26

Developmental Dysplasia of the Hip

Congenital Hip Dysplasia (CHD)

Back 26

Signs: asymmetry of gluteal and thigh fold, limited hip abduction, apparent shortening of the femur, positive Ortolani click, significant limp
TX: Pavlik harness – 3 months or <, skin traction > 3 months; surgery and casting – >18 mons

Congenital Hip Dysplasia-ball and socket of hip are not formed correctly.
Take patients knees up to belly wishbone the patient. Ortolani click is positive identification.
P 1124 Peds book Pavlick harness.
Child does need to be on normal developmental track.

positive Ortolani click

Congenital Hip Dysplasia-ball and socket of hip are not formed correctly.
Take patients knees up to belly wishbone the patient. Ortolani click is positive identification.
P 1124 Peds book Pavlick harness.
Child does need to be on normal developmental track.

Impaired physical mobility
High risk for alteration in skin integrity
Altered family processes
Knowledge Deficit
Parents should be taught maintenance of device and adaptation of nurturing activities
No powders or lotions; wear long stockings or shirts, age-appropriate toys and play

Front 27

Legg-Calve-Perthes Disease

Back 27

Avascular necrosis of the proximal femoral head. Etiology: painful inflammation (prenecrosis), avascular necrosis, revascularization, bone healing and then remodeling.
S&S: mild pain, limited ROM, limp,weakness, muscle wasting and spasms
DX: MRI
TX: rest, active motion, braces
Emphasis: compliance with care

5 times more likely in boys.
Caucasion-10 times more likely than African Americans.
Occurs in children-4 to middle school age.
Somehow the head revascularizes take 3-4 years to happen.

Front 28

Toronto Brace-

Back 28

2-4 years abducted. By 5th year will not correct itself lets do hip replacement.

Front 29

Slipped Femoral Capital Epiphysis

Back 29

Spontaneous displacement of the proximal femoral epiphysis
S&S: limp, pain, loss of hip motion
TX: surgical, simple pin fixation
Needs simple pin to stabilize.

Front 30

Scoliosis

Back 30

Spinal deformity, a lateral curvature of the spine usually associated with a rotary deformity
S&S: truncal asymmetry, uneven shoulders and hips, a one-sided rib hump, a prominent scapula
DX: observation, x-ray, MRI, CT, Bone Scan
TX: Early detection and treatment are essential to successful management.

Adolescent girls are primary patients.

#1 NANDA-body image disturbance-patients problem

Front 31

Treatment of Scoliosis

Back 31

< 20 degrees: exercises flexibility & strength

20-40 degrees: Milwaukee, Boston, halo brace, surgery or a combination. Milwaukee or Boston brace is worn 23 hours a day/ 7 days a week. Maybe TENS unit

> 40 degrees: surgery, spinal fusion

Front 32

Postsurgical:

Back 32

Promote adequate pulmonary functioning
Maintain alignment
Log roll q2hr
NV checks q2 X 24 hours, then q4h
Passive ROM
Participate in ADLs
Up in chair on 2 or 4 days

Front 33

Juvenile Rheumatoid Arthritis (JRA)

Back 33

Relapsing/remitting autoimmune disorder
Affects girls more than boys
Presents at 2-5 years old or 9-12 years old
5-18 cases/100,000/year
Cause is unknown

Adolescent-symptoms subside. Later down road may have rheumatoid again. Deformaties remain.

Primarily affects joints, but can also affect heart, lungs, liver, eyes
Inflammation begins in the joints and results in pain, swelling that leads to scar tissue and decreased joint mobility

Pauciarticular: large joints (knees, elbows, ankles)
Systemic: fever, multiple joints, rash
Polyarticular: many (small) joints

Front 34

JRA

Presenting Symptoms:

Back 34

Presenting Symptoms:
Localized: joint pain, selling, stiffness (limps)
Systemic: fever, rash, lymphadenopathy, HSM-(perpatic)
Diagnosis: Arthritis (<16 y/o) which persists for >6 wks
Labs: RF, HLA-B27(?ask fawn), +ANA, elevated ESR
Treatment: NSAIDS/steriods, ASA, sulfasalazine, methotrexate; PT, surgery

People test only 25% will not have RHEUMatoid but test positive. Usually begin at child bearing age more often in women than men. Usually with 1st child persists after that.
2-4 weeks of nonsteroidal therapy
Then chemotherapy
Then water exercises-ROM

Front 35

JRA

Nursing Priorities:

Nursing Actions

Back 35

(Chronic) Pain r/t joint inflammation
Activity Intolerance, Impaired Physical Mobility
Anxiety, Disturbed Body Image

Manage pain (Medications, warm compresses)
Promote mobility (ROM, stretch, refer to PT)
Adequate Nutrition (calorie contol, nutritional)
Psychosocial support (American JRA Foundation

Methotrexate 25 mg IM twice a week.
Cytoxan 2 x week
Side effects: blisters, nausea, anus blisters,

If pain persists:
Disease modifying agents: Enbrel, Humira, Remicade, Oriencia (TNF class drugs) blisters GI tract, anus,

1st thing of the day-ROM exercises-Rotating extending flexing
Liguids on a regular basis, bathroom breaks.
Corticosteroids-mask symptoms. Short term low dose is ok. Longterm can cause diabetes.

Front 36

Muscular Dystrophy

Back 36

Pseodohypertrophic (Duchanne’s MD)
Bilateral muscle wasting and hypertrophy of muscles, replaces muscle tissue with fatty deposits and connective tissue
S&S: progressive muscle weakness, wasting and contractures. Waddling gait and scoliosis
Labs: Increased CPK, decreased Electrical activity, muscle biopsy

Front 37

CPK(Creatine phosphokinase)-

Back 37

only looking at muscle tissue.

TX: medications, physical therapy, and surgery
Perform good respiratory assessments
Low-calorie, high-protein, fiber diet with increased fluids
Refer to Muscular Dystrophy Association

NO good medications available.
Ones that are good are very expensive.
Good respiratory function. Mucolytics, broncho dilators are used. Send to muscular Distrophy foundation for assistance.

Front 38

Systemic Lupus Erythematosus (SLE)

Back 38

Autoimmune disorder
Chronic, multisystem disorder characterized by inflammation of connective tissue
S&S: Malar butterfly rash, photosensitive, oral and nasal ulcers, arthritis, pericarditis, nephritis, HA, personality changes, seizures, psychosis, leukopenia, lymphoma, thrombocytopenic, +ANA

DX: +ANA, complement, increased BUN, ESR, etc.
TX: Systemic corticosteroids, NSAIDS, supportive

Treat all symptoms support them that way NSAIDS.
Begins with child bearing ages, steady state patient complience to stay with steady state.