Pediatric Nursing Care Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey...

Pediatric Nursing Care

Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Pediatric Nursing CareEllise Adams and Mary Ann Towle

Chapter 20Care of the Child with Musculoskeletal Disorders




Anatomy and Physiology of the Muscles

Muscles– 3 Types of body muscles– Skeletal muscles are striated

Assists in movement, maintains posture

Tendons– Attach bones to muscles




Anatomy and Physiology of the Skeleton

Skeleton– Ossification almost complete at birth– 3 sections of bone– Epiphyseal plate (growth plates)– Hematopoiesis




A and P of the BoneDiagram




Postural Changes with Growth

Cervical and lumbar areas become concave Bowed legs (genu varum) in infant Knock knees (genu valgum) in preschool child Resolve with growth




Postural Changes




Assessment of the Musculoskeletal System History

History– Review history of birth in infants– Obtain information about injuries in children– Inquire about deformities– Determine activity level, developmental delays




Assessment of the Musculoskeletal System History

Inspect posture and gait Note symmetry of shoulders, hips, an any

unusual curvature of spine Assess for full ROM of joints Assess muscle strength




Congenital Skeletal Defects

Range from minor and easy to correct to major malformations requiring long-term therapy

Rarely life threatening Two common defects

– Developmental dysplasia of the hip– Clubfoot




Developmental Dysplasia of the Hip

Developmental hip abnormality Involves femoral head, acetabulum, or both




Developmental Dysplasia of Hip Manifestations

Partial or complete dislocation of hip joint Shortening of femur Uneven thigh and gluteal folds Limited abduction on the affected side




Developmental Dysplasia of Hip Diagnosis

Physical examination of hip– Allis sign

Flex knees and hips with heels close to buttocks and feet flat on exam table

Dislocation of hip demonstrated by lower position of knee on affected side

– Ortolani-Barlow maneuver See figure




Ortolani-Barlow Maneuver




Developmental Dysplasia of Hip Treatment

Medical Management– Small abnormality – apply three diapers– Apply Pavlik harness for 3 – 4 months– Place in skin traction for older children– Perform surgery followed by hip spica cast




Developmental Dysplasia of Hip




Developmental Dysplasia of Hip Nursing Care

Maintain traction Provide cast care Assess lung sounds, neurovascular symptoms,

skin Reposition with cast every 2 hours Encourage diet high in fiber, adequate fluids




Talipes

Talipes or Clubfoot– Congenital twisting of the foot– Unilateral or bilateral– Usually inward twisting




Talipes Manifestations

Manifestations– Equines or midfoot directed downward– Varus or hindfoot turns inward– Forefoot curls toward heel and upward– Smaller foot, shortened Achilles tendon– Atrophies muscles of lower leg




TalipesDiagnosis and Treatment

Diagnosis– Observation of symptoms– X-ray

Treatment– Apply cast to correct foot position– Change cast every 1-2 weeks for 3 months– Perform surgical correction if casting fails




TalipesNursing Considerations

Nursing interventions– Assist with cast application– Teach parents cast care– Administer pain medications– Observe for drainage and bleeding




Musculoskeletal Disorders

Most common disorders affecting older child Partially due to changes in bone structure

during rapid growth or accidents Common disorders

– Muscular dystrophy– Legg-Calve-Perthes Disease– Scoliosis– Juvenile rheumatoid arthritis




Scoliosis

Lateral S-or-C shaped curve of spine Rotation of spine and ribs Right-sided thoracic curve Left-sided lumbar curve More common in girls




ScoliosisManifestations

Manifestations– Shoulders and hips

different heights– Rotation of vertebrae

and ribs– One-sided rib hump,

prominent scapula– Asymmetrical

posterior chest




ScoliosisDiagnosis

Diagnosis– Moiré photography – Spinal x-ray




ScoliosisTreatment

Treatment– Mild scoliosis

Exercise, chiropractic adjustments

– Moderate scoliosis Boston or Milwaukee brace

– Severe scoliosis Surgery with rods, wires, halo brace




Other Spinal Curvatures

Kyphosis– Excessive convex curvature of thoracic spine or

hunchback Lordosis

– Excessive concave curvature of lumbar spine, or sway back

Torticollis– Tilt of head caused by rotation of cervical spine or

wry neck




RICE

R - Rest I - Ice C - Compression E - Elevation




Musculoskeletal TraumaFracture

Altered continuity of bone Common occurrence in childhood




FracturesManifestations & Diagnosis

Manifestations– Pain, abnormal positioning, edema– Discoloration, abnormal movement– Broken skin, bleeding

Diagnosis– X-rays of injured area




Fractures Treatment

Treatment– Realign by closed reduction– Realign by open reduction– Apply traction– Immobilize with external fixators or immobilizers– Apply plastic or plaster cast




Fractures Nursing Considerations

Assess neurovascular status using the 5Ps– Paresthesias, pain/pressure, pallor, paralysis,

pulselessness

Prevent skin breakdown Maintain proper alignment Traction weights hang freely Administer pin care




Compartment Syndrome

Occurs when increased pressure in limited space compromises circulation and nerve innervation

May lead to necrosis Symptoms

– Paresthesia, pain/pressure, pallor, paralysis, pulselessness

– Deep pain unrelieved by analgesia– Edema




Compartment SyndromeNursing Care

Report immediately Requires removal or alteration of cast




Fractures Nursing Considerations

Assess for compartment syndrome Administer pain medication Teach cast care, orthopedic appliances Teach proper crutch walking Teach to recognize complications, signs of

abuse




Bucks Traction




Bryant Traction




Skeletal Traction 90/90




Russels Traction




External Fixator




Clavical Strap




Cast Care




Spica Cast




Musculoskeletal InfectionOsteomyelitis

Infection of bone May spread to surrounding tissue Caused by bacteria, virus, fungi Follows injury or surgery




OsteomyelitisManifestations

Constant pain in affected area Edema Decreased mobility of joint Refusal to use limb, limp Redness at site of injury, fever




Osteomyelitis Diagnosis

History of trauma Increased white blood cell count Increased erythrocyte sedimentation rate X-rays, bone scans Needle aspiration of fluid for culture




Osteomyelitis Treatment

Hospitalization Administer intravenous medication




OsteomyelitisNursing Considerations

Administer antibiotics Arrange for home health nurse

– Administer antibiotics– Care of intravenous site




Stump Care




Nursing CarePriorities

Promote independence of the child Promote mobility as allowed Maintain safety Explain resources for support and proper home

care




Nursing CareAssessing

Monitor cardiac, respiratory, urinary, and bowel function

Assess ROM, mobility, posture, and muscle strength

Note swelling, redness With assistive devices assess correct use and

effectiveness For chronic disorders assess family’s ability to

provide care




Nursing Diagnoses

Impaired physical mobility related to musculoskeletal impairment

Activity intolerance related to weakness Risk for injury related to altered mobility Compromised coping: family related to caring

for a child with a chronic condition




Outcomes

Mobility will be restored through the use of assistive devices

Tolerance for activity will be demonstrated as evidenced by vital signs within normal limits

Family will create a safe environment Family will effectively participate in developing

a plan of care




Nursing CareInterventions

Teach use of assistive devices Provide positive encouragement before,

during, and after use of device Assist the family in planning daily activities to

include rest Keep frequently used objects within easy reach




Nursing CareInterventions

Assist parents in assessing home environment for hazards

Provide information about correcting identified hazards

Discuss common responses to caring for a child with a musculoskeletal disorder

Provide family with specific information on home care




Nursing CareEvaluating

Evaluate for– Mobility– Tolerance for activity– Safety– Family coping

Pediatric Nursing Care Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey...

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