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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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Anatomy and Physiology of the Skeleton
Skeleton– Ossification almost complete at birth– 3 sections of bone– Epiphyseal plate (growth plates)– Hematopoiesis
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
A and P of the BoneDiagram
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Postural Changes
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of the Hip
Developmental hip abnormality Involves femoral head, acetabulum, or both
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Ortolani-Barlow Maneuver
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Talipes
Talipes or Clubfoot– Congenital twisting of the foot– Unilateral or bilateral– Usually inward twisting
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
TalipesNursing Considerations
Nursing interventions– Assist with cast application– Teach parents cast care– Administer pain medications– Observe for drainage and bleeding
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
ScoliosisManifestations
Manifestations– Shoulders and hips
different heights– Rotation of vertebrae
and ribs– One-sided rib hump,
prominent scapula– Asymmetrical
posterior chest
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
ScoliosisDiagnosis
Diagnosis– Moiré photography – Spinal x-ray
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
ScoliosisTreatment
Treatment– Mild scoliosis
Exercise, chiropractic adjustments
– Moderate scoliosis Boston or Milwaukee brace
– Severe scoliosis Surgery with rods, wires, halo brace
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
RICE
R - Rest I - Ice C - Compression E - Elevation
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Musculoskeletal TraumaFracture
Altered continuity of bone Common occurrence in childhood
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
FracturesManifestations & Diagnosis
Manifestations– Pain, abnormal positioning, edema– Discoloration, abnormal movement– Broken skin, bleeding
Diagnosis– X-rays of injured area
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Fractures Treatment
Treatment– Realign by closed reduction– Realign by open reduction– Apply traction– Immobilize with external fixators or immobilizers– Apply plastic or plaster cast
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Compartment SyndromeNursing Care
Report immediately Requires removal or alteration of cast
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Bucks Traction
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Bryant Traction
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Skeletal Traction 90/90
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Russels Traction
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
External Fixator
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Clavical Strap
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Cast Care
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Spica Cast
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Musculoskeletal InfectionOsteomyelitis
Infection of bone May spread to surrounding tissue Caused by bacteria, virus, fungi Follows injury or surgery
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
OsteomyelitisManifestations
Constant pain in affected area Edema Decreased mobility of joint Refusal to use limb, limp Redness at site of injury, fever
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis Diagnosis
History of trauma Increased white blood cell count Increased erythrocyte sedimentation rate X-rays, bone scans Needle aspiration of fluid for culture
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis Treatment
Hospitalization Administer intravenous medication
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
OsteomyelitisNursing Considerations
Administer antibiotics Arrange for home health nurse
– Administer antibiotics– Care of intravenous site
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Stump Care
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing CarePriorities
Promote independence of the child Promote mobility as allowed Maintain safety Explain resources for support and proper home
care
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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
Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing CareEvaluating
Evaluate for– Mobility– Tolerance for activity– Safety– Family coping