Immobilized Child: Health Promotion

• Health promotion, restoration, and maintenance of the family for the care of a child with altered mobility

The Immobilized Child

• Immobilization for children has serious consequences of physical and psychological nature

Physical Effects of Immobilization

• Muscular system: Decreased muscle strength leads to decreased venous return and cardiac output
• Skeletal system: Bone demineralization leads to renal calculi
• Metabolism: Decreased metabolic rate results in the slowing of all systems
• Cardiovascular system: Venous stasis can lead to pulmonary emboli or thrombi
• Respiratory system: Decreased chest expansion results in diminished O₂ intake
• Gastrointestinal system: Difficulty with feeding due to positioning can result in anorexia and constipation
• Urinary system: Impaired ureteral peristalsis leads to urinary retention
• Integumentary system: Altered tissue integrity results in decreased circulation and increased pressure to bony prominences, potentially leading to tissue injury

Psychological Effects of Immobilization

• Immobilization can result in feelings of isolation and boredom
• Immobilization may also cause feelings of helplessness and depression related to changes in body image
• Children may respond to immobilization with anger or aggressive behavior, or become quiet, passive, and submissive
• Children may also revert to earlier developmental behaviors like wanting to be fed, bed-wetting, or using baby talk
• Children may view immobilization as justified punishment for misbehavior

Neural Tube Defects

• These account for the majority of congenital anomalies of the CNS
• Closure of the neural tubes happens between the 3rd and 4th week of gestation
• The cause is unknown; multiple factors include drugs, radiation, malnutrition, chemicals, genetics and previous neural tube defect pregnancy
• Prenatal screening involves maternal serum AFP level, ultra sound, and chorionic villus sample
• These Primarily affect the spinal cord development,
• Examples: Spina bifida occulta, meningocele, and myelomeningocele

Classifications of Spina Bifida

• Spina Bifida has two classifications: Occulta and Cystica

Spina Bifida Occulta

• Most often has no observable manifestations
• Common location: L5-S1
• Most cases have no neuromuscular compromise.
• It can be associated with one or more cutaneous manifestations: Tufts of hair, dimple, or port-wine angiomatous nevi
• An MRI can detect these findings
• Surgical intervention is rarely needed

Spina Bifida Cystica: Meningocele

• It is a less serious form
• It occurs in the lumbar region
• Has a visible external sac with meninges protruding
• Is usually not associated with neurologic deficits
• Can be corrected through Surgery
• Requires CT, MRI & US prior to surgery

Spina Bifida Cystica: Myelomeningocele

• It is the most severe form
• Contains meninges, spinal fluid & nerves
• Increases the risk for meningitis, hypoxia & hemorrhage
• Is associated with neurologic deficits: Neurogenic bladder & bowel, paralysis, ortho deformities
• Hydrocephalus is a frequently associated anomaly in 80-90% of the children

Therapeutic Management of Spina Bifida

• Surgical intervention is needed
• Can be repaired prenatally
• Shunt may be needed to treat hydrocephalus
• Multi surgical repairs may be needed throughout life
• Prevent infection especially with ruptured sac
• Antibiotic therapy is needed
• Orthopedic considerations are important
• Manage GU/GI function
• Catheterization & bowel regime is needed
• Be aware of Latex allergy precautions
• Determine Prognosis
• Act on Prevention

Nursing Considerations: Pre-Op and Post-Op Care of the Sac

• Care of the Sac: Pre-op -Use an incubator or warmer to maintain temperature without clothes -Apply a sterile moist dressing over the sac -Prevent stool contamination -Assess for signs of infection -Put the patient in a Prone position before surgery
• Prevent complications: Post-op: -Avoid pressure on the operative site -Assess pressure areas for skin breakdown -Perform ROM to prevent contractures -Turn head to one side for feeding, can be held post-op for feeds
• Post op care requirements: Same as any post op patient, assess for cerebral spinal fluid (CSF) leakage
• Support and educate family on positioning, feeding, skin care & ROM exercises

Latex Allergy

• There is a high risk for latex allergy due to repeated procedures using latex products
• Most hospitals are now latex free
• The goal is to identify children with a hypersensitivity to latex
• A Latex-free environment is the gold standard

Pectus Excavatum & Carinatum

• Anterior chest wall deformities are referred to as Pectus Excavatum & Carinatum.
• Pectus Excavatum: -Chests sink inward at the xiphoid process -Progresses during puberty -Compression of the heart and lungs can occur, causing SOB, exercise intolerance, and chest pain -Elective surgical repair can improve body image
• Carinatum: A protuberance of the chest wall is referred to as Pectus Carinatum

Pectus Excavatum: Therapeutic Management

• Diagnosis of Pectus Excavatum is done through Xray, CT, & MRI
• Therapeutic Management: Serial assessments, PT, and Surgery Steel bar is used with Surgery to Use a rib bone to lift the depression

Postoperative Care of Pectus Excavatum

• Monitor Respiratory functionality by checking Lung sounds, cardiorespiratory monitoring, pulse ox, assess for pneumothorax, incentive spirometer
• Check for Wound infection: VS, assess site, small dressing or steri strips
• Protect position of the surgical bar following these directions: - Do not leg roll, lie on either side or prone, rotate or flex spine -Bedrest for a short time -Can do OOB with PT
• Manage Pain with these techniques: IV, epidural, PCA

Metatarsus Adductus

• The most common foot deformity with medial deviation
• Caused by in utero positioning
• 50% of cases are bilateral
• The degree of flexibility determines treatment, including Observation, Stretching exercises, Serial casting preferably < 8 months of age, if not Surgery is needed.

Congenital Clubfoot- Etiology

• Also known as, congenital talipes equinovarus
• Related to abnormal position in utero
• Chromosomal abnormalities, cerebral palsy, spina bifida or idiopathic can cause this
• 50% are bilateral
• Diagnosis is possible by Prenatal ultra sound or at birth

Congenital Clubfoot

• This is also known as, congenital talipes equinovarus
• Therapeutic Management: Corrective shoes or bracing, Serial casting begun shortly after birth, Cast change Q 2 weeks
• Surgery if failure to align with above measures , Cast x 12 weeks, Ankle-foot orthoses (AFO's) or corrective shoes for several years.
• Same Nursing Consideration as is provided to the child that has a cast

Osteogenesis Imperfect

• Has a genetic collagen type 1 gene defect
• Has low bone mass, fragile bones (fractures) & connective tissue disorders (joint hypermobility, instability of joints)
• can cause Moderate to severe connective tissue and bone involvement
• Symptoms seen in this condition are: Multiple fractures, Short stature, Hearing loss, Pain, Scoliosis, Respiratory difficulties, Blue sclera.
• Diagnostics for it include the following: Skin biopsy, DNA testing, Frequent fractures or screaming, Sclera color (not dx)
• Therapeutic Management consists of these: pamidronate (Aredia), PT, OT, Bracing, splints, Surgery
• These are the following Nursing Considerations to Prevent Injury (22.4): Gentle care, Educate parents to avoid trauma (Participatory guidance, Do not lift child from under the arms, Do not lift legs by ankles to change a diaper), and Provide Referrals to support groups

Developmental Dysplasia of the Hip (DDH)

• Formerly called congenital hip dysplasia or congenital dislocation of the hip
• An Abnormality with the developing hip
• This defect can occur during fetal life, infancy, and childhood
• Incidence of DDH : 1.5 per1000 live births, 15% to 50% are born breech, 80% are female, can be caused by A positive family hx in ~ 12% to 33% affected
• The Complications of DDH are: avascular necrosis of the femoral head, loss of ROM, unstable hip, femoral nerve palsy, unequal leg length & early osteoarthritis
• Assessment techniques for diagnosis: -- Asymmetry of thigh & gluteal fold, Barlow test: feel or hear a clunk with adduction of hip, Ortolani sign: feel or hear a clunk with abduction of hip. Unequal knee height related to femur shortening
• Positive trendelenburg sign: pelvis/hip drops with raised leg. -- In older children, an Affected leg is shorter than the other,, When standing on one foot bearing weight on affected hip the pelvis/hip tilts down when the leg is raised, Waddling gait with bilateral dislocations may be observed

Therapeutic Management of Developmental Dysplasia of the Hip (DDH)

• Importance of early intervention leads less invasive procedures
• Newborn to age 6 months treatment: Pavlik harness for maintaining hip flexion & abduction
• Age 4-24 months treatment: closed reduction, Spica cast immobilization for ~ 12 weeks
• Children older than 2 years: open reduction with cast if failed to respond to prior treatment.

Nursing Assessment for a patient with Development Dysplasia of the hip (DDH)

• The Main concern post cast application is neurovascular compromise: This is an emergency = report to MD
  • Symptoms include Severe pain unrelieved after medication, C: pale skin, cool extremity, capillary refill > 2 sec, absent distal pulse, S: tingling digits, absent sensation, M: decrease movement
• Signs of infection: Hot spots on the cast surface, Fever
• Spica cast care includes the following: ROM to joints above & below cast, and Casts have a Gore-Tex lining for waterproofing
• Safety Considerations like; Children should not play with anything small enough to stuff inside cast, and Special passenger car seat & restraints

Torticolis

• Tightening of the sternocleidomastoid muscle caused either by:
  • Congenital issues like Utero position or difficult birth
  • Acquired issues like Head positioned to one side or Plagiocephaly,
• Managment techniques exist to help reduce the impact of this illness: Passive stretching of muscle, PT, Torticollis collar, Surgery uncommon, Early treatment = better outcome
• medication can be given like, Baclofen and injection of botulinum toxin (Botox) to provide temporary relief by decreasing muscle spasticity.

Muscular Dystrophy

• Progressive weakness & wasting of muscles
• Typically: Begins in patients of Onset 1 - 5 years old and is Genetic: primarily males
• Causes are: History of motor development delay, Clumsiness, Frequent falls, Difficulty climbing stairs, Wadlling gait
• Typically Ambulation is frequently impossible after 12 years old
• Breathing muscles become more affected, life-threatening infections are common: this ussualy leads to death by age 15-18 years. Nursing Considerations: -- Fatigue -- Diet -- Mobility -- Psychological Effects
• Diagnostics for Muscular Dystrophy Include: DNA testing reveals the gene and is seen to occur in an X-linked recessive fashion -- Suspected dx. based on clinical appearance -- History regarding loss of muscle strength -- Definitive dx -- EMG -- Muscle biopsy -- Serum creatine kinase (CK) levels will be elevated

Therapeutic Management of a patient with Muscular Dystrophy

• Maintain Pulmonary Function by: -- Focused respiratory assessment -- Incentive spirometer -- CPT( Chest percusision therapy) -- Monitor PFT's(pulmonary function tests) -- Flu and pneumococcal vaccines -- Treat respiratory illness quickly --Promote Mobility -- Corticosteroids & calcium -- Keep child as active as possible -- Prevent contractures -- ROM, bracing, self-care, surgical release of contractures if indicated

Spinal Muscular Atrophy (SMA)

• Caused by an autosomal recessive trait with progressive degeneration of the nerve cells in the spinal cord
• Type 1- Werdnig-Hoffmann disease, infantile SMA Most common paralytic form of floppy infant syndrome (congenital hypotonia)
• • Degeneration occurs in the spinal cord and brainstem, resulting in atrophy of skeletal muscles
• • Rapid progression with early death
• Type 2- intermediate
• • Slower progression, survival into adulthood common
• Type 3- Kugelberg-Welander disease
• • Lifespan usually unaffected
• Diagnostic evaluation: the Gold standard is genetic analysis, prenatal testing may be made
• Clinical Manifestations include: Age of onset: within 6 months Earlier onset has poorest prognosis of death usually busce from Respiratory failure or infection
• Rapid progressive generalized weakness follows as well as: Wasting of skeletal muscles, Poor suck and swallow, Weak cry and cough, Respiratory difficulty, Short life expectancy.
• SMA Type 1 requires that There is No cure, treatment is supportive, Symptomatic & preventive:
• • Respiratory treatment with Nonivasive ventilation or Bilateral positive airway pressure( BIPAP)
• Inavsive measures include: Tracheotomy / mechanical ventilation:
• • At risk for URI & aspiration
• Provide Orthopedic management (especially scoliosis)
• Implement G-tube for feeds and remember to make Ethical decisions

Management of type 1 Spina Muscular Atrophy requires the following Nursing Consideration

• The following conditions require Nursing Observation, Protection and treatment:
• • Maintain the patient's Airway and implement CPT, Positioning, Monitoring of Suck and Swallow
• Maintain or improve the patient's Mobility through:
• -Cares should be given to the patient similarly as one as is Immobilized Patient to promote Pulmonary Function & prevent Complications
• Keep in mind Developmental Considerations as follows:
• Children are intellectually Normal so we should Provide Age Appropriate Developmental Activities like
• • Verbal, Tactile and Auditory Stimulation
• Care for, and support the patient's Family by providing
• • Referrals to Genetic Counselling and discussion on the use of Palliative Care Support

Cerebral Palsy (CP)

• Defined as an abnormal development of, or damage to, the motor areas of the brain
• Is a group of disorders causing activity limitations, disturbances of sensation, communication, perception, cognition, and behavior secondary to musculoskeletal problems & epilepsy
• Is one of the most common permanent physical disability of childhood characterized by abnormal muscle tone and coordination
• The followiong is a list of possible etiologies of Cerebral Palsy Prenatal:
• • Brain abnormalities, Hpoxis, Prematurity & Low Birth Wweight
• Perinatal: Birth Asphyxsia, Cerebral, hhemorrhage and abormal Fetal Presentation The followiong is a list of possible etiologies of Cerebral Palsy Postnatal:
• • Shaken baby syndrome/child abuse, and head trauma -- Viral Encephalitis The diagnositc Eval. includes the primary modes of dx used include, the following: Neuro exams, a nd history analysis is critical to determining whether to request imaging methods; MRI, PET, and/or, CT scans, metabolic, Genetic studies

###Therapeutics CP therapy

• Early therapies focus on development and optimal milestones promotions

• Surgical managements involves spasticity, contractures and hydrocephalus precautions

• Motor unction assessments are integrated to optimize the following domains: Abilities Educational programming is implemented which includes these areas: child skills and needs, and socializations with the other children available Management of the patient require several medications as well:

• -Diaz spam – bacofem -Botulin toxin IM route

Acquired Disorders:

• Diseases are those which aare not present since birth but may aapeer during the course of life.
• The Dislocation of the femoral head at the epiphyseal plate is: Slipped Capital Femoral Epiphysis, causes include " Exact cases unknown " but " More Freuently See in Obasee Males age 12-15".
• Diagnostsic of Slipped Capital Femoral Epiphysis includes the following observations: " X-Ray Bonescan and CT".
  • the various S/S of this diease include the following observations: " Sudden onset of hip pain, Referral pain to groin and or medial tight or Knee,, Limp to inability to Bear Wright, trendelenburg Gait, decrease --Therapuetic management typically consist of thess steps::" Orthopedic Surgery, Insertion of Pinns or Seating cases." ---Slipped Capital Femoral EPhysis occurs in more males between the ages of 12-15 so ensure that the correct diagnosis measures are implement."

###Legg-Calve Perthese Disease.

• -A- Vascular necrosis of femoral head is known as; (The"Leig's Cab Perthese" diseasses

• --The disease of Leige-Calves will,Self Iimiting disease/or Idiopathic , and occurs more Commonly in Male age Four -Eight" -10% of all cases.

• -----"Leg" Cabs for Perthises disease -

• ---Diagnostsic methods includes; Insdiouse onset., History of Lims. Limited range of Motion. Soft Tissueswelling , Muscle spasms., hip pain can be refferred as the thigh., Trientlennbrug
• • the Therauptic Management can be made in the team or: Reeeerr too: Orthopedics!!
• A Limit actioity,. Brarace Casting. Or Traaction.!!

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