Nursing Care of the Child With Alteration in Mobility/Musculoskeletal Disorder PDF

Nursing Care of the Child With an Alteration in Mobility/ Musculoskeletal Disorder NURS 328 Kristen McLaughlin PhD, RN, CRNP  Learning Objectives Compare differences between the anatomy and physiology of the musculoskeletal systems in children versus adults. Describe t...

Nursing Care of the Child With an Alteration in Mobility/ Musculoskeletal Disorder NURS 328 Kristen McLaughlin PhD, RN, CRNP  Learning Objectives Compare differences between the anatomy and physiology of the musculoskeletal systems in children versus adults. Describe the psychosocial impact of chronic musculoskeletal disorders on the growth and development of children. Distinguish various musculoskeletal disorders occurring in childhood. Identify nursing interventions related to common musculoskeletal conditions. Devise an individualized nursing care plan for the child with a cast or in traction.  4-year-old male. The parent reports he seems to be falling often and has started to have difficulty climbing the stairs on his own. His mother states, “Recently he hasn’t been able to keep up with his 6-year-old sister when Clinical we’re playing at the park. He usually ends up sitting on the bench with Scenario me.” She is concerned about the changes she has seen in her son. What additional history is important to ask?  Pediatric Musculoskeletal Differences Children’s bones Less dense & more porous than adult bones Not as strong & fracture more easily The growth plate /epiphyseal plate Common place for injury Can lead to improper growth if not treated correctly The periosteum of the child’s bone Thicker with an abundant blood supply Aids in rapid healing Adolescents that limit their intake of calories & calcium/Vit D Risk for stress fractures MSK Differences Growth palate=ossified into mature bone periosteum=more blood supply Growth plate weakest point in child’s bone Malnutrition & obesity= detrimental to health Fracture before sprain obesity=excess stress on joints, If growth plate damaged w/ injury infection immobility,decreased movement Teenagers have all bone stores of calcium by 21 Physiologic Effects of Immobilization  Psychologic Effects of Immobilization Diminished environmental stimuli Developmental regression Altered perception of self and environment Disrupts family function Increased feelings of frustration, anxiety Extended periods of immobilization Depression, anger, aggressive -Logistical management for sick child behavior -Need for family support and home care assistance Best goal is to maximize movement abilities  Key Nursing Consideration Focusing on a child’s abilities may enhance his or her strength to overcome anything. *Maximize physical abilities*  Associated Nursing Diagnoses Imbalanced Urinary retention Impaired nutrition: less (* with sensory Risk for Self-care deficit Pain physical mobility than body motor constipation (specify) requirements impairment) Deficient Family Risk for impaired Risk for delayed Chronic sorrow Risk for injury knowledge processes, skin integrity development (specify) interrupted  Therapeutic Management of Injuries RICE(S) Rest the injured part Ice immediately (max 20 min on at a time) Compression with elastic bandage Elevation of the extremity Support (casts or splints as appropriate to injury) Therapeutic Management of Injuries Managing swelling=managing pain Elevate above level of the heart, Picture A  Fracture Common injury in children Methods of treatment are different in children than in adults Warrants investigation in children under 2 yrs of age (also consider osteogenic imperfecta) Distal forearm: the most frequently broken bone in childhood *Suspicion of fracture in a young child who refuses to walk or bear weight and xray negative Fracture All children under age 2 sent in for skeletal survey Assessing for signs of bone formations Investigate reasons why child is falling down stairs  Diagnostic evaluation History Radiographs Goals of fracture Diagnosis management and Reduction and immobilization Management Restoring function of Fractures Preventing deformity Cast/Traction/Brace Osteogenesis imperfecta brittle bone disease Not calcium,phosphorus storage Abnormal pre-collagen type 1  Neurovascular Assessment Pain and point of tenderness Pallor Pulse Paresthesia: sensation distal to the fracture site Paralysis: movement distal to the fracture site AND Increasing Pressure Neurovascular Assessment 5 P’s Key to assessment Is pain localized or diffuse? Pallor: blanch skin at nail bed Pulse: assess pulses distally to injury Paresthesia: sensation distal to injury Paralysis: movement distal to injury Compartment syndrome too much blood, muscles can’t expand Increased pressure *If patient takes albuterol treatment, they are 1st priority*  Cast Care Home Instructions  Traction for Fracture In children, most balanced skeletal traction is applied to Allow physiologic stability Align bone fragments Enable closer evaluation of the injured site Newer technology: orthopedic external fixation devices allow for mobility  Immobilized Child-Traction Immobilized Child- Traction External Fixation Position change 2 hours Mark where buttocks were Assess respiratory (incentive spirometer) Pressure reduction mattresses, Assess ROM position changes, ROM exercises Assess GI Braden Q scale Assess according to bodily system, body function  Infections of Bones Osteomyelitis Infectious process in the bone Staphylococcus aureus: the most common causative organism Signs/symptoms begin abruptly, resemble symptoms of arthritis and Infections of Bones leukemia Localized pain,swelling Marked leukocytosis Measure circumference of redness, swelling Bone cultures are obtained from biopsy or aspirate. Need sensitivity for Markers of inflammation pharmacologic management ESR (Erythrocyte sedimentation rate) Radiographs: may appear normal at first Care Management of Osteomyelitis Long-term Complete bed rest intravenous access Incision and and immobility of Pain management if IV antibiotic drainage limb- initial period administration; PO antibiotics Potential longer- term Labs Wound care Psychosocial needs hospitalization/thera py  Developmental Dysplasia of the Hip (DDH) DDH Occurs b/c hip doesn’t fully form and doesn’t push into spine (in utero) Check neonates with: Hx breech Girls Formerly called “congenital hip dysplasia” or “congenital First-born dislocation of the hip” Incidence: 1.5 per 1000 live births DDH Treatment Girls: more commonly affected Pavlik harness Worn for 24 hours a day for 2 months Strong family history Breech presentation-high risk DDH Teaching-Pavlik Harness Check under straps Bryant’s Traction For DDH  Clinical Manifestations of DDH Infant Hip joint laxity Shortened limb on the affected side (C) Restricted abduction of hip on affected side (B) Unequal thigh folds when infant prone (A) Positive Ortolani test result (clunk felt) Positive Barlow test result (clunk felt) Therapeutic Management of DDH Pavlik harness: worn 24 hours/day  Bryant’s Traction Modified extension traction with the body as a counterweight Skin traction: 75- 90 degrees hip flexion Risk of circulatory insufficiency Nursing care Hips suspended Neurovascular assessment Safety (ex. eating) Bryant’s Traction For DDH Nursing Considerations-Bryant’s Traction Be mindful of eating while supine Clubfoot (Talipes equinovarus) Clubfoot Abnormal development of bones, muscles, tendons Genetic relation  Therapeutic Management of Clubfoot Three stages Correction of the deformity Maintenance of the correction until normal muscle balance is regained Follow-up to avert possible recurrence Ponseti method (serial casting) Serial Casting Weekly casting with position changes to stretch shortened muscles Patient comes in frequently Begins the first week of life (dx’ed in utero or at birth)  Scoliosis Most common spinal deformity Complex spinal deformity in three planes Lateral curvature Spinal rotation, causing rib asymmetry May be congenital or develop during childhood Scoliosis Assessed using Adam’s bend forward test Maintain eye level when assessing For nurse description, say “ prominent right asymmetrical scapula Patient maintains 6 hours out of brace  Diagnostic Evaluation of Spinal Curvatures Standing radiographs to determine degree of curvature Asymmetry of shoulder height, scapular or flank shape, or hip height In addition to the primary curve, a Adam’s forward bend test compensatory curve is often present to align the head with the gluteal cleft What is wrong in this picture?  Therapeutic Management of Spinal Curvatures Team approach to treatment (orthotist, PT) Bracing (xray 25-50 degrees) until growth cessation How do you know when this occurs? Surgical intervention for severe curvature (50 degrees) Instrumentation and fusion of vertebrae Care Management of Spinal Curvatures Monitor hemoglobins b/c bleeding risk (CBC) Monitor CNS/Neurological effects Monitor I & O Care Management of Spinal Curvatures Psychosocial Preoperative care Postoperative care Blood loss (?labs) Neuro assessment Log rolling Family issues  Duchenne Muscular Dystrophy The most severe and most common of muscular dystrophy in childhood X-linked inheritance pattern; one- third of cases result from fresh mutations Incidence: 1 per 3500-5000 male births Duchenne Muscular Dystrophy No higher risk for any ethnic group Affects males Waddling gait Muscles replaced w/ fat Progressive condition Cognitive impairment Gower’s sign Life expectancy in 20’s age group  Clinical Manifestations of Duchenne Muscular Dystrophy Waddling gait, frequent falls, Gower sign Lordosis Enlarged muscles, especially in the thighs and upper arms Profound muscular atrophy in later stages Mild to moderate cognitive impairment Obesity-related to immobility Gower’s Sign Therapeutic Management of Duchenne Muscular Dystrophy No effective treatment established Primary goal: maintain function in unaffected muscles as long as possible Keep child as active as possible Range-of-motion exercises, bracing, performance of activities of daily living, surgical release of contractures as needed Genetic counseling for family Multidisciplinary team helps child and family cope with chronic, progressive, debilitating disease Design program to foster independence and activity as long as possible  Cerebral Palsy (CP) Nonprogressive disorder of motor function Classifications Spastic: muscle hypertonicity, postural difficulty, impaired gross & fine motor skills. Drooling and dysarthria present. Dyskinetic: abnormal involuntary motion, athetosis Ataxic: poor coordination, balance, control of upper extremities, wide gait. Mixed types 34  Delayed gross motor development Abnormal motor skills – Asymmetry – Early handedness – Feeding/swallowing problems – Persistent toe-walking Clinical Altered muscle tone Manifestations: – Hypotonia, hypertonia Cerebral Palsy – Scissoring Persistence of primitive reflexes Associated abnormalities of cognition, seizures, hearing & vision 35 Hemipleg ia, Toe Walking 36 Nursing Implications: Cerebral Palsy Coordinate multiple therapies Gentle handling & positioning; braces Nutrition (increased caloric need) Self-care skills *goal is independence Educational & social opportunities Family support United Cerebral Palsy Association: www.ucpa.org 37