Nursing Care of Musculoskeletal Disorders in Children

NURSING CARE OF A FAMILY WHEN A CHILD HAS A MUSCULOSKELETA L DISORDER Copyright © 2018 Wolters Kluwer · All Rights Reserved  STRUCTUR E OF BONE Copyright © 2018 Wolters Kluwer · All...

NURSING CARE OF A FAMILY WHEN A CHILD HAS A MUSCULOSKELETA L DISORDER Copyright © 2018 Wolters Kluwer · All Rights Reserved  STRUCTUR E OF BONE Copyright © 2018 Wolters Kluwer · All Rights Reserved  Skeletal muscles Attached to bones by connective tissue, tendons, ANATOMY AND PHYSIOLOGY OF and ligaments THE Allow for voluntary MUSCULOSKELET AL SYSTEM movement, including gross motor activities and fine motor activities Joints and tendons Copyright © 2018 Wolters Kluwer · All Rights Reserved DISORDERS OF THE MUSCULOSKELETAL SYSTEM Infectious and Disorders of inflammatory Disorders of bone disorders of the skeletal structure development bones and joints Disorders of the joints and Disorders of the tendons: skeletal muscles collagen vascular disease Copyright © 2018 Wolters Kluwer · All Rights Reserved INJURIES OF THE EXTREMITIES Copyright © 2018 Wolters Kluwer · All Rights Reserved INJURIES OF THE EXTREMITIES ◼Fractures ◼ Forearm fractures; elbow fractures ◼ Volkmann ischemic contracture ◼ Epiphyseal separations of the radius ◼ Clavicle fractures ◼ Dislocation of the radial head ◼ Fractures of the femur Copyright © 2018 Wolters Kluwer · All Rights Reserved INJURIES OF THE EXTREMITIES ◼Other ◼ Athletic injuries ◼ Knee injuries ◼ Throwing injuries ◼ Strains and sprains Copyright © 2018 Wolters Kluwer · All Rights Reserved 2020 NATIONAL HEALTH GOALS RELATED TO MUSCULOSKELETAL HEALTH IN CHILDREN #1 ◼ Increase the proportion of the nation’s public and private schools that require daily physical education for elementary grade students from a baseline of 3.8% to 4.2%. ◼ Increase the proportion of the nation’s public and private schools that require daily physical education for middle or junior high students from a baseline of 7.9% to 8.6% and for senior high students from 2.1% to 2.3%. Copyright © 2018 Wolters Kluwer · All Rights Reserved 2020 NATIONAL HEALTH GOALS RELATED TO MUSCULOSKELETAL HEALTH IN CHILDREN #2 ◼ Increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (developmental). ◼ Increase the proportion of children and adolescents aged 2 years through 12th grade who view television, videos, or play video games for no more than 2 hours a day from 78.9% to 86.8%. Copyright © 2018 Wolters Kluwer · All Rights Reserved 2020 NATIONAL HEALTH GOALS RELATED TO MUSCULOSKELETAL HEALTH IN CHILDREN #3 ◼ Increase the proportion of trips that children and adolescents make by walking (Developmental). Copyright © 2018 Wolters Kluwer · All Rights Reserved NURSING PROCESS: MUSCULOSKELETAL DISORDER ◼ Assessment ◼ Nursing diagnosis ◼ Outcome identification and planning ◼ Implementation ◼ Outcome evaluation Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING MUSCULOSKELETAL FUNCTION ◼ History ◼ Physical exam ◼ Diagnostic tests ◼ Radiography ◼ X-ray of the bone or joint ◼ Bone scan (scintigraphy) ◼ study of the uptake by bone of intravenously injected radioactive substances. Copyright © 2018 Wolters Kluwer · All Rights Reserved ◼ Electromyography ◼ Studies the electrical activity of skeletal muscle and nerve conduction to determine the location and cause of disorders such as myasthenia gravis or muscular dystrophy etc. ◼ Muscle or bone biopsy ◼ Involve removal of a tissue sample for examination of its microscopic structure ◼ Arthroscopy ◼ Involve direct visualization of a joint with a fiber optic instrument. Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF BONE DEVELOPMENT ◼ Flat feet (pes planus) ◼ Evaluate longitudinal arch while child on tiptoe; observe if able to stand on heels with soles of feet off ground; examine ankle joint for full range of motion. ◼ Blount disease (tibia vara) ◼ X-ray shows medial aspect of proximal tibia with sharp, beaklike appearance. ◼ Toeing-in ◼ Visual exam shows heel in good alignment; only forefoot turned in. Copyright © 2018 Wolters Kluwer · All Rights Reserved FLAT FEET BLOUNT TOEING IN Copyright © 2018 Wolters Kluwer · All Rights Reserved ◼Bowlegs( Genu Varum) >Lateral bowing of the tibia ◼Knock Knees ( Genu Valgum) >opposite of genu varum Copyright © 2018 Wolters Kluwer · All Rights Reserved  A. GENU VARUM ( BOWLEGS) B. GENU VALGUM (KNOCK KNEES) Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF BONE DEVELOPMENT ◼Flat feet (pes planus) ◼ Do not need high top or rigid shoe; sneaker offers enough support for normal arch development. ◼Bowlegs (genu varum) ◼Knock knees (genu valgum) ◼ Refer to specialist if continues or worsens after age 3 to 4 years. Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF BONE DEVELOPMENT Occur in muscle, never in joint; often Growing pains reported in preschool and school-age children Osteogenesis Tendency for bones to fracture easily imperfecta because of poor collagen formation Slipped capital Internal rotation of hip difficult, painful on femoral physical exam; X-ray reveals slip epiphysis Copyright © 2018 Wolters Kluwer · All Rights Reserved  THERAPEUTIC TECHNIQUES FOR DISORDERS OF BONE DEVELOPMENT ◼Blount disease (tibia vara) ◼ Bracing or osteotomy; patient education ◼Toeing-in ◼ Passive stretching exercises; if extreme rigidity, casts or splints ◼Growing pains ◼ Possibly daily vitamin pill with iron Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF BONE DEVELOPMENT ◼ Legg-Calvé-Perthes disease (coxa plana) ◼ Pain in hip joint accompanied by spasm, limited motion; X-rays distinguish from synovitis; followed by shrinkage, increased density of bone in femur head; resorption of dead bone over 1 to 2 years; deposition of new bone Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF BONE DEVELOPMENT ◼Osteogenesis imperfecta ◼ Protection from trauma; casting of fractures; patient education ◼Legg-Calvé-Perthes disease (coxa plana) ◼ Younger than age 6 years, NSAID; keeping head of femur within acetabulum with containment device; if older than age 6 years, reconstructive surgery Copyright © 2018 Wolters Kluwer · All Rights Reserved  ◼ Osgood–Schlatter disease ◼ Gender (more boys than girls); age (preadolescence or early adolescence); in boys, pain and swelling just below knee Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF BONE DEVELOPMENT ◼Osgood–Schlatter disease ◼ NSAID; ice; limiting strenuous physical exercise; immobilization of leg in walking cast, if indicated ◼Slipped capital femoral epiphysis ◼ Surgery with pinning or external fixation; possibly, total hip replacement Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC MANAGEMENT OF MUSCULOSKELETAL DISORDERS ◼Casting ◼ Cast application ◼ Cast removal ◼Medical boots/splints ◼Crutches ◼ Fit and adjustment ◼ Crutch walking Copyright © 2018 Wolters Kluwer · All Rights Reserved CAST APPLICATION Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING INFECTIOUS AND INFLAMMATORY DISORDERS OF BONES AND JOINTS ◼ Osteomyelitis ◼ Malaise; fever; irritability; sharp pain at metaphysis site; followed by skin over infected bone warm to touch, often edema; X-ray shows sequestrum; CT shows bone changes ◼ Transient synovitis ◼ Pain in groin, lower thigh or knee, or buttocks; pain intense in morning and late day; X-ray, MRI show capsular swelling Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR INFECTIOUS AND INFLAMMATORY DISORDERS OF BONES AND JOINTS ◼Osteomyelitis ◼ Limitation on weight bearing; immobilization; short administration of IV antibiotic followed by oral antibiotic; if pus forms under periosteum, aspiration ◼Synovitis ◼ NSAID; limited activity Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING SCOLIOSIS Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF SKELETAL STRUCTURE ◼Functional (postural) scoliosis ◼ Correction of underlying cause; spinal fusion, if needed ◼Structural scoliosis ◼ Bracing; halo traction; or surgical intervention: spinal instrumentation Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF THE JOINTS AND TENDONS #1 ◼Juvenile arthritis ◼ Persistent fever, rash present before pain, stiffness of joint involvement ◼ Assess effect disease is having on self-care; child’s and parents’ understanding of illness, planned therapy Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF THE JOINTS AND TENDONS ◼Juvenile arthritis ◼ Daily activities and exercise ◼ Heat application ◼ Medication ◼ Nutrition Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF THE JOINTS AND TENDONS Copyright © 2018 Wolters Kluwer · All Rights Reserved  ASSESSING DISORDERS OF THE SKELETAL MUSCLES #1 ◼ Myasthenia gravis ◼ Diplopia, ptosis; weakened facial, neck, jaw, swallowing, intercostal muscles; extreme fatigue; enlarged thymus gland; immediate increase of muscle strength after edrophonium injection ◼ Dermatomyositis ◼ Muscle weakness; difficulty swallowing; swollen, discolored eyelids; confluent rash on cheeks; scaling; subcutaneous calcifications; electromyography reveals lack of electrical activity in muscle fibers Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF THE SKELETAL MUSCLES ◼ Myasthenia gravis ◼ Neostigmine or pyridostigmine bromide, acetylcholinesterase inhibitors; prednisone or immunosuppressant, if indicated; in still others, plasmapheresis to remove immune complexes or IV immunoglobulin to provide immune suppression; excision of thymus gland, if indicated ◼ Dermatomyositis ◼ High-dose corticosteroids, methotrexate, or specific immunosuppressants Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING DISORDERS OF THE SKELETAL MUSCLES #2 ◼Muscular dystrophies ◼ History of meeting motor milestones later than average ◼ At 3 years, waddling gait; difficulty climbing stairs; Gower sign; possibly walk on toes; difficult speech, swallowing. ◼ By junior high school age, most become wheelchair-dependent; tachycardia; pneumonia ◼ Fibrous degeneration, fatty deposits on muscle biopsy; increased serum creatine phosphokinase, Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC TECHNIQUES FOR DISORDERS OF THE SKELETAL MUSCLES—(CONT.) ◼Muscular dystrophies ◼Active and passive daily range-of- motion exercises; splinting, bracing if necessary; low-calorie, high-protein diet; high intake of fiber, fluids; corticosteroid therapy Copyright © 2018 Wolters Kluwer · All Rights Reserved ASSESSING INJURIES OF THE EXTREMITIES ◼Fractures ◼Observation of deformity, edema, pain; history of accident ◼Rule out child maltreatment in all unintentional injuries Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC MANAGEMENT OF MUSCULOSKELETAL DISORDERS ◼Traction ◼Skin traction ◼Skeletal traction ◼Traction-related care Copyright © 2018 Wolters Kluwer · All Rights Reserved THERAPEUTIC MANAGEMENT OF MUSCULOSKELETAL DISORDERS ◼ Distraction ◼ Open reduction Copyright © 2018 Wolters Kluwer · All Rights Reserved NURSING DIAGNOSES ◼Pain ◼Impaired physical mobility ◼Deficient diversional activity ◼Situational low self-esteem Copyright © 2018 Wolters Kluwer · All Rights Reserved QUALITY & SAFETY EDUCATION FOR NURSES (QSEN) ◼ Patient-Centered Care ◼ Teamwork & Collaboration ◼ Evidence-Based Practice ◼ Quality Improvement ◼ Safety ◼ Informatics Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved QUESTION #1 A 7-year-old with a fractured femur is in skeletal traction. Which nutrient should the nurse encourage in his diet during this time? A. Vitamin D B. Calcium C. Protein D. Carbohydrates Copyright © 2018 Wolters Kluwer · All Rights Reserved ANSWER TO QUESTION #1 C. Protein Rationale: Protein helps with overall healing in the body. The addition of extra calcium is not recommended if the child is on bed rest due to the potential for development of renal calculi. Copyright © 2018 Wolters Kluwer · All Rights Reserved QUESTION #2 A 6-year-old child has just spent 10 days in skeletal traction for a fractured femur. When doing preoperative teaching prior to the cast application, which is the priority teaching for the parents and child? A. Needing physical therapy for crutch training postoperatively B. Being able to have a walking cast applied after 2 weeks C. Having the cast on for at least 3 to 4 weeks D. Being able to have the cast removed after 12 weeks Copyright © 2018 Wolters Kluwer · All Rights Reserved ANSWER TO QUESTION #2 C. Having the cast on for at least 3 to 4 weeks Rationale: Once callus formation begins, a cast is applied. The younger child will have a more rapid healing process than the older child. Use of crutches or walking casts is not appropriate with a fractured femur in a young child. Copyright © 2018 Wolters Kluwer · All Rights Reserved  QUESTION #3 The mother of a child with muscular dystrophy asks the nurse what type of diet her son will need to follow. Which advise should the nurse provide? A. There is no special diet necessary for her son. B. A high-protein, high-carbohydrate diet may be helpful. C. Extra creatinine should be added to his diet daily. D. A moderate calorie diet will help him remain ambulatory longer. Copyright © 2018 Wolters Kluwer · All Rights Reserved ANSWER TO QUESTION #3 D. A moderate calorie diet will help him remain ambulatory longer. Rationale: Preventing a child from gaining excess weight can allow him to be ambulatory longer. Because of lack of activity, it is easy to gain weight. Copyright © 2018 Wolters Kluwer · All Rights Reserved