Peds Exam 3 Study Guide PDF

Peds Exam 3 Modules 8, 9, 10 Pediatric Neurological Disorders Neurologic Assessment    Find baseline and compare Different assessment for different age groups Key elements: o History, head size, shape, reflexes, tone, muscle development, head circumference, cry, respiratory activity, strength an...

Peds Exam 3 Modules 8, 9, 10 Pediatric Neurological Disorders Neurologic Assessment    Find baseline and compare Different assessment for different age groups Key elements: o History, head size, shape, reflexes, tone, muscle development, head circumference, cry, respiratory activity, strength and coordination, ability to follow direction (children <2 require special assessment) Glasgow Coma Scale- Infant (normal score is 15) Increased Intracranial Pressure  Excess of fluid (blood, CSF) or matter (brain) within the cranium causing pressure buildup due to proportional imbalance  Cranial system will initially compensateincreased ICP occurs when compensation is exhausted  Medical emergencyimmediate intervention Causes of Increased ICP  Tumor  Infection  Closed head injury  Bleeding  CSF accumulation Measurement of CSF Pressure  Measured by spinal tap, ventricular puncture (most common)    Normal 0-15mmHg (note age variations) Moderate increase 20-40mmHg Severe increase >40mmHg o Do NOT need to know numbers for exam Clinical manifestations  Growth and development play a major role- need to know for exam!!  Subtle to begin with: o Irritability, personality changes (behavioral changes will happen first) o Headache when lying flat, in the morning o N/V o Sleepiness o Blurred vision (diplopia), poor feeding  Infants: o Bulging fontanel (posterior closes 3 months, anterior closes 18 months) o Cranial suture separation o High-pitched cry o Increased head circumference  Widened suture linesincreased head circumference  Children with open fontanel compensate for increased volume with skull expansion and widening sutures  Skull expansion NOT seen in 2-year-old because fontanels are closed o Sun setting eyes  Increased ICP forces child’s eyes to look downless of pupil, more of iris and sclera o Reflexes- retention of infantile reflexes, rooting, grasping, moro, Babinski, tonic neck Diagnosis  Dependent of manifestations  Cushing’s Triad o Late sign o Increased systolic BP o Decreased HRfrom brain swelling o Decreased respirations (Cheyne stokes)  ICP monitoring o Burrow hole Management/Nursing Interventions  PRESSURE o Position  HOB 30-35 degrees, head midline, hips straight ( intraabdominal pressure) o Respiratory  Prevent hypoxia and hypercapnia  Monitor ABGs KNOW VALUES o Elevated Temperature  Antipyretics, cool baths, remove extra blankets, decrease room temp o Systems to monitor   Neuro checks: PEERLA, follow commands, strength, GCS o Straining activities avoided  Avoid vomiting, give antiemetics, no sneezing, coughing, blowing nose, stool softeners, calm environment o Unconscious Patient  Do not over sedate, assess lung sounds, skin breakdown, nutrition o RX  Barbituratesdecrease brain metabolism  Vasopressorsdecrease BP  IVF, Epi, antihypertensives, anticonvulsants o Edema management  Medically treat first while figuring out what is causing fluid buildup  Mannitoldehydrates the brain Surgical: extra ventricular drain or closed drainage system (VA or VP shunt) Closed Head Injuries  Forcible collision of the brain and skull-may or may not include bleeding  Leading cause of injury and death in children >1 year of age  Brain, blood, and CSF are damaged because force is too great to be absorbed by skull  Deformation: head is stationaryreceives blow (mass movement of brain) bruising o Coup: bruising at point of impact o countercoup: bruising at a distance  Causes: o MVA, fall, recreation, child abuse (shaken baby syndrome) Closed Head Injuries-Minor Clinical manifestations  Brief or no loss of consciousness (GCS 13-15)  Vomiting  Headache  Lethargy  Transient confusion o Biggest concern is return or worsening of symptoms (unsteady gait, vomiting, worsening headache)worry about cerebral edemapeaks 24-72 hrs after head injury Diagnosis  In-depth neuro assessment, history of injury Treatment  Treat symptoms (Tylenol for headache)  Avoid sedatives  No school or sports until recovered Closed Head Injuries-Severe Clinical manifestations  Increased ICP o Determined by if infant or toddler (fontanels)  Altered LOC/prolonged loss of consciousness (GCS <8)  Unsteady gait, elevated Temperature, CSF leakage, eye changes (retinal hemorrhages, edema, extraocular palsies, unequal pupils Diagnosis  In-depth neuro assessment, history of injury  MRI Treatment  Stabilize ABCs (depending on LOC, may have to intubate) Nursing Care-Severe Closed Head Injuries  Neuro checks Q15 o Assess LOC and pupils  Maintain ABCs  SIADH & DI are a concern  Fluid and electrolytes  Treat increased ICP o VA or VP shunt, mannitol, anticonvulsants, Tylenol (no heavy narcotics, do not want to sedate)  May need to induce coma to decrease activity level  Seizure precautions  Dim/low lights, decrease stimuli, cluster care  Monitor drainage from ears or nose  Education o Home monitoring, vomiting, headache, behavior changes o Exclusion from sports o Seatbelt, car seat, and helmet safety Meningitis (Acute Disorder)  Infection or inflammation of the meninges  Potentially life threatening  Multiple forms: viral, bacterial (most severe), fungal, toxic Clinical manifestations  Signs and symptoms of increased ICP  Fever o Worried about infectionany infant with fever for 2 daystreat with antibiotics until results come back for meningitis  Nuchal rigidity o Inability to put chin to chestwhen they try, knees raise up Diagnosis  Lumbar puncture (KNOW TABLE BELOW FOR EXAM) Viral Meningitis  Less severe, more common  Low fever, headache, feel crummy  Droplet precaution roomlumbar puncturestart them on broad spectrum antibioticsonce results come back as viralantibiotics will be stoppedsymptoms treatedtreat at home o In this exact order** Bacterial Meningitis   Most severe Rapid progression - can cause septicemia and meningococcemia o Red rash (purpuric lesions) - hallmark sign of bacterial septicemia o Immediate treatmentcan lead to sepsis and death within 12 hours  Bacteria travels from outside CNS into the CNS and affects meninges o Strep throat, ear infection, sinus infection  Children/adolescents o Fever, chills, headache, vomiting, irritability, nuchal rigidity, positive Kernig and Brudzinski signs  Infants/young children o Fever or hypothermia, poor feeding, vomiting, irritability, bulging fontanel, high pitched cry Nursing care  ICP/LOC, droplet precautions, lumbar puncture  Antibiotics/antipyretics/steroids, hydration o If bacterial: steroids for inflammation, manage fever, broad spectrum antibiotics  Hydration- half maintenance!! to reduce risk of increased ICP  Monitor ICP, may get a drain  Education o Immunizations have decreased incidence-especially bacterial (Hib, PVC) o Highly contagious (bacterial & viral) Normal Bacterial Viral Appearance Clear Cloudy Clear WBCs 0-5 100-60,000 (elevated) 10-1000 (slightly elevated) Protein 10-30 100-500 (increased) Not > 100 Sugar 40-80 decreased normal/low <40 Pressure 5-15 increased normal/slightly increased Bacterial eats the sugar and poops the protein- sugar is low in CSF and protein is elevated Chronic Disorders Hydrocephalus  Disturbance in CSF circulation (not a disease) o Overproduction of fluid o Obstruction preventing flow through ventricles o Impaired absorption in the subarachnoid space  Causes increased ICP o Increased CSFventricles dilate and swellbrain is being pressed against the skullbrain damage if not treated o They have hydrocephalus because they have ICP**know relationship between the two o Imbalance of secretion and absorption o In children <12, this can reopen previously closed sutures Clinical Manifestations  Increased head circumference, monitor daily (age appropriate – only if fontanels are still open)  Unequal pupil response, sun setting eyes  Bulging fontanel (age appropriate)  Irritability, lethargy, poor feeding, changes in LOC  Older than 2 o Headache upon awakening, palpable edema in the morning (around eyes), ataxia, lethargy, confusion  Infants o First sign may be bulging fontanelsthen head get bigger, lethargy, poor feeding, lower extremity spasticity, will cry when picked up/rocked but will be quiet when lying still Diagnosis  Antepartum: ultrasound usually around 25 weeks  CT/MRI Treatment  Medication to decrease CSF production (mannitol, anticonvulsants)  Shunt o Ventriculostomy: external ventricular drain (EVD) Types of VP Shunts (once internalized)  VP Shunt (most common) - drains into peritoneum  VA Shunt - drains into right atrium to be pumped into body o requires repeated lengthening as child grows and is often reserved for older children who are no longer growing  These shunts are permanent** Nursing care for Shunts  Key assessments o Infection, ICP monitoring  Pain management  Positioning o Lay on non-operative side to prevent pressure on shunt valve  Head circumference (age appropriate)  Signs of malfunction - headaches, infection (fever)  Once internalized, no contact sports (swimming is the safest) Nursing Care EVD  Neuro checks  Management of drainage system o Assessment of function, assessment of drainage, fluid replacement o Tells us how many mLs the patient has put out o To get it into collection bag - turn off from patientunclamplet it drain into bag and see where it fills to if too low or draining too rapidly, it can cause bleeding and pain o Whatever they put outreplace with normal saline (if they put out 5mL/hr, give 5mL of NS over one hour)   Weekly dressing change unless it is compromised, then more frequent Patient positioning o VA: drain should be zeroed and placed at the level of patient’s ear** o VP: placed at level of patient’s abdomen**  Position patient leveled at the ear Drainage should be clear/yellowish o When first inserted, blood is normal (pink for first few days)If it turns red, report  Pain management***  If patient gets up, drain must be clamped! Once back in bed, level it back to ear and unclamp  Should be supine, semi-fowler  Keep temperature under controlif temp too highincreased ICP Spina Bifida  Failure of the neuro tube to close during fetal development  Two types: Spina Bifida Occulta and Spina Bifida Systica Spina Bifida Occulta  No spinal cord herniation or involvement of neural tissue or meninges  Not externally visible o Lumbarsacral vertebrae fail to fuse Clinical Manifestations  Hair tuff or dimple  Bowel and/or bladder dysfunction  Gait abnormalities/Tethered cord o Growth of spinal cord is restricted as spine growsspinal cord remains attachedcauses traction and tethering o Will not notice until walking or toilet training Diagnosis  Fetal ultrasound  CT or MRI Treatment  Treat weakness and nerve dysfunction Spinal Bifida Cystica  Involves spinal cord, meninges and/or CSF  Two types: Meningocele and Myelomeningocele o Meningocele: no spinal cord or nerve root involvement, significant neurological dysfunction uncommon  Involves meninges and spinal fluid, no neural elements/defects  Sac is visible at defect location o Myelomeningocele: nerve root or spinal cord involvement, varying degrees of neurological dysfunction, paralysis below level of lesion  MOST SEVERE  Diagnosed prenatally with elevated alpha fetal protein level (done 6-8 wks)  Born by c-section  After birth surgery is the treatment goal  Associated complications: hydrocephalus, club feet, hip dysplasia, contractures, bowel/bladder dysfunction, cardiac defects, scoliosis, latex allergy  o The higher it is the more problems you will havewherever the cyst is, anything below it will have permanent disability Transilluminate: test to decipher between the two  Shine a light through the sacif it lights up it is meningocele (nothing from permitting the light from shining through) Nursing Care  Place prone with hips flexed and legs abducted to relieve pressure off sac o After birth and before surgery, place sterile moist dressing on sac to protect from tearing o Still need to be prone after surgery for 14 days, turn hide side to side  Monitor for CSF leakage, infectionincreased risk for meningitis, ICP  Daily head circumference, ROM, pain management, bowel and bladder monitoring Long Term Care  Bone strength, mobility, skin, bladder, bowel, shunt considerations, school issues o Will have neurogenic bowel and bladder - will not be able to feel urge to void or have a bowel movement o Straight cath every 4 hours (Clean at home, sterile in hospital)can do this themselves at around 8-10 years o May need suppositories or enema every day to develop a schedule  Insensitive to pressure below level of lesioncheck for skin breakdown  Often have latex allergy due to frequent surgery and hospitalization - always avoid** o Cross-reactions with banana, avocado, kiwi, chestnut o Reducing exposure from birth can decrease the chance of allergy development  High in calcium and vitamin D to prevent osteoporosis  May need a shunt (common for hydrocephalus to present with myelomeningocele) Cerebral Palsy  Non-progressive, non-repairable brain alteration that occurs before or during birth most likely from brain anoxia or ischemia Clinical Manifestations  Permanent alterations in development, movement, and/or posture o Walk on tiptoes, uncoordinated movements, poor suck  Early sign: early hand dominance by 6 months, usually does not develop until preschool age  Alterations in sensation, perception, communication, cognition, and/or behavior  Abnormal muscle tone and poor coordination, retention of infantile reflexes  No muscle control to chew, suck, or swallowhigh aspiration risk Diagnosis  Typically 6-12 months of agenot noticeable until they are not reaching milestones  Altered growth and development Therapeutic Management  PT/OT o Nutrition: thickened liquids  Adaptive equipment  Medications: baclofen, Ativan, Depakote  Orthopedic alterations/surgical intervention (for nutritional statusPEG tube lifelong)    Computerized toys or games to improve communication abilities and hand eye coordination Provide rest periods Decreased muscle toneIncreased risk for respiratory infections-immunizations is so important PITITUARY DISORDERS Diabetes Insipidus  Pituitary dysfunction-inadequate secretion of antidiuretic hormone (DO NOT HAVE A GLUCOSE PROBLEM)  Causes- tumor, CNS, trauma, brain surgery, meningitis Clinical Manifestations  Polyurialeads to a state of uncontrolled diuresis (3-4 L or urine/day)  Polydipsiacaused by dehydration o Decreased urine specific gravity o Hypernatremia o Weight loss, crying  Symptoms relieved if they drink water, but will still feel thirsty Diagnosis  Dehydration test: urine specific gravity will be decreased, it is very diluted  Early sign of child developing DI is anuresiswhen child is toilet trained, they start bed wetting and have excessive thirst  Early sign of infant developing DI is persistent irritability and crying only when they get water Treatment  Medication and Fluid replacement o Synthetic hormone of ADH: DDAVP (desmopressin)will slow down output of urine Nursing Considerations  Fluid balance and hypernatremia (monitor electrolytes) Syndrome of Inappropriate Antidiuretic Hormone (SIADH)  Excessive secretion of antidiuretic hormone  Caused by CNS infection, brain tumor, diuretic use Clinical Manifestations  Water reabsorption and toxicity, elevated blood pressure, hyponatremia, increased specific gravity, hypoosmolality, oliguric, signs of fluid overload o Concerned about brain swelling o Water intoxication: n/v, lethargy, headache, weight gain Diagnosis  Laboratory findings: electrolytes, osmolarity Treatment  Medication (3% sodium chloride to help them pee) and fluid restriction (1/3 or 1/5 maintenance) o Treat underlying cause and SIADH will go away Nursing Considerations  Fluid balance monitoring  Daily weight Seizures  Abnormal discharges of electrical activity within the brain  Involuntary movements, behavior, and sensory alterations  May be due to birth trauma, congenital defects, tumors, infections, electrolyte imbalances, temperature changes Diagnosis  History, MRI/CT, labs, LP, EEG (shows abnormal activity in the brain) Clinical Manifestations  Based upon seizure type  Includes alteration in LOC  Motor and sensory involvement Therapeutic Management  Anticonvulsants- primary treatment (Keppra)  Ketogenic (high fat) diet (whipped cream, butter)  Cannabis  Vagus nerve stimulator  Hemispherectomy (remove part of the brain that is causing seizures) Types  Patrial Seizure: 1 hemisphere or lobe of the brain o Localized motor or sensory symptoms based upon the area of the brain involved o Usually have an aura (see a color before having a seizure), no loss of consciousness  Generalized Seizure: 2 hemispheres of the brain o Loss of consciousness o Broad impairment of motor function o No aura: absence seizure o Longer post Ictal period- do not wake them up, let them recover  Unclassified Epileptic Seizure o Chronic repeated seizures o Brain dysfunction and abnormal EEG o Diagnosis of epilepsy2 or more seizures and/or abnormal EEG Febrile Seizures  Benign, transient disorder, occurs between 4-5 years  Occurrence due to infection causes temperature to risetreat underlying cause with Tylenol, cooling room, light blanket  Prevent fever from reaching 103 greatest risk for febrile seizure Nursing Interventions  During seizure: secure airway, time seizure, remove objects away from patient, DO NOT MOVE patient (hold head only if they start hitting it on floor), document  During recovery: support, assess LOC, VS, turn patient or head to left side, document Documentation  Ictal state: duration, time onset, precipitating events, behavior during seizure, movement, eye position, respiratory effort, incontinence  Post Ictal: duration, assess LOC, orientation, orientation, motor function, speech/sensations Epilepsy     Chronic seizure condition Progressive brain dysfunction and deterioration Abnormal EEG changes Status Epilepticus: continuous seizure state for more than 30 minutes o Support vital functions o Administer anticonvulsants (only by IV or rectal suppository of valium) o Medical emergency o Do not give anything oral (can give Valium suppository) Nursing Care-Seizures  Strict medication regimen  Monitor serum drug levels (adjust based on peak and trough)  Drug combinations and dosages are different for everyone  Monitor neurological status  Education on seizure management, medication side effects & schedules, driving restrictions (must be seizure free for 6 months before driving again), follow up with neurologist (will have continuous 24hr EEG done at every visit)  Take showers instead of baths because baths cause them to get too hottemperature changeseizure  Supervise while swimming, ask for side rail padding when in the hospital ORTHOPEDIC DISORDERS  Babies have more bones than adults, continuous growing, more flexible, heal faster and can remodel or reshape their bones  Ligaments are stronger than parts of their bones o Ligaments have greater strength than epiphyseal plates - incidence of sprains, ligament injuries, dislocations are reduced in children  Kneecaps don’t develop until 2-6 years  Immature gait until age 3 (more likely to fall)  Looser ligaments more likely in girls (due to maternal hormones)  Bowing of the legs common in <2 years, usually straightens on its own  Flat feet are normal, develop arch in foot by age 6  Bone grows from the ends, so a fracture near the growth plate can affect growing bones Scoliosis  Most common spinal deformity- lateral S or C shaped curve o Congenital: fetal development o Infantile: birth - 3 years o Juvenile: 3-10 years o Adolescent: 10 years and older  Occurs most often in girls, congenital (spina bifida), acquired after injury to spinal cord o No muscle control in lower spineunequal pulling of the musclesscoliosis  Kyphosis is more of a forward rounding of the back, which leads to a hunchback or slouching Clinical Manifestations  Truncal asymmetry, uneven shoulder, and hips, one sided rib hump, prominent scapula  Usually identified during preadolescent growth spurt (curvature develops, child will not complain of pain) o Girls screened at 10-12 years, boys screened at 13-14 years Diagnosis  Adam testthe patient will bend forward at the waist allowing the head and arms to fall freely towards the groundcurvature in spine will become apparent  Xray o Cobb technique o Risser scale: 0-5, loos at the likely progression of the spinal curvature Treatment  Bracing: for moderate curves 25-45 degrees  TLSO: thoracolumbosacral orthosis o Provides support for upper/middle/lower spine o Worn for 23 hours/day, can stop wearing after puberty o T-shirt worn underneath the brace to prevent skin breakdown o Watch for pressure points  Cons: kids don’t want to wear the bracepreoccupation with body image and appearance  Pros: goal is to prevent progression of the curve until they have gone through puberty, prevent surgery  Surgical intervention: for curves >45 degrees o Spinal fusion: treats deformities of the spine  Posterior/anterior spinal fusion  Internal fixation of rods or wires (they are permanent) o Permanently connects 2 or more vertebrae in the spine o Goal is to improve curvatures o Cannot get MRIs after fusion (metal rods) o Leads to decreased spinal mobility long-term Post-op Nursing Care  Wound o Surgical site is clean and dry, any drainage, color, signs of infection o May have Hemovac drain  Neurovascular o Wiggle their toes, sensation on feet and urination, cap refill, pedal pulses  Pain management around the clock (PCA pump, may have epidural in place)  Labs: Hgb, Hct, WBC, CRP  Ambulation: 24-48 hrs later  Logrolling: keep spine aligned (cannot bend, twist, or lift)  May wake up with a foley: assess bowel and bladder control Developmental Dysplasia of the Hip (DDH)  Abnormal development of the hip o May occur any time during fetal life, infancy, and childhood  2 major groups: idiopathic (infant is neurologically intact), teratologic (involves neuromuscular defectmyelomeningocele)  Degrees: o Acetabular dysplasia - abnormal cellular/structural development  Mildest form of DDH  Femoral head remains in acetabulum with no dislocation or subluxation o Subluxation - incomplete dislocation  Femoral head remains in contact with acetabulum, but head of femur is partially displaced creating pressure that inhibits ossification and produces a flattening of the socket  Most common o Low dislocation, High dislocation  Femoral head loses contact with acetabulum and is completely displaced  Most serious Diagnosis and Assessment  Treatment before 2 months oldhighest rate of success  Unequal gluteal skin folds  Shortening of the thigh on the affected sidehead of femur not in socket o Ortolani Maneuver  Abduct thighs, apply gentle pressure forward over the greater trochanter  Clunking sensation o Barlow test: hip is dislocated or unstable o Only be done with by a clinician to prevent injury  X-ray: not reliableossification of femoral head is not until 4-6 months of life so will not see on x-ray  Ultrasound more common, can see hip moving around Treatment  Goal: keep hip flexed and abducted, the longer the treatment is delayed the harder it is to fix  Newborn-6 months o Splinting in a safe position with the proximal femur centered in the acetabulum in a degree of flexion o Pavlik Harness- abduction device, worn continuously until hip is stable6-12 weeks  Clinical and ultrasound exam to make sure hip Is stable  Not ridged, prevent hip extension and adduction  Promote skin care and parental bonding, encourage parents to hold the baby  Check for reddened area under straps, put diaper under straps, avoid lotion and powder, massage under the straps to promote circulation  Remove harness once a day for NO MORE than an hour and inspect the skin  Look for feet flipping out of harness, difficulty putting clothes on, how to bathe (take harness offbatheput back in harness) o Closed reduction surgery and a spica cast is necessary when splinting fails  6-24 months o Surgery with closed reduction of the hip and then put in a spica cast for about 12 weeks  Cast from under nipple down to knees or feet, with a whole for the diaper  Keep cast clean (timed diaper changes), cap refill, move toes, swelling, discoloration, do not put anything in the cast (can cause skin breakdown) For play: can be put in laps, in a wagon, special wheelchairs, encourage inclusion of child to promote development o Open reduction is necessary if a closed reduction is unsuccessful  Older children o Harder to treat due to the structural deformity o More invasive surgery o May require preoperative traction o PT after cast removal o Muscle strengthening and crutch walking Clubfoot (Talipes Equinovarus)  Deformity of the ankle and foot Diagnosis  Visible at birth or prenatally  Diagnosis of clubfoothigher risk for hip dysplasia Management  Goal: painless, plantigrade, and stable foot  3 stages: o Correction of the deformity, maintenance of the correction through growth, follow-up observation to prevent recurrence  Serial casting: o Starts within 1st month of life o Every week they will have gentle manipulation and stretching of the feet o Serial long-leg casts o Maximum correction achieved usually within 5-8 weeks  After serial casting, they will be fitted for Denis Browne Bar with Ponseti sandals o To maintain correction and prevent recurrence o Used at night for 3-5 years  May need surgery if neither cast works Fractures  In kids, bones are more pliable, porous, and, bendy and if they bend too much it can break in a green stick pattern  If fracture occurs on a growth platecause shortening of bone & progressive angular deformity o With long bones: ossification progresses from the diaphysis o Epiphyses: at the end of long bones o Physis/growth plate: between epiphysis and diaphysis; weakest point of the bone  Open fracture: bone is sticking out of skin, but can also be a small wound (road rash) o Need antibiotics to prevent infection and possible surgery  Non-Accidental Trauma – abuse concern, unlikely that an infant will have a fracture, if they do, it will likely lead to an investigation (bone scan to see if there are other fractures), osteogenesis imperfecta will be ruled out at the same time  Foosh injury (fall on outstretched hand): most common fracture to the distal forearm, affect radial, ulnar or both Clavicle Fractures  Very common, 1⁄2 occur in children younger than 10, fall and land on shoulder   In newborns: common from childbirth Treatment  Pain control: Tylenol, ibuprofen, hycet  Immobilize: sling (newborns: pin shirt sleeve to chest)  Callus will form over clavicle, present for about a year, will eventually go away Types of Fractures in Children  Greenstick: break occurs through periosteum on one side of the bone while only bowing or buckling on the other side; most often in the forearm o Incomplete fracture when the compressed side bends  Spiral: twisted or circular break that affects the length not the width; often seen with child abuse  Transverse: break or fracture line occurs at right angles to the long axis of the bone  Comminuted: bone is splintered into pieces; rare (MVAs)  Oblique: diagonal or slanting break that occurs between horizontal and perpendicular planes of the bone Stages of Bone Healing  Stage 1: Hematoma formation; first 24 hours - injury to tissue, bleeding and clotting around the area  Stage 2: cellular proliferation: 2-3 days - blood supply increases to the site, hematoma becomes granulation tissue for new bone to form  Stage 3: Callus formation: 6-21 days - cartilage is formed and differentiates to bone tissue  Stage 4: ossification: 3-10 weeks- callus turns into bone  Stage 5: consolidation and remodeling, happens after 9 months, fracture line will always be visible on radiography  The whole process takes about 9 months; the younger the child the faster the bone heals Immobilization  Cast: joints above and below the injury site are immobilized to keep the fracture in alignment o Made of plaster or synthetics material (fiberglass) o Long leg cast, short leg cast, full spica cast, single spica, shoulder spica, etc.  Nursing: 5 Ps, swelling, compartment syndrome o Pain and point of tenderness (are pain out of proportion than what we expect), pulselessness (check pulses distal to fracture site), pallor, paresthesia, paralysis (can they move distal to fracture site) o Compartment syndrome: pressure within the closed space increases and compromises circulation to the muscles and nerves  Will likely be put in a splint rather than a cast if possible because we are expecting swelling o Neurovascular assessment - movement, feeling, capillary refill o Elevate extremity above hearthelps with swelling  Case care o Check skin, check edges of cast, keep it dry (cover with bag, no baths, no swimming)  Can use hair dryerheat helps with itching, do not do it for too longcan cause skin breakdown Traction  Pulling force to injured body part with counter traction in opposite direction to maintain bone alignmentdecreases muscle spasms, realigns bone, promotes healing, treats dislocation  Used infrequently  Most skeletal traction is applied after a severe complex injury  3 primary purposes: o To fatigue the involved muscle and reduce muscle spasm o To position the distal and proximal bone ends in the desired realignment o To immobilize the fracture site until realignment prior to casting or splinting  Types: manual, skin, skeletal o Manual: using hands to pull the bone straight (not long term, usually done before splinting or casting) o Skin: applied directly to skin surface with adhesive (strap on ankle with weight) o Skeletal: uses pins and wires hooked into the bone and the traction pulls direction on the bone  Knee 90-90 Traction: supports the lower extremity and provides good venous return  Thomas ring and Pearson attachment: balanced suspension at both sides  Patient is immobile!!  DO NOT MOVE the weights at the end of the bed!!  Risk of pin infection (directly in bone), keep site clean  Bryant’s Traction: o Children less than 3 and less than 40 pounds o DDH and femur fractures  Buck’s Traction: fractures, contractures, and muscle spasms - legs in extended position (supine) with weight hanging off the bed o Usually used short term (pre-op)  Russell’s Traction: stabilize femur fracture; skin traction on lower leg and padded sling under knee to pull and realign lower extremity, keeping hip and knee in a flexed position o Supine with sling pulling up from knee and down with weight off bed Nursing Care  Understand why your patient is in traction and how to maintain the traction equipment  Make sure there is no fraying, weight is not on the ground, keep visitors away from the weights  Neurovascular assessments (5 P’s), skin care (redness, prevent pressure injury)  Complications of immobility o Respiratory rate may be lower and more shallow - prevent atelectasis and pneumonia cough, deep breathe, incentive spirometer/blow bubbles in water or juice o Decreased cardiac output, risk for clots o Will lose muscle strengthmuscle atrophydo passive or active ROM, keep upright position if possible o Compression socks or SCDs to promote venous return o Decreased bone calcium - osteopenia; monitor electrolytes, monitor calcium levels o Decreased food intake may lead to decreased healing ability - high protein diet o Prevent skin breakdown Pain meds will cause constipationmay need stool softeners, may be at risk for kidney stones because amount of calcium o Make sure kids have a routine bedtime, homework, set amount of TV time Pin care: keep it clean and monitor Activity: play therapy - give them toys, TV Cluster care Keep hips even and aligned o     WIKIS: PRESCHOOL (3-5 years)  Learn about group cooperation, adjust to sociocultural differences, coping with frustration/dissatisfaction/stress/anger  Quiet play, outdoor activity, group activities, snack, and rest periods Preschool Temperament  Adaptability to new situations, intensity of response, distractibility, amount of persistence, mood, and activity level  Parents should be aware of normal behaviors of their children and inform caregivers/teachers how to handle them o Allowing a child with high activity levels to be in an environment that supports freedom o Supporting a child who may need gradual transition to new situations Discipline  Discipline for temperament and aggression is similar to toddler discipline  Time out and solidarity are effective  Minimize anger and frustration  Aggression should not be used to solve aggression; instead they should be taught the reason they are in trouble  More important to teach child right from wrong rather than try to punish them o Time outs are effective  Promote use of anger expression in play by allowing them to pound clay or use punching bag Magical Thinking  Preoperational phase: egocentricity is still present but there is some social awareness and ability to consider other viewpoints  They can only think of one idea at a time and are unable to think of all parts of a whole  Rich imagination and unlimited ability to invent and imitate  They explain concepts as they have heard from others, but their understanding is limited What is Magical Thinking?  A preschooler’s thinking: they believe thoughts are all powerful  Occurs because of their egocentrism and transductive reasoning  At risk for feeling guilty and responsible for bad thoughts that may coincide with the occurrence of a wished event o They lack ability to reason cause and effect o They accept meaning of words literally How to Manage Magical Thinking  Relate words to actions  Clarify why they are not responsible Sleep in Preschoolers  Peak time for sleep disturbance  Often sleep 12 hours per night o Daytime naps o Waking during the night is common  Need a consistent bedtime, nap schedule, and bedtime routine Nightmares  Scary dream that takes place during REM sleep and is followed by full waking  Child wakes and cries/calls for help; comforted by the physical presence of another  Usually occurs during second half of the night; difficulty returning to sleep  Interventions: o Accept that the dream is a real fear for the child o Offer comfort, assurance, and sense of protection o Avoid forcing child back to own bed o Seek professional counseling Night Terrors  Partial arousal from very deep sleep, stage 4 non-REM  Distress during terror, screaming, thrashing  Occurs 1-4 hours after falling asleep  May sit up, trash, run in a bizarre manner with bulging eyes o Racing heart, sweating, crying, screaming, talking o Fright, anger, confusion until child is fully awake  Unaware of another presence, may be difficult to comfort and may push person away and scream if held or restrained  Rapidly falls back asleep and has no memory  Interventions: o Observe their behaviors o Try not to intervene until child is calm or fully awake  If at risk for injury it is necessary to protect them o Guide back to bed if necessary o Can be difficult to watch and manage; important to reinforce that these are normal and common; best thing to do is promote safety Stress in Preschoolers  Child is beginning to understand the world better; starting school can be challenging  Birth of a sibling, marital discord, relocation, illness  Signs of stress: stubbornness, uncooperative, jealousy, separation anxiety, stuttering, disinterest in eating, bad dreams, disruptive, worried Stress Management       Preschool years are a good time to explain what stress is and how to cope It is a part of daily life, but too much can be harmful Teach physical signs of stress Relaxation and imagery are effective coping mechanisms Encourage them to speak about their feelings Toys such as drums or punching bags can be helpful ABUSE AND NEGLECT  Child maltreatment: physical, emotional, or sexual abuse and/or neglect  Abuse: intentional acts of harm inflicted on a child  Neglect: failure of a parent/guardian to provide child with basic needs and adequate care Physical Abuse/Neglect  Abuse: deliberate infliction of physical injury on a child o Hitting, slapping, kicking, throwing objects, hair pulling  Neglect: deprivation of necessities - food, clothing, shelter, supervision, medical care, education Risk Factors of Physical Maltreatment  Parental: family structure, socioeconomic factors, personal concerns o Younger parents, single-parent families o Low income, limited education, lack of support o Under the influence, low self-esteem, socially isolated, little knowledge of parenting skills  Child: o birth -1year, infants/children that require continuous care and rely heavily on others (disability, premature infants)  Environmental: o Divorce, poverty, unemployment, poor housing, frequent relocation, alcoholism, drug addiction, crowded living conditions Manifestations of Physical Maltreatment  Physical abuse o bruises, welts, burns, fractures, dislocations, lacerations, abrasions, poisoning o Wary of physical contact with adults, fear of parents or going home, not crying from pain, lack of reaction to frightening events, withdrawal  Physical Neglect: o Signs of malnutrition, poor personal hygiene, unclean or inappropriate dress, evidence of poor healthcare, frequent injuries from lack of supervision o Dull and inactive affect, begging or stealing food, absent from school, substance abuse, vandalism, shoplifting Abusive Head Trauma (AHT) - shaken baby syndrome  Physical abuse caused by violently shaking child  Typically, due to frustration with crying, stress, depression  Characteristics: intracranial bleeding, bilateral retinal hemorrhage, vomiting, irritability, lethargy, seizures, posturing, alterations in LOC  Can lead to: seizures, visual impairments, developmental delays, hearing loss, mild to profound mental/cognitive/motor impairments Emotional Abuse and Neglect  Emotional abuse: psychological maltreatment; deliberate attempt to destroy or significantly impair child’s self-esteem or competence o Rejecting, isolating, terrorizing, ignoring, corrupting, verbal assaulting, over-pressuring  Emotional neglect: failure to meet child’s needs for affection, attention, emotional support Manifestations  Growth failure, eating or feeding disorder, enuresis, sleep disorder  Self-stimulatory behaviors, during infancy a lack of social smile and stranger anxiety, withdrawal, unusual fearfulness, antisocial, extreme behaviors, delays in emotional and intellectual development, suicide attempts Sexual Abuse  The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, sexually explicit conduct or any simulation of such conduct, or the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children  Incest: sexual activity between family members  Molestation: touching, fondling, kissing, single or mutual masturbation, or oral-genital contact  Exhibitionism: indecent exposure of genitalia  Child pornography: arranging and photographing sexual acts involving children; regardless if they have consent by legal guardian  Child prostitution: involving children in sex acts for profit  Pedophilia: “love of child” and does not denote a type of sexual activity but rather the preference of an adult for pre-pubertal children as the means of sexual excitement Characteristics of Sexual Abusers  Anyone can be a sexual abuser - siblings, mothers, friends, extended family  Typical: male, knows the victim; income below poverty level; parents with lower educational level; full time jobs (often with children); active members in community; prior criminal record Characteristics of Sexual Abuse Victims  Males: less likely to report abuse and may suffer greater emotional harm o More likely to be subjected to anal penetration or oral-genital contact o Often abused by father, stepfather, mother’s boyfriend  For both males and females: most sexual abuse is committed by men and by a person the child knows  20-25% of child sex involves penetration or oral-genital contact Risk Factors for Sexual Abuse  Parental unavailability, lack of emotional closeness and flexibility, social isolation, emotional deprivation, communication difficulties Methods used to Pressure Children into Sexual Activity  Offer gifts or privileges, or have the privileges withheld  Adult misrepresents moral standards and tells child “It is okay to do”  Isolated and socially/emotionally deprived are enticed by adults who meet their needs for warmth and human contact  Pressures victim into secrecy by describing it as a “Secret between us” that other people would take away if they found out  Plays on the child’s fears such as fear of punishment, repercussions if the child tells, fear of abandonment or rejection by the family Cycle of Sexual Abuse  Starts insidiously (unless rape) → offenders spend me with vic m to gain trust (grooming) → victims are usually then pressures to be an accessory → children do not tell for fear of blame or limited vocabulary Manifestations of Sexual Abuse  Bruises, bleeding, lacerations, or irritation of external genitalia/anus/mouth/throat  Torn, stained, or bloody under clothing  Pain on urination or pain/swelling/itching of genital area, recurrent UTIs  Presence of sperm, pregnancy, penile discharge, STI, difficulty walking or sitting, unusual odor  Withdrawn, fantasies/daydreaming, poor relationships with peers  Sudden emergence of sexually related problems - public masturbation, sexual play, promiscuity, overly seductive behavior  Anxiety, loss/gain of weight, clinging, anger at mother, regression, running away, poor school performance, substance abuse, mood changes, sudden onset of phobias/fears Nursing Care of Maltreated Child  Know and identify different forms of maltreatment  Early identification can lead to early intervention and protection of the child  Interview and history, physical assessment, providing support for child and family, prevention Interview and History  Account from caregiver and child - date, time, location, who was present  Family history of bleeding and bone disorders  Determine if child feels safe  Caregiver’s ability to care for child  Warning signs: history of events is inconsistent with physical findings, child is silent, and caregiver speaks on their behalf, parent or guardian disappears when abuse is suspected, child tells identical facts repeatedly Physical Exam  Physical abuse: Identify all injuries: color, size, location; use body diagrams and take photos  Sexual abuse: document genital findings - abrasions, bruising, bleeding, scars o Collect specimens to determine presence of STIs  Emotional abuse: observe for changes in behavior  Check child’s growth and development - height, weight, nutritional status, hygiene Support for Child and Family  Provide a role model for parents, encourage child to resume normal activities, referrals, and groups Prevention  Home visits, nurse-family partnerships, prepare expectant families for adjustment to parenthood  Educate - encourage communication, information of sexual assault, listen