CHAPTER 46 NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL

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CHAPTER 46: NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS CALLIE WHITTINGTON,

CHAPTER 46: NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS CALLIE WHITTINGTON, MSN, RN

GOUT • A systemic connective tissue disorder cause by the accumulation of uric acid

GOUT • A systemic connective tissue disorder cause by the accumulation of uric acid crystals in one or more joints – Uric acid is a waste product, results from the breakdown of purines (proteins) in the body – Crystals are formed from excessive uric acid build up and deposits in joints • Build up causes severe inflammation and pain in one or more joints – Usually the great toe

GOUT, CONT. • Primary Gout – Most common type, caused by problem with purine

GOUT, CONT. • Primary Gout – Most common type, caused by problem with purine metabolism – Uric acid production > kidney’s ability to excrete – Triggered by: stress, ETOH consumption, illness, trauma, dieting, certain medications • Secondary Gout – Results from another health problem (renal insufficiency, medications – diuretics, chemotherapy) • Acute Gout: – One or more severely inflamed joints (usually small joints) – Joint is swollen, red, hot, and too painful to touch – Individual attacks usually subside in 2 -10 days • Chronic Gout: – May not show obvious S/S – Elevated uric acid levels can cause renal stone development

GOUT, CONT. • Diagnostic Testing: – Serum Uric Acid Levels (elevated) • • Normal

GOUT, CONT. • Diagnostic Testing: – Serum Uric Acid Levels (elevated) • • Normal ranges – Adult Male= 4. 0 -8. 5 mg/d. L – Adult Female= 2. 7 -7. 3 mg/d. L – Joint fluid aspiration from synovial fluid – Detailed history and physical assessment Treatment: – Drug Therapy: First-line treatment for primary gout – Secondary Gout: Managing underlying cause – Acute Gout: NSAIDs, cholchicine, steroids – Uricosuric agents (Allopurinol) prescribed to prevent increased serum uric acid • Must take daily to keep uric acid level within normal range – Diet must exclude certain foods (high purine foods, avoid ETOH) – Avoid ASA and diuretics – Use of footboards may be effective to hold bedding away from painful joints (feet)

OSTEOARTHRITIS • Most common form of joint disease in North America – Also called

OSTEOARTHRITIS • Most common form of joint disease in North America – Also called degenerative joint disease or “wear and tear” arthritis • A slow deterioration of articular cartilage and bone ends of joints (bones begin to rub together) – Joint becomes inflamed – Loss of cartilage and bone, resulting in pain, swelling, and stiffness • Most common joints affected include hips, knees, hands, and the vertebral column • Primary OA: – Unknown cause – Risk Factors: Aging, obesity, physical activities causing joint stress • Secondary OA: – Joint degeneration occurs as a result of trauma, sepsis, congenital anomalies, metabolic diseases (Paget’s), or rheumatoid arthritis

OSTEOARTHRITIS, CONT. • Clinical Manifestations: – One or more joint may be affected –

OSTEOARTHRITIS, CONT. • Clinical Manifestations: – One or more joint may be affected – Joint pain and stiffness – Morning stiffness resolving within 30 minutes – Pain increasing with activity, decreasing with rest – Red, swollen, tender nodes on distal and proximal phalanges (Heberden’s nodes, Bouchard’s nodes) • No systemic manifestations present in OA localized to joint/affects asymmetrically – Key difference between OA and RA • Mild discomfort ranges to significant disability – Pain worsens with joint use (predominant symptom) – Sitting down becomes difficult, as does getting up from a chair when hips are lower than knees

OSTEOARTHRITIS, CONT. • Diagnostic Tests: – X-Rays – CT scan, MRI – Analysis of

OSTEOARTHRITIS, CONT. • Diagnostic Tests: – X-Rays – CT scan, MRI – Analysis of synovial fluid • Therapeutic Measures: – No cure for OA – Focus of Tx: Pain control • Accomplished with drug therapy, other pain relief measures, or surgery – Medications: NSAIDs, Acetaminophen, Muscle Relaxants • Cautionary with older adults and frequent NSAID use – – – Rest and Exercise Heat and Cold Diet Complementary and Alternative Exercises Surgery

OSTEOARTHRITIS, CONT. • Therapeutic Care focuses on: – Managing pain and inflammation – Preventing

OSTEOARTHRITIS, CONT. • Therapeutic Care focuses on: – Managing pain and inflammation – Preventing disability – Maintaining and improving joint function • Balance Rest & Exercise – Protect Joints – – – Rest joint during periods of acute inflammation Immobilize if necessary (not greater than one week) – risk of joint stiffness w/ inactivity Modify usual activities to decrease joint stress Use assistive devices if necessary Exercise is a fundamental part of OA management • Preserves articular cartilage, improves joint stiffness, increases muscles • Heat & Cold – Reduce complications of pain and stiffness – Ice acute inflammation – Heat therapy stiffness • Hot showers in the morning, use of heating pad, whirlpool paths

OSTEOARTHRITIS, CONT. • Diet – Lose weight (if overweight) to decrease stress on joints

OSTEOARTHRITIS, CONT. • Diet – Lose weight (if overweight) to decrease stress on joints • Complementary Therapy – Acupuncture, Yoga, Massage, etc. • Drug Therapy – Based on severity of symptoms – Mild to Moderate: • Tylenol – 1000 mg q 6 hours (4 g in 24 hours) • Topical agent, Capsaicin cream: Blocks the transmission of pain impulses – Moderate to Severe: • When joints become inflamed NSAIDs (Motrin 200 mg QID) • Glucosamine: aides in cartilage regeneration, decreases inflammation

OSTEOARTHRITIS, CONT. • Surgical Therapy – If disease becomes debilitating, surgical interventions may be

OSTEOARTHRITIS, CONT. • Surgical Therapy – If disease becomes debilitating, surgical interventions may be necessary – Arthroscopic surgery: repairs cartilage and removes bone debris/cartilage • Improves joint motion • Delays need for knee replacement • Options only available for patients < 55 y/o – Joint arthroplasty may be indicated when pain cannot be managed or joint function affects QOL

OSTEOARTHRITIS, CONT. NURSING MANAGEMENT • Acute Intervention: – Treated in outpatient setting, thorough assessment

OSTEOARTHRITIS, CONT. NURSING MANAGEMENT • Acute Intervention: – Treated in outpatient setting, thorough assessment – Assess joint pain and stiffness, signs of inflammation or deformity – Impact on ability to perform ADLs – Pain management practices • Patient Education – Outpatient setting, unless patient scheduled for surgery – Diet, Exercise – Alteration of modifiable risk factors (weight loss, occupational hazards) – Way to protect joints and conserve energy

QUIZ! The nurse determines that teaching about management of osteoarthritis of the feet and

QUIZ! The nurse determines that teaching about management of osteoarthritis of the feet and hands has been effective when the patient says: 1. “I will be careful to avoid crowds and people with infections. ” 2. “I can use heat to relieve the stiffness when I wake up in the morning. ” 3. “I should exercise my hands every day, especially if they are painful and inflamed. ” 4. “I should avoid the use of glucosamine as it has been shown to have no therapeutic value. ”

RHEUMATOID ARTHRITIS • A chronic, progressive, systemic autoimmune disease – Destroys synovial joints and

RHEUMATOID ARTHRITIS • A chronic, progressive, systemic autoimmune disease – Destroys synovial joints and other connective tissues – Immune system attacks the joints, creating inflammation and causing synovitis (thickening of synovium) • Any connective tissue may be affected in RA – Blood vessels, nerves, kidneys, pericardium, lungs, and subcutaneous tissue • Dysfunction or failure of an organ or organ system can occur – If RA does not respond to treatment, death can result • RA affects people with a family history of this disease 2 -3 x more often • Can occur at any age

PATHOLOGIC CHANGES IN RHEUMATOID ARTHRITIS

PATHOLOGIC CHANGES IN RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS, CONT. CLINICAL MANIFESTATIONS • Vary person to person, can be divided into

RHEUMATOID ARTHRITIS, CONT. CLINICAL MANIFESTATIONS • Vary person to person, can be divided into early and late manifestations • Early Manifestations: – Bilateral and symmetrical joint inflammation, beginning in UE and progressing to other joints – Affected joints are slightly reddened, warm, swollen, stiff, and painful – Morning stiffness lasting for up to an hour or all day (if disease is severe) – Joint stiffness after periods of inactivity is common – Activity can help decrease pain and stiffness – Systemic Nature: • Stiff, sore joints often reason for initially seeking care • Low grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and weight loss – Organ system involvement • Late Manifestations: – Joint deformities – Secondary osteoporosis occurs, can lead to bone fractures

RHEUMATOID ARTHRITIS, CONT. • Systemic involvement of RA • Also know as extraarticular manifestations

RHEUMATOID ARTHRITIS, CONT. • Systemic involvement of RA • Also know as extraarticular manifestations

RHEUMATOID ARTHRITIS, CONT. • Possible to have associated syndromes with RA • Sjögren’s Syndrome

RHEUMATOID ARTHRITIS, CONT. • Possible to have associated syndromes with RA • Sjögren’s Syndrome – Inflammation of lacrimal and salivary glands – Diminished gland secretion • Dry mouth • Dry/burning/itchy eyes, decreased tearing • Intervention: Eye drops (artificial tears) to improve dryness • Felty’s Syndrome – Less common, characterized by enlarged liver and spleen, and leukopenia

RHEUMATOID ARTHRITIS, CONT. • Diagnostic Tests: – No specific test confirms RA – Lab/Immunological

RHEUMATOID ARTHRITIS, CONT. • Diagnostic Tests: – No specific test confirms RA – Lab/Immunological Tests: • Increase in WBC’s and platelets (except when Felty’s Syndrome is present) • Presence of rheumatoid factor (RF) • Increased ESR rate (presence of systemic inflammation) – ESR can also help evaluate effectiveness of treatment • Positive CRP (inflammation) – CRP can help evaluate effectiveness of treatment – X-Ray and MRI (evaluate joint damage/bone loss) – Bone Scan (shows involvement throughout body) – Arthrocentesis • Synovial fluid will be cloudy, milky, or dark yellow with inflammatory cells present

RHEUMATOID ARTHRITIS, CONT. • Therapeutic Measures – Medications • Antibiotics • Disease-Modifying Antirheumatic Drugs

RHEUMATOID ARTHRITIS, CONT. • Therapeutic Measures – Medications • Antibiotics • Disease-Modifying Antirheumatic Drugs (DMARDs) • NSAIDs • Corticosteroids (watch blood sugars closely—causes elevation) – Heat and Cold • Hot showers, heating pads – Warm bath and short rest might be effective for starting day • Cold applications for acutely inflamed, “hot joints”; cold packs before exercise may help during exacerbations • Balance rest and exercise; manage stress – Surgery • If arthritic pain continues, despite nonsurgical interventions, a total joint replacement may be performed

RHEUMATOID ARTHRITIS, CONT. NURSING MANAGEMENT • Data Collection: – Complete history and physical exam

RHEUMATOID ARTHRITIS, CONT. NURSING MANAGEMENT • Data Collection: – Complete history and physical exam – ADL involvement • Primary goals in managing RA – Decrease inflammation – Manage pain – Maintain joint function – Prevent or correct joint deformity • Patient Education: – Disease process, medication management, symptom management – Help patient plan a schedule balancing rest and exercise (swimming pool activities may be beneficial) – Involve family in teaching

CHAPTER 46: NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS MUSCULOSKELETAL SURGERY

CHAPTER 46: NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS MUSCULOSKELETAL SURGERY CALLIE WHITTINGTON, MSN, RN

TOTAL JOINT REPLACEMENT • Also known as arthroplasty • Performed for patients with some

TOTAL JOINT REPLACEMENT • Also known as arthroplasty • Performed for patients with some type of connective tissue disease – Joints have become severely deteriorated • May also be performed for patients on long-term steroid therapy – Patients with Systemic Lupus Erythematosus or Asthma – Causes avascular necrosis (bone tissue dies – usually the femoral head) • Very painful, doesn’t respond to conservative pain relief measures • Primary goal of TJR – Relieve severe chronic pain – Improve ability to carry out ADLs • Most common TJR surgeries – total hip replacement and total knee replacement – Any synovial joint can be replaced

TOTAL JOINT REPLACEMENT, CONT. • Replacement devices (prostheses) – Made of metal, ceramic, plastic,

TOTAL JOINT REPLACEMENT, CONT. • Replacement devices (prostheses) – Made of metal, ceramic, plastic, or a combo of these materials – Some prostheses are help in place by cement or by patients own bone

TOTAL HIP REPLACEMENT • Elective procedure, Lasts 15 years to a lifetime • Acetabular

TOTAL HIP REPLACEMENT • Elective procedure, Lasts 15 years to a lifetime • Acetabular cup inserted into pelvic acetabulum and a femoral component inserted into the femur to replace femoral head • Pre-Op: – Teaching and Screening: about surgery, what to expect post-op – Case Manager assess patient’s needs and support systems available post-op – Patient must have caregiver to help assist post-op – Nursing Assessment: Neurovascular, Pain, additional baseline assessments – Donation of autologous blood – Admitted to hospital day of, administered prophylactic antibiotic • Ideal length of stay 2 to 5 days • Joint Camp Programs at some hospitals

TOTAL HIP REPLACEMENT, CONT. • Post-Op: – General Post-Op Care performed – Interdisciplinary approach

TOTAL HIP REPLACEMENT, CONT. • Post-Op: – General Post-Op Care performed – Interdisciplinary approach – Patient usually gets out of bed the night of surgery, or early next day • Ensure proper positioning – do not allow adduction or hyperflexion of surgical hip – Patient may report less pain post-op • Pain controlled using PCA or injections of analgesics – Early ambulation is encouraged • Helps post-op complications – DVT – Patients should not bend over to tie shoes or put pants on

TOTAL HIP REPLACEMENT, CONT. • Hip Dislocation • Skin Breakdown • Infection • Bleeding

TOTAL HIP REPLACEMENT, CONT. • Hip Dislocation • Skin Breakdown • Infection • Bleeding • Neurovascular Compromise • Venous Thromboembolic Complications

TOTAL HIP REPLACEMENT, CONT. HIP DISLOCATION • Most common post-op complication from THR •

TOTAL HIP REPLACEMENT, CONT. HIP DISLOCATION • Most common post-op complication from THR • Femoral component dislodges from acetabular cup • Audible “POP” often heard, followed by immediate pain • Surgical hip will shorten, possible internal rotation of leg • Notify surgeon IMMEDIATELY! • Administer additional pain medications, if ordered • Patient will return to OR to have hip reduced – Leg will remain immobilized until it heals

TOTAL HIP REPLACEMENT, CONT. HIP DISLOCATION • Preventing hip dislocation after THR is a

TOTAL HIP REPLACEMENT, CONT. HIP DISLOCATION • Preventing hip dislocation after THR is a BIG nursing responsibility • Ensure surgical leg remains in correct position – Prevent hip adduction (across body midline) and hyperflexion (bending forward > 90 degrees) • Correct patient positioning after THR: – Supine, head slightly elevated – Place trapezoid-shaped adduction pillow in between legs to prevent adduction • May also use splint, wedge, or regular bed pillow • Patient may be turned to the side specified by HCP – Turn with abductor pillow or three regular pillows (one proximal and two distal – shape of trapezoid) – Turn hip and leg simultaneously to minimize chance of dislocation • Preventing hyperflexion – Some surgeons only allow patient to sit at no more than a 60 degree angle • Progressing to 90 degrees – Use fracture bedpan while patient on bedrest

TOTAL HIP REPLACEMENT, CONT. SKIN BREAKDOWN • Most patients having THR are older, must

TOTAL HIP REPLACEMENT, CONT. SKIN BREAKDOWN • Most patients having THR are older, must ensure skin breakdown is prevented • Turn patient q 2 h (or more often if high risk) • Keep heels off of the bed to prevent pressure ulcers • Vulnerable areas – heels, elbows, sacrum – Can breakdown within 24 hours • Prophylactically apply cushioning dressings and heel protectors • Keep incontinent patients clean and dry – Toilet assist q 2 h – Use protective barrier cream • Ensure adequate diet and hydration

TOTAL HIP REPLACEMENT, CONT. INFECTION • In addition to pre-op IV antibiotics, the surgeon

TOTAL HIP REPLACEMENT, CONT. INFECTION • In addition to pre-op IV antibiotics, the surgeon may irrigate the incision with antibiotics intra-op, place beads in the incision, or continue patient on IV antibiotics for 24 hours post-op • Aseptic care of surgical wound is very important to minimize chance of infection • Dressing changes: – Observe for S/S of infection • Redness, swelling, warmth, odor, pain, yellow/green/brown drainage • Monitor vital signs (temperature elevation) • Older adults may show confusion due to infection • Late infection can occur 1 or more years after THR – If it does not respond to antibiotics, prosthesis may be removed and replaced

TOTAL HIP REPLACEMENT, CONT. BLEEDING • Up to 2/3 of any blood loss can

TOTAL HIP REPLACEMENT, CONT. BLEEDING • Up to 2/3 of any blood loss can occur post-op (in THR or TJR) • Surgical drain (Hemovac or Jackson-Pratt) may be emptied q 8 -12 h – The use of drains has decreased to help prevent infections • Monitor dressings for drainage – Draw a line around drainage to monitor hourly progression – Report large or unexpected amounts • Hgb & Hct may decrease post-op and blood transfusion may be necessary – Use autologous blood if provided pre-op • Monitor for additional blood loss from incision • Monitor for S/S of hypovolemic shock

TOTAL HIP REPLACEMENT, CONT.

TOTAL HIP REPLACEMENT, CONT.

TOTAL HIP REPLACEMENT, CONT. NEUROVASCULAR COMPROMISE • Nurse must perform frequent neurovascular assessments –

TOTAL HIP REPLACEMENT, CONT. NEUROVASCULAR COMPROMISE • Nurse must perform frequent neurovascular assessments – Assess DISTAL to surgical procedure – Circulation (color, warmth, pulses), sensation, movement – Compare with unaffected side and pre-op assessment

TOTAL HIP REPLACEMENT, CONT. VENOUS THROMBOEMBOLIC COMPLICATIONS • THR patients are at greatest risk

TOTAL HIP REPLACEMENT, CONT. VENOUS THROMBOEMBOLIC COMPLICATIONS • THR patients are at greatest risk for DVT or PE • Even higher risk population (potentially fatal problems) – Obese, Older Adults, patients with hx of thromboembolic problems • Apply thigh-high compression stockings and use intermittent pneumatic compression devices • Administer anticoagulation medication • Perform leg exercises immediately post-op • Educate importance of anticoagulation medication & exercises

AMPUTATION • Removal of a body extremity by trauma or surgery • Surgical Amputation

AMPUTATION • Removal of a body extremity by trauma or surgery • Surgical Amputation – Ischemia from PVD, atherosclerosis, vascular changes from DM • Peripheral neuropathy ulcers, gangrene – Also performed to remove bone tumors, thermal injuries (frostbite, electric shock), crush injuries, congenital problems, or infections (osteomyelitis) • Traumatic Amputation: – Occurs from accidents (industrial machinery, motor vehicles, lawn mowers, chain saws, snow blowers, etc. ) – Amputated limb is usually healthy in these cases, surgeon may attempt replantation (common – finger) • Pre-hospital care: rinse body part if dirty, wrap in clean, moist cloth and place in sealed bag • Then place sealed bag in ice cold water and transport to hospital • Surgeon must reattach nerves, vessels, and muscles

AMPUTATION, CONT. • Most common amputation site is lower extremity • Attempt to remove

AMPUTATION, CONT. • Most common amputation site is lower extremity • Attempt to remove extremity most distal – Toe before foot, foot before BKA, BKA before AKA – More proximal the amputation, the more disability present • Great Toe: – Loss affects balance and gait • BKA preferred over AKA – Preserve joint function – Higher level of amputation requires more energy for ambulation • Upper extremity amputations result more from trauma – Loss of UE are more significant and result in more difficulty performing ADLs

AMPUTATION, CONT. • Pre-Op Care: – Elective amputations have time advantage • Education, prosthesis

AMPUTATION, CONT. • Pre-Op Care: – Elective amputations have time advantage • Education, prosthesis fitting, emotional adjustment, autologous blood donation • Meet with rehabilitated amputee if possible • Identify support systems and coping – Traumatic amputations do not have time to prepare for the significant changes that are soon to come

AMPUTATION, CONT. • Post-Op Care: – General Post-Op Care – Assess stump and perform

AMPUTATION, CONT. • Post-Op Care: – General Post-Op Care – Assess stump and perform dressing changes at least q 8 h, perform stump shaping – Prevent hemorrhage and infection • Assess bulky drainage for bleeding, assess pulses • If blood is on dressing when patient comes to PACU – circle area of drainage and date/time – Closely monitor for enlargement – Notify surgeon immediately if bleeding continues • Inspect wound for redness, warmth, drainage – Control Pain • Phantom pain – ALWAYS real pain, treat with prescribed pain medications • Phantom sensation – Patient feels as if limb is still there, however it is not painful – Mobility and Ambulation • Do not keep leg flexed for long periods of time • PT will assist with muscle strengthening exercises • Trapeze Overhead Bar

AMPUTATION, CONT. • Post-Op Care Cont. : – Prosthesis Care: • Residual limb swelling

AMPUTATION, CONT. • Post-Op Care Cont. : – Prosthesis Care: • Residual limb swelling must subside prior to using prosthesis • Residual limb is wrapped q 8 h with elastic wrap (helps mold stump to fit prosthesis) – Neurovascular assessment, skin integrity, healing, infection • Teach patient prosthesis care – Lifestyle Adaptation • Patient may feel life will be markedly changed after amputation • Most people can return to work after prosthesis • Patients can bowl, ski, hike, and continue with all recreational hobbies • Supportive family is vital • If patient is not a candidate for a prosthesis, wheelchair will be needed – Home adaptations – Self-Care Help

QUIZ Which of the following actions would be a priority for a client who

QUIZ Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bandage above the amputation site? • A. Elevate the stump • B. Reinforcing the dressing • C. Calling the surgeon • D. Drawing a mark around the site

THE CHILD WITH MUSCULOSKELETAL OR ARTICULAR DYSFUNCTION ------------------THE CHILD WITH NEUROMUSCULAR OR MUSCULAR DYSFUNCTION

THE CHILD WITH MUSCULOSKELETAL OR ARTICULAR DYSFUNCTION ------------------THE CHILD WITH NEUROMUSCULAR OR MUSCULAR DYSFUNCTION CH. 31 (1050 – 1089) & CH. 32 (1090 – 1109) CREATED BY: CALLIE WHITTINGTON, MSN, RN

LEADING CAUSES OF INJURY TO CHILDREN • Falls – Leading cause of nonfatal injury

LEADING CAUSES OF INJURY TO CHILDREN • Falls – Leading cause of nonfatal injury among children 0 -15 years • Struck by object • Motor vehicle collision/MVC – Trauma caused by MVC leading cause of nonfatal injury 15 -19 years

IMMOBILIZATION & GROWTH • Child illness can sometimes cause or require immobilization. Impaired mobility

IMMOBILIZATION & GROWTH • Child illness can sometimes cause or require immobilization. Impaired mobility presents challenges in many ways. • Profound effect on child’s growth & development • Efforts directed toward early ambulation • Physiologic Effects of prolonged immobilization: – – – – Loss of muscle strength, endurance, and muscle mass Decreased metabolic rate Bone demineralization can lead to osteoporosis Contractures Venous stasis thrombus or emboli formation Tissue ischemia Pressure Ulcer development from decreased circulation Decreased need for O 2, loss of respiratory muscle strength • Very difficult on families, must promote coping skills

SPRAINS & STRAINS • Trauma to a joint ligament is torn or stretched •

SPRAINS & STRAINS • Trauma to a joint ligament is torn or stretched • First 12 – 24 hours are critical for soft-tissue injuries – Immediately ice, no longer than 30 minutes at a time – RICE! – Immobilize and support injured extremity

BONE FRACTURE IN A CHILD • Children have presence of: – Growth plate, Thicker

BONE FRACTURE IN A CHILD • Children have presence of: – Growth plate, Thicker and stronger periosteum, More rapid healing – Fractures in children are dealt with much differently than in adults • Fractures are rare in infants, except with MVA – Bone injury in this age group usually requires further investigation – Nonaccidental trauma • School-age children commonly fracture extremities from sports injuries • Adolescents are vulnerable to severe trauma due to recreational activities • Common fractures in children: Distal Forearm or Clavicle • Infants: Fractured clavicle can occur at birth

FRACTURES, GROWTH PLATE INJURIES • Area of growing tissue near the ends of the

FRACTURES, GROWTH PLATE INJURIES • Area of growing tissue near the ends of the long bones in children and adolescents – Weakest point of long bones • Frequent side of damage during childhood trauma • Detection of these injuries can be difficult but is critical – X-Ray may be negative (if fracture is nondisplaced) – Must prevent longitudinal deformities and premature arrest of bone growth • When a fracture occurs, muscles immediately contract and splint the area for protection – Muscles pull bone ends out of alignment – To overcome this response, traction is used to realign the bone

FRACTURES, BONE HEALING & REMODELING • Bone healing is rapid in growing children •

FRACTURES, BONE HEALING & REMODELING • Bone healing is rapid in growing children • Osteoblasts are stimulated to maximal activity after a break – New bone cells are formed almost immediately after the injury • Fractures heal in less time in children than in adults

FRACTURES, EVALUATION • Diagnosis of a childhood fracture may be difficult – Lacking history

FRACTURES, EVALUATION • Diagnosis of a childhood fracture may be difficult – Lacking history – Obtain information from a witness if possible • Clinical Manifestations are similar as in adults: – Swelling, Pain, Tenderness, Deformity, Diminished Use – However, a child may be able to use affected extremity due to periosteum

FRACTURES, MANAGEMENT: REVIEW • Regain alignment and length of the bony fragments (Reduction) •

FRACTURES, MANAGEMENT: REVIEW • Regain alignment and length of the bony fragments (Reduction) • Retain alignment and length (immobilization) • Restore function • Prevent further injury • Nursing Management: – Remain calm with injured child – Use age appropriate explanations – Communicate with parents – If open fracture, change dressing with sterile technique

CASTS • Four major categories: UE, LE, Spinal and Cervical, Spica Casts • Cast

CASTS • Four major categories: UE, LE, Spinal and Cervical, Spica Casts • Cast Application – – Determine child’s developmental age prior to application of cast Use distraction methods if necessary Fiberglass cast vs. Paris cast Use of palms instead of fingers • Nursing assessment: – Neurovascular assessment, edema, pain, drainage (bloody) • Educate parents of child, especially upon discharge – – If child goes home with a cast, instruct parents to rest and elevate the extremity Teach about proper cast care S/S of infection! (Hot spots) S/S of compartment syndrome!!!!!! {VERY IMPORTANT} • Cast Removal – Cutting the cast off can be frightening for child – Skin will be caked with desquamated skin & sebaceous secretions • Apply baby oil or soak extremity in tub, do not pull, pick or forcibly remove material

TRACTION • Fatigues involved muscles to reduce muscle spasms, realigning bones • Position bones

TRACTION • Fatigues involved muscles to reduce muscle spasms, realigning bones • Position bones in desired realignment to promote satisfactory bone healing • Immobilize fracture site until realignment achieved or casting/splinting occurs • Buck’s Traction – Legs in extended position, short-term immobilization (pre-op) • Russell’s Traction – Realignment of lower extremity and immobilizes hip and knee in flexed position – Special nursing measures include checking position of traction frequently • Ensure traction is maintained continuously and desired hip flexion is maintained • Halo Brace/Vest – Halo attached to head using four screws (inserted into outer skull) – Used for cervical spine injury – Allows movement of body without involving cervical spine

AMPUTATION • A child may have been born with the congenital absence of an

AMPUTATION • A child may have been born with the congenital absence of an extremity, had a traumatic amputation of an extremity (from MVA), or need surgical amputation for a pathologic condition (i. e. osteosarcoma) • Stump Shaping • Phantom Limb Sensation • Phantom Limb Pain • For more about amputations: Refer to N 126 Lecture 2 (Chapter 46)

OSTEOSARCOMA • Most common bone cancer in children • Femur most common site (more

OSTEOSARCOMA • Most common bone cancer in children • Femur most common site (more than 50% of cases occur in this site) • Optimal treatment includes surgery and chemotherapy • Limb salvage or amputation • Nursing care depends on surgical approach • If amputation performed, child is fitted for temporary prosthesis immediately and a permanent one in 6 to 8 weeks

STRESS FRACTURES • Occurs due to repetitive, excessive stress on the bone – Causes

STRESS FRACTURES • Occurs due to repetitive, excessive stress on the bone – Causes microfractures within the bone • Continued stress to that bone can lead to the spread of the microfracture and eventual macrofracture • Occur most commonly in lower extremities, track & field athletes have the highest incidence • Sharp, persistent, progressive pain or a deep, persistent dull ache located over the bone • Diagnosis based on clinical observation and history • Therapeutic Measures: rest, physical therapy, medications, alternate activities

DEVELOPMENTAL DYSPLASIA OF THE HIP • Broad terms describing a spectrum of disorders related

DEVELOPMENTAL DYSPLASIA OF THE HIP • Broad terms describing a spectrum of disorders related to abnormal development of the hip – May occur anytime during fetal life, infancy, or childhood • Cause of DDH is unknown (could be due to certain factors: gender, birth order, etc. ) • New recommendations regarding infant swaddling position to help decrease incidence of DDH – There was a significant relationship between tight swaddling and hip dysplasia – When infants hips are held apart, low rates of hip dysplasia occur • Diagnostic Evaluation: – Not usually detected at initial examination at birth, all infants should be carefully monitored at follow-up visits – Radiographic examination is not always reliable • Femoral head is not ossified

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT. • Therapeutic Management: – Begins as soon as

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT. • Therapeutic Management: – Begins as soon as condition is recognized, the longer delayed the more severe the deformity – Treatment varies with child age and extent of dysplasia – Goal of treatment is to obtain and maintain a safe, congruent position of the hip joint • Promote normal hip joint development – Newborn – 6 mos. : • Place child in a Pavlik Harness – gently aligns baby’s hips so they are aligned in the joint, keeping hip joint secure • Wears 6 -12 weeks, checked every week or two for adjustment – 6 mos. – 24 mos. : • Dislocation not often recognized until child begins to stand walk • Closed reduction performed under general anesthesia • Baby placed in spica cast for about 12 weeks – Older Children: • Open reduction is usually required, body cast used for 6 -8 weeks http: //hipdysplasia. org/developmental -dysplasia-of-the-hip/child-treatmentmethods/hip-spica-cast/

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT.

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT.

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT. • Nursing Care Management: – Inspect infant carefully

DEVELOPMENTAL DYSPLASIA OF THE HIP, CONT. • Nursing Care Management: – Inspect infant carefully during routine activities, report abnormal findings to physician – Caring for child in cast • Teaching parents to apply and maintain reduction device • Pavlik harness allows to easy handling of infant, less apprehension – Maintain skin integrity and prevent breakdown • Put undershirt on child, check frequently for redness, massage healthy skin – Instruct parents to hold and nurture child – Children in corrective devices need to be involved in all of the activities of any child in the same age group

CLUBFOOT • Complex deformity of the ankle and foot • Precise cause unknown, may

CLUBFOOT • Complex deformity of the ankle and foot • Precise cause unknown, may be from abnormal positioning and restricted movement in utero • Deformity is readily apparent and easily detected prenatally through ultrasonography • Therapeutic Management: – Goal of treatment is to achieve a painless, plantigrade and stable foot – Treatment includes: 1. Correction of deformity, 2. Maintenance of the correction until normal muscle balance regained, and 3. Follow-Up observation to avert possible recurrence of deformity – Common approach include the Ponseti method • Serial casting beginning shortly after birth • Weekly manipulation allows for gradual repositioning of the foot

CLUBFOOT, CONT. • Nursing Care: – Same as for any child in a cast

CLUBFOOT, CONT. • Nursing Care: – Same as for any child in a cast – Observe skin and circulation – Parent Education and support • Ensure they understand the overall treatment program, importance of regular cast changes, and the role they play in the long term effectiveness of therapy

SPINE CURVATURE DISORDERS • Kyphosis – Outward curve (convex) of the upper spine •

SPINE CURVATURE DISORDERS • Kyphosis – Outward curve (convex) of the upper spine • Lordosis – Inward curve (concave) of the cervical or lumbar spine

SPINE CURVATURE DISORDERS, CONT. IDIOPATHIC SCOLIOSIS • Complex spinal deformity in three planes –

SPINE CURVATURE DISORDERS, CONT. IDIOPATHIC SCOLIOSIS • Complex spinal deformity in three planes – Involved lateral curvature, spinal rotation (causing rib asymmetry), and thoracic hypokyphosis • Can be caused by a number of conditions • Noticeable during preadolescent growth spurt • Diagnostic Evaluation: – Observe standing child from behind noting their shoulder height, flank shape, and hip height/alignment – Child bending forward at waist with hanging arms, asymmetry of ribs and flank may be noted

SPINE CURVATURE DISORDERS, CONT. IDIOPATHIC SCOLIOSIS • Therapeutic Management: – Bracing and Exercise •

SPINE CURVATURE DISORDERS, CONT. IDIOPATHIC SCOLIOSIS • Therapeutic Management: – Bracing and Exercise • Treatment of choice • Bracing is not curative but may slow progression of curvature to allow for skeletal growth and maturity – Surgical Management • Required for treatment of severe curves, > 45 degrees • Nursing Care – Pre- and Post-Op Care (Neurological Assessment) – Management of child in brace – Child and parent education

MOVING ON… Chapter 32! Neuromuscular Dysfunction

MOVING ON… Chapter 32! Neuromuscular Dysfunction

CEREBRAL PALSY • Caused by disturbances occurring during development of fetal or infant brain

CEREBRAL PALSY • Caused by disturbances occurring during development of fetal or infant brain – Genetic Factors – Perinatal Ischemic Stroke – Child Abuse • Multiple types of CP classified by severity level, motor function, muscle tone, and more – Spastic, dyskinetic, ataxic, and mixed • Most common clinical CP: Spastic CP – Upper motor neuron muscular weakness • Early recognition made difficult due to lack of reliable neonatal neurologic signs – Nurses should monitor infants with known risk factors closely for the first 2 years of life

CEREBRAL PALSY, CONT. • Clinical Manifestations: – Impairment of muscle tone, gross and fine

CEREBRAL PALSY, CONT. • Clinical Manifestations: – Impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes, and posture – Oral motor dysfunction, such as swallowing and feeding difficulties, speech impairment, and poor facial muscle tone • https: //www. youtube. com/watch? v=Dx. ENA 1 grs. NU • https: //www. youtube. com/watch? v=gdi. MNPOcln. U

CEREBRAL PALSY, CONT. • Therapeutic Management: – Early recognition and promotion of development •

CEREBRAL PALSY, CONT. • Therapeutic Management: – Early recognition and promotion of development • Allows children to attain normalization – Disorder is permanent • Therapy is preventative and symptomatic – Establish communication, self-help skills, promote socialization, correct defects – Children managed on individual basis dependent upon extent of disease • Prognosis: – If child does not achieve independent ambulation by age 7, chances for ambulation and independence are poor – About 30% of adults with CP remain in home, 50% live in independent settings • Nursing Management: – Parent Education – Reinforce therapeutic plan – Support Family

MYELOMENINGOCELE • Type of Neural Tube Defect • Birth defect of spine and spinal

MYELOMENINGOCELE • Type of Neural Tube Defect • Birth defect of spine and spinal cord – does not close before birth – External protrusion of a saclike cyst containing meninges, spinal fluid, and nerves – Type of Spina Bifida • Clinical manifestations: – Dependent upon where sac is located on vertebra • Lumber Vertebra – Flaccid, partial paralysis of lower extremities – Neurogenic bladder common • Sacral Vertebra – No motor impairment – Hydrocephalus {MOST COMMON PROBLEM ASSOCIATED WITH MYELOMENINGOCELE!!!!)

MYELOMENINGOCELE • Care for infant: – Early closure (within 24 – 72 hours) offer

MYELOMENINGOCELE • Care for infant: – Early closure (within 24 – 72 hours) offer favorable outcome – Prevent infection • Watch for early S/S – temperature instability, irritability, lethargy – Infant must lay in prone position • Minimizes tension on the sac, decreases risk of trauma • Feed in this position – turn head to side and nipple feed – Diapering may be contraindicated until repair – Be aware of skin breakdown due to position – Cover with sterile moist non-adherant dressing to protect sac • Post-Op Care – VS, I&Os, S/S of infection • Family support • Over half of Neural Tube Defects can be prevented by daily folic acid intake for women of child bearing age! {0. 4 mg is recommended daily value}

SPINAL MUSCULAR ATROPHY, TYPE 1 • Also known as Werdnig-Hoffmann Disease • Disorder characterized

SPINAL MUSCULAR ATROPHY, TYPE 1 • Also known as Werdnig-Hoffmann Disease • Disorder characterized by progressive weakness and wasting of skeletal muscles • Autosomal recessive trait – Most common form of floppy infant syndrome • Profound symmetrical weakness and wasting of skeletal muscles • Clinical manifestations within first few weeks of life – Inactivity – Infant lying in frog-leg position----very suggestive of diagnosis – Active movement usually limited to fingers and toes • Prognosis: – Individuals may succumb to respiratory infections or failure between 1 to 24 mos. – Some may live into their third or fourth decade of life – Significant number require a tracheotomy

SPINAL MUSCULAR ATROPHY, TYPE 1, CONT.

SPINAL MUSCULAR ATROPHY, TYPE 1, CONT.

MUSCULAR DYSTROPHY • Muscular dystrophies are the largest and most important single group of

MUSCULAR DYSTROPHY • Muscular dystrophies are the largest and most important single group of muscle diseases of childhood • Gradual degeneration of muscle fibers • Characterized by progressive weakness and wasting of symmetric groups of skeletal muscles – Increasing disability and deformity • In all forms of MD: – Insidious loss of strength • Each type of MD differs in regard to muscle groups affected

MUSCULAR DYSTROPHY, CONT. DUCHENNE MD • Most severe and most common form of MD

MUSCULAR DYSTROPHY, CONT. DUCHENNE MD • Most severe and most common form of MD • Inherited X-linked recessive trait (males affected almost exclusively) • Characteristics: – Most children reach appropriate developmental milestones early in life with mild, subtle delays – Onset occurs between ages 3 – 7 – Difficulties running, riding bicycle, climbing stairs – Mild to moderate cognitive impairment – Gower Sign: rise from squatting or sitting position on the floor – Waddling Gait, Frequent falls – Loss of ambulation occurs between ages 9 – 12 • https: //www. youtube. com/watch? v=KW 4 Wv. Ld 5 Nq. Y • https: //www. youtube. com/watch? v=Ipo. T 46 EAu. CU

MUSCULAR DYSTROPHY, CONT. DUCHENNE MD • Eventually, cardiac and respiratory problems become the central

MUSCULAR DYSTROPHY, CONT. DUCHENNE MD • Eventually, cardiac and respiratory problems become the central focus of the debilitating illness – Bi. PAP, at home monitoring of oxygenation levels, mechanically assisted coughing machines • Therapeutic Management: – No effective treatment exists – Maintain optimal function in all muscles for as long as possible – Prevent contractures – Help child and family cope with chronic, progressive, incapacitating disease • Nursing Care: – Help child and family cope with chronic, progressive, incapacitating disease – Discussion of long-term care, end-of-life care, and palliative care • Prognosis: – Some children only live into their teens – Outlook for condition is much better today than it used to be (with noninvasive ventilation and mechanically assisted coughing machines) – Recommend genetic counseling as part of treatment plan