Module 6

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Pediatric Nursing Care
Chapter 20
Care of the Child with
Musculoskeletal Disorders
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Anatomy and Physiology of the
Muscles
 Muscles
– 3 Types of body muscles
– Skeletal muscles are striated
 Assists in movement, maintains posture
 Tendons
– Attach bones to muscles
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Anatomy and Physiology of the
Skeleton
 Skeleton
– Ossification almost complete at birth
– 3 sections of bone
– Epiphyseal plate (growth plates)
– Hematopoiesis
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
A and P of the Bone
Diagram
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Postural Changes with Growth
 Cervical and lumbar areas become concave
 Bowed legs (genu varum) in infant
 Knock knees (genu valgum) in preschool child
 Resolve with growth
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Postural Changes
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Assessment of the
Musculoskeletal System History
 History
– Review history of birth in infants
– Obtain information about injuries in children
– Inquire about deformities
– Determine activity level, developmental delays
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assessment of the
Musculoskeletal System History
 Inspect posture and gait
 Note symmetry of shoulders, hips, an any
unusual curvature of spine
 Assess for full ROM of joints
 Assess muscle strength
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Congenital Skeletal Defects
 Range from minor and easy to correct to major
malformations requiring long-term therapy
 Rarely life threatening
 Two common defects
– Developmental dysplasia of the hip
– Clubfoot
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of the
Hip
 Developmental hip abnormality
 Involves femoral head, acetabulum, or both
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Manifestations
 Partial or complete dislocation of hip joint
 Shortening of femur
 Uneven thigh and gluteal folds
 Limited abduction on the affected side
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Diagnosis
 Physical examination of hip
– Allis sign
 Flex knees and hips with heels close to buttocks and feet
flat on exam table
 Dislocation of hip demonstrated by lower position of knee
on affected side
– Ortolani-Barlow maneuver
 See figure
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Ortolani-Barlow Maneuver
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Treatment
 Medical Management
– Small abnormality – apply three diapers
– Apply Pavlik harness for 3 – 4 months
– Place in skin traction for older children
– Perform surgery followed by hip spica cast
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Developmental Dysplasia of Hip
Nursing Care
 Maintain traction
 Provide cast care
 Assess lung sounds, neurovascular symptoms,
skin
 Reposition with cast every 2 hours
 Encourage diet high in fiber, adequate fluids
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Talipes
 Talipes or Clubfoot
– Congenital twisting of the foot
– Unilateral or bilateral
– Usually inward twisting
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Talipes Manifestations
 Manifestations
– Equines or midfoot directed downward
– Varus or hindfoot turns inward
– Forefoot curls toward heel and upward
– Smaller foot, shortened Achilles tendon
– Atrophies muscles of lower leg
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Talipes
Diagnosis and Treatment
 Diagnosis
– Observation of symptoms
– X-ray
 Treatment
– Apply cast to correct foot position
– Change cast every 1-2 weeks for 3 months
– Perform surgical correction if casting fails
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Talipes
Nursing Considerations
 Nursing interventions
– Assist with cast application
– Teach parents cast care
– Administer pain medications
– Observe for drainage and bleeding
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Musculoskeletal Disorders
 Most common disorders affecting older child
 Partially due to changes in bone structure
during rapid growth or accidents
 Common disorders
–
–
–
–
Muscular dystrophy
Legg-Calve-Perthes Disease
Scoliosis
Juvenile rheumatoid arthritis
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Scoliosis
 Lateral S-or-C shaped curve of spine
 Rotation of spine and ribs
 Right-sided thoracic curve
 Left-sided lumbar curve
 More common in girls
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Scoliosis
Manifestations
 Manifestations
– Shoulders and hips
different heights
– Rotation of vertebrae
and ribs
– One-sided rib hump,
prominent scapula
– Asymmetrical
posterior chest
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Scoliosis
Diagnosis
 Diagnosis
– Moiré photography
– Spinal x-ray
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Scoliosis
Treatment
 Treatment
– Mild scoliosis
 Exercise, chiropractic adjustments
– Moderate scoliosis
 Boston or Milwaukee brace
– Severe scoliosis
 Surgery with rods, wires, halo brace
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Other Spinal Curvatures
 Kyphosis
– Excessive convex curvature of thoracic spine or
hunchback
 Lordosis
– Excessive concave curvature of lumbar spine, or
sway back
 Torticollis
– Tilt of head caused by rotation of cervical spine or
wry neck
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
RICE
 R - Rest
 I - Ice
 C - Compression
 E - Elevation
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Musculoskeletal Trauma
Fracture
 Altered continuity of bone
 Common occurrence in childhood
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Fractures
Manifestations & Diagnosis
 Manifestations
– Pain, abnormal positioning, edema
– Discoloration, abnormal movement
– Broken skin, bleeding
 Diagnosis
– X-rays of injured area
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Fractures
Treatment
 Treatment
– Realign by closed reduction
– Realign by open reduction
– Apply traction
– Immobilize with external fixators or immobilizers
– Apply plastic or plaster cast
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Fractures
Nursing Considerations
 Assess neurovascular status using the 5Ps
– Paresthesias, pain/pressure, pallor, paralysis,
pulselessness
 Prevent skin breakdown
 Maintain proper alignment
 Traction weights hang freely
 Administer pin care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Compartment Syndrome
 Occurs when increased pressure in limited
space compromises circulation and nerve
innervation
 May lead to necrosis
 Symptoms
– Paresthesia, pain/pressure, pallor, paralysis,
pulselessness
– Deep pain unrelieved by analgesia
– Edema
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Compartment Syndrome
Nursing Care
 Report immediately
 Requires removal or alteration of cast
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Fractures
Nursing Considerations
 Assess for compartment syndrome
 Administer pain medication
 Teach cast care, orthopedic appliances
 Teach proper crutch walking
 Teach to recognize complications, signs of
abuse
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Bucks Traction
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Bryant Traction
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Skeletal Traction 90/90
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Russels Traction
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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External Fixator
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Clavical Strap
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Cast Care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Spica Cast
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Musculoskeletal Infection
Osteomyelitis
 Infection of bone
 May spread to surrounding tissue
 Caused by bacteria, virus, fungi
 Follows injury or surgery
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis
Manifestations
 Constant pain in affected area
 Edema
 Decreased mobility of joint
 Refusal to use limb, limp
 Redness at site of injury, fever
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis
Diagnosis
 History of trauma
 Increased white blood cell count
 Increased erythrocyte sedimentation rate
 X-rays, bone scans
 Needle aspiration of fluid for culture
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis
Treatment
 Hospitalization
 Administer intravenous medication
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Osteomyelitis
Nursing Considerations
 Administer antibiotics
 Arrange for home health nurse
– Administer antibiotics
– Care of intravenous site
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Stump Care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
Priorities
 Promote independence of the child
 Promote mobility as allowed
 Maintain safety
 Explain resources for support and proper home
care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
Assessing
 Monitor cardiac, respiratory, urinary, and bowel
function
 Assess ROM, mobility, posture, and muscle
strength
 Note swelling, redness
 With assistive devices assess correct use and
effectiveness
 For chronic disorders assess family’s ability to
provide care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Diagnoses
 Impaired physical mobility related to
musculoskeletal impairment
 Activity intolerance related to weakness
 Risk for injury related to altered mobility
 Compromised coping: family related to caring
for a child with a chronic condition
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Outcomes
 Mobility will be restored through the use of
assistive devices
 Tolerance for activity will be demonstrated as
evidenced by vital signs within normal limits
 Family will create a safe environment
 Family will effectively participate in developing
a plan of care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
Interventions
 Teach use of assistive devices
 Provide positive encouragement before,
during, and after use of device
 Assist the family in planning daily activities to
include rest
 Keep frequently used objects within easy reach
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
Interventions
 Assist parents in assessing home environment
for hazards
 Provide information about correcting identified
hazards
 Discuss common responses to caring for a
child with a musculoskeletal disorder
 Provide family with specific information on
home care
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
Evaluating
 Evaluate for
– Mobility
– Tolerance for activity
– Safety
– Family coping
Pediatric Nursing Care
Ellise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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