Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 30
Caring for the Child with a
Musculoskeletal Condition
Susan Ward
Shelton Hisley
A & P Review
 Bones
 Ligaments and tendons
 Muscles
Immobilizing Devices
Casts
 A cast is applied to
the affected extremity
to keep it immobile
while healing.
Casts
 Four categories (fiberglass or plaster casts)
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Upper extremity
Lower extremity
Spinal or cervical
Total body
 Cast complications
 Compartment syndrome (accumulation of fluid in the fascia)
 Cast syndrome (portion of the duodenum is compressed
between the superior and mesenteric artery and the aorta)
Clinical Alert: Complication of the Child
with a Fracture
 The classic sign of compartment syndrome is
unrelenting pain that is unrelieved by narcotics.
The nurse must notify the physician immediately.
The priority intervention for compartment
syndrome is prevention. Prevention is achieved
by elevating the extremity to prevent excessive
swelling and conducting frequent neurovascular
checks.
Critical Nursing Action: Cast Syndrome
 Cast syndrome can be prevented by three
nursing interventions
 Reposition frequently
 Increase fluids and fiber in the child’s diet
 Cut a “belly hole” or a window in the cast to
allow for abdominal expansion
Casts: Nursing Care
 Five “Ps”—pain, pulse, pallor, paresthesia, and
paralysis
 Elevate the affected extremity
 Give good hygiene (bathing and perineal care)
 Prevent constipation
 Educate parents about itching, small objects in
cast, and cast removal)
 Assess child’s emotions
Principles of Traction
Skin Traction
 Types
 Bryant’s traction
 Russell’s traction
 Balanced suspension
Nursing Care
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Neuromuscular assessments Q 4 hours
Traction weights checked, hanging free
Traction removed and reapplied Q 4 hours
Perform skin care Q 4 hours
Provide diversional activities
Skeletal Traction
 Types
 Crutchfield tongs
 90/90 femoral traction
 Dunlop traction
Performing the
Neurovascular Assessment
 Pain—Does the child complain of pain in the affected limb? Is it relieved by
narcotic medication? Does it become worse when fingers or toes are flexed?
If yes, notify the physician immediately (compartment syndrome).
 Sensation—Can the child feel touch on the extremity? Is two-point
discrimination decreased? If yes, notify the physician immediately
(compartment syndrome).
 Motion—Can the child move fingers or toes? Lack of movement may
indicate nerve damage.
 Temperature—Does the affected limb feel warm? Does it feel cool? A cool
extremity may change to feeling warm if a blanket is placed over it and the
extremity is elevated. If the extremity is still cool after these interventions,
there is poor circulation.
Performing the
Neurovascular Assessment
 Capillary refill time
(CRT)—Apply brief
pressure to the nail bed
and note how quickly pink
color returns to the nail
bed. CRT of less than 3
seconds is the norm. If
CRT is greater than 3
seconds, circulation is
poor.
Performing the
Neurovascular Assessment
 Color—Note the color of the affected limb. Compare it to
the color of the unaffected limb. Pink is the norm. If the
color is paler than the unaffected limb, circulation is poor.
 Pulses—Check pulses distal to the injury or cast. If the
pulse is difficult to locate, assess with a Doppler and
mark the spot with an “X.” If the cast covers the foot or
hand, it may not be possible to check the pulse, but the
other neurovascular assessment can be implemented.
Nursing Care for Skeletal Traction
 Neuromuscular assessments Q 4 hours
 Know signs of compartment syndrome and report them to the physician
immediately
 Maintain traction
 Prevent skin breakdown
 Assess pin sites Q 8 hours of s/s of infection
 Manage pain
 Maintain good nutrition and elimination
 Assess for complications (osteomyelitis, pneumonia, circulatory compromise,
ischemia, and disuse)
 Prepare family for discharge
 Provide psychosocial support
Complications of Skeletal Traction
 Osteomyelitis
 Compartment syndrome
Common Musculoskeletal
Conditions Found in Children
Club Foot
 Signs and symptoms
 Foot is plantar-flexed with an inverted heel
 Adducted forefoot
 Nursing care
 Provide cast care, neurovascular assessments
 Manage pain
 Educate family
Legg-Calvé-Perthes
Disease
 Signs and symptoms
 Hip or knee soreness or stiffness
 Painful limp, quadriceps muscle atrophy
 Nursing care
 Monitor non–weight-bearing
 Assess range of motion, pain, and neurovascular
status; educate family
Slipped Femoral
Capital Epiphysis
 Signs and symptoms
 Pain in hip and knees, limping
 Externally rotating the leg
 Nursing care
 Maintain non–weight-bearing
 Ensure no range of motion
 Postoperative care
Fractures (Bone Undergoes More
Stress Than It Can Absorb)
 Characterized as open or closed
 Treatment
 Closed or open reduction
 Complications
 Compartment syndrome
 Shock, fat emboli, deep vein thrombosis
 Pulmonary embolism, infection
Fractures
 Nursing care
 Obtain history
 Immobilize the bone (splints, braces, cases, external fixators, or traction)
 Prevent infection
 Perform neurovascular assessment
 Manage pain
 Provide pin care (if applicable)
 Prevent complications
 Restore function
 Educate family (nutrition)
 Provide emotional support
Soft Tissue Injuries
(Sprains and Strains)
 Signs and symptoms
 Pain, swelling, and ecchymosis
 Nursing care
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RICE
Immobilize the joint
Collaborate with the physical therapist
Provide home care education
Sports Injuries
 Signs and symptoms (knee and elbow injury)
 Pain
 Tenderness in joint
 Loss of full extension of the joint
 Nursing care
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Manage pain
Immobilize the joint
RICE
Teach parents about prevention
Osgood-Schlatter Disease
 Signs and symptoms
 Pain below the kneecap
 Pain aggravated by activity and relieved by rest
 Nursing care
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Manage pain
Ice knee after exercising
Maintain limited activity
Collaborate with physical therapist
Osteomyelitis
 Signs and symptoms
 Localized tenderness, redness,
warmth
 Pain on palpation
 Nursing care
 Administer intravenous
antibiotics
 Promote rest and manage pain
 Provide good nutrition and
diversional activities
 Teach parents about antibiotic
compliance
Juvenile Arthritis
 Signs and symptoms
 Joints are swollen, tender, and warm to touch
 Limited range of motion of joints
 Nursing care
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Medications
Prevent injuries and identify exacerbations
Teach family about disease and proper care
Collaborate with physical therapist
Provide age-appropriate activities
Include the child in decision making
Muscular Dystrophies
Muscular Dystrophies
 A group of muscle disorders that cause
the gradual wasting of symmetrical groups
of skeletal muscle
Muscular Dystrophies
 Types
 Congenital myotonic dystrophy
 Facioscapulohumeral muscular dystrophy
 Pseudohypertrophic muscular dystrophy
(Duchenne)
Muscular Dystrophies
 Signs and symptoms
 Progressive symmetrical muscle wasting
 Muscle weakness without loss of sensation
 Gower maneuver
 Nursing care
 Help patient maintain independent living for as long as possible
 Prevent respiratory infections
 Monitor skin
 Ensure good nutrition
 Assess mobility
 Foster independence and self-care
 Provide emotional support
Scoliosis
 Signs and symptoms
 Unequal shoulder
heights
 Scapulae prominences
 Waist angles, rib
prominences, and chest
asymmetry
 Leg length discrepancy
Scoliosis
 Nursing care
 Perform scoliosis screening
 Discuss bracing and exercise
 Assess body image and maintain orthotic brace compliance
 Surgery when pulmonary function becomes compromised
 Preoperative care (explain to child and parents what to expect, tour
ICU, and teach ROM exercises)
 Postoperative care (VS, neurological status, fluid balance, pain
control, NG tube, advance diet, chest tube, s/s infection, logrolling,
prevent constipation, discharge teaching, community resources, and
encourage adolescent to be as active as possible)
Kyphosis
 Signs and symptoms
 Uneven shoulder heights
 Pain in the thoracic region
 Nursing care
 Perform kyphosis screening
 Maintain orthotic brace compliance
 Surgery may be necessary (pre- and postoperative
care same as scoliosis)
Lordosis
 Signs and symptoms
 “Swayback”
 Excessive backward cavity of the spine
 Nursing care
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Perform lordosis screening
Reduce predisposing factors; obesity
Teach about postural exercises
Discuss support garments
Spinal Fusion
 Nursing care
 Pre- and postoperative care similar to scoliosis
 Monitor fluid balance (monitor for Syndrome of Inappropriate
Antidiuretic Hormone [SIADH])
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Assess circulation
Manage pain
Begin ambulation after __ days (follow medical doctor’s order)
Provide good nutrition
Collaborate with the physical therapist
Arrange for home care (durable medical equipment)
Tetanus (Lockjaw)
 Signs and symptoms
 Progressive stiffness and tenderness of the
muscles in the neck and jaw
 Trismus (difficulty opening the mouth)
 Risus sardonicus (a peculiar grin)
 Opisthotonus posturing
 Laryngospasm of the respiratory muscles
 Tetanus prophylaxis through immunization
is the key to preventing tetanus.
 Nursing care
 Give tetanus immune globulin (TIG) and
antibiotics
 Closely monitor and maintain respiratory
support
 Monitor fluids and electrolytes and caloric
intake
 Give NG feedings or TPN
 Assist with ET intubation (laryngospasms)
 Eliminate stimulation
 Conduct frequent neurological assessments
 Assess O2 saturation and blood gasses
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Perform oropharyngeal suctioning
Give medications
Maintain hydration
Collaborate with other health team members
Osteogenesis Imperfecta (OI)
 Signs and symptoms
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Lax joints
Small and weak muscles
Numerous fractures
Bone deformities (bowing)
Growth pattern disturbances
 Nursing care
 Give medication (Reclast)
 Rule out child abuse
 Postoperative care
 VS, neurovascular assessments, pain management, and hydration
 Coordinate play and physical therapy
 Encourage genetic counseling
 Provide family education
Osteoporosis
 A condition where the bones lose density and
calcium and become brittle
 Signs and symptoms
 Osteopenia, fractures
 Nursing care
 Facilitate nutritional counseling
 Provide family education