cast petaling
- using tape to cover sharp or rough edges that may come in contact w/ the skin
scratching w/ a cast on
- make sure patient is not scratching underneath the cast
- may need to give diphenhydramine
- if scratch skin open, can lead to infection
skeletal traction
- pull directly applied to skeletal structure by a pin, wire, tongs
- used when significant traction is needed
- placement of skin/wire puts stress on bone (not surrounding tissue) so can use more weight than skin traction
- weights need to be correct and not on floor
- if moving patient, hold weightso so don’t sway and give pain meds
- biggest concern: infection b/c pin going through bone
- assess site, monitor V/S–esp temp
skin traction
- pull applied to the skin surfaces and indirectly to the skeletal surfaces
- pulling mechanism applied to the skin w/ adhesive material or elastic bandage
- not to be used if there is altered skin integrity
- limited weight allowed b/c can pull/tear skin
orthotics
- don’t put directly against skin
- especially if lack of sensation b/c can cause breakdown
- wear long athletic socks underneath
ilizarov external fixator
- used for limb lengthening
- assess for infection where pin goes through skin
neurovascular assessment of immobilized child
- 5 P’s:
- P: pain
- P: pallor
- P: pulselessness
- P: paresthesia
- P: paralysis
what pathology occurs with decreased muscle activity?
- dec muscle activity–>disuse atrophy–>dec venous return and catabolism–>dependent edema and negative nitrogen balance
- dec metabolism–>dec need for O2–>dec ventilation
- bone demineralization–>osteoporosis and hypercalcemia–>renal calculi
- make sure they have lots of fluids!
analgesia with immobilization
- can use tylenol or ibuprofen (if over 6 mos)
- but may also need an opioid–assess RR, depth of respirations, should be on continuous pulse oximeter, inc fluids and monitor for constipation
preventing muscle atrophy and impaired mobility
- prevent contractures in the unaffected extremities
- collaborate with PT/OT
- prepare for disuse atrophy
fractures: etiology
- have to differentiate b/w intentional and non-intentional injury
- trauma: certain developmental characteristics make them more susceptible to injury
- infants: dependent on us to keep them safe
- make sure strapped in infant seat
- car seat has not been involved in an accident
- toddlers:
- learning to walk
- curious, getting into things
- school age/adolescents:
- drugs, sex, alcohol
- thrill seeking
- feel invincible
- infants: dependent on us to keep them safe
S/S, diagnostics, and mgmt of fractures
- clinical manifestations: swelling, pain, diminished use
- x-rays: may need pain meds to keep them in specific position w/o pain
- mgmt: splint/cast, pain meds
goals of fracture mgmt
- reduction: regain alignment and length
- may have open or closed reduction
- immobilization:
- retain alignment and length
- restore function
- prevent further injury
criteria for determining use of reduction method for fractures
- age of child
- degree of displacement
- amount of overriding
- degree of edema
- condition of skin and soft tissue
- sensation and circulation distal to the fracture
rapidity of bone healing
inversely related ot the child’s age, so the younger the child, the more quickly their bone will heal
cast care
- most casts are made of synthetic material
- advantages:
- dries w/in minutes
- lightweight
- may get wet w/ permission of MD–clean with soap and water and blow dry on cool!
- advantages:
- when handling, don’t use fingertips, b/c can cause indentations–>pressure
- “hot spots” indicate inflammation or infection
- chief concern during first few hours is compartment syndrome–>elevate extremity, check temp/color of skin, pulses, cap refill
pathophys of development dysplasia of the hip (DDH)
- cause is unknown, but 4 P’s related
- gender (Female)
- birth order (First born)
- Family hx
- intrauterine position (Feet first–breech)
- delivery type and postnatal positioning known to inc risk
clinical manifestations of DDH
- infants:
- unequal skin folds on thighs and buttocks
- limitation of abduction on affected side
- unequal knee height or leg length
- older children
- limp and trendelenberg’s gait (pelvis tips forward on normal side rather than upward)
Barlow and Ortolani maneuvers
- for DDH
- for Barlow: if hip is dislocated, so if the hip can be popped out of the socket–>test is positive
- for Ortolani: positive sign is distinctive “clunk” which can be heard and felt as the femoral head relocates anteriorly into acetabulum
diagnosis of DDH
- <3 mos old: U/S–>high incidence of false positives
- >3 mos old: x ray–>ossification of the femoral head occurs b/w 3-6 mos
tx of DDH
- Pavlik harness:
- dynamic splinting used to keep femoral head where it should be
- make sure the infant doesn’t wear harness w/o undershirt and diaper b/w skin and straps
- used for 3-6 mos
- need to check straps every 1-2 weeks due to infant’s rapid growth
etiology and patho of osteomyelitis
- acquired from exogenous or hematogeneous sources
- most commonly caused by staph aureus
- infective emboli travel from focus of infection to the small end arteries in the bone
- infection leads to local bone destruction and abscess formation
- abscess and necrotic debris exerts pressure on the bone and infection spreads to periosteum
clinical manifestations and lab findings of osteomyelitis
- manifestations: don’t start occurring for 7-10 days
- fever
- failure ot use affected extremity
- erythema, heat, and swelling
- tenderness in affected area
- dec ROM in joints of affected extremity
- labs:
- CBC w/ diff: elevated WBC
- inc ESR
- cultures
nursing mgmt of osteomyelitis
- aggressive abx tx for 4-6 weeks
- usually given a PICC line and parents taught how to assess and flush PICC and then infuse abx
- must finish full course of abx
- usually cephalosporins, gentamycin
- if MRSA, may have to use vancomycin
scoliosis etiology
- often unknown cause
- complex spinal deformity in 3 planes:
- lateral curvature
- spinal rotation causing rib asymmetry
- thoracic hypokyphosis
- issue is degree of curvature and how much pulmonary function is being affected
clinical manifestations, diagnostics, and mgmt of scoliosis
- idiopathic curvature not typically evident until 10 yo
- usually no pain
- eval:
- check with x ray in standing position
- Cobb technique for curvature magnitude
- have child bend over and touch toes
- assess gait
- mgmt:
- bracing and exercise (in and out of brace)
- should not be worn directly against skin
- encourage exercise
- wear for 16-23 hrs a day
- if >40 deg, need surgery
- bracing and exercise (in and out of brace)
surgical repair of scoliosis
- realignment and straightening w/ internal fixator
- post op:
- neuro checks, circulation checks
- assess for infection at the incision site
- pulmonary system
- assess skin, U/O, bowel sounds
- logroll for first 24 hrs, then ambulate 2-3x per day
- remove foley asap
- need good pain mgmt
- monitor H&H b/c potential for significant blood loss
- typically d/c in 48-72 hrs
cerebral palsy etiology
- any perinatal or neonatal brain lesion or brain maldevelopment
- prenatal/postnatal infection
- prenatal/postnatal hypoxia/asphyxia
- often no identifiable immediate cause
- inc incidence with prematurity
- preterm birth of ELBW and VLBW is most important determinant
- anoxia–most common cause of brain damage whenever it occurs
spastic CP
- most common type
- presents as hypotonia most often
motor signs of CP
- poor head control after age 3-4 mos
- stiff or rigid limbs
- arching back/pushing away
- floppy tone
- unable to sit w/o support at age 8 mos
- clenched fists after 3 mos
behavioral signs of CP
- excessive irritability
- no smiling by age 3 mos
- feeding difficulties
- persistent tongue thrust
- frequent gagging or choking w/ feeds–aspiration common
pharmacology to dec spasticity in CP
- botulinum toxin (botox)
- baclofen
- oral
- implanted pump for intrathecal administration
- dantrolene sodium
- diazepam
assoc disabilities with CP
- intellectual impairment
- ADHD
- SZs
- drooling
- difficulty feeding–can lead to aspiration
- impaired gas exchange
- orthopedic complications
- visual (nystagmus) and hearing loss
- constipation
- dental problems–caries, malocclusion, gingivitis
nursing mgmt of CP
- holistic approach
- interdisciplinary
- PT/OT, speech therapy
- when feeding, make sure they are not lying flat
- may need jaw support to help swallow
- may thicken foods/fluids to prevent aspiration
hypotonia
- “floppy infant syndrome”
- muscles feel atrophied, marked head lag, poor suck
- characteristics of SMA type 1 and 2:
- progressive weakness and wasting of skeletal muscles
- degeneration occurs in spinal cord and brainstem–>atrophy of skeletal muscles
- age of onset variable, earlier onset=poorer prognosis
- eventually progresses to affected respiratory muscles
infantile SMA (spinal muscular atrophy) type 1
- Werdnig Hoffmann dz
- autosomal recessive trait
- most common form of floppy infant syndrome
- often die at an early age, b/c affects respiratory Ms
infantile SMA type 2
- manifests b/w 2-12 mos
- first weakness of arms and legs, then generalized weakness
- prominent pectus excavatum
- movements absent during relaxation and sleep
- life span: 7 mos to 7 yrs
muscular dystrophy
- X linked inheritance pattern
- mutation of gene that encodes dystrophic–>protein product in skeletal muscle, so it builds up
- muscle weakness begins to demonstrate around 3 yo
- its an ascending disorder
- starts in extremities and works way up
DMD clinical manifestations
- pelvic weakness:
- waddling gait, lordosis, falls frequently
- Glower’s sign: push themselves up with hands instead of legs
- muscle atrophy–>calf muscle hypertrophies and fatty infiltrates develop
- occasional mental deficiency
- inc respiratory distress–>eventually affects diaphragm
nursing mgmt of DMD
- genetic counseling: prenatal testing
- encourage exercise: delays wheelchair confinement
- interdisciplinary consultation
talipes equinovarus
- AKA clubfoot
- strong familial tendency
- mgmt: 3 stages:
- correct deformity
- maintenance of correction
- f/u to avoid recurrence
- will have serial casting
- will need analgesics and edu about cast care
- if severe, may need surgery
- after correction, may need splint to prevent reoccurrence
osteogenesis imperfecta (OI)
- brittle bone dz: on a continuum
- manifestations:
- bone fragility, deformity, fx
- blue sclerae
- hearing loss
- dentinogenesis imperfecta
- inheritance: most are autosomal dominant, but most severe form is sometimes autosomal recessive
- mgmt: mainly supportive