Test #7 Flashcards
What do you assess for when assessing the musculoskeletal?
- Observe infant’s movements in crib
- Inspect for differences in extremity length & size
- Assess muscle tone & symmetry
- Gentle passive ROM to assess joint rotation
- Assess head lag
-Skin folds on thigh (To see their musculature in their long bones,
are they attached how they should be? Are the folds symmetrical)
- Posture, gait, strength, screening
- Comparing left to right extremities, ROM
- Comparing growth & development to normal chart (nutrition, activities)
Promote well child visits, see doctors at scheduled times
Nutritional Status Assessment: HAIR is a good indicator,
height/weight, bowels
-Complaints, history
What do you assess for when pertaining to sleep and how many hours a night do children need by age?
- Infants periods of reactivity
- # of hours of sleep/day/age & growth
Newborn: 15-20 hours a day
Toddler 2-4 years: 12-14 hours a day
Preschool 4-6 years: 10-12 hours a day
School Age 6-12 years: 8-12 hours a day
Adolescent 12-18 years: 9 hours a day (Most only get about 6 hours)
-Sleep Apnea: stop in breathing of greater than 20 seconds
Not going to grow as well
-SIDS Prevention (P. 107)
What is Comparment Syndrome?
occurs when swelling causes pressure within these closed fascial compartments to rise, compromising vascular perfusion to the muscles and nerves
What are some assessments for Compartment Syndrome?
severe pain, often unrelieved by analgesics
signs of neurovascular impairment
If extending the fingers or wiggling the toes produces pain, and/or the quality of the radial or pedal pulse is poor to absent
What are some assessments of Cast Syndrome of a child in a hip spica cast?
Abdominal Cramps
Bloating
Vomiting
How do you prevent cast syndrome with a hip spica cast?
Reposition Q2HR
Inc fluid & dietary fiber
Provider cut a “belly hole” to allow “belly” expansion
Legs abducted
What are all the items we need to teach for home cast care?
Check the Edges of the Cast as Follows:
- If they appear rough or are irritating the skin, “petal” the cast by overlapping moleskin or adhesive tape (1 to 2 inches in width; 3 to 4 inches in length with one rounded edge) around the cast edges.
- Waterproof tape should be used in the perineal area.
To Assist with Drying the Cast, Do the Following:
- Place the child on a firm mattress.
- Support the cast and adjacent joints with pillows.
- For a plaster cast, reposition every 2 to 4 hours to ensure thorough drying.
- Lift the cast with the palms of your hands.
- You may direct a fan toward the cast to facilitate drying.
- Once dry, the cast should sound hollow and be cool to the touch.
Swelling Generally Peaks within 24 to 48 Hours. To Prevent Problems, Do the Following:
- Apply bagged ice to the casted area (be sure to keep melting ice from touching the cast or leaking underneath).
- Elevate the extremity at the level of the heart with pillows.
- Apply pressure to the nail bed of the child’s casted extremity and count how long it takes for the color to return (it should take no longer than 2 seconds). Repeat every 2 hours for the first 24 to 48 hours.
- The casted extremity should be the same color and temperature as the other extremity.
- Check each finger or toe for sensation and movement several times each day for 2 days.
Protect the Cast as Follows:
- If the child is permitted to bathe or shower, be sure to cover the cast with plastic and waterproof tape to keep the cast dry.
- Do not put anything inside the cast. Keep small toys and sharp objects away from the cast. Supervise your child during mealtimes so the child does not get food underneath the cast.
Contact the Physician If Any of the Following Occurs:
- The cast feels warm or hot or has an unusual smell.
- Any drainage or blood suddenly appears on the cast.
- Your child reports pain, burning, numbness, or tingling.
- The extremity changes color or temperature, or any swelling persists.
- Any fever above 101.5° F (40° C) taken by mouth.
- Slipping of cast, inability to visualize toes or fingers.
When Preparing to Remove the Cast, Do the Following:
- Explain the cast removal to your child. The cast remover works by vibration that creates a warm tickling feeling on the skin and sounds like a vacuum cleaner.
- Allow time for the child to adjust to the cast remover. Ask the technician or physician if your child can examine the cast remover and see how it works ahead of time.
- Once the cast is removed, the skin will be dry and flaky. Wash the area with warm water and soap. Discourage the child from scratching.
• The extremity will be stiff for a while and will look smaller because the muscles have not been used. It may need to be supported with a sling. Normal movement will correct the stiffness. (McKinney 1347)
McKinney, Emily, Susan James, Sharon Murray, Kristine Nelson, Jean Ashwill. Maternal-Child Nursing, 4th Edition. W.B. Saunders Company, 2013. VitalBook file.
What are some nursing care items of a child in skin traction?
- Fractures, muscle spasms, spine alignment
- Neuromuscular assessments Q4H
- Traction weights checked, hanging free
Don’t bump, don’t move, monitor the pull of traction that
they are in alignment, don’t set on bed, don’t let touch the floor
- Perform skin care Q4H
- Provide diversional activities
3 Year Old: Painting, iPad, Things that move and keep attention
8 Year Old: Video Games, homework, tutoring, movies, books
Teenage: Phone, friends, electronics
P. 1341 Box For Tractions
What are all the nursing care items for a child in skeletal traction? TONS
- Portal of Entry - RISK for infection!! HUGE!
- Localized infection of the tissue, the bone and can lead to sepsis!
- Neuromuscular assessment Q4H
- Pins going into the bone
- Know signs of compartment syndrome & report them to PCP immediately
Causes decrease in blood flow and the tissues do not receive blood flow thats needed
Causes tissue death
Irretractable pain, delayed cap refill, check peripheral pulses distal, lack of blood flow, pallor, pulselessness, paresthesia (This is when there is already tissue death), pain, paralysis (Tissue death), poikilothermic
Interventions: Elevate extremity, split cast to relieve pressure (Make sure to maintain alignment), may need surgery to restore blood flow
- Maintain Traction
- Assess & care for pin sites with post-op VS for S/S of infection
- Prevent Skin Breakdown
- Manage pain
- Maintain good nutrition & elimination
Inc Fiber, protein, green leafy’s, fruit
-Assess for complications
osteomyelitis, pneumonia, circulatory,
compromise, ischemia, & disuse
PT, OT all come to help keep things working good
- Prepare family for discharge
- Provide psychosocial support
- POST OP CARE: EXTERNAL FIXATOR (P.1343)
Neurovascular checks
Pin care
Drainage
Collaborate with Physical Therapy
Prepare to self/family care at home
We do a neurovascular assessment every 2 hours for the first 48 hours after cast/traction is applied. What are we looking for?
- Done at least every 2 hours during the first 48 hours after the device is applied
- 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 provider PCP IMMEDIATELY (Compartment Syndrome P.1344)
- Sensation: Can the child feel touch on the extremity? Is two-point discrimination decreased? If yes call PCP IMMEDIATELY (Compartment Syndrome)
- 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 to heart level. If the extremity is still cool after these interventions, there is poor circulation
- Edema: Compare the size of the extremity with the other extremities
- Capillary refill time: Apply brief pressure to the nail bed and note how quickly pink color returns to the nail bed. <3 seconds is normal. If >3 sec, circulation is poor
- 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
- Motion: Can the child move fingers or toes? Lack of movement may indicate nerve damage
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
What are the affects of immobility?
-Decreased Muscle Strength
Decreased Venous return
Dec Cardiac Output & Dec Exercise intolerance
-Bone demineralization: Osteoporosis
Fractures (Inc in lab values)
Hypercalcemia:
Cardia irregularity, renal calculi, bone spurs
@ Risk for falls and fractures
-Slowed growth and development
Orthostatic Hypotension
Difficulty expanding chest/pneumonia
Difficulty feeding, anorexia, constipation
Urinary retention/infection
Skin Breakdown
Boredom/Separation from friends & family
Nursing Plan P. 1345 Table 50-2
Promote Health & Safety
What are some consequences of immobility?
Integumentary:
Red or irritated skin, presence of ulceration or drainage
Impaired Skin Integrity
PREVENT: Reposition the child every 2 hr and as needed; encourage the child in traction to use a trapeze to facilitate movement.
Use an egg crate–type or sheepskin mattress for comfort under the back and lower legs. If the child is not capable of any independent repositioning or has decreased sensation, use a pressure relief overlay or mattress. Pay particular attention to the heels to prevent skin breakdown.
Wash and thoroughly dry the areas twice a day; refrain from using lotion, powder, or talc, which can retain moisture.
Change the untrained child’s diapers frequently to prevent skin breakdown.
Examine and record the child’s skin condition once per shift.
Gastrointestinal
Decrease in number or consistency of bowel movements because of decreased gastrointestinal motility
Risk for Constipation
Assess bowel sounds, abdominal distention, elimination pattern; be sure to know the child’s normal pattern, usual stool consistency, and words used for defecation.
Provide a diet high in roughage and fiber and increase fluid intake with foods and fluids the child likes.
Position the child as upright as possible during defecation.
Administer laxatives and/or stool softeners if needed.
Respiratory
Decreased or altered respirations, shortness of breath, decreased breath sounds, adventitious breath sounds
Ineffective Breathing Pattern
Assess respiratory status at least once per shift.
Encourage coughing and deep breathing through the use of games, such as blowing bubbles, pinwheels; older children can use an incentive spirometer.
Reposition every 2 hr and as needed.
Genitourinary
Decreased urinary output from stasis or retention, concentrated or foul-smelling urine
Impaired Urinary Elimination
Maintain hydration levels.
Offer juices (cranberry, apple) and acid-ash foods (cereal, meats) that will acidify the urine.
Monitor the child’s urinary output.
Musculoskeletal
Reduced strength and joint mobility, loss of muscle tone and potential for muscle atrophy, limited range of motion
Impaired Physical Mobility
Test muscle strength and joint mobility every shift and as needed.
Encourage active range-of-motion and stretching exercises of unaffected extremities.
Plan developmentally appropriate activities that require the use of unaffected extremities.
Provide foods high in protein and calcium.
Use elastic stockings or thromboembolic disease hose to promote venous return and decrease circulatory stasis.
Developmental regression, irritability, anxiety, excessive dependence on others, passive behavior
Powerlessness
Recognize the child’s need to regress in response to the immobility; help child regain prior developmental stages when ready.
Explain all routines and procedures to the child and parents and encourage them to participate in care.
Provide the opportunity for therapeutic play: modeling clay, paints, remote-control toys (which give the feeling of mobility and control), puppet play, storytelling, role playing.
Allow the child to use age-appropriate dishes and cups, clothing from home (may have to be adapted to fit over an immobilizing device), transitional object, night-light.
Determine and follow the child’s usual routine.
Encourage the school-age child and adolescent to keep up with schoolwork and keep in contact with peers.
Frequently provide a change in environment: move the bed to take advantage of a different view; move the bed into the playroom; keep side rails up for safety.
Allow and encourage the child’s autonomy in decision making.
What is the first thing we do when there is an Emergency situation with a fracture?
1st: Survey the scene
2nd: Assess extent of injury
What are the 6P’s and T for Neurovascular assessment?
Pain & point of tenderness
Pulses-distal to the fracture site
Pallor
Paresthesia-Sensation distal to fx site
Paralysis-Movement distal to fx site
Pressure-Skin is tense, edema
Temperature distal to fx site compare to the other extremity
What are the steps you take after surveying the scene and assessing injury when there is a fracture?
- Determine mechanism of injury: History
- Immobilize the injury and maintain alignment
- Cover open wounds with sterile or clean dressing (moist)
- Immobilize the limb, including joints above & below the fracture site
- Do not attempt to reduce the fracture or push protruding bone under the skin
- Soft Splint (pillow or folded towel)
- Rigid Splint (Rolled newspaper or magazine)
- Uninjured leg can serve as a splint for leg fx
- Reassess neurovascular status
- Apply traction if circulation compromised
- Elevate injured limb if possible
- Apply cold to injured area (For inflammation and to stop blood flow)
Call emergency medical service or transport to medical facility
What are some assessments if there is a fracture? Open/Closed
-Of a CLOSED fracture:
Generalized swelling
Pain or tenderness
Diminished function/use-Small child refuses to walk/crawl
May include: bruising, severe muscular rigidity, crepitus/grating
Positive X-Ray, MRI, CT scan, fluoroscopy or myelogram
-Additional findings of an OPEN fracture
Bleeding and visible bone possible
What are some fracture complications?
- Compartment syndrome
- Shock
- Fat Emboli - When long bones are broken there are small pieces of fat in the bone marrow. It can escape into the tissue and end up in the blood supply… BAD NEWS
SOB, Cyanosis, Chest Pain, Impending Doom
- Deep Vein Thrombosis
- Pulmonary Embolism
Movement of all the fat and bone getting into the lungs
-Infection
Especially open fracture, surgery with pins
What are some nursing care items for a fracture?
-Obtain Hx
Can be a sign of abuse
- Perform neurovascular assessment
- Prevent infection: ABT, wound cleansing
- Manage Pain
- Care of immobilizers (splints, braces, cases, external fixators, or traction) after closed or open reduction
- Provide Pin care (if applicable)
- Prevent Complications
- Restore function
- Educate Family (Nutrition)
Protein, Calcium (dairy & green leafy)
Care of immobilizers
Provide emotional support
What are some assessments for soft tissue injuries?
Pain, swelling, and ecchymosis
Evaluate neurovascular & ROM
What are some interventions for soft tissue injuries?
RICE (P.1351)
Immobilize the joint
Collaborate with PT
Ibuprofen or acetaminophen
Provide Home care education
Sports Injury
Use protective gear, stretch before
What are some assessments for Osteomyelitis?
Localized tenderness, redness, warmth & dec mobility
Pain on palpitation
Affects the whole body, VS, Fever
Frequently a hx of trauma
Check tetanus immunization
Positive radiography, CT scan
Blood Cultures - Do BEFORE antibiotics
What are some interventions for osteomyelitis?
Contact isolation for open wounds
IV Antibiotics & IV site care
Infiltration, Phlebitis, Allergic reaction, adverse reaction to meds, interactions with IV fluids
Monitor erythrocyte sedimentation rate (ESR), C-Reactive protein, CBC, CMP
Indicates how well the infection is doing and responding (DEC ESR & C-Reactive Protein)
Promote rest & manage pain
Turn gently with limb positioned & supported
Monitor I&O
Nutrition balanced - Inc protein, Vit C & Calories
Diversional activities
Teach parents about antibiotic completion
What are some assessments for tetanus?
Progressive stiffness and tenderness of the muscles in the neck & jaw
Trismus (Difficulty opening the mouth)
Risus Sardonicus (A peculiar Grin)
Opisthotonus Posturing (Neck is pulled back and tight)
Laryngospasm of the respiratory muscles
Tetanus Prophylaxis through immunization is the key to preventing tetanus
What are some interventions for tetanus?
Give tetanus Immuno Globulin (TIG) and antibiotics
Closely monitor and maintain respiratory support
Monitor fluids, electrolytes & calorie intake
Give NG feedings or TPN,
Assist with ET intubation (Laryngospasms)
Eliminate stimulation
Conduct frequent neurological assessments
Assess O2 Saturation and blood gases
Perform oropharyngeal suctioning
Give medications - Neuromuscular blocking agent requires ventillation support
Maintain Hydration
Collaborate with other health team members
Medications
Diazepam
Lorazepam
Baclofen
Dantrolene Sodium
Midazolam
Rocuronium
Vecuronium (Neuromuscular medication that causes muscles to calm and relax) (BE FAMILIAR)
