Caring for the Child with a Musculoskeletal Condition

1
Chapter 30

• Caring for the Child with a Musculoskeletal
  Condition

2
A P Review

• Bones
• Ligaments and tendons
• Muscles

3
Immobilizing Devices
4
Casts

• A cast is applied to the affected extremity to
  keep it immobile while healing.

5
Casts

• Four categories (fiberglass or plaster casts)
• 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)

6

• 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.

7

• Critical Nursing Action Cast Syndrome
• Cast syndrome can be prevented by three nursing
  interventions
• Reposition frequently
• Increase fluids and fiber in the childs diet
• Cut a belly hole or a window in the cast to
  allow for abdominal expansion

8
Casts Nursing Care

• Five Pspain, 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 childs emotions

9
Principles of Traction
10
Skin Traction

• Types
• Bryants traction
• Russells traction
• Balanced suspension

11
Nursing Care

• 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

12
Skeletal Traction

• Types
• Crutchfield tongs
• 90/90 femoral traction
• Dunlop traction

13
Performing the Neurovascular Assessment

• PainDoes 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).
• SensationCan the child feel touch on the
  extremity? Is two-point discrimination decreased?
  If yes, notify the physician immediately
  (compartment syndrome).
• MotionCan the child move fingers or toes? Lack
  of movement may indicate nerve damage.
• TemperatureDoes 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.

14
Performing theNeurovascular 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.

15
Performing theNeurovascular Assessment

• ColorNote 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.
• PulsesCheck 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.

16
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

17
Complications of Skeletal Traction

• Osteomyelitis
• Compartment syndrome

18
Common Musculoskeletal Conditions Found in
Children
19
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

20
Legg-Calvé-Perthes Disease

• Signs and symptoms
• Hip or knee soreness or stiffness
• Painful limp, quadriceps muscle atrophy
• Nursing care
• Monitor nonweight-bearing
• Assess range of motion, pain, and neurovascular
  status educate family

21
Slipped Femoral Capital Epiphysis

• Signs and symptoms
• Pain in hip and knees, limping
• Externally rotating the leg
• Nursing care
• Maintain nonweight-bearing
• Ensure no range of motion
• Postoperative care

22
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

23
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

24
Soft Tissue Injuries (Sprains and Strains)

• Signs and symptoms
• Pain, swelling, and ecchymosis
• Nursing care
• RICE
• Immobilize the joint
• Collaborate with the physical therapist
• Provide home care education

25
Sports Injuries

• Signs and symptoms (knee and elbow injury)
• Pain
• Tenderness in joint
• Loss of full extension of the joint
• Nursing care
• Manage pain
• Immobilize the joint
• RICE
• Teach parents about prevention

26
Osgood-Schlatter Disease

• Signs and symptoms
• Pain below the kneecap
• Pain aggravated by activity and relieved by rest
• Nursing care
• Manage pain
• Ice knee after exercising
• Maintain limited activity
• Collaborate with physical therapist

27
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

28
Juvenile Arthritis

• Signs and symptoms
• Joints are swollen, tender, and warm to touch
• Limited range of motion of joints
• Nursing care
• 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

29
Muscular Dystrophies
30
Muscular Dystrophies

• A group of muscle disorders that cause the
  gradual wasting of symmetrical groups of skeletal
  muscle

31
Muscular Dystrophies

• Types
• Congenital myotonic dystrophy
• Facioscapulohumeral muscular dystrophy
• Pseudohypertrophic muscular dystrophy (Duchenne)

32
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

33
Scoliosis

• Signs and symptoms
• Unequal shoulder heights
• Scapulae prominences
• Waist angles, rib prominences, and chest
  asymmetry
• Leg length discrepancy

34
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)

35
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)

36
Lordosis

• Signs and symptoms
• Swayback
• Excessive backward cavity of the spine
• Nursing care
• Perform lordosis screening
• Reduce predisposing factors obesity
• Teach about postural exercises
• Discuss support garments

37
Spinal Fusion

• Nursing care
• Pre- and postoperative care similar to scoliosis
• Monitor fluid balance (monitor for Syndrome of
  Inappropriate Antidiuretic Hormone SIADH)
• Assess circulation
• Manage pain
• Begin ambulation after __ days (follow medical
  doctors order)
• Provide good nutrition
• Collaborate with the physical therapist
• Arrange for home care (durable medical equipment)

38
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
• Perform oropharyngeal suctioning
• Give medications
• Maintain hydration
• Collaborate with other health team members

39
Osteogenesis Imperfecta (OI)

• Signs and symptoms
• 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

40
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