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Pediatric Nursing Care
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Chapter 20Care of the Child with Musculoskeletal Disorders
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Anatomy and Physiology of the Skeleton
Skeleton– Ossification almost complete at birth– 3 sections of bone– Epiphyseal plate (growth plates)– Hematopoiesis
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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A and P of the BoneDiagram
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Postural Changes
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise 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
Inspect posture and gait Note symmetry of shoulders, hips, an any
unusual curvature of spine Assess for full ROM of joints Assess muscle strength
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Developmental Dysplasia of the Hip
Developmental hip abnormality Involves femoral head, acetabulum, or both
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Ortolani-Barlow Maneuver
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Developmental Dysplasia of Hip
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Talipes
Talipes or Clubfoot– Congenital twisting of the foot– Unilateral or bilateral– Usually inward twisting
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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TalipesDiagnosis 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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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TalipesNursing Considerations
Nursing interventions– Assist with cast application– Teach parents cast care– Administer pain medications– Observe for drainage and bleeding
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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ScoliosisManifestations
Manifestations– Shoulders and hips
different heights– Rotation of vertebrae
and ribs– One-sided rib hump,
prominent scapula– Asymmetrical
posterior chest
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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ScoliosisDiagnosis
Diagnosis– Moiré photography – Spinal x-ray
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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ScoliosisTreatment
Treatment– Mild scoliosis
Exercise, chiropractic adjustments
– Moderate scoliosis Boston or Milwaukee brace
– Severe scoliosis Surgery with rods, wires, halo brace
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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RICE
R - Rest I - Ice C - Compression E - Elevation
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Musculoskeletal TraumaFracture
Altered continuity of bone Common occurrence in childhood
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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FracturesManifestations & Diagnosis
Manifestations– Pain, abnormal positioning, edema– Discoloration, abnormal movement– Broken skin, bleeding
Diagnosis– X-rays of injured area
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Fractures Treatment
Treatment– Realign by closed reduction– Realign by open reduction– Apply traction– Immobilize with external fixators or immobilizers– Apply plastic or plaster cast
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Compartment SyndromeNursing Care
Report immediately Requires removal or alteration of cast
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Bucks Traction
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Bryant Traction
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Skeletal Traction 90/90
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Russels Traction
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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External Fixator
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Clavical Strap
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Cast Care
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Spica Cast
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Musculoskeletal InfectionOsteomyelitis
Infection of bone May spread to surrounding tissue Caused by bacteria, virus, fungi Follows injury or surgery
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OsteomyelitisManifestations
Constant pain in affected area Edema Decreased mobility of joint Refusal to use limb, limp Redness at site of injury, fever
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Osteomyelitis Diagnosis
History of trauma Increased white blood cell count Increased erythrocyte sedimentation rate X-rays, bone scans Needle aspiration of fluid for culture
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Osteomyelitis Treatment
Hospitalization Administer intravenous medication
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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OsteomyelitisNursing Considerations
Administer antibiotics Arrange for home health nurse
– Administer antibiotics– Care of intravenous site
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Stump Care
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Nursing CarePriorities
Promote independence of the child Promote mobility as allowed Maintain safety Explain resources for support and proper home
care
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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Nursing CareAssessing
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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
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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
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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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing CareInterventions
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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing CareInterventions
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
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Pediatric Nursing CareEllise Adams and Mary Ann Towle
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing CareEvaluating
Evaluate for– Mobility– Tolerance for activity– Safety– Family coping