NURS 303 Nursing Care of Children & Families

Musculoskeletal Disorders & Trauma

Nursing Diagnoses

• Pain related to inflammation• Impaired ability • Self-esteem disturbance related to

need to wear brace or cast• Diversional activity deficit related

to restricted activity.

Genu Varum• Bowlegs• Malleoli of ankles touch, medial

surface of knees are over 1 inch apart.• Seen most commonly in 1-year-olds.

Corrects itself by normal growth.• Blount’s Disease is failure of growth of

epiphyseal line of tibia. Serious Disorder.

• Corrected by bracing or osteotomy.

Genu Valgum

• Knock Knees• Medial surfaces of knees touch,

ankles are separated by more than 1 inch.

• Corrected by normal growth.

Talipes Deformities• “Club foot”• Plantar flexion• Dorsiflexion (heel lower than foot)• Valgus: foot turns out• Varus (foot turns in)• equinovarus (down and in)• calcaneovalgus (heel down and out)

Talipes Deformities• Some newborns have intrauterine

deviation• True condition cannot be brought

back into line.• Therapy: cast to above knee• Change frequently as child grows so

rapidly.• Teach parent to do neuro check of

foot.

Hip Dysplasia

• Shallow acetabulum of hip allows femur to “ride up” in socket.

• Assessment: • Extra skin folds on affected side.• Hip does not abduct.• “Click” heard on abduction

(Ortolani’s sign)

Hip Dysplasia

• Therapy:• Keep hips in abducted (frog leg)

position.• Frejka splint• Pavlik harness • Long term correction.• Good results

Legg-Calvé-Perthes Disease• Avascular necrosis of the proximal

femoral epiphysis.• More frequent in males than female• Peak age of incidence: 4-8 yrs..• Assessment:• Pain in the hip joint limitation of

motion due to spasm• X-ray reveals problems.

Legg-Calvé-Perthes Disease• Therapy:• In the past, child couldn’t put weight on

leg for 18 months.• Today, they wear a brace which abducts

the hip and brings femur head unto good alignment OR

• Surgery to center the femur head.

• May need a spica cast for 3-4 months.

Legg-Calvé-Perthes Disease• Evaluation:• Without correction, degenerative

changes occur that might necessitate hip replacement in later years.

Osgood Schlatter Disease

• Enlargement of tibial tuberosity from stress

• Occurs in preadolescence• Athletic children• Assessment: • Pain and swelling below knee • Aggravated by running /squatting

Osgood Schlatter Disease

• Therapy:• Limit exercise• Brace to immobilize knee for 6 weeks.• Evaluation:• Good outcome

Slipped Capital Femoral Epiphysis

• Slipping of femur head at neck epiphyseal line

• Destroys circulation to femur• Occurs in preadolescence• Most frequent in African-Americans• Obese or rapidly growing

Slipped Capital Femoral Epiphysis

• Assessment:• Hold leg externally rotated• May have knee pain from strain on knee• Therapy:• Surgery to stabilize femur head • Evaluation:• 30% develop same problem in second

hip.

Osteomyelitis

• Infection of bone• Staphylococcus aureus in older children• Hemophilus infuenzae in young children• Children with sickle cell are particularly

susceptible.

Osteomyelitis

• Assessment:• High fever, pain• Skin over area feels warm and redeened.• Positive blood culture• Therapy:• Intravenous antibiotics• Rest to infected bone

Osteomyelitis

• Evaluation:• Will continue on oral antibiotics for

extended time.• Chronic infectious process with sinuses

draining to surface can be result.• Growth plates can be destroyed.

Scoliosis

• Lateral curvature of the spine• Most frequent in girls• Have a primary and secondary curvature. • Begins in preadolescence• Family tendency

Scoliosis

• Assessment:• Mandatory screening in schools• More obvious in thin than obese children• X-ray reveals deformity.• Therapy:• Curve between 20 and 40 degrees,

bracing may be use.• Over 40%, surgery with spinal rods

Scoliosis• Postoperative Care:• Keep back straight.• Log roll.• Hemovac drains to remove blood.• NG tube for paralytic ileus• Assess for lower extremity circulation &

movement.• Provide pain relief (PCA?)

Juvenile Rheumatoid Arthritis (JRA)

• Inflammation of connective tissue• Incidence peaks at 1-3 years or 8-12 yrs.• Probably an autoimmune proves• More common in girls than boys• Joints are inflamed and very painful on

movement.

Juvenile Rheumatoid Arthritis (JRA)• Therapy:• Program of physical exercise• Rest inflamed joints during acute

inflammation.• Heat application• Splinting to maintain alignment• Anti-inflammatory drugs (May receive

aspirin or Motrin)• Nonsteroidal anti-inflammatory drugs

NSAIDS or DMARDS (naproxen)• Steroid such as prednisone

Juvenile Rheumatoid Arthritis• Evaluation:• Most today do not have permanent

deformities.• Maintain long term drug therapy.• May have iris involvement.; need

frequent eye examinations.

Muscular Dystrophy

• Occurs in several types.• Most common is inherited as sex linked

recessive and occurs only in boys.• Pseudohypertrophic (Duchenne’s

Disease)• Assessment;• Progressive skeletal muscle weakness• Positive Gower’s sign.• “Slip through hands.”

Muscular Dystrophy

• Therapy:• Keep ambulatory as long as possible.• Try and avoid over weight.

Trauma

• Infant: falls, aspiration, drowning• Preschool: Falls, drowning, MVA,

poisoning, burns• Schoolage: MVA, bicycle, drowning,

burns, firearms.• Adolescence: MVA, drowning, falls,

firearms.

• Be aware that trauma may the result of abuse

Head InjuriesSubdural hematoma:• Bleeding into space between dura and

arachnoid membrane from a lacerated vein.• Most frequent in infants. Assessment: • Symptoms: ICP; seizures, vomiting,

enlargement of head, anemia• Angiography• Therapy: • Subdural puncture through anterior

fontanelle. • Surgery to repair lacerated vein.

Head InjuriesEpidural hematoma• Bleeding into space between dura and the

skull from a lacerated artery.• Result of severe head trauma’ bleeding is

extreme.Assessment:

• Vomiting, LOC, headache, seizures, hemiparesis, unequal pupil dilatation,

decorticate posturing • SonogramTherapy: OR to repair damaged vessel.

Concussion• Head injury from a hard, jarring shock.Assessment:• At least transitory LOC at time of injury.• No memory for accident.• To test alertness: Ask to name a familiar

object, name a color or name• Children don’t do this well (bored with

exercise).• Parents assess Q2h while at home.

Coma

• Unconsciousness from which children cannot be roused

• Stupor: Grogginess from they can be aroused.

• Based on Glasgow coma scale.

Glasgow Coma Scale• Areas Assessed: • Eye opening (1-4)• Motor Response (1-6)• Verbal Response (1-5)

• Total is 15. 3-8 = severe trauma; 9-12 = moderate; 13-14 = slight.

Glasgow Come Scale Scoring• Eye Opening4. Child opens eyes spontaneously when

you approach.3. Child opens eyes in response to speech

(spoken or shouted)2. Child opens eyes only n response to

painful stimuli such as pressure on a nail bed

1. Child does not open eyes in response to painful stimuli (tested by eye pressure)

Glasgow Come Scale Scoring• Motor Response6. Child obeys simple commands such as

“hand me a toy” (infant smiles or attunes)5. Child moves an extremity to locate a

painful stimuli applied to head or trunk.4. Child withdraws from source of pain.3. Child flexes arms at the elbows in response

to painful stimuli (decorticate rigidity)2. Child extends arms in response to painful

stimuli (cerebrate rigidity)1. Child has no motor response to pain.

Glasgow Come Scale Scoring• Verbal Response5. Child is oriented to time, place and

person (over 4 yrs, knows name, date + where he is; infant recognizes parents.

4. Child can converse, although not oriented X3.

3. Child speaks but words make no sense; infant’s vocabulary is less than usual.

2. Child makes incomprehensible sounds or groans.

1. Child does not respond verbally at all.

Abdominal Trauma

• Spleen and Liver trauma greater in children than adults.

Assessment:• ABD tenderness• X-ray shows fluid level in abdomen.• Paracentesis reveals blood.• Liver enzymes are elevated.• Anemia

Dental Trauma

• Dislodged teeth should be washed in water and replaced or dropped in salt water or milk and taken to E.R.

• Tooth is replaced and wired into place.• Antibiotics & tetanus prophylaxis may be

administered.• Teeth may discolor.

Near Drowning

Episode of suffocation from submersion in liquid.

• First reaction is spasm of larynx. Simple asphyxia. Can be revived easily.

• Second reaction is airway relaxation; water enters. Blocks exchange space; carries contaminants.

• Young children have a “diving reflex” in cold water.

Near Drowning

• Therapy depends on type of water:• Salt Water is hypertonic; fluid shifts into

from blood stream alveoli; hypovolemia & blood viscosity can occur.

• Non-salt water is hypotonic: water shifts into blood stream; hypervolemia & RBC destruction can occur. Potassium release may hyperkalemia.

• In both, loss of surfactant can occur.• Pneumonia occurs from water

contaminants.

Near Drowning

• Oxygen is given at 100% to make use of all exchange space available.

• Warm gradually so need does not exceed availability.

• NG tube to prevent vomiting from stomach water.

• Often awake with nightmare for months afterward.

Poisoning

• Acetaminophen Poisoning is most frequent.

• Causes liver damage• Syrup of Ipecac at home

• Activated charcoal in E.R.

Other Poisoning

Caustic: lye, oven cleaner, etc.• Burns esophagus; do not induce

vomiting.Hydrocarbon: (furniture polish, kerosene)• Do not induce vomiting; fumes cause

sever pneumonia in lungs.Iron: Pregnancy vitamins• Severe corrosion to stomach; bloody

vomiting. Activated charcoal not effective.

Lead Poisoning (plumbism)• Usual source is chips of paint (B4 1950).• Can be batteries, lead sinkers, older home

restoration.• Assessment:• Interferes with incorporation of

protophorin in hemoglobin.• Microcytic, hypochromic anemia• Basophilic stripling• Lead lines in bones• Encephalapy; cognitive challenges.

Lead Poisoning• Therapy:• Chelating agent: Edetate Calcium

Disodium (EDTA) or BAL (dimercaprol). • Check kidney function b4 administration.• Succimer (Chermet) new agent (oral).• Remove from source of lead• Cover with masonite or tile (not contact

paper).

Glasgow Coma Scale

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

4 3 2 1

Eye OpeningSpont.To speechTo PainNo response

Fractures:

Poisoning

Near Drowning