2 Musculoskeletal Development Infant bones are only 65% ossifiedLong bones are porous and less dense and can bend, buckle or break easilyGrowth takes place in Epiphyseal plates, and if these are injured, can cause abnormal growthGrowing bones heal quickly and decrease need for treatmentHow does the growth process contribute to complications in musculoskeletal development?
3 ClubfootA congenital abnormality in which the foot is twisted out of its normal position.
4 Talipes Equinovarus (Clubfoot) Muscles, tendons, and bones are involved in the abnormality.Adduction and supination of forefootInversion of the heelFixed plantar flexionAssessment findings- adduction and supination of forefoot with an inversion of the heel and fixed plantar flexion. Equinus Varus= Equinus is the midfoot is directed downward, Varus= The hindfoot turns inward, and the forefoot curls toward the heelProvide emotional support for family throughout discovery (loss of “perfect child”)Orthopedic specialists, OT and PT for consult. May also need financial consultation as the treatment requires multiple castings or surgical repair
5 Return the foot to a maximal anatomic position Goal of CareStretch tightened ligaments andtendons gently toReturn the foot to a maximal anatomic positionWhat is the priority goal in the care of the infant with a clubfoot?
6 Treatment for Clubfoot Serial manipulationCorrective castingSplintsSurgical correctionCompare the medical measures utilized in aligning the clubfoot – discuss specificnursing interventions/teaching related to each type of treatment?a. serial manipulation- rotation of the ROM and manipulation of the foot into correct alignment forapproximately 8-12 weeks until maximum correction achieved. then corrective splints or shoes to maintaincorrectionb. corrective Serial castingc. Dennis-Brown splint-d. Surgical correction- timing varies among surgeons- most treat between 3-12 months of age. Realigns bonesof the foot and reconstruction of soft tissue. Bones are held in proper position by stainless steel pins, thencasted with knee flexed to prevent weight baring. Casting typically continues for 6-12 weeks. May requirecorrective shoes or brace
7 Serial Casting Cast applied to hold foot in desired position. Changed every 1-2 weeks until maximum correction is achieved.Nursing Care:Cast careSkin CareEducation of parents
8 Neurovascular Assessment CirculationSSensoryMMotionWhat is included in a neurovascular assessment?
9 Cast Care – Assessment Unusual odor beneath the cast Tingling, burning, numbness of toesDrainage through castSwelling or inability to move toesToes that are cold, blue or whiteSudden unexplained feverPain that is not relieved by comfort measures
10 Cast Care Teaching “Petaling” the edges of the cast Drying of the cast Prevention of swellingProtecting the castWhen to call the doctor
11 Try thisA infant has a cast applied for treatment of club foot. Which of the following symptoms requires immediate attention and should be reported to the health care provider?A. Capillary refill of 4 seconds in the affected toes.B. Edema in the affected toes that improves withelevation.C. Numbness of the toes on the affected foot.D. Skin distal to the cast is warmC – feeling asleep is numbness. This and a tingling sensation indicates something is wrong with neuro supply.
12 Splinting is used after casts are removed to maintain the correction. Dennis Brown SplintStraight-last shoes separated by a metal bar keep the calcaneus in valgus, the forefoot in abduction and the ankle dorsiflexed - all in an attempt to straighten out the child with Club Foot.Splinting is used after casts are removed to maintain the correction.
13 Care of a child in a splint Braces should fit snugly but should not interfere with neurovascular function. Before wearing the brace, check the skin for any areas of redness or breakdown.Give parents guidelines for braces.If redness develops, arrange to have the fit of the brace evaluated and modified.Bar between legs is not a handle.Teach appropriate positioning for safety to prevent falls, and allow mobility and "tummy-time“What are specific measures related to care of the child with a Dennis-Browne splint?
14 Parent SupportParents are trained and become active participants in the physical therapy treatments and child’s stretching programNurses need to help the parents understand the time commitment involvedAssess the parents’ ability to monitor the child adequately for complications and confirm they understand the signs and symptoms of thecomplicationsWhat is parent’s role in treatment and how can the nurse assist the parents in this role?
15 QuestionThe parents of an infant with clubfoot ask how it is treated. Which of the following treatments should the nurse discuss with the parents?Weekly cast changes with manipulationProbably surgery on the affectedAbduction device to keep the extremity in alignmentUse of a Dennis-Browne splint to achieve correction.
16 Hip DysplasiaThe head of the femur is improperly seated in the acetabulum of the pelvisWhat is the pathology related to a congenital hip dislocation?
17 Developmental Dysplasia of Hip Clinical Manifestations Limited abduction of the affected hip during Ortolani maneuver. May hear a click upon movement.Asymmetry of gluteal and thigh fat folds when lying with legs extended.Telescoping of thighLimp and abnormal gait in olderchildOrtolani maneuverWhat are the classic signs and symptoms of congenital hip dislocation?What is Ortolani sign – how performed?Asymmetry of gluteal folds
18 Treatment and Nursing care of a child with Dysplasia of the Hip: Pavlik harnessEnsures hip flexion and abduction and does not allow hip extension or adduction.It maintains correct position of the femoral head in the acetabulum.How does the Pavlik harness assist to correct this anomaly?
19 Nursing CareTeach parents/caregivers to remove and apply harness appropriately –only remove for bathing and skin checks.Teach skin assessmentEncourage cuddling infant to promote cognitive development and infant/caregiver bondingWhat is the nursing care for the child while wearing this harness?
20 Ask Yourself ?A parent asks why the infant must wear a Pavlik harness. What is the nurse's best response? This treatment is to:provide comfort and support.shorten the limb on the affected side.maintain the femur within the acetabulum.provide outward displacement of the femoral head.Maintain the femur within the acetabulum
21 Treatment and Nursing care of a child with Dysplasia of the Hip: Spica castCovers lower half ofbody except perineal areaNursing CareElimination/ protection of castPositioningNeurovascular assessmentSkin careHygieneDiscuss care of the child in a spica cast related to hygiene, feeding, cast care, and elimination.To prevent complications:assess breathing patterns and lung sounds frequentlyperform skin and neurovascular assessments every 2 hoursprovide padding and skin wrapping to avoid pressure on popliteal space (pressure can lead to nerve damage)change child's position every 2-3 hours while awake to increase respiratory status, circulation, and decrease pressure. Place either prone or supine on sidePrevent skin irritating and breakdown. Use moleskin to protect from rough edges of cast (flute edges with soft tape- petaling )Increase fiber and fluids to maintain bowel statusrelease from traction for meals and daily hygiene (should not release more than one hour per day)
23 Causes of Fractures Increased mobility and immature motor skills TraumaBone diseases
24 Manifestations of Fracture Pain or tenderness at siteImmobility or decreased ROMDeformity of extremityEdemaOther signs – crepitus, ecchymosis, muscle spasm and inability to bear weightWhat are the signs and symptoms of a fracture?
25 Repositioning of the bone fragments into normal alignment TreatmentReductionRepositioning of the bone fragments into normal alignmentApplication of a device or mechanism that maintains alignment until healing occursWhat are reduction and retention related to treatment of a fracture?Retention
26 Retention Application of Cast Traction What are reduction and retention related to treatment of a fracture? How are these accomplished?Pull or force exerted on one part of the body
27 QuestionWhich of the following nursing interventions takes highest priority when caring for a child in skeletal traction?Assessing bowel sounds every shiftProviding adequate nutritionAssessing temperature every 4 hoursProviding age-appropriate activities
28 Complications associated with Orthopedic Trauma/ Fractures Fat EmbolismParticles of fat are carried through circulation and lodge in lung capillaries causing:Pulmonary edemaRespiratory distress with hypoxemia and respiratory acidosisTreatmentIncrease in IV fluidsRespiratory support and adequate oxygenation
30 Legal & Ethical implications when caring for a child with a fracture? All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect.The nurse must report all suspected abuse to the appropriate authority.Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.What legal and ethical implications must the nurse include when caring for a child with a fracture?
31 Progressive degeneration of Muscular DystrophyProgressive degeneration ofMuscle fibers
32 Manifestations of Muscular Dystrophy Delayed walking – (first sign)Progressive, symmetric muscle wastingFrequent fallsEasily tired when walking, running, or climbing stairsHypertrophied calves muscleWaddling wide-based gaitUses Gower’s maneuver to rise from floorUnable to walk independently byage 9 – 12.What clinical manifestations would a parent or care giver report first? What are additional signsand symptoms?
33 Diagnostic findings:Muscle biopsy – reveal fatty fibrous tissue that gradually replaces muscles (the protein dystrophin is low in the muscles of these patients)Elevated serum enzyme CK (creatine kinase)What specific diagnostic findings confirm muscular dystrophy?
34 Maintain ambulation and independence for as long as possible. Goal of CareMaintain ambulation and independence for as long as possible.
35 Nursing Care Coordinate a variety of health care services Maintain activity and self-care functionsSkin careMaintain bladder and bowel functioningProtect from respiratory infectionsTeach dietary modifications to decrease obesityWhat is the nursing care for this child/family?
36 Question Which of the following interventions is INAPPROPRIATE to incorporate in the care for achild with muscular dystrophy hospitalized with arespiratory infection?Physical therapyAggressive antibiotic therapyPassive range of motion exercisesComplete Bedrest
37 Lateral S curvature of the spine ScoliosisLateral S curvature of the spine
38 Scoliosis Assessment findings: Lateral curvature of spine Truncal asymmetryUneven shouldersProminent scapula – uneven heightRib-humpuneven hipsWhat are the classic manifestations of scoliosis?
39 Braces used in Treatment of Scoliosis What types of braces are used in treating scoliosis?
40 Quick Question:What is the priority psychosocial nursing diagnosis for the adolescent diagnosed with scoliosis?What psychosocial implications do the adolescent experience with this treatment? **At risk for Disturbed Body Image related to deformity and brace wear
41 Treatment and Nursing Care for Scoliosis Spinal Fusion Pre-operative teachingDemonstrate incentive spirometer and C&DBDiscuss all potential equipment (chest tubes, IV, O2 masks & nasal canula, Foley catheter)Teach use of pumps for PCA or epidural block.Demonstrate log rolling and assist out of bed.What is the pre-operative teaching for spinal fusion?What is post-op care
42 Nursing Care for spinal fusion Post-operative CareMaintain airwayNeurovascular Assessment of lower extremitiesTeach passive and active ROM exercisesEncourage independence in ADL’sProvide with resources / information on scoliosis support groups
43 Post operative care of an adolescent following a spinal fusion for scoliosis includes: (select ALLthat apply)Oral analgesics for painLogrolling every 2 hoursNasogastric intubationBilateral Neurovascular checks of lower extremitiesUse of incentive spirometer q 2 hoursAssess skin on bony prominencesbdef