The Child with Musculoskeletal or Articular Dysfunction

The Child with Musculoskeletal or Articular Dysfunction
Chapter 39

Emergency Management ABCs Spinal cord injury EMS/BLS/ALS
Systematic “head-to-toe” assessment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The Immobilized Child Immobilization was once thought to be restorative from illness and injury We know now that immobilization has serious consequences Physical Social Psychologic Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Physiologic Effects of Immobilization
Muscular system Decreased muscle strength and endurance Atrophy Loss of joint mobility Skeletal system Bone demineralization Negative calcium balance Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Physiologic Effects of Immobilization
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Physiologic Effects of Immobilization (cont.)
Metabolism Decreased metabolic rate Negative nitrogen balance Hypercalcemia Decreased production of stress hormones Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Physiologic Effects of Immobility (cont.)
Cardiovascular system Decreased efficiency of orthostatic neurovascular reflexes Diminished vasopressor mechanism Altered distribution of blood volume Venous stasis Dependent edema Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory system Decreased need for oxygen Diminished vital capacity Poor abdominal tone and distention Mechanical or biochemical secretion retention Loss of respiratory muscle strength Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

GI system Distention caused by poor abdominal muscle tone Difficulty feeding in prone position Gravitation effect on feces Anorexia Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Integumentary system Decreased circulation and pressure leading to decreased healing capacity Urinary system Alteration of gravitational force Difficulty voiding in supine position Urinary retention Impaired ureteral peristalsis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Effects of Immobility on Neurosensory System
Loss of innervation If nerve tissue is damaged by pressure If circulation to nerve tissue is interrupted Effects of improper positioning Sensory and perceptual deprivation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychologic Effects of Immobility
Diminished environmental stimuli Altered perception of self and environment Increased feelings of frustration, helplessness, anxiety Depression, anger, aggressive behavior Developmental regression Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Effect on Families Extended periods of immobilization
Logistical management of sick child Need for family support and home care assistance Coping skills Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Mobilization Devices Orthotics and prosthetics Nursing considerations
Crutches and canes Wheelchairs Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Knee-Ankle-Foot Orthosis

Thoracolumbosacral Orthosis

Gait Walker with Suspension Belts

Epiphyseal Injuries Weakest point of long bones is the cartilage growth plate (epiphyseal plate) Frequent site of damage during trauma May affect future bone growth Treatment may include open reduction and internal fixation to prevent growth disturbances Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Fractures Common injury in children
Methods of treatment different in pediatrics than in older adult population Rare in infants, except with MVC Clavicle most frequently broken bone in child, especially younger than age 10 School age: bike, sports injuries Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Fractures Compound or open: fractured bone protrudes through the skin Complicated: bone fragments have damaged other organs or tissues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Fractures (cont.)
Comminuted: small fragments of bone are broken from the fractured shaft and lie in surrounding tissue Greenstick: compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations of Fracture
Generalized swelling Pain or tenderness Diminished functional use May have bruising, severe muscular rigidity, crepitus Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Bone Healing and Remodeling
Typically rapid healing in children Neonatal period—2 to 3 weeks Early childhood—4 weeks Later childhood—6 to 8 weeks Adolescence—8 to 12 weeks Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Time Devoted to Phases of Bone Healing

Assessment of Fractures: The Five Ps
Pain and point of tenderness Pulse—distal to the fracture site Pallor Paresthesia—sensation distal to the fracture site Paralysis—movement distal to the fracture site Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The Child in a Cast Cast application techniques Nursing considerations
Cast care at home Cast removal Skin care Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Spica Cast with Hip Abductor

Young Children Come to Regard Casts as Part of Their Body

The Child in Traction Traction: extended pulling force may be used to:
Provide rest for an extremity Help prevent or improve contracture deformity Correct a deformity Treat a dislocation Allow position and alignment Provide immobilization Reduce muscle spasms (rare in children) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Traction: Essential Components
Traction: forward force produced by attaching weight to distal bone fragment Adjust by adding or subtracting weights Countertraction: backward force provided by body weight Increase by elevating foot of bed Frictional force: provided by patient’s contact with the bed Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Application of Traction for Maintaining Equilibrium

Types of Traction Manual traction: applied to the body part by the hand placed distally to the fracture site Skin traction: pulling mechanisms are attached to the skin with adhesive material or elastic bandage Skeletal traction: applied directly to skeletal structure by pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Cervical Traction Crutchfield or Barton tongs
Inserted through burr holes in skull with weights attached to the hyperextended head As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord no longer pinched between vertebrae Halo traction can be applied in some cases Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Considerations
Assessing the patient in traction Skin care issues Pain management/comfort Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Distraction Process of separating opposing bone to encourage regeneration of new bone in the created space Can be used when limbs are unequal in length and new bone is needed to elongate the shorter limb Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

External Fixation Ilizarov external fixator Nursing considerations
Permits limb lengthening by manual distraction Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Internal Fixation ORIF (surgical intervention)
Preoperative preparation Postoperative complications Infection Neurovascular compromise Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Fracture Complications
Circulatory impairment Nerve compression syndromes Compartment syndromes Volkmann contracture Epiphyseal damage Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Fracture Complications (cont.)
Nonunion/malunion Infection Kidney stones from increased free CA++ Pulmonary emboli Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Amputation Congenital or traumatic
Potential for reattachment of amputated part Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Amputation (cont.) Surgical amputation Surgical repair of severed limb
Prosthetics Pain management/“phantom pain” Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management
Prosthetics as early as possible Early prosthetics encourage maximum exploration and development in infancy Phocomelic digits may be surgically modified, preserved, and reattached for use with prosthetics Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Injuries and Health Problems Related to Sports Participation
Preparation for sports AAP classification of sports according to strenuousness and probability of collision AAP guidelines for inclusion or exclusion from specific sports based on medical and/or surgical condition of child Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Football is Strenuous Collision Sport

Traumatic Injury Soft tissue injury: injuries to muscles, ligaments, and tendons Sports injuries Mishaps during play Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Contusions Damage to soft tissue, subcutaneous tissue, and muscle
Escape of blood into tissues—ecchymosis—black-and-blue discoloration Swelling, pain, disability Crush injuries Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Dislocations Occurs when the force of stress on the ligament is great enough to disrupt the normal position of the opposing bone ends or the bone end and its socket Pain increases with active or passive movement of the affected extremity More common in Down syndrome Hip dislocation: potential loss of blood supply to head of femur Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Sprains Trauma to a joint from ligament partially or completely torn or stretched by force May have associated damage to blood vessels, muscles, tendons, and nerves Presence of joint laxity as indicator of severity Rapid onset of swelling with disability Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Sites of Injuries to Bones, Joints, and Tissues

Strains A microscopic tear to musculotendinous unit Similar to sprain
Swollen, painful to touch Generally incurred over time Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Stress Fractures Occur as result of repeated muscle contraction
Often seen in repetitive weight-bearing sports (running, gymnastics, basketball) Tibial fracture most common Symptoms Therapeutic management Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Gymnastics is Strenuous Limited-Contact Sport

Therapeutic Management of Sports Injuries
RICE: Rest the injured part Ice immediately (max 30 minutes at a time) Compression with wet elastic bandage Elevation of the extremity Immobilization and support (casts or splints as appropriate to injury) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Correct and Incorrect Methods for Elevating a Lower Extremity

Therapeutic Management of Sports Injuries (cont.)
ICES Ice, Compression, Elevation, Support Alleviate repetitive stress Rest as primary therapy Usually means reduced activity and alternative exercises, not bedrest Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Injury/Illness Susceptibility of infants and children Heat cramps
Heat exhaustion Heatstroke Therapeutic interventions Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Underwater Sports-Related Injuries
Near-drowning is primarily a respiratory and neurologic problem Ear injuries when middle ear pressures unequalized Diving-related concerns Sports and accidental drowning Risk elevated with alcohol use Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Health Concerns Associated with Sports
Nutrition Water and electrolytes Minerals Glycogen Weight Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Considerations for the Female Athlete
Female athlete triad Amenorrhea Osteoporosis Eating disorders -to stay in weight range Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Use by Athletes “Ergogenic aids” Amphetamines Anabolic steroids
“Nutritional aids” Life-threatening risks Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Sudden Death Also called instantaneous death: death occurs within minutes or within 24 hours of the episode Sports with high inherent risk for death Unrecognized underlying medical problems Idiopathic hypertrophic subaortic stenosis Present with chest pain, dizziness, prominent pulses, murmur at left sternal border Sports environment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nurse’s Role in Sports for Children and Adolescents
Evaluation for activities Prevention of injury Treatment of injuries Rehabilitation after injuries Instruction to student and parents Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

MUSCULOSKELETAL DYSFUNCTION

Torticollis “Wry neck”
Congenital or acquired limited neck motion with neck flexed to affected side Long-term effects Physical therapy Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Slipped Femoral Capital Epiphysis (SFCE)
Spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior direction Occurs shortly before or during accelerated growth periods or puberty Usually idiopathic, multifactorial Obesity, puberty hormone changes, bone changes Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

SFCE (cont.) Clinical manifestations Therapeutic management
Episode of trauma with acute displacement Gradual displacement without definite injury Intermittent displacement (or combination of all) Therapeutic management Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Lordosis Accentuation of the cervical or lumbar curvature beyond physiologic limits May be secondary complication of trauma or idiopathic May occur with flexion contractures of hip, congenital dislocated hip In obese children abdominal fat alters center of gravity, causing lordosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Kyphosis Abnormally increased convex angulation in the curvature of the thoracic spine Most common form is “postural” Can result from TB, arthritis, osteodystrophy, or compression fracture Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Scoliosis The most common spinal deformity
Complex spinal deformity in three planes Lateral curvature Spinal rotation causing rib asymmetry Thoracic hypokyphosis May be congenital or develop during childhood Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Scoliosis (cont.) Multiple potential causes; most cases idiopathic
Generally becomes noticeable after preadolescent growth spurt May have complaint of “ill-fitting clothes” School screening controversial Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Evaluation
Standing radiographs to determine degree of curvature Asymmetry of shoulder height, scapular or flank shape, or hip height Often have a primary curve and a compensatory curve to align head with gluteal cleft Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Treatment goal: keep head of femur in acetabulum Containment with various appliances and devices Rest, no weight bearing initially Surgery in some cases Home traction in some cases Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations
Insidious onset, may have history of limp, soreness or stiffness, limited ROM, vague history of trauma Pain and limp most evident on arising and at end of activity Diagnosed by x-ray Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Team approach to treatment Bracing Exercise Surgical intervention for severe curvature (instrumentation and fusion) Harrington rods L-rods Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Concerns of body image Concerns of prolonged treatment of condition Preoperative care Postoperative care Family issues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Osteomyelitis Inflammation and infection of bony tissue
May be caused by exogenous or hematogenous sources Infectious agent invades the bone following penetrating wound, open fracture, contamination in surgery, or secondary extension from an abscess or burn Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Hematogenous Osteomyelitis
Preexisting infection spreads to bone Source may be skin infections, URI, abscessed teeth, pyelonephritis, etc. Any organism can cause osteomyelitis Infective emboli travel to arteries in the bone metaphysis, causing abscess formation and bone destruction Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Osteomyelitis Signs and symptoms begin abruptly; resemble symptoms of arthritis and leukemia Marked leukocytosis Bone cultures obtained from biopsy or aspirate Early x-rays may appear normal Bone scans for diagnosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management of Osteomyelitis
May have subacute presentation with walled-off abscess rather than a spreading infection Prompt, vigorous IV antibiotics for extended period (3 to 4 weeks or up to several months) Monitor hematologic, renal, hepatic responses to treatment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Complete bedrest and immobility of limb Pain management concerns Long-term IV access (for antibiotic administration) Nutritional considerations Long-term hospitalization or home therapy Psychosocial & school needs Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Juvenile Rheumatoid Arthritis (JRA)
Also called juvenile chronic arthritis or idiopathic arthritis of childhood Possible causes Peak ages: 1 to 3 years and 8 to 10 years Often undiagnosed Actually a heterogenous group of diseases Pauciarticular onset (involves ≤4 joints) Polyarticular onset (involves ≥5 joints) Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

JRA (cont.) Actually a heterogenous group of diseases
Pauciarticular onset (involves ≤4 joints) Polyarticular onset (involves ≥5 joints) Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

JRA (cont.) 90% children have negative rheumatic factor
Symptoms may “burn out” and become inactive Chronic inflammation of synovium with joint effusion, destruction of cartilage, and ankylosis of joints as disease progresses Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Symptoms of JRA Stiffness Swelling Loss of mobility in affected joints
Warm to touch, usually without erythema Tender to touch in some cases Symptoms increase with stressors Growth retardation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Evaluation of JRA
No definitive diagnostic tests Elevated sedimentation rate in some cases Antinuclear antibodies common but not specific for JRA Leukocytosis during exacerbations Diagnosis based on criteria of American College of Rheumatology Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

American College of Rheumatology Diagnostic Criteria
Age of onset younger than 16 years One or more affected joints Duration of arthritis more than 6 weeks Exclusion of other forms of arthritis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

JRA: Therapeutic Management
No specific cure Goals of therapy: preserve function, prevent deformities, and relieve symptoms Iridocyclitis/uveitis Inflammation of iris and ciliary body Unique to JRA Requires treatment by ophthalmologist Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

JRA: Pharmacology NSAIDs SAARDs Corticosteroids Cytotoxic agents
Immunomodulators Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

JRA: Management Therapy individualized to child PT, OT
Nutrition, exercise Splinting devices Pain management Prognosis Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The Child with Neuromuscular or Muscular Dysfunction
Chapter 40 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Neuromuscular Dysfunction
Terms to understand Myopathy Upper motor neurons Lower motor neurons Motor unit Pyramidal Extrapyramidal Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Classification and Diagnosis
Upper motor neuron lesions Weakness/spasticity Increased DTRs and abnormal superficial reflexes Primarily cerebral palsy Lower motor neuron lesions Weakness, atrophy of skeletal muscles, hypotonia Usually symmetric Gradual or sudden onset indicates causation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Site of Origin of Neuromuscular Disorders

Classification (cont.)
Diseases of anterior horn cells Neuropathies Neuromuscular junction disease Diseases of muscles Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Tools EMG Nerve conduction velocity Muscle biopsy
Serum enzyme measurement/CPK Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Cerebral Palsy (CP) Characterized by early onset and impaired movement and posture Incidence 1.5 to 3 per 1000 live births Most common permanent physical disability in childhood Definition: Nonspecific term applied to disorders characterized by early onset and impaired movement and posture. Incidence 1.5 to 3 per 1000 live births Most common permanent physical disability in childhood Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

CP: Etiology Intrauterine hypoxia/asphyxia Intrapartum asphyxia
12% to 23% of CP occurs in term infants with intrapartum asphyxia Postnatal Often no identifiable immediate cause Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

CP: Etiology (cont.) Preterm birth of ELBW and VLBW is single most important determinant of CP Anoxia—most common cause of brain damage whenever it occurs Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of CP Spastic Athetoid/dyskinetic Ataxic Mixed/dystonic
Athetoid/ dyskinetic—Slow wormlike movements of extremities, trunk, face, tongue Drooling, speech problems Lead to chorea—jerky involuntary movements worsen w/ emotional stress Ataxic—rapid repetitive movements; wide gait, unable to hold on to objects Mixed/dystonic—combination or spastic and athetosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of CP (cont.) Spastic Most common clinical type
Presents as hypotonia most often Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Spastic CP Quadriparesis (tetraparesis)
Four extremities involved/severe disability Speech and swallowing difficulties Tongue protrusion (incomplete) Labile emotions in some patients Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of CP (cont.) Diplegia Monoplegia Triplegia Paraplegia
Diplegia—both arms or both legs Monoplegia—only one extremity Triplegia—3 extremities Paraplegia—Pure cerebral paraplegia of lower extremities Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Possible Motor Signs of CP
Poor head control after age 3 months Stiff or rigid limbs Arching back/pushing away Floppy tone Unable to sit without support at age 8 months Clenched fists after age 3 months Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Possible Behavioral Signs of CP
Excessive irritability No smiling by age 3 months Feeding difficulties Persistent tongue thrusting Frequent gagging or choking with feeds Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Child Ambulating with an Assistive Device

Cerebral Palsy and IQ Wide variation 70% of CP patients have normal IQ
Difficult to assess Rigid, atonic, and quadriparetic CP have highest incidence of profound impairment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management: Therapies, Education, Recreation
PT Functional and adaptive training (OT) Speech therapy Recreation Normalization Family support Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Muscular Dystrophies (MDs)
Largest group of muscular diseases in children All have genetic origin with gradual degeneration of muscle fibers, progressive weakness, and wasting of skeletal muscles All have increasing disability and deformity with loss of strength Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Initial Muscle Groups Involved in MDs

Duchenne Muscular Dystrophy (DMD)
Also called pseudohypertrophic muscular dystrophy Most severe and most common of the MDs in childhood X-linked inheritance pattern; one third are fresh mutations Incidence: 1 in 3500 male births Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Characteristics of DMD
Onset between ages 3 and 5 years Progressive muscle weakness, wasting, and contractures Calf muscles hypertrophy in most patients Progressive generalized weakness in adolescence Death from respiratory or cardiac failure Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Evaluation of DMD
Suspected based on clinical appearance Confirmation by EMG, muscle biopsy, and serum enzyme measurement Serum CPK and AST levels high in first 2 years of life, before onset of weakness; levels diminish as muscle deterioration continues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

DMD: Clinical Manifestations
Waddling gait, frequent falls, Gower sign Lordosis Enlarged muscles, especially thighs and upper arms Profound muscular atrophy in later stages Mental deficiency common Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management of DMD
No effective treatment has been established Primary goal: maintain function in unaffected muscles as long as possible Keep child as active as possible ROM, bracing, performance of ADLs, surgical release of contractures prn Genetic counseling for family Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

DMD: Nursing Considerations
Help child and family cope with chronic, progressive, debilitating disease Help design a program to foster independence and activity as long as possible Teach child self-help skills Arrange for appropriate health care assistance as child’s needs intensify (home health, skilled nursing facility, respite care for family, etc.) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Guillain-Barré Syndrome (GBS)
Also called infectious polyneuritis An acute demyelinating polyneuropathy with progressive paralysis Children less often affected than adults Occurrence in children most often between ages 4 and 10 years Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

GBS: Pathophysiology Immune-mediated disease
Often associated with viral or bacterial infection or administration of vaccines Inflammation and edema in spinal and cranial nerves progresses to impaired nerve conduction, then partial or complete paralysis of involved muscles Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

GBS: Diagnostic Evaluation
Based on paralytic manifestation and/or EMG findings CSF may have increased protein concentration; other labs WNL Symmetric paralysis is part of the differential diagnosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations of GBS
Initially: muscle tenderness, paresthesia, muscle weakness Paralysis rapidly ascends from lower extremities; may involve trunk, arms, face Flaccid paralysis, loss of reflexes Intercostal and phrenic nerve involvement Frequently urinary incontinency or retention and constipation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management of GBS
Treatment is symptomatic Possibly steroids, IV immunoglobulin, and plasmapheresis Respiratory support Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

GBS Prognosis: Better outcomes associated with younger ages; most patients have complete recovery Most patients have muscle function begin to return 2 days to 2 weeks after onset of symptoms, but prolonged period to complete recovery Most deaths due to respiratory failure Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

GBS: Nursing Considerations
Supportive care Observe for early signs of respiratory distress/difficulty swallowing Focus on prevention of complications Support for child and family Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Tetanus Also called lockjaw
An acute, preventable, and often fatal disease Caused by exotoxin of Clostridium tetani Characterized by muscle rigidity involving the masseter and neck muscles Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Four Requirements for Developing Lockjaw
Presence of tetanus spores or vegetative forms of the bacillus Injury to the tissues Wound conditions that encourage multiplication of the organism A susceptible host Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Tetanus Spores are found in soil, dust, and GI tract of humans and animals Bacteria enter body through wound, especially puncture or crush wound or burn May enter through scratch, bee sting, thorn, or needle prick Exposure greater during outdoor activities Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Pathophysiology of Tetanus
Exotoxin spreads from wound to CNS by way of neurons or bloodstream Toxin becomes fixed on nerve cells of brainstem and spinal cord Toxin produces muscle stiffness Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations of Tetanus
Initially: progressive stiffness and tenderness of neck and jaw muscles, difficulty in opening the mouth, facial muscle spasm Progressive: opisthotonos, difficulty swallowing, laryngospasm, and tetany of respiratory muscles Rigid abdominal and limb muscles Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations of Tetanus (cont.)
Respiratory: accumulated secretions, atelectasis, pneumonia, respiratory arrest Patient anxious but alert; mentation unaffected Rapid HR, diaphoresis, mild or absent fever Incubation: 3 to 10 days Mortality approximately 30%; usually fatal in newborn Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management of Tetanus
Prevention by tetanus toxoid or tetanus antitoxin after exposure Treatment of wounds contaminated with dirt, feces, soil, saliva, puncture wounds, avulsions, crushing, burns, and frostbite should include tetanus immune globulin if patient inadequately immunized Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Therapeutic Management of Tetanus (cont.)
ICU for constant observation and respiratory support availability Monitor fluid and electrolyte status Tetanus immune globulin therapy to neutralize toxins Wound care to decrease organism proliferation Muscle relaxants, sedatives, pancuronium (Pavulon) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Control environmental stimuli Careful monitoring of respiratory status Attempt to reduce anxiety of child and family Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The Child with Renal Dysfunction
Chapter 30 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Renal Structure and Function
Primary responsibility of kidney is to maintain the composition and volume of the body fluids in equilibrium Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Major Functions of Nephron Components

Renal System Assessment
Physical assessment Palpation, percussion Health history Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer Medications: antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene Patterns of elimination Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Urinary Tract Infection: Nursing Assessment
Nausea, vomiting, anorexia, chills, nocturia, urinary frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Urinary Tract Infection Nursing Assessment (Cont.)
Objective data Fever Hematuria; foul-smelling urine; tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Studies Renal scan UA Cystogram Urine C&S
Retrograde pyelogram Ultrasound CT MRI Renal arteriogram UA Urine C&S BUN Creatinine KUB IVP VCG/VCUG Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Normal Urinalysis pH 5 to 9 Sp gr 1.001 to 1.035 Protein <20 mg/dl
Urobilinogen up to 1 mg/dl NONE OF THE FOLLOWING: Glucose Ketones Hgb WBCs RBCs Casts Nitrites Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Normal Characteristics of Urine
Color range Clear Newborn production about 1 to 2 ml/kg/hr Child production about 1 ml/kg/hr NB will produce 1-2 ml/kg/hr; after 1 mo. Approx 1 ml/kg/hr Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Urinary Tract Infection (UTI)
Is it really that serious? Concept of “asymptomatic bacteria” in urinary tract Second most common bacterial disease Account for more than 8 million office visits per year Results in >100,000 people hospitalized annually >15% patients who develop gram-negative bacteria DIE 1/3 of gram-negative infections originate in urinary tract Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Causes Escherichia coli most common pathogen Streptococci
Staphylococcus saprophyticus Occasionally fungal and parasitic pathogens Gram-negative bacilli from GI tract common cause Fungal generally after multiple antibiotic courses Also more common w/ immunosuppressed or diabetics Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Classification Upper tract involves renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Lower tract involves lower urinary tract Usually no systemic manifestations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Classification (Cont.)
Lower tract: Cystitis Urethritis Upper tract: Pyelonephritis VUR Glomerulonephritis Cystitis—Contained in bladder Urethritis—Irritation>>infection; potential for ascending Pyelonephritis—Inflam of upper urinary tract and may involve kidneys Role of vesicoureteral reflux VUR—we avoid, urine goes up into ureter and is opportunity for microbial proliferation Glomerulonephritis—Immunologic disorder in the kidney proper; did not begin in the bladder and ascend; Generally follows other bacterial illness, esp strep Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Classification (Cont.)
Uncomplicated infection Complicated infections Stones Obstruction Catheters Diabetes or neurologic disease Recurrent infections Uncomplicated infection: occurs in otherwise normal urinary tract Complicated Infections: Stones Obstruction Catheters Diabetes or neurologic disease Recurrent infection Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of UTIs Recurrent—repeated episodes
Persistent—bacteriuria despite antibiotics Febrile—typically indicates pyelonephritis Urosepsis—bacterial illness; urinary pathogens in blood Recurrent is reinfection in person whose prior infection was successfully eradicated Recurrent occurs because original infection not adequately eradicated Unresolved bacteriuria: bacteria resistant or drug discontinued before bacteriuria is completely eradicated Bacterial persistence: resistance developed or foreign body in urinary system serves as harbor and anchor for bacteria to survive despite therapy Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Etiology and Pathophysiology
Physiologic and mechanical defense mechanisms maintain sterility Emptying bladder Normal antibacterial properties of urine and tract Ureterovesical junction competence Peristaltic activity Explain what this means Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Etiology and Pathophysiology (Cont.)
Alteration of defense mechanisms increases risk of UTI Organisms usually introduced via ascending route from urethra Less common routes Bloodstream Lymphatic system Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Contributing factor: urologic instrumentation Allows bacteria present in opening of urethra to enter urethra or bladder Sexual intercourse promotes “milking” of bacteria from perineum and vagina May cause minor urethral trauma Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTIs rarely result from hematogenous route For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract Obstruction of ureter Damage from stones Renal scars Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI is a common nosocomial infection Often Escherichia coli Seldom Pseudomonas Urologic instrumentation common predisposing factor Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Clinical Manifestations
Symptoms Dysuria Frequent urination (>q2h) Urgency Suprapubic discomfort or pressure Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Clinical Manifestations (Cont.)
Urine may contain visible blood or sediment (cloudy appearance) Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis) Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Pediatric Manifestations
Frequency Fever in some cases Odiferous urine Blood or blood-tinged urine Sometimes no symptoms except generalized sepsis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Diagnostic Studies
Dipstick Microscopic urinalysis Culture Dipstick: to identify presence of nitrates, WBCs, and leukocyte esterase Confirm w/ micro ua Urine culture indicated in complicated or nosocomial, persistent bacteria, or frequently recurring (>2 episodes annually) May be cultured if infection is unresponsive to empiric therapy or diagnosis is questionable Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Diagnostic Studies (Cont.)
Clean-catch is preferred U-bag for collection from child Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results May be necessary when clean-catch cannot be obtained Clean-catch is preferred Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results May be necessary when clean-catch cannot be obtained Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI: Diagnostic Studies (Cont.)
Sensitivity testing determines susceptibility to antibiotics Imaging studies for suspected obstruction IVP or abdominal CT Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI Collaborative Care: Drug Therapy—Antibiotics
Uncomplicated cystitis: short-term course of antibiotics Complicated UTIs: long-term treatment Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin Amoxicillin Antibiotic selected on empiric therapy or results of sensitivity testing Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI Collaborative Care: Drug Therapy (Cont.)
Cephalexin Others Gentamycin, carbenicillin ++ Pyridium (OTC) Combination agents (e.g., Urised) used to relieve pain Preparations with methylene blue tint Sulfa: used to treat empiric uncomplicated or initial Inexpensive TMP-SMX taken bid Pyridium is OTC that provides soothing effect on urinary tract mucosa Stains urine reddish orange that can be mistaken for blood and may stain underclothing Effective in relieving discomfort Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

UTI Collaborative Care: Drug Therapy for Repeated UTIs
Prophylactic or suppressive antibiotics TMP-SMX administered every day to prevent recurrence or single dose prior to events likely to cause UTI Suppressive therapy often effective on short-term basis Limited because of antibiotic resistance ultimately leading to breakthrough infections Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Vesicoureteral Reflux (VUR)
Retrograde flow of bladder urine into the ureters Increases potential for infection Primary vs. secondary reflux Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Etiology and Pathophysiology
Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys Urosepsis: systemic infection from urologic source Can lead to septic shock and death in 15% of cases Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Etiology and Pathophysiology (Cont.)
Usually infection is via ascending urethral route Frequent causes Escherichia coli Proteus Klebsiella Enterobacter Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis Etiology and Pathophysiology (Cont.)
Preexisting factor (usually) Vesicoureteral reflux Dysfunction of lower urinary tract function Obstruction Stricture Obstruction from BPH or from stone Stricture (narrowing) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Etiology and Pathophysiology (Cont.)
Commonly starts in renal medulla and spreads to adjacent cortex Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Clinical Manifestations
Vary from mild to classic and very severe Presenting symptoms N/V, anorexia, chills, nocturia, frequency, urgency Suprapubic or low back pain, dysuria Fever, hematuria, foul-smelling urine Costovertebral tenderness Symptoms often subside in a few days, even without therapy Bacteriuria and pyuria still persist Vary from mild fatigue to sudden onset of chills, fever, vomiting, malaise, flank pain, and lower urinary tract symptoms characteristic of cystitis Costovertebral tenderness usually present on affected side, kidney usually palpated as enlarged Acute Pyelonephritis Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination Fever, Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Diagnostic Studies
Urinalysis WBC casts CBC Imaging studies (IVP or CT) Ultrasound Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria WBC casts indicate involvement of renal parenchyma CBC will show leukocytosis with increase in immature bands If bacteremia is a possibility, close observation and vitals monitoring are essential Prompt recognition and treatment of septic shock may prevent irreversible damage or death Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pyelonephritis: Collaborative Care
Hospitalization Parenteral antibiotics Relapses treated with 6-week course of antibiotics Reinfections treated as individual episodes or managed with long-term therapy Prophylaxis may be used for recurrence Hospitalization for patients with severe infections and complications such as nausea and vomiting with dehydration Parenteral antibiotics to establish high serum levels Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Glomerulonephritis
Most are postinfectious Pneumococcal, streptococcal, or viral May be distinct entity or May be a manifestation of systemic disorder SLE Sickle cell disease Others Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Glomerulonephritis Symptoms
Generalized edema due to decreased glomerular filtration Begins with periorbital Progresses to lower extremities and then to ascites HTN due to increased ECF Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Glomerulonephritis Symptoms (Cont.)
Oliguria Hematuria Bleeding in upper urinary tract → smoky urine Proteinuria Increased amount of protein = increase in severity of renal disease Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Poststreptococcal Glomerulonephritis (APSG)
Is a noninfectious renal disease (autoimmune) Onset 5 to 12 days after other type of infection Often group A β-hemolytic streptococci Most common in children 6 to 7 years old Uncommon in younger than 2 years old Can occur at any age Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Prognosis 95%—rapid improvement to complete recovery
5% to 15%—chronic glomerulonephritis 1%—irreversible damage Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management of APSG
Manage edema Daily weights Accurate I&O Daily abdominal girth Nutrition Low-sodium, low to moderate protein Susceptibility to infections Bed rest is not necessary Most kids will normally restrict activity due to malaise Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nephrotic Syndrome Most common presentation of glomerular injury in children Characteristics: Proteinuria Hypoalbuminemia Hyperlipidemia Edema Massive urinary protein loss Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Nephrotic Syndrome
Minimal change nephrotic syndrome (MCNS) Also called: Idiopathic nephrosis Nil disease Uncomplicated nephrosis Childhood nephrosis Minimal lesion nephrosis Congenital nephrotic syndrome Secondary nephrotic syndrome MCNS is most common of these Pathogenesis not known Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Changes in Nephrotic Syndrome
Glomerular membrane Normally impermeable to large proteins Becomes permeable to proteins, especially albumin Albumin lost in urine (hyperalbuminuria) Serum albumin decreases (hypoalbuminemia) Fluid shifts from plasma to interstitial spaces Hypovolemia Ascites Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nephrotic Syndrome (Cont.)
“Edema phase” “Remission phase” Prognosis Prognosis is usually good for ultimate recovery in most cases (80%) Self limiting If child responds to steroids, usually will do ok Early detection and treatment to decrease proteinuria, and permanent renal damage About 20% will have relapses for up to 5 yrs, some up to 10 yrs. Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nephrotic Syndrome Management
Supportive care Diet Low to moderate protein Sodium restrictions if large amount of edema Steroids 2 mg/kg divided into BID doses Prednisone drug of choice (cheapest and safest) Immunosuppressant therapy (Cytoxan) Diuretics Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Family Issues Chronic condition with relapses Developmental milestones
Social isolation Lack of energy Immunosuppression/protection Change in appearance due to edema—self-image Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions
Aseptic technique during catheterizations Avoid unnecessary catheterization and early removal of indwelling catheters Prevents nosocomial infections Wash hands before and after contact Wear gloves for care of urinary system Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions (Cont.)
Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable) Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods Potential bladder irritants Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Discharge to home instructions Follow-up urine culture Recurrent symptoms typically occur in 1 to 2 weeks after therapy Encourage adequate fluids even after infection Low-dose, long-term antibiotics to prevent relapses or reinfections Explain rationale to enhance compliance Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Renal Tubular Disorders
Renal tubular acidosis Proximal tubular acidosis (type II) Distal tubular acidosis (type I) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Nephrogenic Diabetes Insipidus (NDI)
Major disorder associated with a defect in ability to concentrate urine Distal tubules and collecting ducts are insensitive to action of ADH (vasopressin) X-linked recessive inheritance Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Manifestations of Diabetes Insipidus
Newborn: vomiting, fever, failure to thrive, hypernatremia Copious amounts of dilute urine Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemolytic-Uremic Syndrome
Pathophysiology Diagnostic evaluation Therapeutic management Prognosis Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Renal Failure Acute renal failure (ARF) Chronic renal failure (CRF)

Acute Renal Failure (ARF)
Definition: kidneys suddenly unable to regulate the volume and composition of urine Not common in children Principal feature is oliguria Associated with azotemia, metabolic acidosis, and electrolyte disturbances Most common pathologic cause: transient renal failure resulting from severe dehydration Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

ARF (Cont.) Pathophysiology—usually reversible Diagnostic evaluation
Therapeutic management Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Complications of ARF Hyperkalemia Hypertension Anemia Seizures
Hypervolemia Cardiac failure with pulmonary edema Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Chronic Renal Failure (CRF)
Begins when diseased kidneys cannot maintain normal chemical structure of body fluids Clinical syndrome called uremia Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Potential Causes of CRF
Congenital renal and urinary tract malformations VUR associated with recurrent UTIs Chronic pyelonephritis Chronic glomerulonephritis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

CRF Pathophysiology Diagnostic evaluation Therapeutic management
Manage diet, hypertension, recurrent infections, seizures Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Renal Replacement Therapy
Dialysis types Hemodialysis Peritoneal dialysis Hemofiltration Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodialysis Requires creation of a vascular access and special dialysis equipment Best suited for children who can be brought to facility 3 times per week for 4 to 6 hours Achieves rapid correction of fluid and electrolyte abnormalities Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Child Receiving Hemodialysis

Diversional Activities Lessen Boredom During Hemodialysis

Peritoneal Dialysis Abdominal cavity acts as semipermeable membrane for filtration Can be managed at home in some cases Warmed solution enters peritoneal cavity by gravity; remains for period of time before removal Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Continuous Venovenous Hemofiltration
Uses technique for ultrafiltration of blood continuously at a very slow rate Works with the fluid overload in postoperative period Successful alternative for critically ill children who might not survive rapid volume changes of hemodialysis and/or PD Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Transplantation From living, related donor From cadaver donor
Primary goal is long-term survival of grafted tissue Role of immunosuppressant therapy Rejection Prognosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

The Child with Musculoskeletal or Articular Dysfunction

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The Child with Musculoskeletal or Articular Dysfunction

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