Pediatric orthopedic care

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The immobilized child what should nursing care focus on: healing, regaining function and promoting normal development
The immobilized child Etiology: includes fractures, congenital diseases, neurological and musculoskeletal disease
The immobilized child Effects of immobilization on the musculoskeletal system: Reduced strength and coordination
bone demineralization leading to Osteoporsis
-loss of joint mobility and contracture formation
The immobilized child Nursing Diagnoses Effects of immobilization on the musculoskeletal system: #1 Neurovascular dysfunction, risk for
mobility impaired
self-care deficit
body image disturbed
The immobilized child Assess the effects o immobility on neurosensory system: Damage is IATROGENIC
poor postioning/pressure on nerves
pain, burning, reduced sensation and movement
Peroneal Nerve damage-foot drop
radial nerve damage- wrist drop
AVOID UNNATURAL POSITIONS
The immobilized child Assess the effects o immobility on neurosensory /nursing diagnoses: RF peripheral neurovascular dysfunction
pain acute
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE CARDIO- VASCULAR SYSTEM: orthostatic hypotension
thrombus formation-+homans
increased cardiac workload
venous stasis and dependant edema
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE CARDIO- VASCULAR SYSTEM nursing DX: tissue perfusion alteration cerebral R/T orthostatic hypotension and/or emboli
cardiac output decreased R/T increased work load (BV)
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE RESP System: reduced rate and depth
limited chest expansion by position, casts, braces
reduced movement of secretions
atelectasis leading to hypostatic pneumonia
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE RESP System Nursing DX: Ineffective airway clearance
ineffective breathing pattern
impaired gas exchange
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE GI system: overweight r/t inactivity
underweight r/t poor appitite
neg nitrogen balance
muscle wasting
constipation
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE GI system NURSING DX: constipation
nutrition-risk for imbalance
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE GU system and nursing DX: Urinary stasis and UTI/stones
RF infection
risk for fluid volume imbalance (electrolytes too)
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON METABOLISM: ANEMIA- poor appetite and blood and protein loss
HYPERCALCEMIA-after 4-8wks of bedrest. ecourage fluids, ck. lytes and notrmal to low CA intake
signs and symptoms of hypercalcemia: n/v polydipsia and MUSCLE ATONY
The immobilized child sIGNS OF EFFECTS OF IMMOBILITY ON THE iNTEGUMENTARY SYSTEM/ RN DX: ulcers or necrosis
-ck pressure points
-no sheering action
skin integrity impaired/RF
PSYCHOLOGICAL EFFECTS OF BedREST: increased tension as movement used to reduce
if under 3yo may have lang. difficulties
TODDLERS-may not develop autonomy
SCHOOL AGE-concered over achievement
ADOLESCENCE-reduced independence/privacy/self image
PSYCHOLOGICAL EFFECTS OF BedREST PRESCHOOLER: GUILT
unable to move and relieve tension. magical thinking may make them feel it is their fault they got hurt
Reactions to watch for in the immobilized/hospitalized: regression
depression
guilt, protest, anger
Nursing interventions for the immobilized: dependent- tilt table, high protein, high cal diet, hydration, hyperalimentation(TPN/tube feeding)
INTERDEPENDENT-position changes and activity as allowed,hydrate
INDEPENDENT-small meals and bites if flat or abd restircted, private toileting
Nursing Care for the immobilized: encourage visitors
encourage allowable activity
street clothes ASAP
self-care w/i limits
promote play&games&school work
roomates per lenght of stay
know fit of canes, crutches
Know if WB or not
Three types of Club foot: positiona, transitional, mild or posturic
Teratogenic (assocaited with syndrome)
Idiopathic (best case scenerio)
Nursing care club foot: assess
actions-denise brown splint
cast care, prepare and support for surgery
teaching
OUTCOME BASED ON DEGREE OF DEFORMITY
Dysplasia of hip: Incidence girls 4x>than boy
1:100 have instability
1-2:1000 have dislocation
patho: misalignment of the femoral head and the acetabalum results in dysplasia
Types of dislocation: acetabular dysplasia-later angle of the acetabulum which may lead to dislocation
SUBLUXATION-the hip is dislocated
DISLOCATION- liginmentum teres is stretched and hip is displaced upward
Assessment of hip dysplasia: AFFECTED LEG IS SHORTER
asymmetric skin folds-extra or deep folds on affect side
Thigh abduction is reduced on Affected side
ALLIS sign-when supine and knees bent A. knee is lower
ORTALANI'S MANEUVER-hip click w/ abduction that means the hip was dislocated
The five signs of dysplasia of the hip: 1. unequal gluteal folds
2. limited abduction
3.unequal leg length
4. judy did not put on slide
5.allis sign
other tests for hip dysplasia: Barlows test-dislocatable hip
Galleanzzi's sign- limb shorter on a. side
Older infant- bilateral waddle or unilateral limp
delayed walking and prominent trochanter
OlDER child- TRENDELENBURG SIGN-stand on the affected leg and the unaffected hip is down
nursing care for dysplasia: key role is assess and reporting poss. dislocations
treatment is begun immediately
GOAL IS TO MAINTAIN ABDUCTION
maintain cast&avoid complication
nutrition
promote physical,emotional and social development
educate
Treatments for dysplasis: OUTCOME IS GOOD IF RX BEFORE TODDLEHOOD
0-6mo-pavlik harness, pillow splint, spica cast
6-18mo- skin traction to stretch muscles and joint capsule then reduction/spica
Older- more difficult esp with underlying causes
MAINTAIN AND MONITOR SPLINT USE: -wear per order #hours per day
-apply correctly
cotton clothes help w/absorb
-assess skin daily and prn
RECHECK RED SKIN IN 30MIN
-Spica cast-head up to feed
encourage play and walk
parent education
OSTEOGENESIS IMPERFECTA PATHO: Inherited disorder of connective tissue and bone defects. Bone fragility &resultant fracturs
OSTEOGENESIS IMPERFECTA Care: provide GENTLE care and moving to prevent fx
Don't confuse with abuse
reinforce activity level
cast care, brace use, post op care
LEGG-CALVE PERTHES DISEASE patho: avascular necrosis of the head of the femur which is most frequently seen in children from 4-8 yrs of age
LEGG-CALVE PERTHES DISEASE Assessment: intermittent limp w/ or w/o pain
intermittent or constant hip soreness,ache, stiffness which improves with rest
ROM may be limited in hip intenral roatation and hip abduction
PAIN > W/ w/ WB ACTIVITY
pain may radiate to internal thigh and knee
LEGG-CALVE PERTHES DISEASE ROM exam for diagnosis: place prone with knees flexed-if foot goes out than hip is rotated internally
place supine with knee flexed
xray-best info in fragmentation stage
LEGG-CALVE PERTHES DISEASE treatment: may contiue for 2 years
skin traction for abduction/internal rotation
NWB initially
standing//kneeling prohibited
bracing abduct hip at 45deg
surgery
SLIPPED CAPITAL FEMORAL EPIPHYSIS PATHO: spontaneous displacement of the proximal femoral epephysis in a posterior or inferior direction
cause may be increased growth hormone or decreased sex hormone
occur in adolescents who are over wt, or tall and thin
SLIPPED CAPITAL FEMORAL EPIPHYSIS assessment: onset-abrupt w. injury or gradual (peak onset 12-13yr)
limited hip abduction and internal rotation
pain which may be referred to the knee, anterior medial thigh and groin
limp on affected side and finally inability to walk and leg shortening
SLIPPED CAPITAL FEMORAL EPIPHYSIS nursing care/tx: delayed tx may lead to OA
bed rest and traction pre-op
post op- NWB a. side until painless ROM and MD order
care of immobilized child
SCOLIOSIS define: An S shaped lateral curature of the spine with rotation of the rib cage. causes cosmetic and physiologic change in the spine, chest,pelvis
What is idiopathic scoliosis: It is an autosomal dominant with variable penetrance or multifactoral
SCOLIOSIS assessment/diagnosis: prominent scapula
uneven shoulders/hips&hem length
flattening of the flank
progressive curvature of the spine that may end after puberty
rib hump when bending at waist
SCOLIOSIS management: less than 20deg-observe
20-40deg brace
>40deg surgery
SCOLIOSIS when can you log roll after surgery: harrington system-post op
luque-log roll, walk in few days
cortrel(combo)- no post immobilization
SCOLIOSIS complications of surgery: spinal cord injury
nerve damage from surg/hardware
hypotension from blood loss
infection
SCOLIOSIS POST-OP CARE: activity strictly per order
log roll
maintain body alignment and avoid twisting
luque procedure-flat 12h before logrolling
quadriceps setting exercises
assess neuro signs/CSM
TRACTION purpose: reduce a dislocated joint
relieve a muscle spasm
reduce fractures and realign bones
immobilize and align fx until healed
prevent further soft tissue damage
rest a joint
prevent/improve deformityor contractures
Classification of Traction: manual-used in emergencies or temporarily of reappication of skin traction
Mechanical-skin or skeletal
types of skin traction: bucks extension-leg extended&can turn if alignment is maintained/no fx
cervial traction-reduce muscle spasm
russels traction- leg tx plus sling under knee(keeps knee flextion constant)
skeletal traction 90/90 suspension: 90degress/90 degree-less complication and easier care. keep pt in same position.
balanced suspension-designed to life person and everything stays in place. can move up and down the bed
external fixators: ilizarov- immobilzers fx, corrects angulation defects, lengthen limbs (1cm/mo to max15cm) artifical growth plate created. PWB, pin care, cast or cruthces
mechanics of traction: angle determines the line of pull
do nothing to alter the line of pull
maintain bed position
keep child in center of bed
keep in good alignment
weights must hang free and be correct amt&documented
ropes must rest in pulleys correctly
knots must not interfere with pull
continuous vs intermittent traction: cont- never interrupt traction to reduce fx
Intermittent-used for muscle spasms
nursing care for pt in traction: risk for injury
check line of pull
position of bandage,splint,frames
ropes for freying-pullies freely moveable, knots tight and not in pully
WEIGHTS IN SAFE LOCATION&HANGING FREELY,CORRECT WT
chart wt of traction
bed position to counter traction
special rn care for SKIN traction: assess and treat pain
replace non-adhesive straps and ace if allowed
maintain traction when replacing ace
assess bandages; too loose/
too tight/skin integrit
special care for skeletal traction: check pin sites for infection and bleeding
make sure all devices/screws are tight
not for even pull on pin
correct body alignment
dressings for tightness
skin at pressure points
contractures
neuros/csm
hazards of traction: neurovascular complications
5 P's :pallor, pulselessness, pain, paresthesia, paralysis
misalignment
infection at pin site
injury
nonunion

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