musculoskeletal or articular dysfunction in peds
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| Muscular system with immobility | decreased muscle strength and endurance, atrophy, loss of joint mobility
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| skeletal system with immobility | bone demineralization, negative calcium balance
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| metabolism with immobility | decreased metabolic rate, negative nitrogen balance, hypercalcemia, decreased production of stress hormones
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| Gastrointestinal system with immobility | decreased efficiency of orthostatic neurovascular reflexes, diminished vasopressor mechanism, altered distribution of blood volume, venous stasis, dependent edema
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| Integumentary system with immobility | decreased need for oxygen, diminished vital capacity, poor abdominal tone and distention, mechanical or biochemical secretion retention, loss of respiratory muscle strength
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| urinary system with immobility | alteration of gravitational force, difficult voiding in supine position, urinary retention, impaired ureteral peristalsis.
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| Psychologic effects with immobility | diminished environmental stimuli, altered perception of self and environment, increased feelings of frustration, helplessness and anxiety. Depression, anger, aggressive behavior and developmental regression.
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| immobility and the effect on family | extended periods of immobilization: logistic management of sick child, need for family support and home care assistance.
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| Traumatic injury | soft-tissue injuries- injury to muscles, ligaments and tendons from sports injuries or mishaps during play
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| Contusions | damage to soft tissue, subcutaneous tissue and muscle. Escape of blood into the tissue (ecchymosis) black-and-blue discoloration. Swelling, pain and disability. Mainly crush injuries
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| Dislocation | occur when force of stress on ligament is sufficient to displace normal position of opposing bone ends or bone ends to socketpain increases with active or passive movement of affected extremity. More common in down syndrome.
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| Hip dislocation | potential loss of blood supply to head of femur
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| Sprains | trauma to joint from ligament partially or completely torn or stretched by force, may have damage to blood vessels, muscle, tendons and nerves. Rapid onset of swelling with disability, presence of joint laxity as indicator of severity.
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| Strains | a microscopic tear to musculotendinous unit, similar to a sprain, swollen and painful to touch, generally incurred over time (wound not let fully heal)
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| Management of soft tissue injuries | RICE! Rest injured part, ice immediately (30min max), compression, elevation of the extremity and immobilization and support (cast or splint)
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| Fractures | common injury in children, methods of treatment different in children. Rare in infants, except with motor vehicle collision clavicle most broken <10 y/o. school age is from bikes, sport injuries.
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| Epiphyseal injuries | weakest point of long bone is the cartilage growth plate, frequent site of damage during trauma. May affect future bone growth, treatment may include open reduction and internal fixation to prevent growth disturbances.Growth plates are the biggest concern
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| Type of fractures | simple: doesn’t produce a break in the skin. Compound: bone through skin. Complicated: bone fragments have damage other organs or tissue. Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue.
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| Fracture complication | a fracture with heart pain may be a fat emboli, children can have deformities if growth plate damage
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| bone healing | typically rapid healing in children. Neonate: 2-3 weeks, Early childhood: 4 weeks, later childhood: 6-8 weeks, adolescence: 8-12 weeks
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| Diagnostic evaluation of fractures | radiographs, history, suspect fracture in young child who refuses to walk to bear weight, may guard limb.
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| Assessment of fractures 5 P's | Pain and point of tenderness, Pulse is distal to the fracture site. Pallor. Parethesia is sensation distal to the fracture site. Paralysis is movement distal to the fracture site.
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| types of fractions | plastic deformation: if bent bone will straighten but not completely. Buckle: compression of porous bone appears building or raised. Greenstick: bone is angulated beyond limits of bending. Incomplete fracture. Complete fractures divide the bone fragments.
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| patient teaching with casts | keep cast elevated on pillows, restrict strenuous activities for the first few days. Encourage frequent rest. Do not allow child to place objects inside the cast, elevate a lower limb when sitting and avoid standing for too long. clear path for ambulation
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| A child with a cast | before applied check extremities for anything that might cause constrictions. Turn the child in a plaster cast q2h. Wet plaster cast supported by a pillow & handled with the palms of the hands. Look for pain, swelling, discoloration and decrease pulses.
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| Traction | Traction of the forward force by attaching weight to distal bone fragment. Countertraction is the backward force provided by body weight, increased by elevating foot of bed. Frictional force is provided by the patient’s contact with the bed.
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| Traction with children | used to allow physiologic stability, align bone fragments and permit closer evaluation of the injured site. Use isotonic exercise. When first placed increase in discomfort common. IV opioids w/ analgesic and muscle relaxants are helpful during this phase
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| Traction: bryants and bucks | bryant’s: pull Is only one direction, applied to legs that are flexed at 90degrees at the hips. Bucks traction; type of skin traction with legs in extended position, short term mainly for dislocated hips, correcting contracturs or bone deformities.
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| traction: russell and 90-degree-90-degree | Russell: traction on lower leg & padded sling under knee, hip flexion kept at prescribed angle to prevent malalignment. 90degree: most common, lower leg supported by boot & a wire placed in distal fragment of the femur causing 90degree at both hip & knee
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| Cervical traction | halo brace applied to provide greater mobility of the rest of the body while avoiding cervical spinal motion. Inserted through burr holes in skill with weights attached to the hyperextended head
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| Traction care | check bed position, correct body alignment, correct angles at joints, check pin sites frequently for signs of bleeding, inflammation or infection. Apply topical antiseptic to pins. Make total-body skin checks for redness or breakdown. Change position q2h,
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| Developmental dysplasia of the Hip | Shallow acetabulum:mildest form. osseous hypoplasia of acetabular roof, femoral head remains in the acetabulum. Subluxation: incomplete dislocation of hip. Dislocation: femoral head loses contact with acetabulum, displaced posteriorly & superiorly
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| Therapeutic management of DDH | Newborn to 6mo: pavlik harness for abduction of hips. Age 6-18mo: dislocation unrecognized until child begins to stand and walk; use traction and cast immobilization (spica). Older child: operative reduction, tenotomy, osteotomy; very difficult after 4.
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| DDH in older infants and child: | problem is maintenance of device & adaption of nurturing activities. Affected leg shorter, trendelenburg sign. Always put an undershirt on chest straps. Check for red areas. Gently massage healthy skin under the straps once a day to stimulate circulation
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| Clinical manifestations of DDH | infant: restricted abduction of hip on affected side. Unequal gluteal folds when infant prone. Positive otolanitets and positive barlow test. Non-ambulatory children with cerebral palsy should be assessed for evidence of dislocation.
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| Congenital clubfoot | talipes varus-inversion or being inward. Valgus-eversion or bending out. Equinus-plantar flexion with toes lower than the heel. Calcaneus-dorsiflexion with toes higher than the heel
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| Clubfoot classification | positional (mild) may correct spontaneously or passive exercise. Syndromic (tetralogic) with other congenital anomalies, usually require surgical correction with high incidence of recurrence. Congenital (idiopathic) bony abnormality requires surgery.
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| Therapeutic management of clubfoot | correction of deformity, maintenance of the correction until normal muscle balance is regained. Follow-up observation to avert possible recurrence of the deformity. Serial casting is begun shortly after birth. Manipulation and casting repeated frequently
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| Surgical interventions of clubfoot | involves pin fixation and the release of tight joints and tendons. Casting of the affected food and leg is performed and after 2-3 months. A varusprevention brace is used to maintain correction.
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| Nursing care management of club foot | observe the skin and circulation is important in young infants because of their normally rapid growth rate. Parents need to understand the overall treatment program and the importance of regular cast changes in the long-term effectiveness of the therapy.
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| Types of limb deformities | Amelia: absence of entire extremity. Mecromelia: partial absence of extremity. Phocomelia: deficiency of long bones with relatively good development of hands and feet attached at or near shoulder or hip (seal limbs)
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| Therapeutic management of limb deformities | prosthetics as early as possible with physical therapy. Early prothestics encourage maximum exploration and development in infancy. Phocomelic digits may be surgically modified, preserved and reattached for use with prosthetics.
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| Osteogenesis imperfect (IO) | group of heterogeneous inherited disorders of connective tissue. Excessive fragility and bone defects. Defective periosteal bone formation and reduced cortical thickness of bones. Hyperextensibility of ligaments
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| Classification of IO Type I | type I-A: mild bone fragility, blue sclera, normal teeth and prsenile deafness. Type I-B: same as A expect with abnormal dentition. Type I-C: same as B but with no bone fragility 2/3 of all cases are type 1
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| Classification of IO Type II | lethal; stillborn or die in early infancy. Severe bone fragility with multiple fractures at birth. Autosomal recessive inheritance.
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| Classification of IO Type III | severe bone fragility leads to severe progressive deformities. Normal sclera, marked growth failure and most are autosomal recessive, some autosomal dominant inheritance
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| Classification of IO Type IV | type IV-A: mild-moderate bone fragility, normal sclera, short stature, variable deformity, autosomal dominant. Type IV-B: same as A except abnormal dentition. 6% of IO cases IV
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| therapeutic management of OI | primarily supportive care. Bone marrow experimental. Bisphosphonate therapy to promote inc bone density & prevent fractures. Prevent positional contractures & deformities. Muscle weakness & osteoporosis. Lightweight braces & splints help support limbs.
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| Legg-calve-Perthes disease | self-limited, idiopathic, occurs in juveniles 2-12, more common in males age 4-8. Avascular necrosis of femoral head 10% have bilateral hip involvement, most have delayed bone growth.
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| Legg-calve-Perthes disease S/S and treatment | Insidious onset, may have history of limp, soreness or stiffness, limited ROM. Pain and limp most evidence on arising and at end of activity. keep head of femur in acetabulum. Rest, no weight bearing, surgery in some cases. Home traction.
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| scoliosis | most common spinal deformity. Lateral curvature, spinal rotation causing rib asymmetry and thoracic hypokyphosis. May be congenital or develop during childhood. girls screened 10-12, boys screened at age 13-14.
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| scoliosis diagnosis | standing radiographs to determine degree of curvature, asymmetry of shoulder height, scapular or flank shape or hip height. Often have primary curve and compensatory curve to align head with gluteal cleft.
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| Therapeutic management of scoliosis | Bracing is not curative but it may slow down the progression of the curvature to allow skeletal growth and maturity. Exercise are of benefit when used with bracing to maintain and increase the strength of the spine and abdominal muscles
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| harrington rod and lugue rods | internal spinal device, postop child logrolled to stop spinal motion & plastic jacket is used to stabilize the spine. Luge uses bone from iliac crest to fuse the spine. Pt mobile in few days & no postop immobilization, inc risk of nerve damage
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| Nursing management of scoliosis | concerns of body image (encourage peer socialization), prolonged treatment of condition, preop care: routine labs, blood, teaching) and post op care (skin management, prompt recognition of neurologic problems, pain management), family issues
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| osteomyelitis | infectious inflammation of bony tissue. bone scan for diagnosis. Mainly in the leg and femur, in children 10 and younger. Inoculation with a large number of organisms, presence of a foreign body, bone injury, immunosuppression.
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| osteomyelitis S/S | 2-7 day history of pain, warmth, tenderness and decreased ROM, systemic symptoms of fever, irritability and lethargy. Dehydration, rapid pulse, history of trauma to affected bone (frequent)
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| Therapeutic management of osteomyelitis | long term IV antibiotics by pick line (4 weeks). Monitor for hematologic, renal, hepatic, ototoxic and other potential side effects of high-dose antibiotics.
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| surgery for osteomyelitis | Surgery if no response to IV therapy, when surgical drainage is carried out, polyethylene tubes are placed In the wound: one tube instills and antibiotic directly into the infected area and the other provides drainage.
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| Nursing management of osteomyelitis | watch for adequate nutrition (prone to vomiting). Weight bearing on affected limb not permitted until healing is well under way to avoid pathologic fractures. Physical therapy to ensure restoration of optimum function. Sent home on oral antibiotics
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| Osteosarcoma | mot common bone cancer in children (10-25 years). Primary tumor site are in the metaphysis (widest part of shaft) of long bones, especially in lower extremities. >50% occur in the femur.
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| Therapeutic management of Osteosarcoma | surgery and chemotherapy. Amputation of affected extremity at least 3 inches above the proximal tumor margin. Chemo uses antineoplastic drugs in complication and employed both before and after surgery. Survival rate 60-70% in nonmetastatic patients.
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| Nursing management of Osteosarcoma | straightforward honestly to gain child’s trust, should be told a few days before to allow time to think about the diagnosis and consequent treatment and to ask questions. Do not overwhelm the child. Discuss SE of chemo and focus on the positives (wigs)
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| Amputation care with osteosarcoma | fitted with temporary prosthesis immediately after surgery.Physical therapy during hospitalization. Phantom limb pain is sensations in the amputated limb. Elavil used to decrease phantom pain. Select clothing that camouflages the prosthetic
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| Systemic lupus erythematosus (SLE) | chronic multisystem, autoimmune disease of connective tissue and blood vessels. Symptoms variable and unpredictable, mild to life threatening. More common in females 10-19, blacks, Asians and Hispanic. Unknown cause.
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| therapeutic manangment of SLE | balance meds used to avoid exacerbation while preventing treatment-associated morbidity. mix of rituximab and cyclophosphamide shown effective to decrease symptoms. Sufficient nutrition, sleep and rest and exercise. Decreased sunlight and UV light
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| nursing care of SLE | teach family and child how to recognize S/S of disease exacerbation and potential med complication. Social worker, psychologist or support group may help. Include therapy complications: hair loss, steroid therapy, school attendance, social relationships.
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