Musculoskeletal & Burns

What are common patterns of burns with developmental levels?

• hot water scolds are common in toddlers, so turn the pot handle away on the stove

• electrical burns are common in young children, so cover sockets

• flame related burns are more common in older children

• chemical burns depend on agent and duration

• child abuse

Children playing with matches or lighters count for how many house fires?

they count for 1 out of 10 house fires

Which kind of burns are the most common in children?

thermal burns are the most common in children

How are burns classified?

it is classified by the extent of the injury described in terms of total body surface area: age related charts

• depth of injury

• severity of injury

What is a first-degree burn?

• only redness on skin

• superficial

• involve the epidermal layer only

• no blisters

What is a second-degree burn? 

• blistering

• partial thickness

• all the way through epidermis and some of the dermis

What is a third-degree burn?

• can see fat layer

• full thickness

• extends through epidermis, dermis, and nerve endings

What is fourth-degree burns?

• can see bone

• full thickness

• underlying tissue exposed 

What is a minor burn?

• <10% of TBSA and partial thickness

• treat outpatient

• maybe 1-2 day admit

What is a moderate burn? 

• 10-20% of TBSA and partial thickness

• treat inpatient with expertise in burn treatment

What is a major burn?

• >20% if partial thickness

• all full thickness burn

• treat in a specialized burn center

How are minor burns managed and treated?

• usually managed outpatient

• wound cleansed with tepid water and soap

• blister removal is controversial, some think it promotes bacterial growth

• antimicrobial ointment and dressing per provider order

• tetanus vaccine

What kind of burns will always be popped?

chemical burns will always be popped b/c they don't want to leave that chemical agent in contact with the skin

What is always priority with major burns?

• airway, and if any respiratory involvement is suspected, were going to give 100% oxygen

• severe facial edema or altered LOC will get intubated

What is crucial within the first 24 hrs of major burns?

fluid replacement therapy with NS or LR is crucial 

What does nutrition look like with major burns?

they're going to have enhanced metabolic demands

• high protein

• high calorie

Oral feedings are encouraged, if possible, but if more than what percent of body has been burned, they will receive enteral feeds?

if t25% or more of the person’s body is burned

What vitamins are given to promote wound healing?

• vitamin A

• vitamin C

• zinc 

What kind of meds are used for major burns?

• abx

• pain meds (fentanyl more common)

• sedatives (nitrous oxide for procedural pain)

What is an allograft?

it is human cadaver skin

What is a xenograft?

it is a graft pig skin or another animal

What are the complications of burns?

• airway compromise

• body temperature

• infection

• profound shock

• pneumonia

• pulmonary edema

• emboli

• aspiration

• renal failure

• loss of function in burned area

What do we need to teach about scar tissue?

we tell patient and their family that scar tissue doesn't grow and expand as child does, so they may need further surgeries demanding on the burn

How do you know if child abuse related to a burn is suspected?

when the history doesn't match to the injury

Are nurses required to report suspicions of child abuse to CPS?

yes, nurses need to report any and all suspected child abuse to CPS and put in an order for a social service consult and document thoroughly

What is traction?

it is forward force produced by attaching weight to a distal bone fragment

What is countertraction?

it is backward force provided by the body weight

What is frictional force?

it is provided by patients contact with the bed

What is the function of traction?

it immobilizes a bone or fracture site to promote healing and prevent complications

What is manual traction?

it is applied to the body part by the hand placed distal to the fracture site

• may be provided by application of a cast, but more commonly when a closed reduction is performed

What is skin traction? 

it is applied directly to the skin surface and indirectly to the skeletal structures

• pulling mechanism is attached to the skin with adhesive or elastic bandage (brace, splint)

What is skeletal traction?

it is applied directly to the skeletal structure by pins, wires, or tongs through the diameter of the bone distal to the fracture site

• halo, femur fracture

What is Bryant traction?

• is a type of skin traction

• used for less than 3 years old and/or less than 17.5 kg (35lbs)

• with femur fracture or congenital hip dysplasia

• position the pt on back, bottom lifted off of bed - weights pulling up & hanging over bed

How should traction weights hang?

ropes, pulleys, and weights should hang freely

Can you, as the nurse, release traction weights?

you can never release traction unless told by provider 

What are the 6 P's?

• pain

• pallor

• paresthesia

• paralysis

• pulse

• pressure

What is developmental dysplasia of the hip (DDH)?

it is when the femoral head slips in and out of socket

• can be related to incorrect swaddling or congenital factors

• breach is a high risk factor

What are the signs and symptoms of developmental dysplasia of the hip (DDH)?

• shortened limb

• restricted abduction

• asymmetry of gluteal and thigh fat folds

• telescoping of thigh

What is the Ortolani assessment for developmental dysplasia of the hip (DDH)?

it is when the hip clicks with abduction 

What is the Barlow assessment for developmental dysplasia of the hip (DDH)?

is dislocation of the hip with adduction 

What is the Allis assessment for developmental dysplasia of the hip (DDH)?

it is when one knee is lower than the other leg when flexed 

Does the nurse preform Ortolani, Barlow, and Allis assessment for developmental dysplasia of the hip (DDH)?

only a provider can perform these assessments

What is education about the prevention of developmental dysplasia of the hip (DDH)?

educate about correct swaddling

What is the pavlik harness?

it is a harness used for developmental dysplasia of the hip that

• used in newborns to around 6 months of age

How long does a baby wear a palvik harness? 

they wear it for 22-24 hrs a day

What kind of cast in used for developmental dysplasia of the hip (DDH) in children who are older than 6 months?

• closed reduction surgery w/ spica cast

• spica cast is a lower extremity cast

What are education points for the spica cast?

• don't lift or turn the child by the crossbar

• keep the cast dry

• keep small toys and items away from putting things in the cast

What is clubfoot?

• congenital abnormality where foot is twisted out of normal position

• can be unknown cause or occur isolated in association with other disorders

• can be unilateral or bilateral

How is treatment done for clubfoot?

done in stages

1. correct the deformity 

2. maintain the correction until the child has good muscle balance (casting)

3. prevent the deformity from re-occurring (shoes, boots)

What is the treatment of choice for clubfoot?

serial casting for 6-10 weeks at a time ASAP after birth is the treatment of choice b/c the short bone in the foot haven't ossified yet

What are the other treatments for clubfoot?

• corrective shoes they can wear after the casting

• surgery if the deformity is not addressed by shoes and casting

What is osteogenesis imperfecta?

it is an inherited disorder (brittle bone disease)

What are the clinical manifestations of osteogenesis imperfecta?

• frequent fractures

• blue sclera

•  thin, soft skin

• short stature

• hearing loss

• delay in walking

What can osteogenesis imperfecta be mistaken for?

it can be mistaken for child abuse 

What are the medical managements for osteogenesis imperfecta?

• no cure, only medication that can slow the release of calcium from bones (IV pamidronate)

• physical therapy can help strengthen muscles and support bone density

• casting, bracing, or splinting

What are some nursing managements we can do for osteogenesis imperfecta?

• sliding diapers under instead

  of lifting legs

• use blankets for positioning

• non-weight baring activities (swimming)

What is slipped capital femoral epiphysis?

it is when the femoral head slips off neck of femur

• happens more in the adolescent and growth spurt years

What are the signs and symptoms of slipped capital femoral epiphysis?

• hip pain that radiates to the groin or thigh

• limping

• stiffness

• loss of motion

• can't bear weight on the affected side

What is the medical management of slipped capital femoral epiphysis?

• x ray to confirm dx

• non weight bearing to prevent further injury

• surgery within 24 hrs

What is osteomyelitis?

it is an infection of the bone

What children do we see osteomyelitis more in?

it is common to see in children under 10-years-old d/t staph infection or trauma to the bone

What are the general sign and symptoms of osteomyelitis? 

• very ill

• irritability

• fever

• rapid pulse

• dehydration

What are the local signs and symptoms of osteomyelitis? 

• tenderness

• warmth

• swelling

• pain

• tense and resistant to passive movement

What are the treatments for osteomyelitis?

• empirical therapy with abx (before culture) and change once they get sensitivity back

• surgery if severe enough

What is the management of osteomyelitis?

• non-weight bearing in the acute phase

• position for comfort

What labs are we going to check for osteomyelitis?

• ESR (erythrocyte sedimentation rate)

• CRP (c reactive protein)

-these are markers that check inflammation in the blood