NURS 307 PEDS- WK 6: Musculoskeletal Defects, Neuromuscular dysfunction, Integumentary System, Child Maltreatment

Metatarsus Adductus

o Most common foot deformity

o Inward turning of forefoot, “in-toeing”, “pigeon-toed”

- Easily fixed & typically resolved overtime

o Equal in males and females; common in multiples

o Seen in Cerebral Palsy, more likely cause from intrauterine positioning

o Treatment can be exercising if foot is flexible (during diaper changes); may resolve over time, otherwise casting necessary

club foot

● A complex deformity of the ankle and foot

● Can affect one or both feet, occur as an isolated defect, or in association with other disorders (cerebral palsy and spinal bifida).

o More often in boys than girls; usually bilateral

o Etiology unknown; intrauterine positioning? Vascular issues? Genetics?

- Ex) r/t Spina Bifida or Cystic Fibrosis

o Three areas of deformity: midfoot down, hindfoot inward, forefront toward heel and upward

o Lower leg atrophies, lengths normal

o Dx by visual inspection or XRAY to confirm deformity

o Early treatment: serial casting- then splinting; otherwise, surgery at 3-12 months with pins repositioning foot

- May need braces or corrective shoes

- Corrective shoes used to maintain positioning (duration is based on condition of

child)

- Casting = MUST BE CHANGED WEEKLY

positional clubfoot

- Clubfoot occurs from intrauterine crowding

syndromic clubfoot

- Clubfoot occurs in association with other syndromes

Congenital Clubfoot

- idiopathic clubfoot

Developmental dysplasia of the hip (DDH)

- A variety of disorders resulting in abnormal development of the hip structures that can affect infants or children.

- Femoral head and acetabulum improperly aligned: Dislocation, Subluxation, or Dysplasia

o 4:1 females to males, 80% unilateral affecting left hip more often

o May be due to developmental events or positioning in 3rd trimester

● AAP recommends to screen until walk 1-2 years old

● Late diagnosis has lower prognosis for full function

Dislocation

Type of Developmental dysplasia of the hip (DDH):

- Femoral head does not have contact with the acetabulum (not in the right position)

Subluxation

Type of Developmental dysplasia of the hip (DDH):

- Incomplete (partial) dislocation of the hip

Acetabular dysplasia

Type of Developmental dysplasia of the hip (DDH):

- Delay in acetabular development (acetabular roof is shallow and oblique)

clinical manifestations of Developmental Dysplasia of the Hip (DDH)

- Limited adduction of the hip

- Asymmetry of gluteal and thigh folds (# of gluteal/thigh folds is not the same)

- Telescoping of the thigh

- Significant limp

Diagnostic procedures for Developmental Dysplasia of the Hip (DDH)

- Asymmetry of gluteal and thigh folds or telescoping of the thigh

- Ultrasound: performed at 2 weeks of age to determine the cartilaginous head of the femur

- X‑ray: can be used in infants older than 4 months of age

risk factors for Developmental Dysplasia of the Hip (DDH)

● Birth order (firstborn)

● Female gender

● Family history

● Breech intrauterine position

● Delivery type

● Joint stability

● Oligohydramnios

● Large for gestational age

Treatment for Developmental Dysplasia of the Hip (DDH)

- 60-80% resolve by 2 months

- Under 6 months we can apply the Pavlik Harness; Bryant’s traction

- OR surgery at 6 months with spica cast

- OR at 18 months with casting and bracing

Pavlik Harness

o Newborn to 6 months (chest harness that abducts legs)

o Worn continuous for 12 weeks

o Check straps every 1-2 weeks (TEACH PARENT TO NOT ADJUST STRAPS: ONLY PROVIDER CAN)

o SKIN CARE MAINTENANCE: Assess skin 2-3x daily, gently massage under straps, AVOID

lotions/powders, undershirt/socks under harness

o Place diaper UNDER straps

Bryant Traction

o Skin traction used when adduction contracture is present

o Hips Flexed at 90-degree angle w/ buttocks raised off bed

o Rx for HYDRATION & ASPIRATION AFFECTED D/T POSITIONING

o Nsg. Care: Neurovascular checks, maintain traction (ropes, boots, pulleys, weights), ensure alignment, skin care

- Circulation = maintain ROM of extremities to promote circulation

Hip Spica Cast

o Maintains external rotation of hip

o Nsg. Care: assess/maintain hip cast, FREQUENT NEUROVASCULAR CHECKS, REPOSITIONING, ROM on unaffected extremities, freq. skin checks (esp. DIAPER AREA), pain assessment, hydration status, elimination status daily

o NEEDS TO BE CHANGED TO ACCOMMODATE GROWTH

Legg Calves Perthes Disease (LCPD)

o Self-limited avascular necrosis of femoral head

- Lack of blood supply going to femoral head

- Stages: Synovitis, Necrotic, Fragmentation, Reconstruction

- 4:1 males to females

* 2-13 years old- peaks at 7

- Unilateral or bilateral

o Caused by interruption of blood supply to femoral epiphysis, may be genetic, mild traumatic injury, breech position

o Delayed skeletal maturation, increased thyroid levels

* Common in LBW, increased maternal age, smoking, Caucasian, Chinese, Japanese

- S/S: Hip pain, painless limp; exacerbation with activity, relief with rest; limited ROM,

atrophy/shortening of affected thigh, muscle spasms, increased pain

- Dx: Radiograph of hip and Pelvis, MRI

- Late diagnosis or left untreated may lead to osteoarthritis, leg length discrepancy, hip dysfunction

Treatment for Legg Calves Perthes Disease (LCPD)

- Treatment with abduction casting and bracing; surgery (Osteotomy) in severe cases to release adductor muscle to treat bone

- Maintain rest and limited weight bearing, PT, traction

- Tx varies w/ age & appearance of femoral head, administer NSAIDS as prescribed

Slipped Capital Femoral Epiphysis

o Femoral head displaced from femoral neck

o Seen during pubertal growth

o More often in males and African Americans

- Common in school-age/adolescent age

o Etiology unknown- obesity? Growth spurt? Endocrine disorders?

* Ex) Diabetes or thyroid hormone problems

o May be gradual slippage or acute trauma

- Acute lasting 3 weeks, chronic more than 3 weeks

- Inflammation, edema, pain; if untreated deformity of hip and limited ROM

* d/t displacement of femoral head

* unstable will cause more inflammation than stable

o Limp, pain, loss of hip motion, out-toeing, issues with internal/external rotation noted

* Depending on severity; inability to bear weight, difficulty walking

o Goal of management to stabilize femoral head and minimizing displacement

o Surgical treatment with fixation of epiphysis with screws into hip

* Prognosis dependent on severity of deformity and any complications such as LCP or cartilage breakdown

Scoliosis

- A complex deformity of the spine that also

affects the ribs.

o S or C shaped curvature of spine

o Any curvature >10% is considered abnormal

o Most common: Idiopathic structural scoliosis, more common in females and noted during growth spurt

o Other causes congenital, neuromuscular

o S/S: asymmetry, uneven shoulders/hips, one sided rib hump, prominent scapula

o Dx: with radiographs (Cobb technique: to determine the degree of curve; Risser scale: to determine the skeletal maturity)

o Adam’s Forward Bend Test (shows asymmetry of ribs/flanks), X-Ray, scoliometer early detection yields most optimal results; treatment based on presentation of curvature

o Tx = Dependent on degree of curvature

* Mild 10-20º: exercise and muscle toning

* Moderate 20-40º : Boston brace 23 hours a day upon dx: Brace should be worn at all times (except showering), thin t-shirt/tank top under brace to protect skin

* Severe 40-50º : requires surgery, spinal fusion with segmental hooks, rods, wires,

screws; may need bone grafting and casting

o Nsg. Care (POST-OP): neuro checks, turn pt. w/ log rolling, administer analgesics on schedule

Torticollis

o Tilt of head caused by cervical spine

- Due to injury of C spine abnormality

- Injury of mastoid muscle during birth time

- Stretching and lengthening exercises as treatments

- Seen with plagiocephaly, brachycephaly

Kyphosis

o Excessive convex curvature or cervical thoracic spine

* RARE, more common in elderly

o S/S: hunchback, rounded shoulders, SOB, fatigue, abd creases, tight hamstrings (severe)

o Tx: Support, exercise, brace wear

Lordosis (swayback)

o Excessive concave curvature of lumbar spine w/ angle > 60 degrees

o Common in prepubescent girls

o S/S: swayback, prominent buttocks, hip flexion contractures, tight hamstrings

o Tx: Support, postural awareness, child usually outgrows it, exercise, annual follow-up

Osteoporosis

o Decreased bone mass and density

* Fractures, associated with aging

* In children due to imbalanced nutrition or pathologic conditions

- VLBW: Enhance breast milk with fortifiers, balance Ca/Phos

- FTT

- Spina bifida

- Cerebral Palsy

- Conditions that interfere with ambulation/immobilization-casting

- RF: Lack of Vitamin D, Calcium, smoking, alcohol, excessive soda, anorexia nervosa

- Tx: Increase Vitamin D and Calcium intake, diet modifications, parathyroid hormone,

immobilization and rehabilitation for bone strengthening

Osteopenia

o Low bone mass

o Precedes osteoporosis

o Associated conditions: Turner syndrome, Growth hormone deficiency, Osteogenesis Imperfecta, Juvenile rheumatoid arthritis, Diabetes

- Treatments: requiring casting/bracing

• No s/sx unless baby with fractures on radiograph (x-ray)

• Dx: Diagnostics with bone scan, serum studies, measure Vitamin D and Ca

Osteomyelitis

• Infection of long bones, may spread to different organs

o PATHO: Infectious organism causes tissue inflammation, edema, dec. blood flow to bone, resulting in bone necrosis

• RF: recent trauma (ex. Open Fx), bacteremia, orthopedic Sx, circulatory d/o

• Most often but not limited to ages 1-12

o Boys more at risk that females due to greater incidences of trauma

• Bacterial, fungal, viral:

o Most common is bacterial (S. aureus, E. coli, N. meningitidis, S. pneumoniae, M. tuberculosis)

o Due to URI, trauma to bone, surgery

• Inflammation, abscess formation, if untreated

expected findings for osteomyelitis

• Inflammation, abscess formation, if untreated may lead to necrosis:

o Pain/tenderness, swelling, decreased mobility, fever, possible redness over area (erythema), rapid onset

• Findings include leukocytosis, elevated ESR and CRP, positive cultures

o Inc. WBCs

o Normal CRP: 0.5-0.6 (infant)

* ANYTHING ABOVE 1 IS ABNORMAL

treatment for osteomyelitis

• Tx: IV broad spectrum abx before cultures resulted- Vancomycin, Clindamycin

o Once culture resulted, abx adjusted long-term and taken 3-6 weeks

* ENSURE BLOOD CULTURE FOR SENSITIVITY IS CONFIRMED TO ENSURE PROPER ABX

o Monitor labs

o Other: Sx debridement of bone, hyperbaric oxygen therapy

• Early treatment yields better prognosis and recovery, late treatment may lead to growth interruptions, damage to joins, septic arthritis

Skeletal Tuberculosis

o Micro bacterial infection usually in spine and joint

o S/S: dependent on site, pain, limp, severe muscle spasms, kyphosis, muscle atrophy, “doughy” swelling of joints, dec. joint motion, changes in reflexes, low-grade fever

o NOT AIRBORNE CONTAGEOUS = CONTACT PRECAUTION

o Dx: TB skin test

o Tx: Compliant long-term combination abx therapy (6-9 mon), affected site immobilized, drug therapy

o Nsg. Care: test all members for TB, report to local health department, facilitate immobilization and PT at home

Septic Arthritis

o Joint infection of synovial space usually H. influenza, Strep, Staph infections

- Usually in knee, hip, ankle, and elbow

o S/S: fever, pain, local inflammation, joint tenderness, swelling, loss of spontaneous movement

o Dx: Joint aspiration finding = Inc. WBC (100,000), 75% neutrophils, ESR > 44 mm/hr

o Tx: Joint aspiration, open drainage/irrigation, Abx therapy (IV for 3-4 weeks, then PO)

- Ensure Abx Tx is completed to avoid recurrent infection & further joint degeneration

o Nsg. Care: Joint positioning, Encourage Fluids, hydration, support/rest joint

Juvenile idiopathic arthritis (JIA)

• Formerly known as Juvenile Rheumatoid Arthritis

• Criteria by dx: 1+ joints affected more than 6 weeks, diagnosed before 16, no other causes identified

• Peak 1-3 years, more in females than males

• Autoimmune inflammatory disease of joints and tissues:

o Synovial inflammation: wear and tear if articular cartilage

o Results in residual joint deformities and altered joint fxn

o Multiple classifications can be w/ or w/o rheumatoid factor

• RF: Immunogenic susceptibility, environmental triggers, genetic predisposition

• S/S: May be immunologic or environmental

o Joint swelling, stiffness, redness, warmth (worse in morning or after inactivity)

o Mobility limitations/morning stiffness

o Fever

o Rash

o Enlarged lymph nodes

o Delayed growth

• Oligoarthritis = up to 4 joints

• Polyarthritis = 5 or more joints

• Systemic = affects joints and organs; fever, rash, pain

• Disease appears in remissions and exacerbations

Dx Tests for Juvenile idiopathic arthritis (JIA)

o Anticyclic citrullinated peptide (anti-CCP), ESR, CBC, ANAs, Radiographs

Nursing Care and Treatment for Juvenile idiopathic arthritis (JIA)

- Promote exercise/PT, nonpharm pain management, splint joints, moist heat to relieve pain, no pillows (firm mattress) for proper alignment, promote self-care

o Activity as tolerated, full ROM exercises, appropriate exercise (swimming), warm baths, well balanced diet, adequate fluids, encourage participation in school/contact with peers

• Tx: NSAIDs, CCS, DMARDs (disease-modifying anti-rheumatic drugs | ex. Methotrexate)

o NSAIDS (Ibuprofen, Naproxen, Diclofenac, Indomethacin, Tolmetin): pain & inflammation

o DMARDS (Methotrexate): slows joint degeneration/progression (when NSAIDS don’t work)

o CCS (Prednisone): relief of inflammation & pain, reserved for life threatening complications (ex. Severe arthritis, pericarditis, uveitis)

Achondroplasia

• Dwarfism, adult height 58” or less

• Short arms, legs

• Torso and head normal size, decreased growth of long bones

• Abnormal gene chromosome 4- inherited one gene from parent; dominant characteristic

o Prenatally diagnosed or shortly after

• Short fingers, separation between middle and ring fingers, large prominent forehead

o Sometime hydrocephalus

• Frequent otitis media, dental malocclusion, short fingers, bowlegs, lordosis, sleep apnea, slow to meet gross motor development milestones

• ***No ACTUAL treatment***, orthopedic interventions, VP shunt if needed

o Clinical manifestations are treated accordingly

• Support, education, community resources, regular dental/orthodontic care

Marfan Syndrome

• Autosomal dominant disease

• Cardiac (mitral valve prolapse, aortic regurgitation, abnormal aortic root dimension

• Skeletal (pectus excavatum, long arms and digits, scoliosis, elongated head, high arched palate, Depressed sternum

• Ocular (lens subluxation)

• Respiratory (pneumothorax)

• Age of diagnosis 3 years old with heart murmur

• ***No cure, diagnosis difficult since manifestations appear in adolescence***

• Tx: Surgery for cardiac, skeletal and pulmonary issues

• Support, education, family and genetic counseling

Osteogenesis Imperfecta

• Brittle bone disease

o Defect in production of collagen

o Inherited connective tissue condition resulting in bone fx & deformities along w/ restricted growth

• SEVERELY fragile bones, easy to fracture

• Equal in males and females, autosomal dominant

• S/S: Frequent fractures, blue sclera, thin and soft skin, altered joint flexibility, short stature, enlarged anterior fontanel, small/discolored teeth, weak muscles, brittle bones; conductive hearing loss by adolescence

o 4 types, type I most common

• Due to frequency of fractures may be mistaken for child abuse until diagnostics are done

o FOCUS ASSESSMENT to rule out child abuse and detect disease process

o Look at the SCLERA FOR BLUISH DISCOLORATION

• Dx: Bone Biopsy

Treatment for Osteogenesis Imperfecta

• Tx: ***NO CURE***, prevention of fractures and deformities, medical management to increase bone density, PT, pharmacological management with supplements; dental care (abx needed before dental work), hearing screenings

o Med: Pamidronate: inc. bone density

• Supportive care, immobilizing, surgical interventions, casting, bracing, splinting, maintain normal patterns of G/D, adaptive equipment

Muscular Dystrophies

• PATHO: Group of inherited disorders w/ progressive degeneration of symmetric skeletal muscle groups

• PROGRESSIVE Muscle fiber degeneration, muscle wasting; terminal disorders

• Most common is Duchenne Muscular Dystrophy (DMD)

o 1:3,500 male births, X-linked

• Pseudohypertrophy with fatty tissues of thighs

• S/S: Generalized muscle weakness, compensate by using upper extremities

o GOWER SIGN, lordosis, waddling gait

* Gower’s sign: difficulty getting out of bed, rising from seated position, climbing stairs

o Other: Delayed motor movement and speech, cognitive impairment, difficulty walking (possible loss of ability to walk), muscle atrophy (face, chest, neck), cardiomyopathy

• Dx: Enzyme assay, muscle bx, electromyography, genetic analysis

o ELEVATED Creatinine Kinase (CK)

treatment for muscular dystrophies

• Tx: ***NO CURE***, no effective treatment

o Steroids to preserve muscle function, PT

o Goal to maximize independence

- Encourage ROM exercises & activity

• Nsg. Care: genetic counseling, mon. ADLs, Resp/Cardiac func., maintain optimal physical func. (Independence, ROM, proper body alignment, freq. repositioning), maintain resp func. (Incentive spirometry, O2, positioning, noninvasive ventilation), adequate fluids, nutrition (low calorie, high protein/fiber), discuss end-of-life decisions appropriately

• Progressive weakness and paralysis that ascends

o Onset 3-5 years

o Wheelchair bound by 12

o Death during late adolescence (20’s) from respiratory or cardiac failure

Duchenne (pseudohypertrophic) muscular dystrophy

(DMD)

- is the most common form of MD. Inherited as an X‑linked recessive trait, has an onset between 3 and 5 years of age. Progressive disease with life expectancy with current technology reaches into early adulthood. Fat tissue replace muscles in lower limbs (gastrocnemius).

Gower’s sign

- Indicative of muscular dystrophies

- Child walks hands up legs for support

while going to a standing position

- Difficulty getting out of bed, rising from seated position, climbing stairs

Plastic deformation (bend) fracture

The bone is bent no more than 45° without breakage.

Buckle (torus) fracture

- Compression of the bone resulting in a bulge or raised area at the fracture site.

greenstick fracture

- Incomplete fracture of the bone.

transverse fracture

- Break is straight across the bone.

Oblique

- Break is diagonal across the bone.

Spiral

- Break spirals around the bone.

physeal (growth plate) fracture

- Injury to the end of the long bone on the growth plate.

stress fracture

- Small fractures/cracks in the bone due to repeated muscle contractions

complete fracture

- Bone fragments are separated.

incomplete fracture

- Bone fragments are still attached.

closed or simple fracture

- The fracture occurs without a break in the skin.

open or compound fracture

- The fracture occurs with an open wound and bone protruding.

Complicated fracture

- The fracture results in injury to other organs and tissues.

comminuted fracture

- The fracture includes small fragments of bone that lie in surrounding tissue

Epiphyseal injuries

- Injury to the end of the long bone on the growth plate

- Can affect Growth & Development

fractures

o Break in bone where stress is placed

o Risk Factors:

- Trauma, bone disease, Obesity, Poor nutrition

o Common in children (boys) and at any age

o Questions of abuse when?

* SPIRAL FX PRESENT

o S/S: Pain, deformity, abnormal positioning, edema, Immobility, decreased ROM, bruising, guarding, crepitus

● Dx: Radiograph (Xray), reduction and realignment, immobilize

● Tx: Traction, casting, and pain management

● At risk of development compartment syndrome r/t to casting and traction

Compartment syndrome

o PATHO: Compression of nerves, blood vessels, and muscle inside confined space: results in neuromuscular ischemia

* Most common w/ tibial fx or forearm fx

o S/S: hard swollen muscle, 5 P’s = intense Pain, Paresthesia, Paralysis, Pallor, Pulselessness

o RF: tight dressing or cast, hemorrhage, burns, surgery, massive IV infiltration

o Volkmann Contracture: permanent contracture of forearm/hand

o Tx: Fasciotomy, Amputation

- Avoid use of cold & DO NOT ELEVATE affected limb

Sports injuries

o Common 13-19 years

o Vulnerable growth plates

o Increased joint mobility

o Porous bones

o Lack of experience/inadequate training

o Lack of protective gear

o Inadequate healing/recovery time

o Vulnerable to spinal injury due to high impact

o Warm up, cool down, Ice, protective gear

* THINK “RICE”: (Rest, Ice, Compress, Elevate)

- ICE ONLY FOR FIRST 24 HOURS ONLY

Amputation

o Congenital or acquired

o Prosthetics

o Phantom pains: Pain of the amputated limb

o Psychosocial support, resources, PT/OT

Microcephaly

● Small brain with a head circumference below 3rd percentile on growth curves.

● Intellectual disability common

● Not common to see.

Hydrocephalus

● Congenital or acquired from hemorrhage, infection, and injury

● There is a problem with the reabsorption of

the CSF, the CSF absorbed by subarachnoid into venous space is impaired. - this is why the CSF is accumulated in the skull.

● CSF absorbed by subarachnoid into venous space is impaired

● Clinical Manifestations: Increased head circumference, irritability, vomiting,

poor appetite, fever

● Nursing Actions: Assess head circumference frequently

● Treatment: Remove obstruction or place drain (VP shunt) to reroute fluid into peritoneal cavity to be reabsorbed

Ventriculoperitoneal Shunt (VP Shunt)

- A catheter is placed into the ventricles of the brain.

- Two catheter (short catheter inside the ventricles, the long catheter goes all the way down behind the ears to the abdomen).

- It is then advanced, subcutaneously, behind the ear, down the neck and through to the abdomen (long catheter side)

- The excess CSF is released and absorbed by the peritoneal cavity.

- There is a valve behind the ears. The job of the valves is to prevent the fluid from moving in the wrong direction and only lets fluid drain when the pressure is too high.

- The valve is open when the pressure is high and the fluid will start to go down to the peritoneal cavity and then CSF will reabsorb through the abdomen cavity.

Anencephaly

● is not common.

● These patient's have no brain development above the brain stem.

Spinal bifida

- A common neural tube defect (NTD) present at birth and is characterized by failure of the osseous spine to close with CNS effects.

● The patient has malformation of the spinal cord and canal.

- It can be a defect of one or more vertebrae where protrusion occurs.

- Most of the time you see it in the lumbar and sacral area.

● Causes: due to alcohol, medications, folic acid deficiency, gestational diabetes, DM, obesity.

● Diagnosing: Maternal Serum - elevated AFP (alpha-fetoprotein) indicates spina

bifida.

● Level of injury depends on location of malformation

- Different clinical manifestations based on the location of spina bifida.

- Thoracic worse than Sacral area: these patient’s will manifest with sensory loss, paralysis, bowel/bladder incontinence, renal damage

- Hydrocephalus when above the sacral level: will manifest with mobility problems, intellectual disability, visual impairments, musculoskeletal abnormalities, sexual dysfunction

● Treatment:

- Braces for support/assistive devices

- Calcium vitamin D

- In some cases, we need to do surgical intervention to release tethered portion

- Prognosis dependent on type/how extensive defect presents

- HIGH INCIDENCE of LATEX ALLERGY

Spina bifida occulta

- Mostly affects the lumbosacral area

and protruding sac is not visible externally. Surface of the vertebral bone is missing; no spinal cord involvement.

Spina bifida cystica

Protrusion of the sac is visible

2 types: Meningocele & Myelomeningocele

Spina bifida cystica: Meningocele

The sac contains spinal fluid and meninges. Increased risk for infection if ruptures. No neurologic deficits.

Spina bifida cystica: Myelomeningocele

(most common): The sac contains spinal fluid, meninges, and nerves. Failure of the neural tube to close causes decreased motor and sensory function.

Nursing Interventions for spina bifida

- We want to protect the Sac this is why we put the baby in the prone position and cover the Sac with sterile moist dressing, monitor neurological status and encourage parent bonding.

- Post-Op Care: maintain prone position, monitor I/O, assess site, resume feedings, pain management, monitor for complications, bladder dysfunction and skin ulceration

- Latex allergy

Craniosynostosis

● Premature closure of the cranial sutures

● During first 18 months of life.

● Growth occurs parallel to suture line, this is why you see skull deformities.

● Suture should not be closing early, if it closes early this means the brain can’t grow because there is no room this is why you see skull deformities.

● Treatment:

- Orthotic helmet for skull reshaping

- If reshaping does not work with the helmet then we do surgery when it is causing chronic increased ICP or cosmetic reasons.

Plagiocephaly and Brachycephaly

- Are acquired conditions that occur from

cranial molding in infancy. The infant’s head becomes asymmetric or oblique in shape due to flattening of the occiput.

- Attributed to the supine sleep position, to prevent SIDS.

● The key to prevention is educating

parents on the importance of allowing the infant to lie in the prone position for 30 to 60 min/day while awake. Parents should also alternate the infant’s head position each night to avoid persistent pressure on the occiput.

● Treatment: physical therapy and the wearing of a customized helmet (23 hours/day for 3 months continuously) to reshape the skull.

Cerebral palsy

● A nonprogressive impairment of motor function, especially that of muscle control,

coordination, and posture.

● Non-progressive disturbance in fetal or infant brain

● 4 types: spastic 75%, dyskinetic 2-15%, ataxic 2-8%, mixed

● Most often in prenatal period, then perinatal, least in first 2 years of life.

- Due to: prematurity, prenatal factors, genetics, problems during labor and delivery, asphyxia, preeclampsia, Sepsis, TBI, stroke, meningitis

- Manifestations: abnormal perception and sensation; visual, hearing, and speech impairments; seizures; and cognitive disabilities.

- Treatment: focus on maximizing level of

independence and performing ADLs, Mobility, ROMs, control/balance, communication, Braces, splints, serial casting, If above does not work, then surgery to strengthen

muscles, Several medication for spasticity, seizures, muscle relaxers, G-tube may be necessary due to severe stiffness of

their jaw

Expected findings of Spastic CP (pyramidal)

● Hypertonicity (muscle tightness or spasticity); increased deep tendon reflexes; clonus; and poor control of motion, balance, and posture.

● Impairments of fine and gross motor skills.

● Can present in all four extremities (tetraplegia); all extremities affected, lower more than upper (diplegia); three limbs (triplegia); one limb (monoplegia); or one

side of the body (hemiplegia);

● Gait can appear crouched with a scissoring motion of the legs with feet plantar flexed.

● Babinski reflex

Traumatic Brain Injury (TBI)

● is a result of blunt force or penetrating injury that disrupts normal functioning

● Most of the time these patient’s develop concussion to severe injury

- Hematomas and hemorrhages

● Clinical Manifestations: memory problems, HA that does not go away, loss of balance, slow acting and speaking, poor sleeping and poor concentration

● Monitor ICP

- We can give Mannitol for high ICP and if it does not work and the patient still has high ICP then do decompressive craniectomy when ICP can’t be controlled.

Concussion

● Mild TBI from direct blow to head, face, neck or other part of the body

● Rapid onset and short term functional impairment

- physical , cognitive, emotional, sleepy

● Recovery from concussion 6 weeks to 6 months.

Spinal Cord Injury

● 1.99: 100,000 (55% MVC, 45% Sports, activities, abuse, and injuries)

● Occurs in pediatric population due to

motor vehicle accident and sports accidents.

● Based on the site of the injury, the clinical

manifestations will show.

- Above C3 respiratory arrest, death without

ventilatory support.

- Below L3 may have functioning of muscles in upper leg

Autonomic dysreflexia

● An injury above the T6 level and it

is considered a medical emergency because they have over activity of the autonomic nervous system.

● Why do they over-activity of the autonomic nervous system?

- It’s usually due to full bladder, constipation, tight clothes, pain

● Treatment:

- We need to know the underlying cause

- If it’s severe pain? Give pain medication

- If it is because of a full bladder? We put in a foley

- Set patient upright, reverse offending cause

- Bladder/bowel programs necessary

contact dermatitis

● An inflammatory, hypersensitive

reaction of the skin. It is caused when the skin comes into contact with chemicals or other irritants (feces, urine, soaps, poison ivy, animals, metals, dyes, medications).

● Inflammatory response: erythema, edema, pruritis, vesicles, ooze, crust

● Treatment: Calamine lotion, cool compress, oatmeal bath, antihistamines, and corticosteroids

Diaper dermatitis

● 9-12 months or 12-24 months

● RF: Moisture, friction, soil causing acidic irritant, detergents, soaps, chemical that come in contact w/ genital area

● MAIN CAUSE = Candida albicans

● S/S: Raw moist, weeping macules; red, raised plaques, scales, Bright red rash, fiery red scaly areas (scrotum, penis, labia),

pimple/blisters/ulcers/large bumps/pus-filled sores, smaller red patches

● Tx: Treat with barrier creams, zinc oxide, fungal powders if of fungal origin

● Worsening condition = requires exposing affected area to air

● Nsg. Roles: Education on good hygiene practices, use of topical barriers, absorbent diapers, timely diaper changes

Seborrheic dermatitis

● (cradle cap, blepharitis, otitis externa) has an unknown etiology but is most common in infancy and puberty.

●Overgrowth of yeast, influenced by hormones

●Seen in infants up to 3 months and adolescents

● Common sites include scalp, forehead, postauricular and periorbital areas

● S/S: yellowish coloration

●Tx: Treat with daily Anti seborrheic shampoo, use of oils, Vaseline to soften scales to be brushed away.

● Gently rub scalp to remove scales/crusted areas, fine-toothed comb (loosened crusts on

hair)

Impetigo

o Highly contagious skin infection

o Epidermal infection, usually GABHS (group A beta-hemolytic streptococci)

o RF: Hot/humid climates, 2-5 yoa, contact w/ infected person

o S/S: Vesicles rupture, honey colored crust, redness

o Tx: Topical abx (mupirocin), oral if worse

o Pt. Teaching: avoid other children during active outbreaks, cover sores w/ bandages, WASH: hands, linens, clothes that have come in contact w/ infected fluid

o Complications: PIAGN and cellulitis

* PIAGN (Post Infectious Acute Glomerulonephritis)

Community Acquired Methicillin Resistance Staphylococcus aureus (MRSA)

o Skin and soft tissue infection

- RF: Skin to skin contact, wound contact, shared items

o S/S: Furnicles, abscesses, swelling

o Tx: Incision and drainage, wound care, abx treatment

Folliculitis

o Inflammation of pilosebaceous follicles by infection, trauma, irritation

o RF: Usually S. aureus or P. aerunginosa

o S/S: Pain, pruritus, swelling, tiny yellow pustules and red papules at follicular openings

o Tx: Treatment with topical cleanser, drying agents, Systemic antibiotics for severe cases

o In complications, drainage may be needed

Cellulitis

o Inflammation of loose connective tissue and dermis

- Face and extremities

- Nearby abscess or sinusitis

o RF: Common S. aureus, S. pyogenes

o S/S: Rapid onset, appear ill; redness and edema at site, distinct border

o Culture site

o IV or PO abx

o Tx: Prevent spread of infection, education, complete course of abx, follow-up to ensure therapy response

o Pt. Teaching: scarring can occur, avoid vigorous scrubbing of skin, avoid squeezing/picking

Molluscum Contagiosum

o Poxvirus

o Transmission: Contact, contact with contaminated objects, sexual contact

o 2-11 years at risk

o S/S: Pearly, flesh color smooth papules with center depression often on face, trunk, extremities

- Aggressive treatment can cause scars

o Tx: Cryotherapy, topical anesthesia for curettage

Warts (Papillomavirus)

o Infection of epithelial cells

- Common in the adolescent age (HPV vaccine given)

o Common on any skin surface, plantar warts on feet

o Transmission: Direct skin to skin, mucous membrane, surface contact

o S/S: Skin colored, rough, scaly (No pain or itchiness)

o Usually spontaneous resolution over a few years

o Tx: Liquid nitrogen or plasters may be used

o Education on how warts spread:

- No sucking or chewing on warts

- Use of bitter apple or pepper solutions

Oral Candidan Infection (Thrush)

o Cause = Candida albicans

o RF: Newborns, use of CCS inhalers, abx to distribute normal flora

o S/S: White patches like coagulated milk, may bleed (when attempt to wipe off), may be painful, Infant may refuse nursing/feeding

o Diagnosis by appearance

o Tx: Nystatin, clotrimazole swish and swallow or swabbing

o Nsg. Care: Sterilize pacifiers, nipples, bottles

Dermatophytosis (Ringworm)

o Fungal infection of skin, hair, nails

o Transmission: Contact by contaminated object

o S/S: itchy skin, ring-shaped rash, red/scaly/cracked skin, hair loss (w/ tinea capitis)

o Diagnosis: scraping hair and scalp culture

o Tx: Antifungal agents, CCS taper dose (decrease med gradually)

atopic dermatitis

- A type of eczema that is characterized by pruritus and associated with a history of allergies that are of an inherited tendency.

o Superficial inflammatory skin disorder; intense pruritus

- 60% during first year of life

- Asthma, food allergies

o S/S: Dry skin (xerosis), red plaques (silvery sheen), severe pruritus

o No cure; skin hydration and lubrication 3-4 times daily

o Nsg. Care: daily skin care (tepid bath w/ mild soap), apply emollient right after, no bubble baths/harsh soaps, wear soft clothing/mild detergent, avoid heat/humidity, minimize scratching, keep fingernails short and clean

o Tx: Topical CCS, antihistamines

psoriasis

o Chronic, recurring, pruritic skin condition (Often familial)

o S/S: Thick, silvery, scaly, erythematous plaque with irregular border

* Scalp, elbows, knees, umbilicus, genitals, site of trauma

o Dx: Diagnosis based on characteristics

o Tx: Topical steroid, topical Vitamin D, oral therapy in severe cases

Acne

o Chronic inflammatory disorder of pilosebaceous hair follicles on face and trunk

- Excess sebum production and bacterial colonization leads to inflammation

o RF: 85% 12-25 years (adolescents), puberty, sex (male)

o S/S: Comedones (blackheads/whiteheads), erythema, pustules

o Dx: Diagnosis based on appearance

o Tx: treatment based on lesion

- Topical: Retinoids (tretinoin), abx (clindamycin), benzoyl peroxide

- Tretinoin: can irritate skin (wait 20-30 min after washing face to apply), pea-size

amount at night, avoid sun exposure, sunscreen (SPF 15 or >)

- Topical ABX: assess/mon. for allergic reactions, every-other-day application, avoid

sun exposure, use sunscreen

- Benzoyl Peroxide: inhibits growth of P. acnes, can bleach bed linens, towels, and

clothing but NOT SKIN

- Systemic: abx (doxycycline), isotretinoin, contraceptives

- Oral Abx: for SEVERE acne unresponsive to topical agents

- Isotretinoin (accutane): prescribed by dermatologist (severe acne), mon. behavioral changes, teratogenic (NO FOR PREGNANCY)

- AE: dry eyes, dec. night vision, HA, photosensitivity, elevated LDLs,

depression, suicidal ideation, violent behaviors

- Contraceptives: Indicated for adolescent females, ,therapeutic effects may take 4-6 mon. combined w/ topical acne tx

Epidermolyis Bullosa

o Rare, chronic blistering with minor trauma

o Autosomal dominant/recessive

o Defective keratin function

o Diagnosed when ambulatory or at puberty

o High mortality rate due to secondary infection

o Education on dressing changes, infection prevention

Pediculosis Capitis (Lice)

o Parasitic insect living in hair

o Common 3-12 years

o Outbreaks from childcare or elementary school

o Transmission: Hair to hair contact, indirect contact

o Tx: Pediculicide shampoo (permethrin 1%) and egg remover, physical removal w/ lice fine tooth combing, Ivermectin oral tx

* Second treatment in 7-10 days

o Pt. Teaching: Examine/treat whole family (Tx infected person only), launder all belongings in hot water and dry in high heat, seal non-washable items (pillows) in airtight bags for 2 weeks

Scabies

o Contagious infestation caused by mites spread by skin to skin or sexual contact, unlikely with transient contact

- 45 minutes to burrow into skin

o RF: skin-to-skin contact w/ infected person (common in families/those who cohabitate)

o S/S: white lines (indicating mite burrowing), rash with papules and pustules, restlessness, severe pruritus worse at night

* Lesions linear and thread-like, gray 1-10cm in length in various areas of the body (back

and front chest common)

o Dx: Diagnosis by scrapings

o Tx: Treatment with scabicide, warm bath prior to application

- Permethrin 5% topical cream left on 8-14 hours before washing off

- Second treatment 1 to 2 weeks later

- Treat all members of household even if asymptomatic

- Oral antihistamine and abx may be given

- Ivermectin for severe cases

Vascular Tumors (Hemangiomas)

• Caucasian, LBW, multiple births

• Vascular tumors to arise from embolized fetal placental cells; rapid growth

• May be superficial or deep

• S/S: Barely visible when infantile; red macules grow bright red and compressible; blue if deep

o If in presence of vital organ, radiographs done

o Otherwise monitored; no treatment

• Tx: CCS and pulsed-dye laser treatment to rupture vessels and lighten skin surface

• Psychosocial support based on appearance

Burns

● In top 5 of leading causes of injury between 1-14 years

- Thermal - flames, scalds, hot objects

- Chemical- touch or ingestion of caustic agents

- Electrical - wires, appliances, voltage

- Radioactive - radiation or sunlight

● Common cause of child abuse: symmetrical burns, burns in shape of objects (cigarettes),

mechanism of injury DOES NOT match story of incident

● Measure BSA (body surface area)

● Treatment: Measure BSA, ABC’s, Stop burning, Tetanus booster, promote nutrition, fluid resuscitation (LR or NS preferred)

- Large IV bore in unaffected area, foley cath to mon. fluid status, opioids for pain,

maintain body temp, NPO (NG-Tube)

- Wound management: Remove necrotic tissue (debridement), Maintain moist wound conditions and adequate circulation, Conserve body heat and fluids, Protect from infection, Control scarring, prevent contractures

● Sedation, pain management, silver-based dressings

● Allograft vs. Autograft

● Wound vacs

● Psychosocial support, rehabilitation

● Prevention and education

1st degree burn

- Superficial burns through only the epidermis.

- Pink to red in color with no blisters, blanches w/ pressure.

- Painful, heals w/in 3-7 days, no scarring

2nd degree burn

- Superficial partial thickness: damage to the entire epidermis, dermal elements are intact.

-OR-

- Deep partial thickness: Damage to the entire epidermis and some parts of the dermis, Sweat glands and hair follicles remain intact

-APPERANCE: Painful, moist, red in color with blisters, mild

to moderate edema, and no eschar, Blanches with pressure.

-OR-

-APPERANCE: Mottled, red to white in color, with blisters

and moderate edema, Blanches with pressure

- SENSATION/HEALING: Painful, Heals in less than 21 days, Variable amounts of scarring, Sensitive to temperature, changes, exposure to air, and light touch

-OR-

SENSATION/HEALING: Painful, Sensitive to temperature, changes and light touch, Healing time can extend beyond 21 days, Scarring is likely

3rd degree burn

- Full thickness: Damage to the entire epidermis and dermis and possible damage to the subcutaneous tissue, Nerve endings, hair

follicles, and sweat glands are destroyed.

- APPEARANCE: Red to tan, black, brown,

or waxy white in color, Dry, leathery appearance, No blanching.

- SENSATION/HEALING: As burn heals, painful sensations return and severity of pain increases, Heals within weeks to months, Scarring is present, Autografting is required