module 16 - mobility (musculoskeletal disorders)

what is cerebral palsy?

posture and movement limitations from static brain injury in utero or outside

cerebral palsy incidence risk

• infants born before 28 wks

• infants weighing 1000-1499 gm

what are the clinical manifestations of upper motor neuron lesions in cerebral palsy?

• weakness

• spasticity

• inc DTRs

• abn superficial reflexes

what are the clinical manifestations of lower motor neuron lesions in cerebral palsy?

• weakness, skeletal muslce atropgy, hypotonia

• symmetrical

• gradual, sudden onset

• anterior horn disease

• neuropathies

• neuromuscular junction disease

• muscle disease

cerebral palsy prenatal causes

• infection

• hypoxia

• asphyxia

cerebral palsy intrapartum causes

• preterm birth or extra low birth weight

• very low birth weight

• anoxia

cerebral palsy postpartum causes

• anoxia

• roll over in sleep

• AHT (shaken baby)

• motor vehicle accident

what are the seven types of cerebral palsy?

• monoplegia

• hemiplegia (spastic)

• diplegia (spastic)

• quadriplegia (spastic)

• dystonic (dyskinetic)

• ataxic (ataxia)

• athenoid (dyskinetic)

what are the clinical manifestations of cerebral palsy?

• early unilateral hand preference

• abn/asymmetric crawl

• walk on toes

• involuntary mvmts

• poor sucking, feeding

• tongue thrust

• developmental delays (earliest sign)

what are the interventions used to help with locomotion in cerebral palsy?

• wheelchairs, scooters, standing devices

• muscle lengthening surgery

pharmacotherapy for cerebral palsy

• baclofen for spasms (LE and UE)

• botox (LE risk for contractures)

• seizure meds

spina bifida is a…

neural tube defect (NTD)

spina bifida oculta

not visible externally

spina bifida cystica

visible with a sac protrusion.

meningocele

meninges protrude from the spine, creating a fluid filled sac.

myelomeningoceleso

meninges protrude from the spine, creating a fluid filled sac with the spinal cord protruding with it.

spina bifida causes

• maternal drug use

• radiation

• maternal malnutrition

• genetic predisposition

what are the clinical manifestations of spina bifida?

• urine dribbling/overflow incontinence

• poor anal sphincter tone

• orthopedic deformities

what are the diagnostic tools used for spina bifida?

imaging if it is visible.

spina bifida nursing interventions

• at birth (myelomeningocele sac care) → place in prone to protect sac.

• postop care → surgical correction 24-72 hrs for myelomeningocele

myelomeningocele clinical manifestations

• high risk latex

• hydrocephalus (need a shunt)

neurogenic bladder

• spina bifida clinical presentation

• bladder is overactive or underactive

neurogenic bowel

• spina bifida clinical presentation

• loss of normal bowel function

• need bowel training program

how do latex allergies develop?

• repeat exposure to latex from surgery and bladder catheterizations

• associated to spina bifida

hypotonia clinical manifestations

delayed gross motor skill milestones

• holding head up

• roll over

• sitting

• pull to stand

• cruising/walking

• balance and coord

• trouble feed, speech, breathing

hypoxia may suggest some degree of…

hypoxia, neuro abn, disorders (ex. down’s syndrome)

hydrocephalus

fluid accumulation in the brain that increases ICP, leading to brain damage

what are the early signs of raised ICP?

• bad, prolonged HA

• N/V

• blurred vision

what are the late signs of raised ICP?

• pupil size change

• fixed dilated pupils

• respiratory changes (cheyne stokes)

• widening pulse pressure

• bradycardia

• cushing’s triad (bradycardic, widening pulse, resp changes)

what are the other signs of raised ICP in children?

• quieter than usual

• baby stops tracking mvmt w/ their eyes

• swollen, bulging fontanelles

• seizures

• FTT

VP shunt

implanted device to drain CSF from brain ventricles into the peritoneal cavity of the abd

pyloric stenosis

constriction of the pyloric sphincter w/ the obstruction of the gastric outlet

pyloric stenosis clinical manifesstations

• olive-like mass

• projectile vomiting with no bile

• hangry

• FTTT

• dehydration

• metabolic alkalosis

how do you diagnose pyloric stenosis?

US

what is the treatment for pyloric stenosis?

surgery (pyloromyotomy) and fluid replacement prior to surgery if dehydrated/electrolyte imbalance.

what is the nursing care fo pyloric stenosis?

before surgery: hydrate

after surgery: slow start feedings, monitor surgical site

hypospadias

male urethra has an abn ventral placement of the urethral meatus

hypospadias treatment

surgical correction

• improve ability to void while standing

• improve physical appearance

• preserve the organ

hypospadias nursing care

• pain management

• urinary diversion into diaper for 5-10 days

when should the first meconium be passed?

within 24-36 hours of life

hirschsprung

absence of ganglion cells in the colon

hirschsprung clinical manifestations

• obstruction

• stool accumulation w/ distention

• sphincter can’t relax

• enterocolitis

how do you diagnosis hirshprungs?

• X-ray

• barium enema

• anorectal manometric exam

• confirmed w rectal biopsy

what is the therapeutic management for hirshprungs?

depends on extent/location of the aganglionic bowel

• single surgery w/o colostomy

• two stage with temporary ostomy and pull through procedure

gastroschisis

birth defect where bowels grow outside of body

gastroschisis repair

• intestines gathering in silo and hung above abd to allow gravity to ease back into abd

• surgeons reinsert intestines and close the hole

• baby is tube fed until intestines heal

gastroschisis nursing management

• assess, monitor

• cover w/ sterile, moist dressing

• regulate temp

• fluid management

• prevent infection/complications

omphalocele

bowel is covered w peritoneal sac as seen at birth or on US

short gut syndrome

inability to absorb enough water, vits, nutrients that can be caused by enterocolitis, intestinal atresias, and gastroschisis, crohn’s.

short gut syndrome therapeutic management

first phase: TPN

second phase: enteral feedings

administer and monitor nutritional support

ostomy care

muscular dystrophy

x-linked inherited muscle disorder

muscular dystrophy clinical manifestations

• symptom onset: 3-5 years

• progressive muscle weakness, wasting, contractures

• calf muscle hypertrophy

• progressive generalized weakness in adolescence

• death from resp or cardiac failure

• gower’s sign → using upper body to get up

what is used to diagnose muscular dystrophy?

• EMG

• muscle biopsy

• serume enzyme

• serum CPK, AST

• clinical appearance

muscular dystrophy nursing care

• help child and family cope

• debilitating disease

• design a program to foster independence

• teach self help skills

• arrange for appropriate health care assistance