peds exam 3

characteristics of bones early in life?

cartilaginous, soft, easily bendable

muscular dystrophies (general)

-largest group of muscular diseases in children
-genetic origin, gradual degeneration of muscle fibers, progressive weakness, wasting of skeletal (voluntary) muscles
-x-linked inheritance (males exclusively)

most common fatal muscular dystrophy

duchenne muscular dystrophy (inherited when protein. dystrophin is not present)

muscular dystrophies assessment

-developmental milestones
-early onset (3-7 years old)
-slowness in running/climbing
-waddling gait, frequent falls, gower sign
-"woody feeling muscle" (hard and hypertrophic)
-lordosis (pregnant mom stance from weak pelvis)
-calf muscle hypertrophy
-loss of independent ambulation (9-12 years old)
-mental deficiency common
-death from respiratory/cardiac failure

gower sign

-indicates weak muscles, especially in pelvic girdle
-child walks up hands on legs bc lack of glute muscle
-common in muscular dystrophy

muscular dystrophies diagnostic

-prenatal testing if positive family history
-clinical appearance
-blood: polymerase chain reaction (PCR) for dystrophin gene mutation
-electromyogram confirmation (EMG), muscle biopsy, serum enzyme measurement
-serum cpk & ast levels high in first 2 years of life before onset of weakness

muscular dystrophies therapeutic management

-no effective treatment established
-goal: maintain functioning as long as possible
-range of motion, bracing, performance of ADLs, surgical release of contractors if needed

muscular dystrophies priority nursing care

-low calorie, high protein diet
-respiratory risks: atelectasis, pneumonia, resp distress
-cardiac risks: cardiomyopathy, arrhythmias
-r/f constipation, depression
-avoid obesity
-glucocorticosteroids, ace inhibitors

overuse syndrome

-young athletes being forced to train harder, earlier in life
-performing same movement repeatedly can cause microtrauma
-prevention: one sport at one time, 5 days a week maximum, 2-3 months off/year
-kids who participate in wider variety of sports have this less, using different muscles

sprain

-trauma to a joint from ligament partially/completely torn or stretched by force
-assoc. w/ damage to blood vessels, muscles, tendons, nerves
-presence of joint laxity as severity indicator
-rapid onset of swelling w/ disability

strain

-microscopic tear to musculotendinous unit
-similar to sprain
-swollen, painful to touch
-generally incurred over time

tendons connect...

muscle to bone

ligaments connect...

bone to bone

soft tissue injury therapeutic management

RICE & ICES
-rest injured part
-ice immediately (30 mins max at a time)
-compression with wet elastic bandage
-elevation of extremity
-immobilization & support (casts/splint)

dislocation

-displacement of normal position of opposing bone ends or of bone ends to socket
-occurs when force of stress on ligament is sufficient to cause displacement, pulling and twisting motion
-symptoms: IMMEDIATE pain, increases w/ active or passive movement of affected extremity
-more common in children w/ Down Syndrome
-hip dislocation: potential loss of blood supply to head of femur

nursemaid's elbow

-radial head dislocation
-joint becomes unstable for future

fractures

-common childhood injury
-rare in infants: requires investigation
-school age: bike related, sports injuries

most frequently broken bone in childhood

distal forearm

different types of fractures

plastic deformation (bone can bend up to 45 degree)
buckle (compression injury)
greenstick (most common)
complete
complete with periosteal hinge

periosteum in childhood

very thick
allows for fast healing
carries blood supply

growth plate injuries

-weakest point of long bones
-frequent damage site in trauma
-affects future bone growth
-treatment: possible open reduction & internal fixation to prevent growth disturbance
-salter-harris classification

bone healing/remodeling by age group

neonatal: 2-3 weeks
early childhood: 4 weeks
later childhood: 6-8 weeks
adolescence: 8-12 weeks

fractures focused assessment

-generalized swelling
-pain or tenderness
-deformity
-diminished use
-possible bruising, muscular rigidity, crepitus (grating/cracking sensation)

fractures diagnosis

-radiographs
-history taking
-suspicion of fracture in young child who refuses to walk or bear weight
-x-ray important: swelling is not sure sign

fractures goals

-reduction and immobilization
-restoring function
-preventing deformity

fracture 6 P's

-pain & point of tenderness
-pallor
-pulselessness
-paresthesia: sensation distal to site
-paralysis: movement distal to the fracture site
-pressure

compartment syndrome

-serious complication of fractures
-compression of nerves/blood vessel/muscles
-permanent damage in 24-48 hours
-assess color, temp, cap refill, motor refill

common medical treatments

-casts- immobilize a bone
-traction- reduce and/or immobilize a fracture or align an extremity to be restored to normal length
-internal or external fixation- complicated fractures especially open fractures with soft tissue damage or complex fractures

plaster cast

-up to days drying
-bulky, hard, white
-molds better to body part

fiber glass cast

-colorfol
-immediately dries
-more expensive

casting general

-assess swelling- elevate extremity
-careful handling of wet cast
-frequent neurovascular checks of casted extremity (capillary refill, color, warmth, movement, sensation)
-keep edges clean, dry, smooth
-cast removal- noise is scary- warmth and vibration felt

hot spots

warm spots on cast, may indicate infection of suture site

female athlete triad

decreased energy availability, amenorrhea, osteoporosis

pedaling (casting)

tape smooths rough edges of cast

fracture traction (general)

-allows physiologic stability
-aligns bone fragments
-enables closer evaluation of injured site
-newer tech: orthopedic fixation devices that allow for mobility

types of traction

upper extremity (uncommon in children)
lower extremity
-bryant
-buck
-russell
-balance suspension
-cervical (halo brace or vest)

traction nursing considerations

-weights must be free swinging
-pin care important
-watch signs for infection (pin goes into bone)
-assess for muscle spasms
-prevent ulceration
-encourage fluids to prevent constipation (stool softeners)
-deep breathing
-ROM
-diversional therapy
-do not move bed, removes support from weights

skin traction

-apply skin traction over intact skin
-prepare skin with adhesive before applying contraction tapes
-ensure ropes swing freely
-constant and even contraction important

skeletal traction

-weights are applied via skeletal pins
-treat pin sites as surgical wounds
-monitor s/s infection
-constant and even contraction important

external fixation

-required for complicated fractures
-good for bones that are more shattered
-careful, do not bump this, leads to extreme pain

positional plagiocephaly

-"flat head syndrome"
-caused by infants sleeping position, fontanelles are not fused which can cause remodeling of skull

positional plagiocephaly assessment

-occiput is flattened on one side
-ear on flattened side may be pushed forward
-bulging on side opposite from flattening & forehead may be asymmetrical (uneven)
-neck, jaw, face may be asymmetrical

positional plagiocephaly treatment

-switch head position during feeding, carrying, sleeping
-customized helmet if not resolved in 4-8 weeks (removes pressure over flat area, worn 2-3 months)
-tummy time during awake periods
-avoid time spent in car seats/bouncers
-sleep should still be in supine position

torticallis

sternocleidomastoid muscle stretched on one side & weak on another (r/t positional plagiocephaly)

what should be avoided that can lead to bad posture?

-bumbo seats
-extrasaucers
-baby walkers
-prolonged car seat time

congenital club foot

-birth defect
-treatment should be started asap so bones do not continue to develop abnormally

what is word that refers to any deformity of foot or ankle?

talipes
talipes equinovarus is most common (toes lower than heel and face forward

congenital club foot management

-correction of deformity
-maintenance of correction until normal muscle balance is regained
-follow-up to avoid recurrence
-ponseti method (serial casting)
-if manipulation does not work, surgery required to release tight tendons and reposition foot bones
-goal: complete by age 1

denis-browne splint

-shoe worn after casting to make alignment stay in place
-bracing may be needed to maintain alignment until 4 years of age!

developmental dysplasia of hip (DDH)

-various degrees of deformity involving subluxation/dislocation either partially/completely
-girls more commonly affected
-family history present
-head of femur is out of ball and socket joint (more out \= more severe, can lead to dislocation)

DDH assessment

-hip joint laxity
-shortened limb on affected side
-restricted/limited abduction of hip on affected side
-unequal gluteal folds when infant prone
-one hip higher than other when infant prone
-positive ortolani test (abduction)
-positive Barlow test (adduction)
-older child: limp

galeazzi test

shorter leg affected with DDH

ortolani test

tests hip abduction

barlow test

tests hip adduction

DDH management

newborn-6 months: pavlik harness- stabilizes hip by preventing hip extension and adduction- maintains hip in flexion and abduction, gently stretches, allows for leg movement

6-18 months: spica cast, dislocation unrecognized until child begins to stand and walk, use traction to stretch muscles, spica cast for immobilization

older child: operative reduction, followed by 9 months of casting

pavlik harness

-newborn to 6 months
-keeps hips from flexing
-top strap at nipple line
-velcro should not come in contact with skin
-worn 24 hours a day for first weeks
-compliance problem

spica cast

-child under anesthesia when cast is applied
-frog-like cast to maintain external rotation
-check for circulation/neuro checks
-position changes frequent
-urine/feces drains away from cast

scoliosis definition

spine curves laterally and vertebrae rotate, pulling ribs along

kyphosis

front-to-back rounding, usually of thoracic spine, often accompanied by scoliosis (convex curve, hunchback)

lordosis

exaggerated concave curvature of spine, usually in lumbar region

scoliosis general

-complex spinal deformity in 3 planes: lateral curvature, spinal rotation (rib asymmetry), thoracic hypokyphosis
-noticeable after preadolescent growth spurt
-clothes may be ill fitting
-not caused by sleeping position, posture, vitamin deficiency

spinal curvatures diagnostics

-standing radiographs to determine degree of curvature
-assymetry of shoulder height, scapular or flank shape, hip height
-in addition to primary curve, compensatory curve often present to align head with gluteal cleft

spinal curvatures assessment

asymmetries:
-uneven shoulders
-one shoulder blade appears more prominent
-uneven waist
-one hip higher than other
-often have a primary curve and a compensatory curve to align the head with gluteal cleft
-adams forward bending test

spinal curvature- bracing

-can stop progression of curve
-wearing it full time has best results

spinal curvature management

-exercise: increase spine strength
-25-40 degree curve: bracing to decrease progression
-50+ degree curve: surgery w/ rod placement and bone grafting- rids of curve

surgery for scoliosis

-spinal fusion: skeletal growth affected
-metal rods can be implanted using clips to fuse the vertebra

scoliosis surgery nursing care

preop: auto donate blood, IVs, NPO, foley, PCA pump, teach deep breathing, explain log rolling, answer questions, decrease anxiety

postop: neuromuscular check (Q1-2 first 24 hours, then Q4 for 48 hours, pedal pulses QH for first 48 hours), pulmonary care, wound care, bedrest, log rolling Q2, positioning, advance diet as tolerated, diversional activities, physical therapy, WALKING BY DAY 2

cerebral spinal fluid

-cushioning for the brain that follows specific pathway
-subarachnoid space- venous circulation

neurological assessment

-infants/young children: spontaneous/elicited reflexes
-family & health history
-physical exam
-vitals
-skin (in tact? look for drug usage between fingers)
-eyes (perrla)
looking far: dilation
looking close: constriction
roadblock in brain may interfere with indirect response
direct response: light with constriction
-motor funuction
-posturing

nuchal rigidity

stiffness in cervical neck area the flexing down, can indicate increased ICP

what can affected LOC indicate?

neurologic problem

coma assessment

pediatric glascow coma scale
-three part assessment
eyes (opening)
verbal response
motor response
score of 15: no altered LOC
8 or below: coma
3 or below: extremely decreased LOC

decorticate posturing

flexion, arms like c's over chest

decerebrate posturing

extension, arms like e's outward, VERY bad outcome

increased ICP

-symptom, not a disease itself
-increased BP
-decreased pulse
-decreased respirations
-early signs subtle
-as pressure increases, s/s become more pronounced and LOC deteriorates

increased ICP in infants

-irritable
-poor feeding
-high-pitched cry
-fontanels tense/bulging
-cranial sutures separated
-eyes of setting-sun sign
-scalp veins distended
-macewen sign
-increased head circumference

sun setting eyes

infant ICP
pressure on 2nd cranial nerve

bossing

bulging forehead due to head shape change b/c sutures are coming part

macewen sign

hollow sound bc brain is occupied with fluid

increased ICP in children

-headache
-forceful vomiting (when standing fluid falls and location of pressure changes)
-seizures
-drowsiness, lethargy
-diminished physical activity
-inability to follow simple commands

increased ICP late signs

-bradycardia
-decreased LOC
-decreased motor response to commands
-decreased sensory response to painful stimuli
-alterations in pupil size and reactivity
-papilledema- optic disc swelling bc engorgeed eye vein
-flexion or extension posturing
-cheyne stokes respirations (rapid breathing w apnic periods)

increased ICP diagnostics

-lab tests: glucose, CBC, electrolytes, blood culture if -fever, eval for toxic substance, liver function
-imaging: CT, MRI, echoencephalography, ultrasound, nuclear brain scanning, PET
-lumbar puncture
-EEG
-x-ray (rule out skull fractures/dislocations)

increased ICP nursing care

-assess LOC, pupillary reaction, VS (q15min-q2hr)
-positioning
-avoid activities that may increase ICP (suctioning, valsalva maneuver, excess IV fluids (overhydration)
-later, begin gastric feedings via nasogastric or gastrostomy tube
-watch for aspiration risk

intracranial infections general

-CNS has limited response to injury
-difficult to distinguish the cause by looking at clinical manifestations
-lab studies required
-inflammation can affect meninges, brain or spinal cord
-bacterial meningitis more severe than viral

bacterial meningitis general

-IMMEDIATE INTERVENTION
-acute inflammation of CNS and meninges
-Hib and pneumococcal vaccines lower incidence
-can be caused by streptococcus pneumoniae, neisseria meningitidis, B-hemolytic streptococci, listeria monocytogenes, E coli (rare after infancy)

transmission of bacterial meningitis

-close contact w/ respiratory secretions
-penetrating wounds, lumbar puncture, surgery, spina bifida
-once in meningeal space, multiplies rapidly
-infective process: inflammation, exudate, WBC accumulation, tissue damage, brain becomes edematous, hyperemic, brain covered by purulent exudate

bacterial meningitis assessment

-abrupt onset, fever, chills, signs of meningeal irritation:
nausea, vomiting
irritability
seizures (often first sign)
anorexia
headache
photophobia
confusion
nuchal rigidity
positive kernig and brudzinski signs

classic symptoms rarely seen in children b/n 3 months and 2 years old

kernigs sign

back pain when lifting leg \= positive

brudzinski sign

legs lift when neck is lifted up \= positive

bacterial meningitis management

-lumbar puncture is definitive diagnostic
-all cultures must be obtained before starting antibiotics
-isolation precautions
-antimicrobial therapy
-restricted hydration
-maintenance of systemic shock
-maintenance of ventilation
-control seizures and temperature
-dexamethasone management

CSF results: bacterial vs viral

WBC: elevated (bacterial) ; slightly elevated (viral)
protein: elevated (bacterial); normal (viral)
glucose: decreased (bacterial); normal (viral)
gram stain: positive (bacterial); negative (viral)
color: cloudy (bacterial); clear (viral)

bacterial meningitis nursing care

-quiet room (sensitive to light and stimuli)
-children more comfy without pillow
-side lying position (nuchal rigidity)
-pain relief
-vitals, neuro signs, LOC
-head circumference (hydrocephalus risk)
-monitor fluid/electrolyte (sodium)
-maintain IV (10 day antibiotic
-respiratory isolation for 24 hrs
-prevention: vaccines, Hib, meningococcal, pneumococcal

nonbacterial meningitis

-caused by viruses
-benign- no treatment
-headache, fever, malaise
-treat symptoms, acetaminophen, hydration, position for comfort

hydrocephalus

-caused by imbalance in production/absorption of CSF in ventricular system
-chronic neuro condition
-commonly associated with myelomeningocele
-CSF does not absorb in subarachnoid space

hydrocephalus early infancy

-rapid head growth
-bulging fontanels
-dilated scalp veins
-separated sutures
-macewen sign
-thinning of skull bones

hydrocephalus infancy general

-irritability
-lethargy
-cries when picked up, quiet when still
-change in LOC
-vomiting
-advanced: difficulty sucking, shrill high pitched cry

hydrocephalus childhood

-headache on awakening
-papilledema
-strabismus
-irritability
-lethargy
-confusion
-vomiting

transillumination

light shines through head bc there is so much fluid

hydrocephalus nursing care

-daily head circumference
-monitor for increased ICP/malfunction: physical exams, behavioral symptoms, feeding, sleeping, developmental differences

most common treatment of hydrocephalus

ventriculoperitoneal shunt (VP shunt, cerebral fluid drains from head)
fluid drains to peritoneum