Pediatric Nursing Exam 2
Problems in Locomotion
Musculoskeletal Differences in Children:
Epiphyseal growth plate is present
Bones are growing and healing faster
Bones are more pliable
Periosteum is thicker and more active
Abundant blood supply to the bone
The younger the child, the faster the healing
Epidemiology of Trauma:
Trauma is the leading cause of death in children older than 1 year and an important cause of disability during childhood and adolescence
Unintentional injuries – the leading cause of death for ages 1-19 in US
o Motor vehicle crash accounted for largest percentage
Childhood Characteristics
o Injuries may be age and/or developmentally related
o The large head of infants and toddlers predisposes them to head injury – especially in falls or motor vehicle injuries
Lightweight and small size makes them easier to be thrown around
o In school-age children and adolescents, their bone growth > their muscle growth difficult to control movements physical injury
o Children attempt activities beyond their physical capabilities; vulnerable to dares
o Risk taking and feelings of invulnerability are characteristic in adolescence
o School-age to early adolescence may be encouraged to continue sports, even after suffering a contusion or sprain subject to repetitive str
injuries
Unintentional or Accidental Injury:
Leading causes of childhood morbidity – traumatic injury at home, school, in an automobile, or associated with recreational activities
Children engage in vigorous play every day, making them prone to injury
Vulnerable to multiple and severe trauma; do not calculate risks accidents are a part of the childhood experience
Children’s bodies have protective resilience from serious damage to soft tissues, MS system, or other organs
o Bones more flexible don’t offer rigid resistance to external forces
o Unlike more mature bones
Child Abuse or Non-Accidental Trauma:
Careless handling of an infant or child (sometimes intentional physical abuse) is not uncommon
Smaller children who are unable to protect themselves are most vulnerable
Well-documented history and careful exam are essential to determine cause of injury
The ED and Pediatric personnel are alert to situations in which:
o A child’s injuries are not congruent with parent’s story
o Child’s behaviors abnormal – fearful mannerisms, lack of crying
o Radiographs show multiple healed fractures
Reporting these instances aids in securing help for child and family
Prevention of Injury:
Importance on injury prevention efforts in preserving health and well-being of children
Leading causes of injury to children include:
o Falls – leading nonfatal injury in ages 0-15
o Being struck by or against an object – leading nonfatal injury in ages 15-19
o MVAs or pedestrian-vehicle accidents
o Fires
o Drowning
o Firearms
Unintentional injury – primary cause of pediatric mortality and significant contributor to morbidity, including permanent disability
o General lack of public awareness about injury to children
Nurse and Preventing Injury:
Can be active in legislative efforts, public awareness campaigns, group classes on injury prevention, and individual prevention counseling
Admit forms can include screening questions on safety issues
Discharge planning / primary care visits – time to provide family with info on safety practices
Well-child visits for physical/immunizations – excellent time for visit about injury prevention in home and community
Home health nurse can perform home safety assessment
, School nurses can develop safety education programs for different ages
For adolescents, additional resources for injury prevention include:
o Automobile insurance companies
o Police
o First responder personnel
Accident prevention in adolescents – a unique challenge
o They must see the specific interventions as having an impact on their lives for accident prevention to be effective
o Often feel indestructible unless their own life or life of close friend touched by catastrophic injury or death
o YOLO makes it difficult to understand need to follow rules made by authority figures
Increased concern in older school-age and adolescents from use of all-terrain motor vehicles – states don’t have minimum age for riders
Adolescents are known for taking risks
o Approval of peers compounds risk-taking behaviors in games (car surfing, choking game)
o Parents may not be aware – requires frank discussion between parent and adolescent
o Nurses need to be aware of such games and be ready to discuss effects of risk taking with teens
Neurovascular Assessment - 5 P’s:
Pain (and point of tenderness)
Paresthesia (sensation distal to the fx.)
Pallor
Paralysis (movement distal to the fx.)
Pulse (distal to the fx.)
The Child with a Fracture:
Common injury in children
Occurrences with Age Groups
o Infancy – MVA; suspected abuse (B-5 =
o Childhood – forearm, clavicle
o Older children – femur
o Adolescents – knee injuries
Clinical Manifestations of a Fracture
o Generalized swelling
o Pain or tenderness
o Diminished functional use
o May have bruising, severe muscular rigidity, crepitus
Growth Plate or Epiphyseal Injuries
o Weakest point of long bones is the cartilage growth plate (epiphyseal plate)
o Frequent site of damage during trauma
o May affect future bone growth
o Treatment may include open reduction and internal fixation to prevent growth disturbances
Bone Healing and Remodeling
o Typically, there is rapid healing in children
o Neonatal period—2 to 3 weeks
o Early childhood—4 weeks
o Later childhood—6 to 8 weeks
o Adolescence—8 to 12 weeks
Cast Application:
Should consider child’s developmental age before applying cast
Preschoolers:
o Fear bodily harm and fantasize loss of extremity use doll or stuffed animal to explain procedure beforehand
o Do not have easily defined body boundaries if extremity is wrapped then they thing the extremity ceases to exist explain it will be war
but not burn
o Use various distraction methods during application
Discussing favorite pets or activities at school
Blowing bubbles
o Explanations saying it will make them better are futile – child doesn’t have concept of causality
Before cast is applied, check extremities for abrasions, cuts, or other alterations to skin; look for any small objects (rings) that might cause
constriction swelling and remove them
Tube of stockinet or waterproof liner is stretched over area, bony prominences are padded, then dry rolls of casting material are immersed in tep
water, and the wet rolls are applied in bandage fashion, molding to the extremity
o The underlying stockinet is pulled over the raw edges of casting material to protect the skin
o Or can be protected by creating a petal edge
Cast Removal:
Cutting the cast for removal or relieving tightness is frequently frightening for children
, o Fear of the sound of the cast cutter and that their flesh will be cut
o Works by vibration only cuts hard surfaces but will not cut when placed lightly on skin (children report a ticklish feeling)
o Vibration also generates heat
o Explain ticklish sensation and heat sensation to the child
Preparation for procedure helps reduce anxiety, especially if nurse builds trusting relationship with child
o Many children regard cast as part of themselves intensifies fear of removal
o Need continuous reassurance that all is going well and their behavior is accepted
After cast is removed, skin surface caked with desquamated skin and sebaceous secretions
o Simple soaking in the bath usually sufficient for removal
o May take several days to completely eliminate accumulation
o Instruct parent and child to not pull or remove material with vigorous scrubbing may cause excoriation and bleeding
If cast on for long period, decreased muscle mass may be noted
o Reassure child and family that resuming exercise and routine activities will gradually return function/appearance
Nursing Considerations for Cast Care:
Cast Care at Home
o Appropriate cast care guidelines are necessary before discharge
o Instructions are also given for checking s/s of cast being too tight
o Parents should know to see HCP if cast becomes too loose no longer serving its purpose
o Shouldn’t have cast in a dependent position for more than 30 minutes
o Nurse can help family adapt the child’s home environment to meet temporary inconvenience of cast restricting motility
Common situations, like transporting child to car, can be problematic
Specially designed car seats and restraints are available that meet safety requirements
Baths are possible only if cast kept out of water and covered to prevent wetness from splashing
Some synthetic casts are waterproof, but proper care is necessary to avoid skin irritation beneath the cast
Spica casts make sitting and toileting impossible Need to eat in prone position and use a small bedpan for elimination
Suggest waterproofing methods to reduce urine burns and heat rash/improve hygiene of hip spica cast: plastic wraps, protective skin
barrier, and absorbent pads
Skin Care
o Examine skin at cast edges to detect irritation or skin breakdown; pad accordingly
o Relieve itching by an ice pack and administration of medications as recommended by provider
o Avoid placing cast in water
o If patient is incontinent, protect cast with waterproof tape and plastic; use diapers, pull-ups, or other guards
Prepare the child for cast removal – turn on the equipment before using it on the child
The Child in Traction:
Purposes of Traction
o Provide rest for an extremity
o Help prevent or improve contracture deformity
o Correct a deformity
o Treat a dislocation
o Allow position and alignment and provide immobilization
o Reduce muscle spasms (rare in children)
Essential Components of Traction
o Traction: forward force produced by attaching weight to distal bone fragment
o Adjust by adding or subtracting weights
o Counter-traction – backward force provided by body weight; Increase by elevating foot of bed
o Frictional force – provided by patient’s contact with the bed
Types of Traction
o Manual traction – applied to the body part by the hand placed distally to the fracture site
o Skin traction – pulling mechanisms are attached to the skin with adhesive material or elastic bandage
Example – Buck Traction
Usually only used for short-term issues
o Skeletal traction – applied directly to skeletal structure by pin, wire, or tongs inserted into or through the diameter of the bone distal to the
fracture
o Cervical Traction
Crutchfield or Barton tongs
Inserted through burr holes in skull with weights attached to the hyperextended head
As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord no longer pinched between vertebrae
Halo traction can be applied in some cases
Nursing Management for Child in Traction
o Assessing the patient in traction
o Skin care issues
o Pain management/comfort
, Distraction
Process of separating opposing bone to encourage regeneration of new bone in the created space
Can be used when limbs are unequal in length and new bone is needed to elongate the shorter limb
External Fixation:
A system of wires, rings and telescoping rods that permits limb lengthening to occur by manual distraction – can result in a gain of up to 15 cm
Can also be used to correct angular or rotational defects, as well as immobilize fractures
Nursing Management
o Crutch walking – can not fully weight bear until the distraction is complete
o Pin care – what is the best technique to provide pin care and avoid infection? ½ strength peroxide on a sterile q-tip and wiped around the
insertion site; full strength peroxide
o Cast care (post fixator removal)
Internal Fixation:
Pins and plates – screws, wires, or plates used to align bone fragments
Child can sit and walk with a walker or crutches within hours/days of the internal fixator being placed
Nursing Management
o Infection – most common complication of internal fixation
o Neurovascular changes
o Postanesthesia problems
Nursing Considerations of Child in Traction
Assessing the patient
Skin care issues
Pain management/comfort
Congenital (Developmental) Dysplasia of the Hip:
Abnormality in the development of the proximal femur, acetabulum, or both.
Girls affected 6:1
Familial history
Breech presentation
Maternal hormones
Clinical Manifestations
o Head of femur lies outside the acetabulum
o + Ortolani maneuver – flex the hips and carry the knee to mid-abduction and if you feel the head of the femur slide into the acetabulum or
a “click”; reliable to about ages 2-3 months of age
o Notice shortening of the limb as compared to the other
o Asymmetrical lower extremity skin folds*
o Discrepancy in limb length
• Therapeutic Management – Interventions
o Maintain hips in flexed position
o Traction to stretch muscles
o Pavlik harness – used from newborn to about 6 months of age
Check for skin breakdown
Avoid lotion and powders underneath the straps
Wear the harness around the clock unless the child is being bathed
o Hip surgery – between 6 and 18 months of closed reduction; if over 18 months open reduction is used
Tales Equinovarus – Club Foot
• 1 to 2 per 1000
• Males more affected
• Involves both the bony structures and soft tissue
• The entire foot is pointing downward
• Obvious at birth
• Therapeutic Intervention
o Manipulation and serial casting immediately
o Surgery is performed between 4 to 12 months if full correction is not achieved with casting
Osteogenesis Imperfecta:
• Genetic disorder
• Caused by a genetic defect that affects the body’s production of collagen, the major protein of the body’s connective tissue
• Less than normal or poor collagen leads to weak bones that fracture easily
• Often called “brittle bone disease”
• Therapeutic Management
o Primarily supportive care – maximizing independent mobility and function; developing optimal bone mass and muscle strength
o Drugs of limited benefit – vitamin D supplementation,
Problems in Locomotion
Musculoskeletal Differences in Children:
Epiphyseal growth plate is present
Bones are growing and healing faster
Bones are more pliable
Periosteum is thicker and more active
Abundant blood supply to the bone
The younger the child, the faster the healing
Epidemiology of Trauma:
Trauma is the leading cause of death in children older than 1 year and an important cause of disability during childhood and adolescence
Unintentional injuries – the leading cause of death for ages 1-19 in US
o Motor vehicle crash accounted for largest percentage
Childhood Characteristics
o Injuries may be age and/or developmentally related
o The large head of infants and toddlers predisposes them to head injury – especially in falls or motor vehicle injuries
Lightweight and small size makes them easier to be thrown around
o In school-age children and adolescents, their bone growth > their muscle growth difficult to control movements physical injury
o Children attempt activities beyond their physical capabilities; vulnerable to dares
o Risk taking and feelings of invulnerability are characteristic in adolescence
o School-age to early adolescence may be encouraged to continue sports, even after suffering a contusion or sprain subject to repetitive str
injuries
Unintentional or Accidental Injury:
Leading causes of childhood morbidity – traumatic injury at home, school, in an automobile, or associated with recreational activities
Children engage in vigorous play every day, making them prone to injury
Vulnerable to multiple and severe trauma; do not calculate risks accidents are a part of the childhood experience
Children’s bodies have protective resilience from serious damage to soft tissues, MS system, or other organs
o Bones more flexible don’t offer rigid resistance to external forces
o Unlike more mature bones
Child Abuse or Non-Accidental Trauma:
Careless handling of an infant or child (sometimes intentional physical abuse) is not uncommon
Smaller children who are unable to protect themselves are most vulnerable
Well-documented history and careful exam are essential to determine cause of injury
The ED and Pediatric personnel are alert to situations in which:
o A child’s injuries are not congruent with parent’s story
o Child’s behaviors abnormal – fearful mannerisms, lack of crying
o Radiographs show multiple healed fractures
Reporting these instances aids in securing help for child and family
Prevention of Injury:
Importance on injury prevention efforts in preserving health and well-being of children
Leading causes of injury to children include:
o Falls – leading nonfatal injury in ages 0-15
o Being struck by or against an object – leading nonfatal injury in ages 15-19
o MVAs or pedestrian-vehicle accidents
o Fires
o Drowning
o Firearms
Unintentional injury – primary cause of pediatric mortality and significant contributor to morbidity, including permanent disability
o General lack of public awareness about injury to children
Nurse and Preventing Injury:
Can be active in legislative efforts, public awareness campaigns, group classes on injury prevention, and individual prevention counseling
Admit forms can include screening questions on safety issues
Discharge planning / primary care visits – time to provide family with info on safety practices
Well-child visits for physical/immunizations – excellent time for visit about injury prevention in home and community
Home health nurse can perform home safety assessment
, School nurses can develop safety education programs for different ages
For adolescents, additional resources for injury prevention include:
o Automobile insurance companies
o Police
o First responder personnel
Accident prevention in adolescents – a unique challenge
o They must see the specific interventions as having an impact on their lives for accident prevention to be effective
o Often feel indestructible unless their own life or life of close friend touched by catastrophic injury or death
o YOLO makes it difficult to understand need to follow rules made by authority figures
Increased concern in older school-age and adolescents from use of all-terrain motor vehicles – states don’t have minimum age for riders
Adolescents are known for taking risks
o Approval of peers compounds risk-taking behaviors in games (car surfing, choking game)
o Parents may not be aware – requires frank discussion between parent and adolescent
o Nurses need to be aware of such games and be ready to discuss effects of risk taking with teens
Neurovascular Assessment - 5 P’s:
Pain (and point of tenderness)
Paresthesia (sensation distal to the fx.)
Pallor
Paralysis (movement distal to the fx.)
Pulse (distal to the fx.)
The Child with a Fracture:
Common injury in children
Occurrences with Age Groups
o Infancy – MVA; suspected abuse (B-5 =
o Childhood – forearm, clavicle
o Older children – femur
o Adolescents – knee injuries
Clinical Manifestations of a Fracture
o Generalized swelling
o Pain or tenderness
o Diminished functional use
o May have bruising, severe muscular rigidity, crepitus
Growth Plate or Epiphyseal Injuries
o Weakest point of long bones is the cartilage growth plate (epiphyseal plate)
o Frequent site of damage during trauma
o May affect future bone growth
o Treatment may include open reduction and internal fixation to prevent growth disturbances
Bone Healing and Remodeling
o Typically, there is rapid healing in children
o Neonatal period—2 to 3 weeks
o Early childhood—4 weeks
o Later childhood—6 to 8 weeks
o Adolescence—8 to 12 weeks
Cast Application:
Should consider child’s developmental age before applying cast
Preschoolers:
o Fear bodily harm and fantasize loss of extremity use doll or stuffed animal to explain procedure beforehand
o Do not have easily defined body boundaries if extremity is wrapped then they thing the extremity ceases to exist explain it will be war
but not burn
o Use various distraction methods during application
Discussing favorite pets or activities at school
Blowing bubbles
o Explanations saying it will make them better are futile – child doesn’t have concept of causality
Before cast is applied, check extremities for abrasions, cuts, or other alterations to skin; look for any small objects (rings) that might cause
constriction swelling and remove them
Tube of stockinet or waterproof liner is stretched over area, bony prominences are padded, then dry rolls of casting material are immersed in tep
water, and the wet rolls are applied in bandage fashion, molding to the extremity
o The underlying stockinet is pulled over the raw edges of casting material to protect the skin
o Or can be protected by creating a petal edge
Cast Removal:
Cutting the cast for removal or relieving tightness is frequently frightening for children
, o Fear of the sound of the cast cutter and that their flesh will be cut
o Works by vibration only cuts hard surfaces but will not cut when placed lightly on skin (children report a ticklish feeling)
o Vibration also generates heat
o Explain ticklish sensation and heat sensation to the child
Preparation for procedure helps reduce anxiety, especially if nurse builds trusting relationship with child
o Many children regard cast as part of themselves intensifies fear of removal
o Need continuous reassurance that all is going well and their behavior is accepted
After cast is removed, skin surface caked with desquamated skin and sebaceous secretions
o Simple soaking in the bath usually sufficient for removal
o May take several days to completely eliminate accumulation
o Instruct parent and child to not pull or remove material with vigorous scrubbing may cause excoriation and bleeding
If cast on for long period, decreased muscle mass may be noted
o Reassure child and family that resuming exercise and routine activities will gradually return function/appearance
Nursing Considerations for Cast Care:
Cast Care at Home
o Appropriate cast care guidelines are necessary before discharge
o Instructions are also given for checking s/s of cast being too tight
o Parents should know to see HCP if cast becomes too loose no longer serving its purpose
o Shouldn’t have cast in a dependent position for more than 30 minutes
o Nurse can help family adapt the child’s home environment to meet temporary inconvenience of cast restricting motility
Common situations, like transporting child to car, can be problematic
Specially designed car seats and restraints are available that meet safety requirements
Baths are possible only if cast kept out of water and covered to prevent wetness from splashing
Some synthetic casts are waterproof, but proper care is necessary to avoid skin irritation beneath the cast
Spica casts make sitting and toileting impossible Need to eat in prone position and use a small bedpan for elimination
Suggest waterproofing methods to reduce urine burns and heat rash/improve hygiene of hip spica cast: plastic wraps, protective skin
barrier, and absorbent pads
Skin Care
o Examine skin at cast edges to detect irritation or skin breakdown; pad accordingly
o Relieve itching by an ice pack and administration of medications as recommended by provider
o Avoid placing cast in water
o If patient is incontinent, protect cast with waterproof tape and plastic; use diapers, pull-ups, or other guards
Prepare the child for cast removal – turn on the equipment before using it on the child
The Child in Traction:
Purposes of Traction
o Provide rest for an extremity
o Help prevent or improve contracture deformity
o Correct a deformity
o Treat a dislocation
o Allow position and alignment and provide immobilization
o Reduce muscle spasms (rare in children)
Essential Components of Traction
o Traction: forward force produced by attaching weight to distal bone fragment
o Adjust by adding or subtracting weights
o Counter-traction – backward force provided by body weight; Increase by elevating foot of bed
o Frictional force – provided by patient’s contact with the bed
Types of Traction
o Manual traction – applied to the body part by the hand placed distally to the fracture site
o Skin traction – pulling mechanisms are attached to the skin with adhesive material or elastic bandage
Example – Buck Traction
Usually only used for short-term issues
o Skeletal traction – applied directly to skeletal structure by pin, wire, or tongs inserted into or through the diameter of the bone distal to the
fracture
o Cervical Traction
Crutchfield or Barton tongs
Inserted through burr holes in skull with weights attached to the hyperextended head
As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord no longer pinched between vertebrae
Halo traction can be applied in some cases
Nursing Management for Child in Traction
o Assessing the patient in traction
o Skin care issues
o Pain management/comfort
, Distraction
Process of separating opposing bone to encourage regeneration of new bone in the created space
Can be used when limbs are unequal in length and new bone is needed to elongate the shorter limb
External Fixation:
A system of wires, rings and telescoping rods that permits limb lengthening to occur by manual distraction – can result in a gain of up to 15 cm
Can also be used to correct angular or rotational defects, as well as immobilize fractures
Nursing Management
o Crutch walking – can not fully weight bear until the distraction is complete
o Pin care – what is the best technique to provide pin care and avoid infection? ½ strength peroxide on a sterile q-tip and wiped around the
insertion site; full strength peroxide
o Cast care (post fixator removal)
Internal Fixation:
Pins and plates – screws, wires, or plates used to align bone fragments
Child can sit and walk with a walker or crutches within hours/days of the internal fixator being placed
Nursing Management
o Infection – most common complication of internal fixation
o Neurovascular changes
o Postanesthesia problems
Nursing Considerations of Child in Traction
Assessing the patient
Skin care issues
Pain management/comfort
Congenital (Developmental) Dysplasia of the Hip:
Abnormality in the development of the proximal femur, acetabulum, or both.
Girls affected 6:1
Familial history
Breech presentation
Maternal hormones
Clinical Manifestations
o Head of femur lies outside the acetabulum
o + Ortolani maneuver – flex the hips and carry the knee to mid-abduction and if you feel the head of the femur slide into the acetabulum or
a “click”; reliable to about ages 2-3 months of age
o Notice shortening of the limb as compared to the other
o Asymmetrical lower extremity skin folds*
o Discrepancy in limb length
• Therapeutic Management – Interventions
o Maintain hips in flexed position
o Traction to stretch muscles
o Pavlik harness – used from newborn to about 6 months of age
Check for skin breakdown
Avoid lotion and powders underneath the straps
Wear the harness around the clock unless the child is being bathed
o Hip surgery – between 6 and 18 months of closed reduction; if over 18 months open reduction is used
Tales Equinovarus – Club Foot
• 1 to 2 per 1000
• Males more affected
• Involves both the bony structures and soft tissue
• The entire foot is pointing downward
• Obvious at birth
• Therapeutic Intervention
o Manipulation and serial casting immediately
o Surgery is performed between 4 to 12 months if full correction is not achieved with casting
Osteogenesis Imperfecta:
• Genetic disorder
• Caused by a genetic defect that affects the body’s production of collagen, the major protein of the body’s connective tissue
• Less than normal or poor collagen leads to weak bones that fracture easily
• Often called “brittle bone disease”
• Therapeutic Management
o Primarily supportive care – maximizing independent mobility and function; developing optimal bone mass and muscle strength
o Drugs of limited benefit – vitamin D supplementation,
