NURS 3355 - Exam 2 Study guide.
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 strai
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
,NURS 3355 - Exam 2 Study guide.
• 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 warm 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
,NURS 3355 - Exam 2 Study guide.
Cast Removal:
• Cutting the cast for removal or relieving tightness is frequently frightening for children
, NURS 3355 - Exam 2 Study guide.
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
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 strai
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
,NURS 3355 - Exam 2 Study guide.
• 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 warm 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
,NURS 3355 - Exam 2 Study guide.
Cast Removal:
• Cutting the cast for removal or relieving tightness is frequently frightening for children
, NURS 3355 - Exam 2 Study guide.
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
