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The Child with Musculoskeletal
or Articular Dysfunction
Chapter 39
Emergency Management
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ABCs
Spinal cord injury
EMS/BLS/ALS
Systematic “head-to-toe” assessment
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Slide 2
The Immobilized Child
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Immobilization was once thought to be
restorative from illness and injury
We know now that immobilization has serious
consequences
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Physical
Social
Psychologic
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Slide 3
Physiologic Effects of
Immobilization
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Muscular system
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Decreased muscle strength and endurance
Atrophy
Loss of joint mobility
Skeletal system
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Bone demineralization
Negative calcium balance
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Slide 4
Physiologic Effects of
Immobilization
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Slide 5
Physiologic Effects of
Immobilization (cont.)
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Metabolism
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Decreased metabolic rate
Negative nitrogen balance
Hypercalcemia
Decreased production of stress hormones
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Slide 6
Physiologic Effects of Immobility
(cont.)
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Cardiovascular system
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Decreased efficiency of orthostatic neurovascular
reflexes
Diminished vasopressor mechanism
Altered distribution of blood volume
Venous stasis
Dependent edema
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Slide 7
Physiologic Effects of Immobility
(cont.)
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Respiratory system
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Decreased need for oxygen
Diminished vital capacity
Poor abdominal tone and distention
Mechanical or biochemical secretion retention
Loss of respiratory muscle strength
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Slide 8
Physiologic Effects of Immobility
(cont.)
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GI system
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Distention caused by poor abdominal muscle tone
Difficulty feeding in prone position
Gravitation effect on feces
Anorexia
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Slide 9
Physiologic Effects of Immobility
(cont.)
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Integumentary system
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Decreased circulation and pressure leading to
decreased healing capacity
Urinary system
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Alteration of gravitational force
Difficulty voiding in supine position
Urinary retention
Impaired ureteral peristalsis
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Slide 10
Effects of Immobility on
Neurosensory System
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Loss of innervation
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If nerve tissue is damaged by pressure
If circulation to nerve tissue is interrupted
Effects of improper positioning
Sensory and perceptual deprivation
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Slide 11
Tissue Breakdown
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Slide 12
Psychologic Effects of Immobility
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Diminished environmental stimuli
Altered perception of self and environment
Increased feelings of frustration,
helplessness, anxiety
Depression, anger, aggressive behavior
Developmental regression
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Slide 13
Immobilized Child
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Slide 14
Effect on Families

Extended periods of immobilization
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Logistical management of sick child
Need for family support and home care assistance
• Coping skills
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Slide 15
Mobilization Devices
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Orthotics and prosthetics
Nursing considerations
Crutches and canes
Wheelchairs
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Slide 16
Orthotics
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Slide 17
Knee-Ankle-Foot Orthosis
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Slide 18
Thoracolumbosacral Orthosis
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Slide 19
Rear-Rolling Walker
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Slide 20
Gait Walker with Suspension
Belts
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Slide 21
Epiphyseal Injuries
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Weakest point of long bones is the cartilage
growth plate (epiphyseal plate)
Frequent site of damage during trauma
May affect future bone growth
Treatment may include open reduction and
internal fixation to prevent growth
disturbances
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Slide 22
Fractures
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Common injury in children
Methods of treatment different in pediatrics
than in older adult population
Rare in infants, except with MVC
Clavicle most frequently broken bone in child,
especially younger than age 10
School age: bike, sports injuries
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Slide 23
Types of Fractures
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Compound or open: fractured bone protrudes
through the skin
Complicated: bone fragments have damaged
other organs or tissues
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Slide 24
Types of Fractures (cont.)
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Comminuted: small fragments of bone are
broken from the fractured shaft and lie in
surrounding tissue
Greenstick: compressed side of bone bends,
but tension side of bone breaks, causing
incomplete fracture
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Slide 25
Fracture Types
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Slide 26
Clinical Manifestations of
Fracture
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Generalized swelling
Pain or tenderness
Diminished functional use
May have bruising, severe muscular rigidity,
crepitus
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Slide 27
Bone Healing and Remodeling
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Typically rapid healing in children
Neonatal period—2 to 3 weeks
Early childhood—4 weeks
Later childhood—6 to 8 weeks
Adolescence—8 to 12 weeks
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Slide 28
Time Devoted to Phases of Bone
Healing
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Slide 29
Assessment of Fractures:
The Five Ps
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Pain and point of tenderness
Pulse—distal to the fracture site
Pallor
Paresthesia—sensation distal to the fracture
site
Paralysis—movement distal to the fracture
site
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Slide 30
The Child in a Cast
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Cast application techniques
Nursing considerations
Cast care at home
Cast removal
Skin care
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Slide 31
Cast Types
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Slide 32
Spica Cast with Hip Abductor
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Slide 33
Young Children Come to Regard
Casts as Part of Their Body
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Slide 34
The Child in Traction
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Traction: extended pulling force may be used
to:
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Provide rest for an extremity
 Help prevent or improve contracture deformity
 Correct a deformity
 Treat a dislocation
 Allow position and alignment
 Provide immobilization
 Reduce muscle spasms (rare in children)
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Slide 35
Traction: Essential Components
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Traction: forward force produced by attaching
weight to distal bone fragment
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Countertraction: backward force provided by
body weight
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Adjust by adding or subtracting weights
Increase by elevating foot of bed
Frictional force: provided by patient’s contact
with the bed
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Slide 36
Application of Traction for
Maintaining Equilibrium
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Slide 37
Types of Traction
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Manual traction: applied to the body part by
the hand placed distally to the fracture site
Skin traction: pulling mechanisms are
attached to the skin with adhesive material or
elastic bandage
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
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Slide 38
Cervical Traction
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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
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Slide 39
Nursing Considerations
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Assessing the patient in traction
Skin care issues
Pain management/comfort
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Slide 40
Distraction
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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
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Slide 41
External Fixation
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Ilizarov external fixator
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Permits limb lengthening
by manual distraction

Nursing considerations
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Slide 42
Internal Fixation
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ORIF (surgical intervention)
Preoperative preparation
Postoperative complications
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Infection
 Neurovascular compromise
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Slide 43
Fracture Complications
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Circulatory impairment
Nerve compression syndromes
Compartment syndromes
Volkmann contracture
Epiphyseal damage
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Slide 44
Fracture Complications (cont.)
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Nonunion/malunion
Infection
Kidney stones from increased free CA++
Pulmonary emboli
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Slide 45
Amputation
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Congenital or traumatic
Potential for reattachment of amputated part
Nursing considerations
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Slide 46
Amputation (cont.)
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Surgical amputation
Surgical repair of severed limb
Prosthetics
Pain management/“phantom pain”
Nursing considerations
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Slide 47
Therapeutic Management
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Prosthetics as early as possible
Early prosthetics encourage maximum
exploration and development in infancy
Phocomelic digits may be surgically modified,
preserved, and reattached for use with
prosthetics
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Slide 48
Injuries and Health Problems
Related to Sports Participation

Preparation for sports
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AAP classification of sports according to
strenuousness and probability of collision
AAP guidelines for inclusion or exclusion from
specific sports based on medical and/or surgical
condition of child
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Slide 49
Football is Strenuous Collision
Sport
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Slide 50
Traumatic Injury
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Soft tissue injury: injuries to muscles,
ligaments, and tendons
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Sports injuries
Mishaps during play
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Slide 51
Contusions
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Damage to soft tissue, subcutaneous tissue,
and muscle
Escape of blood into tissues—ecchymosis—
black-and-blue discoloration
Swelling, pain, disability
Crush injuries
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Slide 52
Dislocations
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Occurs when the force of stress on the
ligament is great enough to disrupt the
normal position of the opposing bone ends or
the bone end and its socket
Pain increases with active or passive
movement of the affected extremity
More common in Down syndrome
Hip dislocation: potential loss of blood supply
to head of femur
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Slide 53
Sprains
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Trauma to a joint from ligament partially or
completely torn or stretched by force
May have associated damage to blood
vessels, muscles, tendons, and nerves
Presence of joint laxity as indicator of severity
Rapid onset of swelling with disability
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Slide 54
Sites of Injuries to Bones, Joints,
and Tissues
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Slide 55
Strains
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A microscopic tear to musculotendinous unit
Similar to sprain
Swollen, painful to touch
Generally incurred over time
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Slide 56
Stress Fractures
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Occur as result of repeated muscle
contraction
Often seen in repetitive weight-bearing sports
(running, gymnastics, basketball)
Tibial fracture most common
Symptoms
Therapeutic management
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Slide 57
Gymnastics is Strenuous
Limited-Contact Sport
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Slide 58
Therapeutic Management of
Sports Injuries
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RICE:
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Rest the injured part
 Ice immediately (max 30 minutes at a time)
 Compression with wet elastic bandage
 Elevation of the extremity

Immobilization and support (casts or splints
as appropriate to injury)
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Slide 59
Correct and Incorrect Methods
for Elevating a Lower Extremity
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Slide 60
Therapeutic Management of
Sports Injuries (cont.)
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ICES
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Ice, Compression, Elevation, Support
Alleviate repetitive stress
Rest as primary therapy
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Usually means reduced activity and alternative
exercises, not bedrest
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Slide 61
Heat Injury/Illness
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Susceptibility of infants and children
Heat cramps
Heat exhaustion
Heatstroke
Therapeutic interventions
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Slide 62
Underwater Sports-Related Injuries
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Near-drowning is primarily a respiratory and
neurologic problem
Ear injuries when middle ear pressures
unequalized
Diving-related concerns
Sports and accidental drowning
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Risk elevated with alcohol use
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Slide 63
Health Concerns
Associated with Sports
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Nutrition
Water and electrolytes
Minerals
Glycogen
Weight
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Slide 64
Considerations
for the Female Athlete
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Female athlete triad
 Amenorrhea
 Osteoporosis
 Eating
disorders
-to stay in weight range
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Slide 65
Drug Use by Athletes
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“Ergogenic aids”
Amphetamines
Anabolic steroids
“Nutritional aids”
Life-threatening risks
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Slide 66
Sudden Death
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Also called instantaneous death: death
occurs within minutes or within 24 hours of
the episode
Sports with high inherent risk for death
Unrecognized underlying medical problems
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Idiopathic hypertrophic subaortic stenosis
Present with chest pain, dizziness, prominent
pulses, murmur at left sternal border
Sports environment
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Slide 67
Nurse’s Role in Sports
for Children and Adolescents
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Evaluation for activities
Prevention of injury
Treatment of injuries
Rehabilitation after injuries
Instruction to student and parents
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Slide 68
MUSCULOSKELETAL
DYSFUNCTION
Torticollis
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“Wry neck”
Congenital or acquired limited neck motion
with neck flexed to affected side
Long-term effects
Physical therapy
Nursing considerations
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Slide 70
Slipped Femoral
Capital Epiphysis (SFCE)
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Spontaneous displacement of the proximal
femoral epiphysis in a posterior and inferior
direction
Occurs shortly before or during accelerated
growth periods or puberty
Usually idiopathic, multifactorial
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Obesity, puberty hormone changes, bone changes
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Slide 71
SFCE (cont.)
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Clinical manifestations
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Episode of trauma with acute displacement
Gradual displacement without definite injury
Intermittent displacement (or combination of all)
Therapeutic management
Nursing considerations
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Slide 72
Lordosis
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Accentuation of the cervical or lumbar
curvature beyond physiologic limits
May be secondary complication of trauma or
idiopathic
May occur with flexion contractures of hip,
congenital dislocated hip
In obese children abdominal fat alters center
of gravity, causing lordosis
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Slide 73
Kyphosis
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Abnormally increased convex angulation in
the curvature of the thoracic spine
Most common form is “postural”
Can result from TB, arthritis, osteodystrophy,
or compression fracture
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Slide 74
Scoliosis
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The most common spinal deformity
Complex spinal deformity in three planes
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Lateral curvature
 Spinal rotation causing rib asymmetry
 Thoracic hypokyphosis

May be congenital or develop during
childhood
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Slide 75
Severe Scoliosis
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Slide 76
Scoliosis (cont.)
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Multiple potential causes; most cases
idiopathic
Generally becomes noticeable after
preadolescent growth spurt
May have complaint of “ill-fitting clothes”
School screening controversial
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Slide 77
Diagnostic Evaluation
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Standing radiographs to determine degree of
curvature
Asymmetry of shoulder height, scapular or
flank shape, or hip height
Often have a primary curve and a
compensatory curve to align head with gluteal
cleft
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Slide 78
Therapeutic Management
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Treatment goal: keep head of femur in
acetabulum
Containment with various appliances and
devices
Rest, no weight bearing initially
Surgery in some cases
Home traction in some cases
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Slide 79
TLSO Brace
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Slide 80
Clinical Manifestations
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Insidious onset, may have history of limp,
soreness or stiffness, limited ROM, vague
history of trauma
Pain and limp most evident on arising and at
end of activity
Diagnosed by x-ray
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Slide 81
Therapeutic Management
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Team approach to treatment
Bracing
Exercise
Surgical intervention for severe curvature
(instrumentation and fusion)


Harrington rods
L-rods
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Slide 82
Nursing Considerations
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Concerns of body image
Concerns of prolonged treatment of condition
Preoperative care
Postoperative care
Family issues
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Slide 83
Osteomyelitis
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
Inflammation and infection of bony tissue
May be caused by exogenous or
hematogenous sources
Infectious agent invades the bone following
penetrating wound, open fracture,
contamination in surgery, or secondary
extension from an abscess or burn
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Slide 84
Hematogenous Osteomyelitis
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


Preexisting infection spreads to bone
Source may be skin infections, URI,
abscessed teeth, pyelonephritis, etc.
Any organism can cause osteomyelitis
Infective emboli travel to arteries in the bone
metaphysis, causing abscess formation and
bone destruction
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Slide 85
Osteomyelitis
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Signs and symptoms begin abruptly;
resemble symptoms of arthritis and leukemia
Marked leukocytosis
Bone cultures obtained from biopsy or
aspirate
Early x-rays may appear normal
Bone scans for diagnosis
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Slide 86
Therapeutic Management of
Osteomyelitis



May have subacute presentation with walledoff abscess rather than a spreading infection
Prompt, vigorous IV antibiotics for extended
period (3 to 4 weeks or up to several months)
Monitor hematologic, renal, hepatic
responses to treatment
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Slide 87
Nursing Considerations
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Complete bedrest and immobility of limb
Pain management concerns
Long-term IV access (for antibiotic
administration)
Nutritional considerations
Long-term hospitalization or home therapy
Psychosocial & school needs
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Slide 88
Juvenile Rheumatoid
Arthritis (JRA)
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



Also called juvenile chronic arthritis or
idiopathic arthritis of childhood
Possible causes
Peak ages: 1 to 3 years and 8 to 10 years
Often undiagnosed
Actually a heterogenous group of diseases
Pauciarticular onset (involves ≤4 joints)
Polyarticular onset (involves ≥5 joints)
Systemic onset (high fever, rash, hepatosplenomegaly,
pericarditis, pleuritis, lymphadenopathy)
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Slide 89
JRA (cont.)

Actually a heterogenous group of
diseases
onset (involves ≤4 joints)
 Polyarticular onset (involves ≥5 joints)
 Systemic onset (high fever, rash,
hepatosplenomegaly, pericarditis, pleuritis,
lymphadenopathy)
 Pauciarticular
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 90
JRA (cont.)



90% children have negative rheumatic factor
Symptoms may “burn out” and become
inactive
Chronic inflammation of synovium with joint
effusion, destruction of cartilage, and
ankylosis of joints as disease progresses
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 91
Symptoms of JRA







Stiffness
Swelling
Loss of mobility in affected joints
Warm to touch, usually without erythema
Tender to touch in some cases
Symptoms increase with stressors
Growth retardation
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 92
Diagnostic Evaluation of JRA





No definitive diagnostic tests
Elevated sedimentation rate in some cases
Antinuclear antibodies common but not
specific for JRA
Leukocytosis during exacerbations
Diagnosis based on criteria of American
College of Rheumatology
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 93
American College of
Rheumatology Diagnostic Criteria




Age of onset younger than 16 years
One or more affected joints
Duration of arthritis more than 6 weeks
Exclusion of other forms of arthritis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 94
JRA: Therapeutic Management



No specific cure
Goals of therapy: preserve function, prevent
deformities, and relieve symptoms
Iridocyclitis/uveitis



Inflammation of iris and ciliary body
Unique to JRA
Requires treatment by ophthalmologist
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 95
JRA: Pharmacology





NSAIDs
SAARDs
Corticosteroids
Cytotoxic agents
Immunomodulators
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 96
JRA: Management







Therapy individualized to child
PT, OT
Nutrition, exercise
Splinting devices
Pain management
Prognosis
Nursing considerations
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 97
The Child with
Neuromuscular or Muscular
Dysfunction
Chapter 40
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 98
Neuromuscular Dysfunction

Terms to understand

Myopathy
 Upper motor neurons
 Lower motor neurons
 Motor unit
 Pyramidal
 Extrapyramidal
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 99
Classification and Diagnosis

Upper motor neuron lesions




Weakness/spasticity
Increased DTRs and abnormal superficial reflexes
Primarily cerebral palsy
Lower motor neuron lesions



Weakness, atrophy of skeletal muscles, hypotonia
Usually symmetric
Gradual or sudden onset indicates causation
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 100
Site of Origin of
Neuromuscular
Disorders
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 101
Classification (cont.)




Diseases of anterior horn cells
Neuropathies
Neuromuscular junction disease
Diseases of muscles
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 102
Diagnostic Tools




EMG
Nerve conduction velocity
Muscle biopsy
Serum enzyme measurement/CPK
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 103
Cerebral Palsy (CP)



Characterized by early onset and impaired
movement and posture
Incidence 1.5 to 3 per 1000 live births
Most common permanent physical disability
in childhood
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 104
CP: Etiology

Intrauterine hypoxia/asphyxia

Intrapartum asphyxia
• 12% to 23% of CP occurs in term infants with intrapartum
asphyxia


Postnatal
Often no identifiable immediate cause
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 105
CP: Etiology (cont.)


Preterm birth of ELBW and VLBW is single
most important determinant of CP
Anoxia—most common cause of brain
damage whenever it occurs
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 106
Types of CP




Spastic
Athetoid/dyskinetic
Ataxic
Mixed/dystonic
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 107
Types of CP (cont.)

Spastic


Most common clinical type
Presents as hypotonia most often
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 108
Types of Spastic CP

Quadriparesis (tetraparesis)

Four extremities involved/severe disability
 Speech and swallowing difficulties
 Tongue protrusion (incomplete)
 Labile emotions in some patients
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 109
Types of CP (cont.)




Diplegia
Monoplegia
Triplegia
Paraplegia
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 110
Possible Motor Signs of CP






Poor head control after age 3 months
Stiff or rigid limbs
Arching back/pushing away
Floppy tone
Unable to sit without support at age 8 months
Clenched fists after age 3 months
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 111
Possible Behavioral Signs of CP



Excessive irritability
No smiling by age 3 months
Feeding difficulties

Persistent tongue thrusting
 Frequent gagging or choking with feeds
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 112
Therapeutic Management





General concepts
Mobilization
Surgical interventions
Medications
Technical aids
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 113
Child Ambulating with an
Assistive Device
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 114
Cerebral Palsy and IQ




Wide variation
70% of CP patients have normal IQ
Difficult to assess
Rigid, atonic, and quadriparetic CP have
highest incidence of profound impairment
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 115
Therapeutic Management:
Therapies, Education, Recreation






PT
Functional and adaptive training (OT)
Speech therapy
Recreation
Normalization
Family support
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 116
Muscular Dystrophies (MDs)



Largest group of muscular diseases in
children
All have genetic origin with gradual
degeneration of muscle fibers, progressive
weakness, and wasting of skeletal muscles
All have increasing disability and deformity
with loss of strength
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 117
Initial Muscle Groups Involved in MDs
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 118
Duchenne Muscular Dystrophy
(DMD)




Also called pseudohypertrophic muscular
dystrophy
Most severe and most common of the MDs in
childhood
X-linked inheritance pattern; one third are
fresh mutations
Incidence: 1 in 3500 male births
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 119
Characteristics of DMD





Onset between ages 3 and 5 years
Progressive muscle weakness, wasting, and
contractures
Calf muscles hypertrophy in most patients
Progressive generalized weakness in
adolescence
Death from respiratory or cardiac failure
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 120
Diagnostic Evaluation of DMD



Suspected based on clinical appearance
Confirmation by EMG, muscle biopsy, and
serum enzyme measurement
Serum CPK and AST levels high in first
2 years of life, before onset of weakness;
levels diminish as muscle deterioration
continues
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 121
DMD: Clinical Manifestations





Waddling gait, frequent falls, Gower sign
Lordosis
Enlarged muscles, especially thighs and
upper arms
Profound muscular atrophy in later stages
Mental deficiency common
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 122
Therapeutic Management of
DMD





No effective treatment has been established
Primary goal: maintain function in unaffected
muscles as long as possible
Keep child as active as possible
ROM, bracing, performance of ADLs, surgical
release of contractures prn
Genetic counseling for family
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 123
DMD: Nursing Considerations




Help child and family cope with chronic,
progressive, debilitating disease
Help design a program to foster
independence and activity as long as
possible
Teach child self-help skills
Arrange for appropriate health care
assistance as child’s needs intensify (home
health, skilled nursing facility, respite care for
family, etc.)
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 124
Guillain-Barré Syndrome (GBS)




Also called infectious polyneuritis
An acute demyelinating polyneuropathy with
progressive paralysis
Children less often affected than adults
Occurrence in children most often between
ages 4 and 10 years
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 125
GBS: Pathophysiology



Immune-mediated disease
Often associated with viral or bacterial
infection or administration of vaccines
Inflammation and edema in spinal and cranial
nerves progresses to impaired nerve
conduction, then partial or complete paralysis
of involved muscles
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 126
GBS: Diagnostic Evaluation



Based on paralytic manifestation and/or EMG
findings
CSF may have increased protein
concentration; other labs WNL
Symmetric paralysis is part of the differential
diagnosis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 127
Clinical Manifestations of GBS





Initially: muscle tenderness, paresthesia,
muscle weakness
Paralysis rapidly ascends from lower
extremities; may involve trunk, arms, face
Flaccid paralysis, loss of reflexes
Intercostal and phrenic nerve involvement
Frequently urinary incontinency or retention
and constipation
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 128
Therapeutic Management of GBS



Treatment is symptomatic
Possibly steroids, IV immunoglobulin, and
plasmapheresis
Respiratory support
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 129
GBS



Prognosis: Better outcomes associated with
younger ages; most patients have complete
recovery
Most patients have muscle function begin to
return 2 days to 2 weeks after onset of
symptoms, but prolonged period to complete
recovery
Most deaths due to respiratory failure
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 130
GBS: Nursing Considerations




Supportive care
Observe for early signs of respiratory
distress/difficulty swallowing
Focus on prevention of complications
Support for child and family
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 131
Tetanus




Also called lockjaw
An acute, preventable, and often fatal
disease
Caused by exotoxin of Clostridium tetani
Characterized by muscle rigidity involving the
masseter and neck muscles
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 132
Four Requirements for
Developing Lockjaw




Presence of tetanus spores or vegetative
forms of the bacillus
Injury to the tissues
Wound conditions that encourage
multiplication of the organism
A susceptible host
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 133
Tetanus




Spores are found in soil, dust, and GI tract of
humans and animals
Bacteria enter body through wound,
especially puncture or crush wound or burn
May enter through scratch, bee sting, thorn,
or needle prick
Exposure greater during outdoor activities
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 134
Pathophysiology of Tetanus



Exotoxin spreads from wound to CNS by way
of neurons or bloodstream
Toxin becomes fixed on nerve cells of
brainstem and spinal cord
Toxin produces muscle stiffness
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 135
Clinical Manifestations of
Tetanus



Initially: progressive stiffness and tenderness
of neck and jaw muscles, difficulty in opening
the mouth, facial muscle spasm
Progressive: opisthotonos, difficulty
swallowing, laryngospasm, and tetany of
respiratory muscles
Rigid abdominal and limb muscles
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 136
Clinical Manifestations of Tetanus
(cont.)





Respiratory: accumulated secretions,
atelectasis, pneumonia, respiratory arrest
Patient anxious but alert; mentation
unaffected
Rapid HR, diaphoresis, mild or absent fever
Incubation: 3 to 10 days
Mortality approximately 30%; usually fatal in
newborn
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 137
Therapeutic Management of
Tetanus


Prevention by tetanus toxoid or tetanus
antitoxin after exposure
Treatment of wounds contaminated with dirt,
feces, soil, saliva, puncture wounds,
avulsions, crushing, burns, and frostbite
should include tetanus immune globulin if
patient inadequately immunized
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 138
Therapeutic Management of
Tetanus (cont.)





ICU for constant observation and respiratory
support availability
Monitor fluid and electrolyte status
Tetanus immune globulin therapy to
neutralize toxins
Wound care to decrease organism
proliferation
Muscle relaxants, sedatives, pancuronium
(Pavulon)
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 139
Nursing Considerations



Control environmental stimuli
Careful monitoring of respiratory status
Attempt to reduce anxiety of child and family
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 140
The Child with
Renal Dysfunction
Chapter 30
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 141
Renal Structure and Function

Primary responsibility of kidney is to maintain
the composition and volume of the body fluids
in equilibrium
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 142
Major Functions of Nephron
Components
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 143
Renal System Assessment

Physical assessment


Palpation, percussion
Health history

Previous UTIs, calculi, stasis, retention,
pregnancy, STDs, bladder cancer
 Medications: antibiotics, anticholinergics,
antispasmodics
 Urologic instrumentation
 Urinary hygiene
 Patterns of elimination
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 144
Urinary Tract Infection:
Nursing Assessment
Nausea, vomiting, anorexia, chills, nocturia,
urinary frequency, urgency
 Suprapubic or lower back pain, bladder
spasms, dysuria, burning on urination

Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 145
Urinary Tract Infection
Nursing Assessment (Cont.)

Objective data



Fever
Hematuria; foul-smelling urine; tender, enlarged
kidney
Leukocytosis, positive findings for bacteria, WBCs,
RBCs, pyuria, ultrasound, CT scan, IVP
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 146
Diagnostic Studies







UA
Urine C&S
BUN
Creatinine
KUB
IVP
VCG/VCUG







Renal scan
Cystogram
Retrograde pyelogram
Ultrasound
CT
MRI
Renal arteriogram
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 147
Normal Urinalysis





pH 5 to 9
Sp gr 1.001 to 1.035
Protein <20 mg/dl
Urobilinogen up to 1 mg/dl
NONE OF THE FOLLOWING:
Glucose
Ketones
Hgb
WBCs
RBCs
Casts
Nitrites
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 148
Normal Characteristics of Urine




Color range
Clear
Newborn production about 1 to 2 ml/kg/hr
Child production about 1 ml/kg/hr
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 149
Urinary Tract Infection (UTI)


Is it really that serious?
Concept of “asymptomatic bacteria” in urinary
tract
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 150
UTI: Causes




Escherichia coli most common pathogen
Streptococci
Staphylococcus saprophyticus
Occasionally fungal and parasitic pathogens
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 151
UTI: Classification

Upper tract involves renal parenchyma,
pelvis, and ureters


Typically causes fever, chills, flank pain
Lower tract involves lower urinary tract

Usually no systemic manifestations
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 152
UTI: Classification (Cont.)

Lower tract:


Cystitis
Urethritis

Upper tract:



Pyelonephritis
VUR
Glomerulonephritis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 153
UTI: Classification (Cont.)


Uncomplicated infection
Complicated infections

Stones
 Obstruction
 Catheters
 Diabetes or neurologic disease
 Recurrent infections
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 154
Types of UTIs




Recurrent—repeated episodes
Persistent—bacteriuria despite antibiotics
Febrile—typically indicates pyelonephritis
Urosepsis—bacterial illness; urinary
pathogens in blood
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 155
UTI: Etiology and
Pathophysiology

Physiologic and mechanical defense
mechanisms maintain sterility

Emptying bladder
 Normal antibacterial properties of urine and tract
 Ureterovesical junction competence
 Peristaltic activity
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 156
UTI: Etiology and
Pathophysiology (Cont.)



Alteration of defense mechanisms increases
risk of UTI
Organisms usually introduced via ascending
route from urethra
Less common routes


Bloodstream
Lymphatic system
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 157
UTI: Etiology and
Pathophysiology (Cont.)

Contributing factor: urologic instrumentation


Allows bacteria present in opening of urethra to
enter urethra or bladder
Sexual intercourse promotes “milking” of
bacteria from perineum and vagina

May cause minor urethral trauma
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 158
UTI: Etiology and
Pathophysiology (Cont.)


UTIs rarely result from hematogenous route
For kidney infection to occur from
hematogenous transmission, must have prior
injury to urinary tract



Obstruction of ureter
Damage from stones
Renal scars
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 159
UTI: Etiology and
Pathophysiology (Cont.)

UTI is a common nosocomial infection



Often Escherichia coli
Seldom Pseudomonas
Urologic instrumentation common
predisposing factor
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 160
UTI: Clinical Manifestations

Symptoms

Dysuria
 Frequent urination (>q2h)
 Urgency
 Suprapubic discomfort or pressure
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 161
UTI: Clinical
Manifestations (Cont.)



Urine may contain visible blood or sediment
(cloudy appearance)
Flank pain, chills, and fever indicate infection
of upper tract (pyelonephritis)
Pediatric patients with significant bacteriuria
may have no symptoms or nonspecific
symptoms like fatigue or anorexia
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 162
Pediatric Manifestations





Frequency
Fever in some cases
Odiferous urine
Blood or blood-tinged urine
Sometimes no symptoms except generalized
sepsis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 163
UTI: Diagnostic Studies



Dipstick
Microscopic urinalysis
Culture
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 164
UTI: Diagnostic Studies (Cont.)



Clean-catch is preferred
U-bag for collection from child
Specimen obtained by catheterization or
suprapubic needle aspiration has more
accurate results

May be necessary when clean-catch cannot be
obtained
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 165
UTI: Diagnostic Studies (Cont.)


Sensitivity testing determines susceptibility to
antibiotics
Imaging studies for suspected obstruction

IVP or abdominal CT
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 166
UTI Collaborative Care:
Drug Therapy—Antibiotics




Uncomplicated cystitis: short-term course of
antibiotics
Complicated UTIs: long-term treatment
Trimethoprim-sulfamethoxazole (TMP-SMX)
or nitrofurantoin
Amoxicillin
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 167
UTI Collaborative Care:
Drug Therapy (Cont.)


Cephalexin
Others



Gentamycin, carbenicillin ++
Pyridium (OTC)
Combination agents (e.g., Urised) used to
relieve pain

Preparations with methylene blue tint
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 168
UTI Collaborative Care:
Drug Therapy for Repeated UTIs


Prophylactic or suppressive antibiotics
TMP-SMX administered every day to prevent
recurrence or single dose prior to events
likely to cause UTI
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 169
Vesicoureteral Reflux (VUR)



Retrograde flow of bladder urine into the
ureters
Increases potential for infection
Primary vs. secondary reflux
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 170
Acute Pyelonephritis:
Etiology and Pathophysiology


Inflammation caused by bacteria, fungi,
protozoa, or viruses infecting kidneys
Urosepsis: systemic infection from urologic
source

Can lead to septic shock and death in 15% of
cases
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 171
Acute Pyelonephritis:
Etiology and Pathophysiology
(Cont.)


Usually infection is via ascending urethral
route
Frequent causes




Escherichia coli
Proteus
Klebsiella
Enterobacter
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 172
Acute Pyelonephritis
Etiology and Pathophysiology
(Cont.)

Preexisting factor (usually)

Vesicoureteral reflux
 Dysfunction of lower urinary tract function
• Obstruction
• Stricture
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 173
Acute Pyelonephritis:
Etiology and Pathophysiology
(Cont.)


Commonly starts in renal medulla and
spreads to adjacent cortex
Recurring episodes lead to scarred, poorly
functioning kidney and chronic pyelonephritis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 174
Acute Pyelonephritis:
Clinical Manifestations


Vary from mild to classic and very severe
Presenting symptoms

N/V, anorexia, chills, nocturia, frequency, urgency
 Suprapubic or low back pain, dysuria
 Fever, hematuria, foul-smelling urine


Costovertebral tenderness
Symptoms often subside in a few days, even
without therapy

Bacteriuria and pyuria still persist
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 175
Acute Pyelonephritis:
Diagnostic Studies





Urinalysis
WBC casts
CBC
Imaging studies (IVP or CT)
Ultrasound
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 176
Acute Pyelonephritis:
Collaborative Care




Hospitalization
Parenteral antibiotics
Relapses treated with 6-week course of
antibiotics
Reinfections treated as individual episodes or
managed with long-term therapy

Prophylaxis may be used for recurrence
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 177
Types of Glomerulonephritis

Most are postinfectious



Pneumococcal, streptococcal, or viral
May be distinct entity or
May be a manifestation of systemic disorder



SLE
Sickle cell disease
Others
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 178
Glomerulonephritis Symptoms

Generalized edema due to decreased
glomerular filtration



Begins with periorbital
Progresses to lower extremities and then to
ascites
HTN due to increased ECF
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 179
Glomerulonephritis Symptoms
(Cont.)


Oliguria
Hematuria


Bleeding in upper urinary tract → smoky urine
Proteinuria

Increased amount of protein = increase in severity
of renal disease
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 180
Acute Poststreptococcal
Glomerulonephritis (APSG)






Is a noninfectious renal disease
(autoimmune)
Onset 5 to 12 days after other type of
infection
Often group A β-hemolytic streptococci
Most common in children 6 to 7 years old
Uncommon in younger than 2 years old
Can occur at any age
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 181
DIAGNOSING APSG
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 182
Prognosis



95%—rapid improvement to complete
recovery
5% to 15%—chronic glomerulonephritis
1%—irreversible damage
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 183
Nursing Management of APSG

Manage edema




Nutrition



Daily weights
Accurate I&O
Daily abdominal girth
Low-sodium, low to moderate protein
Susceptibility to infections
Bed rest is not necessary
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 184
Nephrotic Syndrome


Most common presentation of glomerular
injury in children
Characteristics:

Proteinuria
 Hypoalbuminemia
 Hyperlipidemia
 Edema
 Massive urinary protein loss
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 185
Types of Nephrotic Syndrome

Minimal change nephrotic syndrome (MCNS)



Also called:
• Idiopathic nephrosis
• Nil disease
• Uncomplicated nephrosis
• Childhood nephrosis
• Minimal lesion nephrosis
Congenital nephrotic syndrome
Secondary nephrotic syndrome
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 186
Changes in Nephrotic Syndrome

Glomerular membrane





Normally impermeable to large proteins
Becomes permeable to proteins, especially
albumin
Albumin lost in urine (hyperalbuminuria)
Serum albumin decreases (hypoalbuminemia)
Fluid shifts from plasma to interstitial spaces
• Hypovolemia
• Ascites
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 187
Nephrotic Syndrome
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 188
Nephrotic Syndrome (Cont.)



“Edema phase”
“Remission phase”
Prognosis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 189
Nephrotic Syndrome
Management


Supportive care
Diet



Steroids




Low to moderate protein
Sodium restrictions if large amount of edema
2 mg/kg divided into BID doses
Prednisone drug of choice (cheapest and safest)
Immunosuppressant therapy (Cytoxan)
Diuretics
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 190
Family Issues



Chronic condition with relapses
Developmental milestones
Social isolation

Lack of energy
 Immunosuppression/protection
 Change in appearance due to edema—self-image
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 191
Nursing Interventions


Aseptic technique during catheterizations
Avoid unnecessary catheterization and early
removal of indwelling catheters



Prevents nosocomial infections
Wash hands before and after contact
Wear gloves for care of urinary system
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 192
Nursing Interventions (Cont.)
Routine and thorough perineal care for all
hospitalized patients
 Avoid incontinent episodes by answering call
light and offering bedpan at frequent intervals

Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 193
Nursing Interventions (Cont.)

Ensure adequate fluid intake (patient with
urinary problems may think will be more
uncomfortable)

Dilutes urine, making bladder less irritable
 Flushes out bacteria before they can colonize
 Avoid caffeine, alcohol, citrus juices, chocolate,
and highly spiced foods
• Potential bladder irritants
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 194
Nursing Interventions (Cont.)


Discharge to home instructions
Follow-up urine culture

Recurrent symptoms typically occur in
1 to 2 weeks after therapy
 Encourage adequate fluids even after infection
 Low-dose, long-term antibiotics to prevent
relapses or reinfections
 Explain rationale to enhance compliance
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 195
Renal Tubular Disorders



Renal tubular acidosis
Proximal tubular acidosis (type II)
Distal tubular acidosis (type I)
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 196
Nephrogenic Diabetes Insipidus
(NDI)



Major disorder associated with a defect in
ability to concentrate urine
Distal tubules and collecting ducts are
insensitive to action of ADH (vasopressin)
X-linked recessive inheritance
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 197
Clinical Manifestations of
Diabetes Insipidus


Newborn: vomiting, fever, failure to thrive,
hypernatremia
Copious amounts of dilute urine
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 198
Therapeutic Management


Fluid management (management of extreme
thirst in child)
Pharmacologic interventions
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 199
Hemolytic-Uremic Syndrome





Pathophysiology
Diagnostic evaluation
Therapeutic management
Prognosis
Nursing considerations
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 200
Renal Failure


Acute renal failure (ARF)
Chronic renal failure (CRF)
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 201
Acute Renal Failure (ARF)



Definition: kidneys suddenly unable to
regulate the volume and composition of urine
Not common in children
Principal feature is oliguria


Associated with azotemia, metabolic acidosis, and
electrolyte disturbances
Most common pathologic cause: transient
renal failure resulting from severe
dehydration
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 202
ARF (Cont.)




Pathophysiology—usually reversible
Diagnostic evaluation
Therapeutic management
Nursing considerations
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 203
Complications of ARF






Hyperkalemia
Hypertension
Anemia
Seizures
Hypervolemia
Cardiac failure with pulmonary edema
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 204
Chronic Renal Failure (CRF)


Begins when diseased kidneys cannot
maintain normal chemical structure of body
fluids
Clinical syndrome called uremia
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 205
Potential Causes of CRF




Congenital renal and urinary tract
malformations
VUR associated with recurrent UTIs
Chronic pyelonephritis
Chronic glomerulonephritis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 206
CRF



Pathophysiology
Diagnostic evaluation
Therapeutic management


Manage diet, hypertension, recurrent infections,
seizures
Nursing considerations
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 207
Renal Replacement Therapy

Dialysis types



Hemodialysis
Peritoneal dialysis
Hemofiltration
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 208
Hemodialysis



Requires creation of a vascular access and
special dialysis equipment
Best suited for children who can be brought
to facility 3 times per week for 4 to 6 hours
Achieves rapid correction of fluid and
electrolyte abnormalities
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 209
Child Receiving Hemodialysis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 210
Diversional Activities Lessen
Boredom During Hemodialysis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 211
Peritoneal Dialysis



Abdominal cavity acts as semipermeable
membrane for filtration
Can be managed at home in some cases
Warmed solution enters peritoneal cavity by
gravity; remains for period of time before
removal
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 212
Continuous Venovenous
Hemofiltration



Uses technique for ultrafiltration of blood
continuously at a very slow rate
Works with the fluid overload in postoperative
period
Successful alternative for critically ill children
who might not survive rapid volume changes
of hemodialysis and/or PD
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 213
Transplantation






From living, related donor
From cadaver donor
Primary goal is long-term survival of grafted
tissue
Role of immunosuppressant therapy
Rejection
Prognosis
Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 214