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The Child with Musculoskeletal or Articular Dysfunction Chapter 39 Emergency Management ABCs Spinal cord injury EMS/BLS/ALS Systematic “head-to-toe” assessment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 The Immobilized Child Immobilization was once thought to be restorative from illness and injury We know now that immobilization has serious consequences Physical Social Psychologic Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Physiologic Effects of Immobilization Muscular system Decreased muscle strength and endurance Atrophy Loss of joint mobility Skeletal system Bone demineralization Negative calcium balance Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Physiologic Effects of Immobilization Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Physiologic Effects of Immobilization (cont.) Metabolism Decreased metabolic rate Negative nitrogen balance Hypercalcemia Decreased production of stress hormones Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Physiologic Effects of Immobility (cont.) Cardiovascular system Decreased efficiency of orthostatic neurovascular reflexes Diminished vasopressor mechanism Altered distribution of blood volume Venous stasis Dependent edema Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Physiologic Effects of Immobility (cont.) Respiratory system Decreased need for oxygen Diminished vital capacity Poor abdominal tone and distention Mechanical or biochemical secretion retention Loss of respiratory muscle strength Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Physiologic Effects of Immobility (cont.) GI system Distention caused by poor abdominal muscle tone Difficulty feeding in prone position Gravitation effect on feces Anorexia Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Physiologic Effects of Immobility (cont.) Integumentary system Decreased circulation and pressure leading to decreased healing capacity Urinary system Alteration of gravitational force Difficulty voiding in supine position Urinary retention Impaired ureteral peristalsis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Effects of Immobility on Neurosensory System Loss of innervation If nerve tissue is damaged by pressure If circulation to nerve tissue is interrupted Effects of improper positioning Sensory and perceptual deprivation Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Tissue Breakdown Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Psychologic Effects of Immobility Diminished environmental stimuli Altered perception of self and environment Increased feelings of frustration, helplessness, anxiety Depression, anger, aggressive behavior Developmental regression Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Immobilized Child Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Effect on Families Extended periods of immobilization Logistical management of sick child Need for family support and home care assistance • Coping skills Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Mobilization Devices Orthotics and prosthetics Nursing considerations Crutches and canes Wheelchairs Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 Orthotics Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 Knee-Ankle-Foot Orthosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Thoracolumbosacral Orthosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 Rear-Rolling Walker Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 Gait Walker with Suspension Belts Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 Epiphyseal Injuries 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Fractures 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Types of Fractures Compound or open: fractured bone protrudes through the skin Complicated: bone fragments have damaged other organs or tissues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 Types of Fractures (cont.) 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Fracture Types Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Clinical Manifestations of Fracture Generalized swelling Pain or tenderness Diminished functional use May have bruising, severe muscular rigidity, crepitus Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Bone Healing and Remodeling 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Time Devoted to Phases of Bone Healing Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Assessment of Fractures: The Five Ps 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 The Child in a Cast Cast application techniques Nursing considerations Cast care at home Cast removal Skin care Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Cast Types Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 Spica Cast with Hip Abductor Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Young Children Come to Regard Casts as Part of Their Body Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 The Child in Traction Traction: extended pulling force may be used to: 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) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Traction: Essential Components Traction: forward force produced by attaching weight to distal bone fragment Countertraction: backward force provided by body weight Adjust by adding or subtracting weights Increase by elevating foot of bed Frictional force: provided by patient’s contact with the bed Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Application of Traction for Maintaining Equilibrium Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Types of Traction 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Nursing Considerations Assessing the patient in traction Skin care issues Pain management/comfort Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 External Fixation Ilizarov external fixator Permits limb lengthening by manual distraction Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 Internal Fixation ORIF (surgical intervention) Preoperative preparation Postoperative complications Infection Neurovascular compromise Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Fracture Complications Circulatory impairment Nerve compression syndromes Compartment syndromes Volkmann contracture Epiphyseal damage Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Fracture Complications (cont.) Nonunion/malunion Infection Kidney stones from increased free CA++ Pulmonary emboli Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Amputation Congenital or traumatic Potential for reattachment of amputated part Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Amputation (cont.) Surgical amputation Surgical repair of severed limb Prosthetics Pain management/“phantom pain” Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Therapeutic Management 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 Injuries and Health Problems Related to Sports Participation Preparation for sports 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 Football is Strenuous Collision Sport Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50 Traumatic Injury Soft tissue injury: injuries to muscles, ligaments, and tendons Sports injuries Mishaps during play Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 Contusions Damage to soft tissue, subcutaneous tissue, and muscle Escape of blood into tissues—ecchymosis— black-and-blue discoloration Swelling, pain, disability Crush injuries Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 Dislocations 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53 Sprains 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 Sites of Injuries to Bones, Joints, and Tissues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55 Strains A microscopic tear to musculotendinous unit Similar to sprain Swollen, painful to touch Generally incurred over time Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Stress Fractures Occur as result of repeated muscle contraction Often seen in repetitive weight-bearing sports (running, gymnastics, basketball) Tibial fracture most common Symptoms Therapeutic management Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Gymnastics is Strenuous Limited-Contact Sport Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58 Therapeutic Management of Sports Injuries RICE: 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) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 Correct and Incorrect Methods for Elevating a Lower Extremity Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Therapeutic Management of Sports Injuries (cont.) ICES Ice, Compression, Elevation, Support Alleviate repetitive stress Rest as primary therapy Usually means reduced activity and alternative exercises, not bedrest Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 61 Heat Injury/Illness Susceptibility of infants and children Heat cramps Heat exhaustion Heatstroke Therapeutic interventions Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 62 Underwater Sports-Related Injuries Near-drowning is primarily a respiratory and neurologic problem Ear injuries when middle ear pressures unequalized Diving-related concerns Sports and accidental drowning Risk elevated with alcohol use Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 63 Health Concerns Associated with Sports Nutrition Water and electrolytes Minerals Glycogen Weight Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 64 Considerations for the Female Athlete Female athlete triad Amenorrhea Osteoporosis Eating disorders -to stay in weight range Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 65 Drug Use by Athletes “Ergogenic aids” Amphetamines Anabolic steroids “Nutritional aids” Life-threatening risks Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 66 Sudden Death 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 Idiopathic hypertrophic subaortic stenosis Present with chest pain, dizziness, prominent pulses, murmur at left sternal border Sports environment Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 67 Nurse’s Role in Sports for Children and Adolescents Evaluation for activities Prevention of injury Treatment of injuries Rehabilitation after injuries Instruction to student and parents Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 68 MUSCULOSKELETAL DYSFUNCTION Torticollis “Wry neck” Congenital or acquired limited neck motion with neck flexed to affected side Long-term effects Physical therapy Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 70 Slipped Femoral Capital Epiphysis (SFCE) 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 Obesity, puberty hormone changes, bone changes Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 71 SFCE (cont.) Clinical manifestations Episode of trauma with acute displacement Gradual displacement without definite injury Intermittent displacement (or combination of all) Therapeutic management Nursing considerations Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 72 Lordosis 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 73 Kyphosis 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 74 Scoliosis The most common spinal deformity Complex spinal deformity in three planes Lateral curvature Spinal rotation causing rib asymmetry Thoracic hypokyphosis May be congenital or develop during childhood Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 75 Severe Scoliosis Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 76 Scoliosis (cont.) Multiple potential causes; most cases idiopathic Generally becomes noticeable after preadolescent growth spurt May have complaint of “ill-fitting clothes” School screening controversial Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 77 Diagnostic Evaluation 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 78 Therapeutic Management 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 79 TLSO Brace Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 80 Clinical Manifestations 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 81 Therapeutic Management Team approach to treatment Bracing Exercise Surgical intervention for severe curvature (instrumentation and fusion) Harrington rods L-rods Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 82 Nursing Considerations Concerns of body image Concerns of prolonged treatment of condition Preoperative care Postoperative care Family issues Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 83 Osteomyelitis 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 84 Hematogenous Osteomyelitis 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 85 Osteomyelitis 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 87 Nursing Considerations 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 Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 88 Juvenile Rheumatoid Arthritis (JRA) 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) Mosby items and derived items © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. 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
