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Bulacan State University College of Nursing COMMON PEDIATRIC DISORDERS SIGNS OF DEVELOPMENTAL DELAY Criteria For Referral Communication and Feeding Feeding difficulties weak sucking or poor coordination of suck-swallowing to sustain normal weight gain No social smile by age 4 months No babbling (ga-ga, da-da) by age 9 months No Mama, Dada (specific) by age 14 months No name of object (one word) by age 14 months At least 10 words by age 18 months (not just repeating) Combines words (eg, me outside, more milk) and uses pronouns by age 24 months Regression in language at any age Unresponsive to his name Motor Delay Not rolling over by age 6 months Not sitting by age 9 months Not walking by age 15 months Not stair-climbing by age 2 years Nursing Diagnoses CARE OF THE CHILD WITH A DEVELOPMENTAL DISABILITY Nursing Assessment Review the child's record to determine existing health problems that may cause or affect the developmental disability. Always rule out a vision or hearing impairment. Assess the family's understanding of the diagnosis and its ramifications. The parents' experiences, cultural biases, cognitive ability, stage of grief, and physical condition affect their ability to assimilate information provided. It will be necessary to repeat the information. (For example, a woman who has just given birth to a child with Down syndrome will not be able to retain much information until her body returns to a state of homeostasis.) Determine the developmental age of the child. The pediatric nurse should be familiar with normal developmental milestones (see Chapter 40, page 1320), noting the child's strengths and areas presenting challenges, for example, the communication skills are at a 12-month level and the gross motor skills are at a 36-month level. Children who are found to be functioning at onehalf or less of their chronological age have a moderate to severe developmental problem. Administer the Clinical Adaptive Test-Clinical Linguistic Auditory Milestone Scales (CAT-CLAMS). It is a reliable tool that nurses can be trained to use to assess cognitive and communicative development in children at the 1- to 36-month developmental level. It has been found tobe more sensitive than the Denver Developmental Screening Scale because language development is the best early predictor of cognitive abilities Assess the functional level of the child. Functional areas to assess include: o Feeding. o Grooming and bathing. o Dressing. o Mobility. o Problem solving. o Communication. Assess parents' perception of the child's development level and the appropriateness of parental expectations. Use such questions as, “Do you have any concerns regarding things your child is doing or should be doing?― “What age child does your child act like?― Assess parent-child interaction. Observe and explore bonding and attachment, ability to set appropriate limits, management of behavioral problems, and methods of discipline. Assess the need for additional resources, such as financial aid, transportation, and counseling, for long-term support of child and family. Impaired Adjustment related to birth and diagnosis of developmentally disabled child Impaired Parenting related to multiple needs of child and difficult bonding Ineffective Infant Feeding Pattern related to protruding tongue, poor muscle tone, and weak sucking Delayed Growth and Development related to disability Social Isolation related to developmental differences from other children Risk for Injury related to developmental age Nursing Interventions Promoting Adjustment Allow the parents access to the infant at all possible times to promote bonding when parents appear ready. Focus on the positive aspects of the infant and serve as a role model for handling and stimulating. Be cognizant of the grieving process (loss of the anticipated and planned for normal child that families experience when a diagnosis is made, and be aware that spouses can be at different stages. Accept all questions and reactions nonjudgmentally, offering verbal and written explanations. Provide the family a quiet place to discuss their questions with each other and someone knowledgeable about the condition (primary care provider, clinical nurse specialist) to support their concerns. Offer the family the option to take advantage of counseling. A social worker or psychologist can help families deal with immediate reactions. Many parents benefit from continuous or periodic support of counseling professionals. Help the family to realize what strengths they have in caring for their child. The role of the parents is critical; a nurturing, loving environment gives the child the best chance at maximizing potential. An individual who grows up at home has markedly higher adaptive abilities and an increased life span compared with those raised in institutions. Enlist the help of family and siblings, who can offer valuable support to the parents and child and assist with stimulation activities. Including siblings in the care can help them feel needed and involved, thus strengthening the family. If sibling issues arise, suggest family counseling to address the needs of all family members. Identify resources available to the family, such as parent support groups, early intervention programs, specialty clinics, pediatrician or primary health care provider, financial support programs, and advocacy groups for individuals with developmental disabilities. For those parents concerned with their ability to care for the child, explore with them their options of adoption or institutionalization in a nonjudgmental manner. Providing Meaningful Social Interaction Establishing Effective Feeding Techniques Be aware that the presence of hypotonia, as in children with Down syndrome; or hypertonia, as in children at high risk for cerebral palsy, can interfere with feeding by compromising sucking and swallowing. Demonstrate proper feeding positioning, with the infant's head elevated, and encourage the parents to always hold the infant during feedings with his head elevated and supported in arms. Try different nipples and bottles to find the easiest for the infant to use without leakage or danger of aspiration. Allow adequate time for feeding, and increase frequency of feedings if infant tires easily. Offer support and guidance for breast-feeding. Refer to lactation consultant if needed. Consider referral for a feeding evaluation to a speech therapist, or to an occupational therapist who has experience working with children and families. Refer parents to the Early Intervention Program administered by their county so that they can take advantage of the educational and support services available for children from birth to age 3. If the condition is identified after age 3, refer parents to the school district in which they reside. RESPIRATORY DISORDERS Pneumonia The most common causative agent is Streptococcus pneumoniae. Responsible for the majority of bacterial pneumonias in ages 1 month through 6 years. However, it is seen in all age groups. The incidence has declined due to the use of the vaccine. Make parents aware that recreational and leisure-time experiences are valuable in building social skills and self-esteem. Offer suggestions that will be enjoyable and developmentally appropriate for the child. Interaction with developmentally delayed and nondevelopmentally delayed peers is desirable. The Special Olympics is one example of an adaptive program. Local programs are also available in many areas. Praise the child for participation in activities, regardless of whether the child succeeds. Maintaining Safety Promoting Optimum Growth and Development Help the parents to understand the concept of developmental age, and identify the functional level of the child. Determine whether there is consistency between the developmental age of the child and degree of independence. Cognitive and physical limitations may interfere with emerging independence; however, parents may “baby― or overindulge a child who has a disability. Work with parents to set reasonable expectations and tobreak down tasks into simple, achievable steps. Care should be taken not to address too many areas at one time so as not to overwhelm the family. Use appropriate behavior modification techniques, such as extinction, time-out, and reward, to achieve cooperation and success. Demonstrate and encourage play with the child at the appropriate level to provide stimulation, and work toward achieving developmental milestones. When handling the infant, provide adequate support with a firm grasp because the infant may be floppy due to poor muscle tone. If hypotonia is accompanied by poor head control and neck strength, position the infant to prevent aspiration should vomiting occur. o Support the infant with a diaper roll, if needed, to maintain position. o Change the infant's position frequently. o Continuously check the environment for the safety needs of this child. Advise the parents to: o Maintain appropriate surveillance of the child when cooking or exposing him to other potential hazards that he may be able to get into but not understand. o Help the child to read words, such as “danger― and “stop.― o Teach the child how to call and ask for help. o Teach the child to say no to strangers. o Provide sex education in a way the child can understand. Infants: Mild upper respiratory infection (URI) of several days' duration, poor feeding, decreased appetite. Abrupt onset of fever 102.2° F (39° C) or higher; restlessness, respiratory distress, air hunger, pallor, cyanosis (common), nasal flaring, retractions, grunting, tachypnea, tachycardia, irritability; may see abdominal distention due to swallowed air or ileus. Winter and spring. Older child: Mild URI, followed by fever up to 104.9° F (40.5°C), shaking chills, headache, decreased appetite, vomiting, drowsiness, restlessness, irritability, lethargy, rhonchi, fine crackles, dry hacking cough, increased respirations, anxiety, occasionally circumoral cyanosis, pleuritic pain, diminished breath sounds, may develop a pleural effusion, empyema. Nursing Assessment Determine the severity of the respiratory distress that the child is experiencing. Make an initial nursing assessment. Observe the respiratory rate and pattern. Count the respirations for 1 full minute, document and note level of activity, such as awake or asleep. Determine if the rate is appropriate for age Observe respiratory rhythm and depth. Rhythm is described as regular, irregular, or periodic. Depth is normal, hypopnea or too shallow, hyperpnea or too deep. Auscultate breath sounds over all lung fields. Note airflow and presence of adventitious sounds such as crackles, wheeze, or stridor. Observe degree of respiratory effort, normal, difficult, or labored. Normal breathing is effortless and easy. Document character of dyspnea or labored breathing; continuous, intermittent, worsening, or sudden onset Note presence of additional signs of respiratory distress: nasal flaring, grunting, and retractions Observe for head bobbing, usually noted in a sleeping or exhausted infant. The infant is held by caregiver with head supported on the caregiver's arm at the suboccipital area. The head bobs forward with each inspiration. Observe the child's color. Note the presence and location of cyanosis—peripheral, perioral, facial, and trunk. Note degree of color changes, duration, and association with activity such as crying, feeding, and sleeping. Observe the presence of cough, noting type and duration, such as dry, barking, paroxysmal, or productive. Note any pattern, such as time of day, night, association with activity, physical exertion, or feeding. Note the presence of sputum, including color, amount, consistency, and frequency. Observe the child's fingernails and toenails for cyanosis and the presence and degree of clubbing, which indicate underlying chronic respiratory disease Nursing Diagnoses Ineffective Airway Clearance related to inflammation, obstruction, secretions, or pain Ineffective Breathing Pattern related to inflammatory process or pain Deficient Fluid Volume related to fever, decreased appetite, and vomiting Fatigue related to increased work of breathing Anxiety related to respiratory distress and hospitalization Parental Role Conflict related to hospitalization of the child Tonsillitis and Adenoiditis In tonsillitis and adenoiditis, structures that are already large become inflamed due to an infectious agent and cause airway obstruction, decreased appetite, and pain. Clinical Manifestations Obstructive Sleep Apnea Loud snoring or noisy breathing in sleep. Excessive daytime sleepiness. Mouth breathing. Chronic Infection of Tonsils and Adenoids Mouth breathing or difficulty breathing. Frequent sore throat. Anorexia, decreased growth velocity. Fever. Obstruction to swallowing or breathing. Nasal, muffled voice. Night cough. Offensive breath. Chronic Otitis Media Ear pain or general irritability in young children. Alterations in hearing. Fever. Enlarged lymph nodes. Anorexia. Diagnostic Evaluation Thorough ears, nose, and throat examination and appropriate cultures to determine presence and source of infection. Preoperative blood studies to determine risk of bleeding—clotting time, smear for platelets, prothrombin time, and partial thromboplastin time. RESPIRATORY DISTRESS SYNDROME (HYALINE MEMBRANE DISEASE) Respiratory distress syndrome (RDS), formerly known as hyaline membrane disease, is a syndrome of premature neonates that is characterized by progressive and usually fatal respiratory failure resulting from atelectasis and immaturity of the lungs. Primary Signs and Symptoms Expiratory grunting or whining (when the infant is not crying). Sternal, suprasternal, substernal, and intercostal retractions progressing to paradoxical seesaw respirations. Inspiratory nasal flaring. Tachypnea less than 60 breaths per minute. Hypothermia. Cyanosis when child is in room air (infants with severe disease may be cyanotic even when given oxygen), increasing need for oxygen. Supportive Management Maintenance of oxygenation Maintenance of respiration with ventilatory support, if necessary Maintenance of normal body temperature Antibiotics as needed to treat infection. PEDIATRIC RESPIRATORY PROCEDURES OXYGEN THERAPY Children with respiratory problems may receive oxygen therapy via nasal cannula, mask, face tent, or trachesotomy device. MECHANICAL VENTILATION Aggressive Management Administration of exogenous surfactant into lungs early in the disease. Surfactant Replacement Therapy Nursing Diagnoses Impaired Gas Exchange related to disease process Imbalanced Nutrition: Less than Body Requirements related to prematurity and increased energy expenditure on breathing Ineffective Thermoregulation related to immaturity Impaired Parenting related to separation from the neonate due to hospitalization Infants and children requiring mechanical ventilation need specialized care. These patients are typically treated in facilities that focus on providing a safe environment for technology-dependent children, with care provided by highly skilled nurses, respiratory therapists, and pediatricians. Specific nursing procedures and interventions and management of technologydependent infants and children are beyond the scope of this text. General considerations are as follows. Maintenance of a Patent Airway Artificial airway options include nasotracheal, orotracheal, and tracheostomy. ET and tracheostomy tubes are available in several sizes, cuffed and uncuffed, for the pediatric population. Several methods are available to determine the appropriate size such as: ET tube size = Age in years + 16 /divided by 4. ________________________________________________________________________________________________________________________ CARDIOVASCULAR DISORDERS CONGENITAL HEART DISEASE Congenital heart disease (or defects) (CHD) is one of the most common forms of congenital anomalies. It involves the chambers, valves, and great vessels arising from the heart NURSING CARE OF THE CHILD WITH CONGENITAL HEART DISEASE Nursing Assessment Obtain a thorough nursing history. Discuss the care plan with the health care team (cardiologist, cardiac surgeon, nursing case manager, social worker, nutritionist). Discuss the care plan with the patient, parents, and other caregivers. Measure and record height and weight. Plot on a growth chart. Record vital signs and oxygen saturations. o Measure vital signs at a time when the infant/child is quiet. o Choose appropriate-size blood pressure (BP) cuff. o Check four extremity BP Assess and record: o Skin color: pink, cyanotic, mottled. o Mucous membranes: moist, dry, cyanotic. o Extremities: check peripheral pulses for quality and symmetry; dependent edema; capillary refill; color and temperature. Assess for clubbing (cyanotic heart disease). Assess chest wall for deformities; prominent precordial activity. Assess respiratory pattern. o Before disturbing the child, stand back and count the respiratory rate. Loosen or remove clothing to directly observe chest movement. o Assess for signs of respiratory distress: increased respiratory rate, grunting, retractions, nasal flaring. o Auscultate for crackles, wheezing, congestion, stridor. Assess heart sounds. o Determine rate (bradycardia, tachycardia, or normal for age) and rhythm (regular or irregular). o Identify murmur (type, location, and grade). Assess fluid status. o Daily weights. o Strict intake and output (number of wet diapers; urine output). Assess and record the child's level of activity. o Observe the infant while feeding. Does the infant need frequent breaks or does he or she fall asleep during feeding? Assess for sweating, color change, or respiratory distress while feeding. o Observe the child at play. Is play interrupted to rest? Ask the parent if the child keeps up with peers while at play. o Assess and record findings relevant to the child's developmental level: ageappropriate behavior, cognitive skills, gross and fine motor skills. o Nursing Diagnoses Impaired Gas Exchange related to altered pulmonary blood flow or pulmonary congestion Decreased Cardiac Output related to decreased myocardial function Activity Intolerance related to hypoxia or decreased myocardial function Imbalanced Nutrition: Less Than Body Requirements related to excessive energy demands required by increased cardiac workload Risk for Infection related to chronic illness Fear and Anxiety related to life-threatening illness Improving Oxygenation and Activity Tolerance Nursing Interventions Relieving Respiratory Distress Position the child in a reclining, semi-upright position. Suction oral and nasal secretions as needed. Identify target oxygen saturations and administer oxygen as prescribed. Administer prescribed medications and document response to medications (improved, no change, or worsening respiratory status). o Diuretics. o Bronchodilators. May need to change oral feedings to nasogastric feedings because of increased risk of aspiration with respiratory distress. Organize nursing care and medication schedule to provide periods of uninterrupted rest. Provide play or educational activities that can be done in bed with minimal exertion. Maintain normothermia. Administer medications as prescribed. o Diuretics (furosemide, spironolactone): Give the medication at the same time each day. For older children, do not give a dose right before bedtime. Monitor the effectiveness of the dose: measure and record urine output. o Digoxin: Check heart rate for 1 minute. Withhold the dose and notify the physician for bradycardia (heart rate less than 90 beats/minute [bpm]). Lead II rhythm strip may be ordered for PR interval monitoring. Prolonged PR interval indicates first-degree heart block (dose of digoxin may be withheld). Give medication at the same time each day. For infants and children, digoxin is usually divided and given twice per day. Monitor serum electrolytes. Increased incidence of digoxin toxicity associated with hypokalemia. o Afterload-reducing medications (captopril, enalapril): When initiating medication for the first time: check BP immediately before and 1 hour after dose. Place pulse oximeter probe (continuous monitoring or measure with vital signs) on finger, earlobe, or toe. Administer oxygen as needed. Titrate amount of oxygen to reach target oxygen saturations. Assess response to oxygen therapy: increase in baseline oxygen saturations, improved work of breathing, and change in patient comfort. Explain to the child how oxygen will help. If possible, give the child the choice for face mask oxygen or nasal cannula oxygen. Providing Adequate Nutrition Improving Cardiac Output Monitor for signs of hypotension: syncope, light-headedness, faint pulses. Withhold medication and notify the physician according to ordered parameters. For the infant: o Small, frequent feedings. o Fortified formula or breast milk (up to 30 cal/oz). o Limit oral feeding time to 15 to 20 minutes. o Supplement oral feeds with nasogastric feedings as needed to provide weight gain (ie, continuous nasogastric feedings at night with ad-lib by-mouth feeds during the day). For the child: o Small, frequent meals. o High-calorie, nutritional supplements. o Determine child's likes and dislikes and plan meals accordingly. o Allow the parents to bring the child's favorite foods to the hospital. Report feeding intolerance: nausea, vomiting, diarrhea. Document daily weight (same time of day, same scale, same clothing). Record accurate inputs and outputs; assess for fluid retention. Fluid restriction not usually needed for children; manage excess fluid with diuretics. Preventing Infection Maintain routine childhood immunization schedule. With the exception of RSV (Synagis) and influenza, immunizations should not be given for 6 weeks after cardiovascular surgery. Administer yearly influenza vaccine. Administer RSV immunization for children younger than age 2 with complex CHD and those at risk for CHF or pulmonary hypertension. Prevent exposure to communicable diseases. Good hand washing. Report fevers. Report signs of URI: runny nose, cough, increase in nasal secretions. Report signs of GI illness: diarrhea, abdominal pain, irritability. Evaluation: Expected Outcomes Improved oxygenation evidenced by easy, comfortable respirations Improved cardiac output demonstrated by stable vital signs, adequate peripheral perfusion, and adequate urine output Increased activity level Maximal nutritional status demonstrated by weight gain and increase in growth curve percentile No signs or symptoms of infection Parents discuss diagnosis and treatment together and with child COMMON PEDIATRIC GASTROINTESTINAL DISORDERS CLEFT LIP AND PALATE Cleft lip and palate are congenital anomalies resulting in structural facial malformation. These defects are usually present in early fetal development. Pathophysiology and Etiology A failure of embryonic development, resulting in defect syndromes associated with other anomalies. Genetic/hereditary predisposition; a fetus with an affected parent or sibling has a 2% to 4% risk compared to 0.15% risk of the general population. Environmental causes are suspected: antiepileptic medications taken during pregnancy, other factors suspected include maternal smoking, heavy alcohol intake, infections, folic acid deficiency, and vitamin A intoxication. Clinical Manifestations Physical appearance of cleft lip or palate: o Incompletely formed lip—varies from slight notch in vermilion to complete separation of lip. o Opening in roof of mouth felt with examiner's finger on palate. Eating difficulty: o Suction cannot be created for effective sucking. o Food returns through the nose. o Nasal speech. Diagnostic Evaluation Prenatal ultrasonography enables many cleft lips and some cleft palates to be identified in utero. Magnetic resonance imaging (MRI) to evaluate extent of abnormality before treatment. Photography to document the abnormality. Serial X-rays before and after treatment. Dental impressions for expansion prosthesis. Genetic evaluation to determine recurrence risk. General management is focused on closure of the clefts, prevention of complications, habilitation, and facilitation of normal growth and development of the child. The cleft lip is generally repaired before the palate defect. o Immediate repair—several hours to several weeks after birth. o Intraoral or extraoral prosthesis to prevent maxillary collapse, stimulate body growth, and aid in feeding and speech development; may be used before surgical repair. o Later repair when infant is 6 to 12 weeks old, hemoglobin 10 g/dL, steady weight gain seen—10 lb (4.5 kg) or white blood cell (WBC) count normal. Cleft palate repair may be done any time between ages 6 months and 5 years; it is based on degree of deformity, width of oropharynx, neuromuscular function of palate and pharynx, and surgeon's preference. o Repair at age 9 to 18 months may be preferred because speech patterns have not been set, yet growth of involved structures allows for improved surgical repair. o If repair is delayed to age 4 or 5, a special denture palate is used to help occlude the cleft and aid in establishing speech patterns. Nursing Assessment If the patient has a cleft lip, assess for cleft palate by direct visualization and palpation with finger. Obtain family history of cleft lip or palate. Evaluate feeding abilities. o Effectiveness of suck and swallow o Amount taken Observe for other syndromic features. Nursing Diagnoses Ineffective Infant Feeding Pattern related to defect Risk for Infection related to open wound created by malformation, ear infections Risk for Impaired Parent/Infant Attachment related to malformation and special care needs Risk for Aspiration related to tongue and palate deformities in Pierre Robin syndrome Deficient Knowledge related to home management of infant with cleft malformation Fear related to surgery Deficient Knowledge related to postoperative care COMMON ORTHOPEDIC DISORDERS IN CHILDREN FRACTURES A fracture is a break or disruption in the continuity of bone FIGURE: Common fractures in children. (A) Plastic deformation (bend). (B) Buckle (torus). (C) Greenstick. (D) Complete. Epiphyseal Injuries Fifteen percent to 30% of all childhood fractures involve the physis (growth plate). The most frequent site of physeal injuries (excluding phalangeal fractures) is the distal radius and ulna. The 11- to 15-year-old age-group tends to sustain the majority of physeal injuries to the distal radius and ulna. The mechanism of injury is usually a fall on an outstretched arm. Clavicle Fractures Frequent site of fracture in children. The shaft of the clavicle is the most common site of injury. A fall on the shoulder or excessive lateral compression of the shoulder is usually the mechanism of injury. Treatment involves support in the form of immobilization with a sling. Reduction of clavicle fractures occurs only in instances of extreme displacement. Forearm and Wrist Fractures Most common site of fracture in children, with most occurring in children older than age 5. Account for 30% to 50% of all fractures in children. Seventy-five percent of forearm fractures occur in the distal third of the radius and ulna and most do not involve the physis. Major categories of classification include fracture dislocations, midshaft fractures, and distal fractures. Most common cause is from a fall on an outstretched arm. Humerus Fractures The mechanism of injury for the majority of humeral fractures is a fall onto an outstretched arm or hand. Less than 1% of fractures occur at the proximal humerus. Ten percent of all humeral fractures occur at the shaft of the humerus; they account for less than 2% of all pediatric fractures. o Humeral shaft fractures are usually a result of twisting injuries in infants and toddlers (child abuse is a common cause of these fractures in this age group). o Direct trauma to the humeral shaft is the most common mechanism of injury in older children. Supracondylar fractures account for 60% of all elbow fractures in children. There is a high incidence of neurovascular injury with supracondylar fractures, 8% of which sustain a neurologic injury. Twenty percent of distal humeral injuries occur in the lateral condyle; this ranks as the second most common elbow fracture in children. Medial epicondyle fractures are the third most common elbow fracture in children, accounting for 5% to 10% of all pediatric elbow fractures. Spinal Fractures Rare in children they account for 1% to 2% of all pediatric fractures. Mechanism of injury is due to significant trauma, such as an motor vehicle accident, fall from a significant height, athletic activities, beatings, or pedestrian-versus-motor-vehicle accident. Most spinal fractures involve the cervical spine. Pelvic Fractures Pelvic fractures are uncommon in children and adolescents with an incidence of 1 per 100,000 children per year. Pelvic fractures are commonly the result of highenergy trauma or a crush-type injury. Associated injuries are present in approximately 75% of children with pelvic fractures and include damage to the abdominal wall and pelvic organs. Hip Fractures Hip fractures account for less than 1% of all fractures in children. Seventy-five percent of hip fractures in children result from high-energy trauma, such as motor vehicle accidents, bicycle accidents, and falls from significant heights. Half of children who sustain a hip fracture have been involved in a motor vehicle accident or pedestrian-versus-motor-vehicle accident; these children usually have other injuries. Child abuse is the most common cause of hip fracture in children under age 3. Hip fractures can result in avascular necrosis of the femoral head, damage to the physis resulting in growth arrest, malunion, and nonunion. Femur Fractures Common in children. Peak incidence occurs in two age groups—children ages 2 to 3 and adolescents. The midshaft of the femur is the most common location for femoral fractures in children and accounts for 1% to 2% of all childhood fractures. Usually the result of high-energy trauma, such as a motor vehicle accident or fall from a significant height. Seventy percent of femur fractures in children younger than age 1 are associated with child abuse. Tibial Fractures The most common lower extremity fracture in children occurs in the tibial and fibular shaft constitutes 10% to 15% of all pediatric fractures. A rotational mechanism of injury to the lower leg is the most common cause of tibial fractures in children under age 3 (toddler's fracture). Greater force is required to injure the tibia in older children; motor vehicle accidents and sports injuries are the most common causes of tibial fractures in children and adolescents. Ankle Fractures Common in children and adolescents approximately 5% of all pediatric fractures. Involve the growth plate in approximately every 1 of 6 injuries. Greatest incidence is in males ages 10 to 15. Usually the result of direct trauma. Foot Fractures o Management Treatment is dependent upon the type of fracture, its location, and the age of the child. Metatarsal and phalangeal fractures make up approximately 7% to 9% of all pediatric fractures. Fractures of the tarsal bones are uncommon in children. Most metatarsal and phalangeal fractures are nondisplaced. Mechanism of injury is usually a direct or indirect trauma such as falls, jumping from heights, and twisting injuries. Classification of Fractures Open fractures: underlying fracture in bone communicates with an external wound. o Usually the result of high-energy trauma or penetrance wounds. o The tibia is the most common site of open fractures in children. Closed fractures: underlying fracture with no open wound. Plastic deformation: a bending of the bone in such a manner as to cause a microscopic fracture line that does not cross the bone. When the force is removed, the bone remains bent. Unique to children, and most common in the ulna. Clinical Manifestations Inability to stand, walk, or use injured part Limb deformity (visible or palpable) Ecchymosis Pain History of injury or trauma (may not be the case with pathologic fractures) Spontaneous onset of pain (usually seen with pathologic fractures). Local swelling and marked tenderness Movement between bone fragments Crepitus or grating Muscle spasm Diagnostic Evaluation X-rays of suspected limb fractures should include the joint above and below the injury. o Should always include a minimum of two views at 90-degree angles to each other (anteroposterior and lateral). o Comparison views of the opposite extremity are frequently needed. They help to distinguish the fracture line from the growth plate. o In some situations, oblique X-rays are warranted in order to help identify a fracture that is difficult to detect. Further radiologic studies may be indicated in certain instances to evaluate a fracture: tomography, computed tomography (CT) scan, magnetic resonance imaging (MRI), bone scan, fluoroscopy. Vascular assessment may include the use of: o Doppler studies. o Compartment pressure monitoring. Angiography. Treatment may consist of: o Immobilization by cast, splint, or brace. o Closed reduction followed by a period of immobilization in a cast or splint. o Open reduction with or without internal fixation and usually followed by a period of immobilization in a cast or splint. o Closed reduction and percutaneous pinning followed by a period of immobilization. o Closed or open reduction and application of an external fixator. o Traction (skin, skeletal) followed by a period of immobilization. Most children's fractures heal in 12 weeks or less. Simple fractures that are closed and nondisplaced can heal enough to be free from immobilization within 3 weeks. Nursing Diagnoses Acute Pain related to tissue trauma and reflex muscle spasms secondary to fracture Ineffective Tissue Perfusion: Peripheral related to swelling and immobilization Impaired Skin Integrity related to mechanical trauma (eg, fixation device, traction, casts, other orthopedic devices) Ineffective Coping related to separation from family and home Impaired Physical Mobility related to fracture and external immobilization device (eg, cast, splint, external fixator) Bathing/Hygiene/Feeding/Toileting Self-Care Deficit related to external devices (eg, cast, splint) Risk for Infection related to trauma (fracture) and surgery Risk for Peripheral Neurovascular Dysfunction related to restrictive envelope secondary to cast or splint Promoting Comfort Monitor and assess pain level using an ageappropriate pain scale (eg, Oucher or FACES scale). Properly position, align, and support affected body part. Administer analgesics as indicated and monitor effectiveness of analgesia. Use nontraditional methods of pain relief—music therapy, diversionary activities, relaxation techniques, therapeutic touch, play therapy. Maintaining Tissue Perfusion Frequently assess perfusion of limb by checking temperature, color, sensation, and pulses. Elevate extremity above heart level to prevent edema. Encourage movement of digits on affected limb. Remove compressive bandages (eg, elastic bandages, splints) that restrict flow of circulation. Maintaining Skin Integrity Assess for and relieve pressure caused by tight bandages, casts, and splints. Provide periodic cleaning, thorough drying, and lubrication to pressure points if in traction. Encourage frequent position changes as allowed. Assess skin condition on a regular basis. Massage healthy skin around affected area to stimulate circulation. Protect skin at risk with special dressings or products (eg, barrier cream, moisture-permeable dressing). Discourage the use of sticks, knitting needles, or small toys to scratch itchy skin. Promote a diet high in protein, carbohydrates, and calcium. Promoting Effective Coping Assess the child's and parents' response to events. Explain condition, treatment, and rehabilitation goals as indicated. Provide reassurance and emotional support when needed. Refer to community-based support agencies (eg, social services, United Way) if indicated. Structure the child's day with routine, activities, and therapy to keep him or her busy. Encourage the child and parents to verbalize feelings. Encourage child to express feelings and emotions through writing (eg, journal), drawing, or play therapy. Promoting Mobility Encourage exercise of uninvolved limbs regularly throughout day. Teach appropriate ambulation techniques using aids, such as crutches, walkers, or wheelchairs, as indicated. Teach safety precautions when using an ambulatory aid. Attaining Independence Assess family situation for ability to care for child at home. Allow child to care for self when able. Encourage parents and siblings to assist only as needed. Encourage child to participate in care as much as possible. Evaluate child's ability to participate in self-care activities. Preventing Infection Assess wounds frequently for warmth, erythema, swelling, tenderness, or purulent drainage. Report signs of infection. Provide appropriate wound care for open injuries and surgical wounds. Administer antibiotics as ordered. Encourage child to eat and maintain good caloric and protein intake to promote healing. Teach good hand-washing technique to child and parents. Preventing Peripheral Neurovascular Dysfunction Assess the neurovascular status of affected limb every hour for the first 24 hours (or as indicated by hospital protocol)—compare with unaffected limb. Assess for nerve injury (eg, abduct all fingers, touch thumb to small finger, plantar flexion, dorsiflexion).