NUR102 - Chp. 40 - The Child With a Musculoskeletal Disorder

Traction

A pulling force applied to an extremity or other part of the body.

Skin Traction

Applies pull on tape, rubber, or a plastic material attached to the skin, which indirectly exerts pull on the musculoskeletal system.

A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast?

Assess the fingers for warmth, pain, and function. * To be certain a compartment syndrome is not developing.

Legg-Calvé-Perthes Disease (LCPD)

Avascular necrosis of the femoral head resulting in limited ROM; swimming, tricycle or bicycle riding are excellent exercises as they provide smooth joint action & will help reduce joint destruction.

The child who has a fracture of the lower extremity or a lower leg injury is usually fitted with, and taught how to use, which type of crutches?

Axillary crutches. * The most common type of crutches are axillary crutches, which are principally used for temporary situations such as children with fractures of the lower extremities and other lower leg injuries.

Gower's Sign

Difficulty rising to standing position; has to walk up legs using hands; occurs in muscular dystrophy.

The nurse is caring for a child with a fractured femur in traction. Which action will the nurse complete while caring for this client?

Ensure traction weights are hanging freely, not touching the bed or floor. * Traction is used as a pulling force on an extremity or body part. For it to be effective, the weights need to hang freely at all times and the ropes need to remain in the pulley grooves.

Lordosis

Forward curvature of the lumbar spine or swayback.

Metaphysis

Growing portion of the bone.

Kyphosis

Hunchback; exaggerated thoracic curvature

The nurse is assessing a child and notes S-shaped curvature of the spine. What terminology would the nurse use when documenting this assessment finding?

Idiopathic scoliosis.

Ankylosis

Immobility of a joint.

Synovitis

Inflammation of synovial membrane / a joint.

Scoliosis

Lateral curvature of the spine.

Epiphysis

Rounded end of a long bone.

An 18-month-old was brought to the emergency department by her mother, who states, "I think she broke her arm." The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse (child maltreatment). Which type of fracture would the radiograph most likely reveal?

Spiral fracture. * A spiral fracture is very rare in children. A spiral femoral or humeral fracture, particularly in a child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of child abuse (child mistreatment).

The nurse is working with a 6-year-old child recently diagnosed with Legg-Calvé-Perthes disease. The child's parents tells the nurse they understand exercise is important for their child but are not sure which activities are appropriate. Which activity will the nurse recommend for this client?

Swimming. * Patient's with Legg-Calvé-Perthes disease will experience limited range of motion in the hip. Thus, swimming and tricycle or bicycle riding are excellent exercises because they provide smooth joint action and will help to reduce joint destruction.

The nurse is observing a child walk down stairs using a swing-through gait. What action by the child is correct?

The child places the crutches on the lower step before placing the good foot down between the crutches. * Both crutches should be moved at the same time.

An adolescent with scoliosis is refusing to wear the prescribed body brace. Which instruction is best to progress the adolescent to the treatment goals?

"It is important to wear the brace now to stabilize your spinal alignment, decreasing your symptoms." * It is important to have the adolescent understand the treatment and how the treatment will benefit him or her. Body bracing helps to hold the spine in alignment and prevent further curvature, decreasing the symptoms.

The nurse is caring for a preschooler with a greenstick fracture. Which statement by a parent indicates an understanding of this type of fracture?

"My child may need the arm broken completely prior to putting a cast on it." * Greenstick fractures are incomplete fractures. They commonly occur in young children. Sometimes greenstick fractures are broken completely before casting to prevent the bone from resuming its "bent" position in the cast.

At an obstetric visit 28 weeks into her pregnancy, an expectant mother tells the nurse that her friend's newborn has a soft spot on his head. She is concerned that something is wrong with this baby and is worried the same thing could happen to her child. The best explanation the nurse could offer this expectant mother regarding the bones in the skull would be which statement?

"The softer spot and unclosed sutures in the skull allow the bones to move as they need to so that the baby's head can move through the narrow birth canal." * Within the first 2 years of life, these suture lines or fontanels fuse together.

A 13-year-old adolescent is being treated for scoliosis with a brace. During the first follow-up appointment after the brace was initiated, which statement by the adolescent indicates the need for further instruction?

"When I get home from school, I look forward to taking off my brace for a few hours before I go to bed." * The brace is worn daily for all activities other than bathing. Clients should remove the brace for only 1 hour each day. Exceeding this time with the brace off will impair the therapeutic effects of the bracing treatment.

The nurse is caring for a child who fractured the arm in an accident. A cast has been applied to the child's right arm. Which action(s) should the nurse implement? Select all that apply.

- Document any signs of pain. - Check capillary refill time in the both arms. - Monitor the color of the nail beds in the right hand.

A child and mother come into the orthopedic clinic. The mother is concerned about her child who has recently been diagnosed with scoliosis. The mother asks about surgical treatment and if it will be necessary. The nurse bases her response on knowledge that surgery is implicated for curvatures greater than:

40 degrees. * Nonsurgical treatment is attempted first for spinal curvatures less than 40 degrees.

The nurse is caring for a 6-year-old boy with Russell traction applied to his left leg. Which intervention would be most appropriate to prevent complications?

Assess the popliteal region carefully for skin breakdown. * The nurse would assess the popliteal region carefully for skin breakdown from the sling.

A nurse is preparing a presentation for a parent group about musculoskeletal injuries. When describing a child's risk for this type of injury, the nurse integrates knowledge that bone growth occurs primarily in which area?

Epiphysis. * Growth of the bones occurs primarily in the epiphyseal region. This area is vulnerable and structurally weak. Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone.

Skeletal Traction

Exerts pull directly on skeletal structures by means of a pin, wire, tongs, or other device surgically inserted through a bone.

Compartment Syndrome

Serious neurovascular concern that occurs when increasing pressure within the muscle compartment causes decreased circulation.

An adolescent wears a body brace for scoliosis. Which client education should the nurse provide?

To continue with age-appropriate activities. * Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem.

The nurse is caring for a school-age child diagnosed with transient synovitis. What statement by a parent indicates a need for further education regarding this diagnosis?

"I will get the prescription for the antibiotics filled as soon as we leave the office today." * Transient synovitis is an inflammatory disease, not an infection; therefore, antibiotics are not needed.

Which client would be the most likely person to be diagnosed with idiopathic scoliosis that requires treatment?

A young adolescent female. * Idiopathic (unknown cause/spontaneous) scoliosis requiring treatment occurs 10 times more often in females than males. Usually, treatment is initiated during early adolescence, around age 11 to 14 years.

Halo Traction Device (External Fixation)

External Fixation; used to treat cervical fractures or for immobilization following a cervical fusion, such as in the child with severe scoliosis. * Think of Regina George off of Mean Girls!

A child is admitted to the pediatric unit with osteomyelitis. The child is to be placed on antibiotics. The nurse expects antibiotic coverage to include which of the following as the most common cause of osteomyelitis?

Staphylococcus aureus. * Staphylococcus aureus is the most common cause of osteomyelitis; therefore, the nurse would expect the antibiotics to cover that bacteria.

In caring for a child in traction, which intervention is the highest priority for the nurse?

The nurse should monitor for decreased circulation every 4 hours. * Any child in traction must be carefully monitored to detect any signs of decreased circulation or neurovascular complications.

The nurse is speaking with the parents of a child who has a cast. The parents state that the child reports itching in the area of the cast. What is the best response by the nurse?

"Blowing cool air with a fan or hair dryer may relieve the feeling." * It's mainly the dead skin cells causing the itching. Blowing cool air with a fan or hair dryer blows the dead skin cells around / out, thus, providing relief to the itching feeling.

The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE). What information would the nurse include when completing a neurovascular assessment of the affected leg? Select all that apply.

- Color - Sensation - Pulse - Capillary refill * A neurovascular assessment includes assessing for color, movement, sensation, edema, and quality of pulses.

Functional Scoliosis

Flexible deviation that corrects by side-bending to the opposite side; more common & can have several causes - poor posture, muscle spasm caused by trauma, or unequal length of legs.

The nurse is concerned that a preschool-age child is demonstrating signs of Duchenne muscular dystrophy. What did the nurse assess in this child?

Gower Sign.

Uveitis

Inflammation of the middle (vascular) tunic of the eye; includes the iris, ciliary body, & choroid.

An infant with a femur fracture is placed in Bryant traction. What would the nurse include in the infant's plan of care?

Keeping the buttocks slightly elevated.

Duchenne Muscular Dystrophy

Rising from the floor is done by rolling onto the stomach and then pushing up to the knees. To stand, the hands are pressed against the ankles, knees, and thighs; Gower's Sign. * Children usually have a history of meeting motor milestones, but by about 3 years of age, symptoms are more acute and obvious.

The nurse is caring for a child in the postanesthesia care unit following a surgical procedure to place pins in the child's fractured femur. This pin placement is an example of which type of traction?

Skeletal.

The charge nurse is observing a student nurse perform skeletal traction pin care. What action by the student nurse would indicate a need for intervention by the charge nurse?

Unhooking a weight while providing pin care. * Weights should never be moved or unhooked during skeletal traction. Pin care is a sterile procedure. Pins are cleaned with half-strength hydrogen peroxide and then typically covered with sterile cotton gauze.

A client has recently been diagnosed with juvenile idiopathic arthritis (JIA). The nurse is providing teaching to the client and family about the disease. Which facts are accurate and should be shared with this family? Select all that apply.

- JIA can affect any number of joints. - The client will need to take several medications, including NSAIDS. - Administer NSAIDS with food to decrease the incidence of gastric irritation. * Patients with JIA have painful swollen joints in varying numbers from one to more than five. The most common age is from 1 to 3 years and from 8 to 10 years.

When teaching a group of parents about the skeletal development in children, what information will the nurse provide?

A young child's bones commonly bend instead of break when an injury occurs. * The infant and a young child's bones are more flexible and more porous with a lower mineral count than adults. The structural differences of a young child's bone allow for greater shock absorption thus, bones will often bend rather than break when an injury occurs.

The client is a 9-month-old whose babysitter brings her to the ER. An x-ray shows a spiral fracture of the femur. The babysitter tells the nurse that she found the infant in this condition when she showed up to watch her an hour ago. How should the nurse respond to this situation?

Arrange for the parents to come in for an evaluation for possible physical abuse. * Spiral femur fractures, rib fractures, and humerus fractures, particularly in the child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of child abuse (child mistreatment). The parents should be contacted first, and the family should undergo an evaluation for possible physical abuse since femoral fractures in non-ambulating infants, particularly spiral fractures, are believed to be highly specific for inflicted injury.

A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority intervention when planning this child's care?

Maintaining intravenous antibiotic therapy. * Osteomyelitis is infection of the bone, thus, needing abx therapy. * For osteomyelitis, medical therapy includes administration of intravenous antibiotics, which is usually initiated in the hospital and then continued at home for as long as 2 weeks; an intermittent infusion device or peripherally inserted central catheter may be used.

The nurse is caring for a 10-year-old child in traction. After performing a skin assessment, she notices that the skin over the calcaneus appears slightly red and irritated. Which of the following would the nurse do next?

Reposition the child's foot on a pressure-reducing device.. * Calcaneus - heel forming bone. Redness makes us think pressure injury beginning, thus, repositioning the patient's foot on a pressure-reducing device. Pressure must be relieved first!

The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

Risk for impaired skin integrity due to cast and location. * Although deficient knowledge, risk for delayed development, and self-care deficit may be applicable, the child is at increased risk for skin breakdown due to the size of the cast and its location. In addition, the cast has an opening, which allows for elimination. Soiling of cast edges or leakage of urine or stool can lead to skin breakdown.

The nurse is preparing an education program for parents of a child diagnosed with Legg-Calvé-Perthes disease (LCPD) disorder. What information does the nurse need to include? Select all that apply.

- This disorder has four stages that last over several years. - The initial stage symptoms include a limp and guarding of the hip while moving. - If left untreated, the femur head will deform, which can lead to chronic pain. * LCPD is avascular necrosis of the femoral head resulting in limited ROM.

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client?

Duchenne muscular dystrophy. * By age 3, children with Duchenne muscular dystrophy can rise from the floor only by rolling onto their stomachs and then pushing themselves to their knees. To stand, they press their hands against their ankles, knees, and thighs (they "walk up their front"); this is a Gower sign.

A child with muscular dystrophy has come into the clinic. The nurse assesses the child and finds him crawling up his legs with his arms to arise from the floor, which is a characteristic sign of muscular dystrophy. The nurse correctly identifies this as:

Gowers sign.

Structural Scoliosis

Involves rotated & malformed vertebrae; relatively fixed & inflexible.

The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?

Soaking the area in warm water every day. * Help soften and remove the dry, flaky skin. Moisturizing lotion, not petroleum jelly, should be applied to the skin.

A nurse is assessing a child with suspected osteomyelitis. Which finding would help support this suspicion?

Swelling and point tenderness. * Findings associated with osteomyelitis include swelling, point tenderness, warmth over the site, decreased range of motion, and an elevated sedimentation rate (non-specific measure of inflammation).

The student nurse is developing a care plan for a child who suffered a fractured tibia and will have a cast on his lower leg for approximately 6 weeks. Which nursing diagnosis would be the priority for this client?

Impaired physical mobility related to a cast on the leg.

An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed opioids. Which action would be the priority?

Notifying the doctor immediately. * The nurse should notify the doctor immediately because the girl's symptoms are the classic sign of compartment syndrome. Immediate treatment is required to prevent excessive swelling and to detect neurovascular compromise as quickly as possible.

A nurse assesses a client who is reporting calf pain and a very sore leg. The client has a temperature of 101°F (38.3°C). X-rays do not reveal any abnormalities but the client's leukocyte count is 21 × 103 cells/mm3 (21 × 109/l) and the erythrocyte sedimentation rate is elevated. What condition does the nurse suspect?

Osteomyelitis. * Osteomyelitis is a bone infection usually caused by Staphylococcus aureus, which causes leg pain and fever. Laboratory work reflects an elevated leukocyte count and an increased erythrocyte sedimentation rate. X-rays look normal until 5 to 10 days after onset of symptoms.

While assessing a preadolescent child, the nurse notes curvature of the child's spine. Which statement by the child's parent supports this observation?

"My child has such a hard time finding pants that fit right. They never seem to fit evenly over the hips." * The curvature of the spine can make the iliac crests uneven and make it difficult to find pants that fit correctly. * Curvature of the spine can indicate scoliosis. Scoliosis is a painless disorder that predominately presents during the rapid growth phase in preadolescence.