Ch. 27 Alterations in Musculoskeletal Fxn

A nurse is providing instructions for home cast care. Which response by the parent indicates a need for further teaching? "We must avoid causing depressions in the cast." "Pale, cool, or blue skin coloration is to be expected." "The casted arm must be kept still." "We need be aware of odor or drainage from the cast."

"Pale, cool, or blue skin coloration is to be expected."

A nurse is caring for a 6-year-old child with a fractured ulna. The child is fearful about the casting process and is resisting treatment. How should the nurse respond? •"The application of the cast will not hurt." •"Would you like to pick out your favorite color cast?" •"Look over there at the neon fish in our aquarium." •"The cast will stop the bone from breaking into several pieces."

"Would you like to pick out your favorite color cast?"

Four labs that need to be ordered in order to treat osteomyelitis.

1. Sedimentary rate (marker for inflammation) --> As resolving, sed rate will come down 2. CRP (marker for inflammation) 3. WBC 4. Blood culture

Children are: Bo-legged until ___ yo. Flat feet until ___ yo. Pigeon-toed until ___ yo. Knock-knees until ___ yo

2 6 8 7

You are the nurse caring for a child that has just undergone a spinal fusion; day 2 of recovery. The child begins to complain of abdominal pain and distention. You also note that the patients blood pressure and heart rate are trending higher than normal. On the basis of these findings what is the immediate action the nurse should take? 1.Administer an antiemetic that is on the medication list 2.Turn up the IV fluids to increase hydration 3.Position the patient upright in the bed 4.Notify the attending physician or resident on call

4.Notify the attending physician or resident on call

Which of the following are included in the clinical presentation of a child with developmental hip dysplasia (DDH)? Select all that apply. A.Limited hip movement with abduction. B.Equal leg lengths. C.Palpable "click" or "clunk" when performing the Ortolani or Barlow test. D.Uneven skin folds on the thigh of the affected limb.

A.Limited hip movement with abduction. C.Palpable "click" or "clunk" when performing the Ortolani or Barlow test. D.Uneven skin folds on the thigh of the affected limb.

The nurse is working with a group of caregivers of school-aged children discussing fractures. The nurse explains that if the fragments of fractured bone are separated, the fracture is said to be: Incomplete Complete Greenstick Spiral

Complete Rationale: If the fragments of fractured bone are separated, the fracture is said to be complete. If fragments remain partially joined, the fracture is termed incomplete.

Definition: Heel tilts in and down, forefoot turns in (inversion), and bottom of the foot faces inward or upward; Shorter Achilles tendon and foot and calf on affected side. More common in boys Nonsurgical tx = serial casting

Congenital Clubfoot

•A child with a newly diagnosed ulnar fracture has a short-arm cast applied. Which of the following symptoms would be most concerning for the nurse? A. Swelling B. Mild pain C. Itching D. Uncontrolled, severe pain

D. Uncontrolled, severe pain Rationale: Uncontrolled pain is the first sign of compartment syndrome. The nurse should assess the neurovascular status of the extremity and intervene immediately to prevent tissue necrosis and permanent damage.

True or False: Bad posture and carrying heavy backpacks can contribute to the development of scoliosis.

False

True or False: Nurses should teach parents of children with osteogenesis imperfecta to lift by the legs when changing the diaper.

False

True or False: Biphosphonates and growth hormones help w/ bone formation in children w/ OI and serve as a cure.

False Rationale: They are NOT a cure! There is NO cure; only palliative tx.

True or False: It is ok for children with OI to participate in contact sports.

False Rationale: Treatment is palliative and focuses on strengthening muscles and preventing fractures; may require mobility aids Treatment is palliative and focuses on strengthening muscles and preventing fractures; may require mobility aids

Grade the strain/sprain: Tissue is stretched. Slight swelling (hardly noticeable). Mild loss of range of motion (ability to move in various directions) and strength (0 - 25%). No decrease in stability.

Grade I (Mild)

Grade the strain/sprain: Involves stretching and some tearing of tissue. Moderate swelling (may look "baseball" size). Usually includes some bruising. Moderate loss of range of motion and strength (25 - 75%). Some decrease in stability.

Grade II (Moderate)

Grade the strain/sprain: Complete tearing of tissue. Significant swelling and bruising. Near complete loss of range of motion and strength (75 - 100%). Marked decrease in stability. In this case, need to immobilize for 10-14 days.

Grade III (Severe)

Definition: overuse injury resulting in pain at the front of the knee due to inflammation of the growth plate at the proximal end of the tibia

Osgood-Schlatter disease

Blue sclera is a cardinal sign of __________ __________. Other symptoms include: frequent fractures, hearing loss, short stature, and muscle weakness.

Osteogenesis Imperfecta (OI)

Definition: Genetic collagen disorder resulting in fragile bones; also known as brittle bone disease There are 8 types (but type I is the most common and mildest form)

Osteogenesis Imperfecta (OI)

Damage occurs in four stages and is typically sports related: 1.Pain after physical activity 2.Pain during activity that does NOT limit participation 3.Pain during activity that MAY limit participation 4.Chronic pain even at rest Name this injury.

Overuse injury

Definition: overuse injury resulting in jumper's knee from repetitive contraction of the quadricep muscle (jumping, basketball, gymnastics)

Patellar tendonitis

Definition: Congenital deformity; ribs and sternum grow inward Surgery includes placing metal chest expansion bars to reshape sternum and relieve pressure if pulmonary or cardiovascular effects. However, majority of the time, there are no major problems and surgery is elective.

Pectus Excavatum

Definition: Also known as pigeon chest; deformity of the chest wall in which the breastbone and ribs are pushed outward.

Pectus carinatum

Definition: Extra digits on the hands and/or feet

Polydactyly

Treat strains and sprains using the _______ method and administering ________.

RICE; NSAIDS

___________ is typically checked around puberty b/c that's when growth spurts tend to happen.

Scoliosis

_________ _________ is the most common bacterial cause of osteomyelitis. Treat w/ IV abx for 4-8 wks and PO abx for 3 wks.

Staphylococcus aureus

Definition: Digits are fused and fail to separate; often involves nerves and muscles; webbed

Syndactyly

True or False: A smaller diaper should be used inside a larger diaper for more absorption in infants with a spica cast.

True

True or False: Automatic BP cuffs must be avoided for people with OI b/c it can cause fractures.

True

True or False: Bad posture, sleeping position, lack of calcium and carrying heavy back packs will not cause scoliosis.

True

True or False: In OI, bones fracture VERY EASILY. Treatment is palliative and focuses on strengthening muscles and preventing fractures; may require mobility aids.

True

True or False: In pediatrics, bones are more porous, elastic, and less dense.

True

True or False: Open fracture needs surgical intervention.

True

True or False: Postoperative care for pectus excavatum includes teaching the child how to splint the chest with a pillow to minimize pain when coughing and with deep breathing.

True

An adolescent wears a body brace for scoliosis. Which client education should the nurse provide? a. to continue with age-appropriate activities b. to stand absolutely still when not wearing the brace c. to wear the brace a maximum of 20 hours each day d. that secondary sex changes will stop until the brace is removed

a. to continue with age-appropriate activities

A small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone

avulsed

The nurse is discussing treatment for a child diagnosed with scoliosis. Which statement indicates the parents understand the nurse's education? a. "Because our child has scoliosis, treatment will include halo traction." b. "The treatment for our child's scoliosis is anticipated to last between 3 to 4 months." c. "Because our child is being treated by using braces, the braces will have to be worn almost all the time." d. "The most successful treatment for scoliosis is surgery before reaching adult age."

c. "Because our child is being treated by using braces, the braces will have to be worn almost all the time."

An adolescent client who has scoliosis and is wearing a Milwaukee brace tells the nurse that she is ugly and cannot wear the same clothing as her friends. Which response by the nurse best addresses this client's altered self-image? a. "You should not worry about what everyone else is wearing. You look fine." b. "Kids can be cruel sometimes. Has anyone told you that you look different?" c. "Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it." d. "Just hold your head up and be confident in how you look. Look for some after-school activities you can do wearing your brace."

c. "Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it."

The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the clinic to report that her child is crying and says that the cast has sand in it. The caregiver states that she has had casts herself and knows how badly they can itch. She says she always used a hanger to scratch but is worried that it will be too sharp for the child. Which statement would be appropriate for the nurse to make to this caregiver? a. "Since the child's cast is synthetic, she could soak it with cool water." b. "A plastic ruler is less likely than a hanger to cut the child's skin." c. "Nothing should be put into the cast. You can blow cool air into it with a hair dryer." d. "You could give the child an extra dose of acetaminophen and see if that helps."

c. "Nothing should be put into the cast. You can blow cool air into it with a hair dryer."

The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this. The best response by the nurse would be: a. "We put these on so the child will not pull the padding from under the cast." b. "These will help the cast look more attractive so the child won't feel self-conscious." c. "These make a smooth edge on the cast so the skin is better protected." d. "In case the child has an accident and misses the bedpan, these can be changed to keep the area dry."

c. "These make a smooth edge on the cast so the skin is better protected."

A fracture where the bone breaks in fragments

comminuted

Disturbance or injury in this area can alter the growth pattern of the bone

growth plate

The ultimate goal of treatment for Legg-Calvé-Perthes disease is to relieve pain, protect the shape of the femoral head, and restore __________ movement.

hip

The most common type of scoliosis, _________________ scoliosis, is the diagnosis given when all other causes have been ruled out and thus indicates a lateral curvature resulting from no known cause.

idiopathic

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? kyphosis lordosis idiopathic scoliosis sway back

idiopathic scoliosis

Broken ends of the bone are jammed together by the force of the injury.

impacted

A 2-year-old is diagnosed with osteomyelitis. Which of the following would you anticipate as a primary nursing intervention to include in the child's plan of care? maintaining intravenous antibiotic therapy keeping the child quiet while in skeletal traction restricting fluid to encourage red cell production assisting the child with crutch walking

maintaining intravenous antibiotic therapy

Extra digits on the hands and/or feet is a genetic condition known as _______________.

polydactyly

Progressive lateral curvature of the spine with rotation of the vertebrae; S-shaped appearance of spine. Manifestations: truncal asymmetry, uneven shoulders, raised hips/uneven waist, and rib hump. Name the disease.

scoliosis

Bone is broken in at least two places

segmental

A _______ is a stretched or torn muscle or tendon. A ________ is an injury to a ligament.

strain sprain

Incomplete, one side of bone compressed & other bends away from growth plate

torus (buckle)

The nurse is assessing the neurovascular status of a client recovering from surgery for Blount disease. What will the nurse include in the assessment? Select all that apply. · pain · pulses · pallor · paresthesia · palliation

· pain · pulses · pallor · paresthesia

The nurse is performing a musculoskeletal assessment for a newborn. Which finding(s) requires further follow up by the nurse? Select all that apply. · unequal skin folds on the thighs · different knee heights during an Ortolani test · palpable clunk noted during a Barlow test · no audible click present during assessment · equal, uninhibited abduction

· unequal skin folds on the thighs · different knee heights during an Ortolani test · palpable clunk noted during a Barlow test

A child has arrived at the outpatient orthopedic physician's office for a cast change. You are the nurse assessing the patient and notice that is irritable and complaining of pain. On examination you are concerned that the child may be developing compartment syndrome. Which of the following are early symptoms of this condition? Select all that apply? 1.Decreased sensation 2.Pain with passive movement 3.Persistent aching pain 4.Paralysis 5.Paresthesia (Tingling)

2.Pain with passive movement 3.Persistent aching pain 5.Paresthesia (Tingling)

You are the nurse preparing a family/child for discharge. The child will be sent home with a plaster cast on his arm, what instructions should be included in your discharge education plan? Select all that apply. A. Use the fingertips to lift the cast during the drying process. B. Keep small toys and sharp objects out of the reach of the child. C.Use a ruler or long object to scratch under the cast. D. Elevate the extremity for 24 hours after application and then every 48 hours to prevent swelling. E.If numbness or tingling develop, call the primary care provider immediately.

B. Keep small toys and sharp objects out of the reach of the child. D. Elevate the extremity for 24 hours after application and then every 48 hours to prevent swelling. E.If numbness or tingling develop, call the primary care provider immediately.

Definition: Also known as tibia vara or bowed legs; Disorder of the tibial growth plate that causes inward turning of the lower legs, which worsens with time. See PCP if this isn't straightened by age 3. Surgical tx: bracing or surgery Possible complications post-op: compartment syndrome or DVT

Blount Disease

True or False: The cardinal sign of compartment syndrome is pain that is out of proportion to the injury and that is unrelieved by opioids.

True

____________ injuries in nonambulating children should raise a red flag indicating potential abuse.

Twisting

A parent calls the clinic nurse to say the child has shin splints after playing soccer. What instructions should the nurse provide this parent? a. "Applying ice to the area will reduce the pain and swelling." b. "Apply ice to the injury for 60 minutes on and 60 minutes off." c. "Elevate the legs, and use bed rest for 24 hours." d. "Taking warm baths will help relax muscles and reduce pain."

a. "Applying ice to the area will reduce the pain and swelling."

The nurse is caring for a 10-year-old boy who plays on two soccer teams. He practices four days a week and his team travels to tournaments once a month. He has been diagnosed with a stress fracture in one of his vertebrae. Which of the following instructions would be most important to emphasize to the boy and his parents? a. "You and your coaches need to understand that you cannot play soccer for at least 6 weeks." b. "Ice will help reduce the inflammation." c. "You will need to see a physical therapist for stretching and strengthening exercises." d. "NSAIDS can help with pain control and inflammation."

a. "You and your coaches need to understand that you cannot play soccer for at least 6 weeks."

A child is in traction and is at risk for impaired skin integrity. Which intervention is most effective? a. Inspect the child's skin for rashes, redness, irritation, or pressure injuries. b. Assess neurovascular status on the affected extremity once every shift. c. Gently massage the child's back to stimulate circulation. d. Keep the child's skin distal to the traction clean and dry.

a. Inspect the child's skin for rashes, redness, irritation, or pressure injuries.

The nurse is caring for a child who had a cast on his lower leg placed two hours ago. When assessing the child's foot, the nurse notes that the toes are cool and the child reports extreme pain. What is the best action by the nurse? a. Notify the health care provider of the findings immediately. b. Administer prescribed pain medication. c. Reposition the leg on pillows so that it is above the level of the child's heart. d. Apply ice bags to the child's foot and ankle.

a. Notify the health care provider of the findings immediately.

The child is recovering from multiple leg fractures in Buck extension traction and reports pain out of proportion to the injury. The child's parent reports that the pain is unrelieved by the opioid treatment. Which action will the nurse perform first? a. Notify the health care provider. b. Increase the elevation of the affected limb. c. Administer an additional dose of opioids as prescribed. d. Remove the limb from the traction apparatus.

a. Notify the health care provider.

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? a. Reposition the child's foot on a pressure-reducing device. b. Apply lotion to his foot and avoid friction to the area. c. Make sure the skin and linens are clean and dry. d. Turn the child regularly.

a. Reposition the child's foot on a pressure-reducing device.

The nurse is caring for a 9-year-old child with osteogenesis imperfecta (OI) with multiple fractures in various stages of healing. What action(s) will the nurse include in the plan of care? Select all that apply. a. Teach the child and parents to avoid contact sports. b. Review the use of bisphosphonates in the child's care with the child and family. c. Review low-impact, non-weight-bearing activities in which the child can participate. d. Assist with referral to physical therapy. e. Ensure proper use of the Pavlik harness.

a. Teach the child and parents to avoid contact sports. b. Review the use of bisphosphonates in the child's care with the child and family. c. Review low-impact, non-weight-bearing activities in which the child can participate.

The primary treatment for osteomyelitis is ___________.

antibiotics

__________ is the protein of the body's connective tissue that bones are formed around.

collagen

The nurse is speaking with a parent of a child diagnosed with scoliosis. The parent states, "I hate to think about my child having to wear a huge brace to treat this disorder. My best friend growing up had to wear one and she hated it." What is the best response by the nurse? a. "Unfortunately, bracing is the only option for treating this disorder. I'm sure your child will get used to it after a few weeks." b. "The newer braces only have to be worn while the child is asleep and don't have to be worn at school." c. "Braces have been replaced with surgical intervention. Your child will only wear a brace for a few weeks after the surgery." d. "The newer type of braces fit under the arms and are made to fit under clothing. They aren't nearly as big as they used to be."

d. "The newer type of braces fit under the arms and are made to fit under clothing. They aren't nearly as big as they used to be."

The nurse is caring for an infant girl in an outpatient setting. The infant has just been diagnosed with developmental dysplasia of the hip (DDH). The mother is very upset about the diagnosis and blames herself for her daughter's condition. Which response best addresses the mother's concerns? a. "There are simple noninvasive treatment options." b. "Your daughter will likely wear a Pavlik harness." c. "Don't worry; this is a relatively common diagnosis." d. "This is not your fault and we will help you with her care and treatment."

d. "This is not your fault and we will help you with her care and treatment."

Incomplete fracture, the bone bends & breaks on convex side

greenstick

Definition: Area of tissue near the ends of long bones in children and teens that determines the future length and shape of the mature bone; Each bone has at least 2 (one at each end)

growth plate

Fractures in the _____ ______ have higher risk for deformity and impaired healing.

growth plate

A break across the bone on a diagonal angle

oblique

An _______________ is a cell that develops bone.

osteoblast

An _________________ is a specialized cell that absorbs and removes bone, allowing for the development of new bone and maintenance of bone strength. Involved in bone breakdown and bone resorption.

osteoclast

A twisting break

spiral fracture

Definition: overuse injury resulting from bone not given time to rebuild (new bone take 6-8 weeks to heal)

stress fracture

A break across the bone on a 90-degree angle

transverse

The nurse is providing postoperative care for a boy who has undergone surgical correction for pectus excavatum ("funnel chest"). The nurse should emphasize which instruction to the child's parents? · "Please watch for signs of infection." · "Be sure to monitor his vital capacity." · "Do not allow him to lie on either side." · "Do not allow him to lie on his stomach."

· "Do not allow him to lie on either side."

The nurse is reinforcing discharge teaching with the caregivers of a child who is going home after a cast has been applied. The nurse explains to the caregivers that which issues should be reported if they occur or are seen related to this child? Select all that apply. · Any area on the cast that is warm to the touch · A foul odor under the cast · Any itching under or around the edges of the cast · Drainage from under the cast · Any pink color in the fingers or toes of casted extremity · Looseness of the cast on the extremity

· Any area on the cast that is warm to the touch · A foul odor under the cast · Drainage from under the cast · Looseness of the cast on the extremity

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 · Apply a tube of stockinette over the cast · Cut a window in the cast over the wrist · X-ray the cast to make sure the bones are aligned properly

· Assess the fingers for warmth, pain, and function

A 12-year-old female client has been diagnosed with scoliosis with a curvature of 30 degrees. What type of treatment would the nurse anticipate being started on this client? · Traction · Exercise · Surgery · Bracing

· Bracing

The nurse is conducting a neuromuscular assessment on a toddler. What assessment technique(s) is important for the nurse to include in this assessment? Select all that apply. · Compare muscle strength and tone bilaterally. · Observe for involuntary muscle contractions. · Perform passive range-of-motion on all extremities. · Assess the hips for extension and abduction. · Observe the stepping reflex.

· Compare muscle strength and tone bilaterally. · Observe for involuntary muscle contractions. · Perform passive range-of-motion on all extremities.

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. · Remove traction weights once per shift for 30 minutes and then replace them. · Plan to add additional weights as the fracture heals, usually once per day. · Have the unlicensed assistive personnel remove the weights daily and encourage the child to move around in bed.

· Ensure traction weights are hanging freely, not touching the bed or floor.

The nurse is evaluating the outcomes for a child undergoing treatment for slipped capital femoral epiphysis (SCFE). Which outcome(s) indicates the plan of care has been effective for the client? Select all that apply. · No further damage has occurred from avascular necrosis. · There is full range of motion and mobility following surgery. · The child has improved spinal alignment. · There are no signs of cardiopulmonary compromise. · The child has optimal function of the foot and digits.

· No further damage has occurred from avascular necrosis. · There is full range of motion and mobility following surgery.

The nurse is caring for a child with osteomyelitis. Which nursing instruction provides accurate information to the parents? Select all that apply. · caused by Staphylococcus aureus · An abscess forms, ruptures, and spreads the infection in the metaphysis of the bone. · Transmission-based precautions are followed if the wound is draining. · Antibiotic treatment is started promptly. · Corticosteroids are the treatment of choice.

· caused by Staphylococcus aureus · An abscess forms, ruptures, and spreads the infection in the metaphysis of the bone. · Transmission-based precautions are followed if the wound is draining. · Antibiotic treatment is started promptly.

The nurse is preparing to administer pamidronate to a child with osteogenesis imperfecta. What intervention(s) will the nurse perform during the child's care? Select all that apply. · monitoring the IV site during infusion · monitoring urinary output · assessing for fever and myalgia · administering by IV every 1 to 2 months

· monitoring the IV site during infusion · monitoring urinary output

The nurse is assessing a 7-year-old child with right Legg-Calvé-Perthes (LCP) disease, and documents the findings shown in the chart note above. Which finding(s) is consistent with LCP disease? Select all that apply. · pain in the leg · right leg shorter than left leg · limited hip mobility · clothes draping unevenly · slouched posture

· pain in the leg · right leg shorter than left leg · limited hip mobility