EXAM # 2

What is the # 1 cause of accidental death in children younger than 15 years old? What is the # 2 cause of accidental death in children younger than 15 years old? Burn injuries can result from what? Burns are considered Major if they occur to what area of the body? Where do we treat each type of burn?

-# 1 Cause: Motor Vehicle Accidents -# 2 Cause: Burns -Extreme heat sources, exposure to cold, chemicals, electricity, & radiation. -Major Burns: face, hands, feet, perianal, anterior chest or circumferential. These burns need to be treated at an actual Burn Center. -Moderate Burns: These burns can be treated at a hospital that specializes in burn care. -Minor Burns: These burns can be treated on an outpatient basis.

What do we do initially for pts. w/ burns in order to treat them? How do we know that we are adequately hydrating the pt.? Why do we do this? What else is a good indicator of how our pt. is doing? What are some signs of dehydration? What are the most frequent causes of burns in children?

-1st we do ABC's in that order, then fluid resuscitation. Fluid resuscitation= lots & lots of fluids. Now these pts. can weigh a lot & be hypovolemic & then go into shock -We have to watch a pts. urinary output in order to know if their hydration is okay. This is done in order to keep the pts. BP up. A change in LOC is a good indicator of how the pt. is doing (pain/ alert/ responsive/ unresponsive)......Decreased BP, increased HR, Increased RR signs of dehydration -The most frequent causes of burns in children are hot liquid scalds, flame burns, contact burns, electrical burns and chemical burns.

Any time pts. present w/ this type of pain, then what needs to be done? How do we manage SCFE? What happens if the intervention is made & pt. is still complaining of pain? Never do what? Describe Scoliosis:.........What age group is it seen in? What can occur if severe? What type of treatment may be needed?

-Anytime a child presents w/ this type of pain, a complete hip examination needs to be done. -Treatment of SCFE: 1. Surgical Pinning. 2. After Surgical pinning is performed on the pt. & the pt. complians of pain- do not place the pt. in a wheel chair b/c they'll to bend. Instead give the pt. crutches or have them lay flat in the bed. -Idiopathic Scoliosis Description: is an abnormal lateral curvature of the spine. Its (typically seen in children age 10-16). If severe, it can cause respiratory compromise. Surgical correction by spinal fusion or instrumentation may be required if conservative treatment is ineffective.

Why do burns result in edema & hypovolemia? What else do we see happen to these pts. because of burns? What is our goal in terms of a urinary output for these pts. ? What does HESI say?

-Burns cause edema & hypovolemia b/c they cause an increase in capillary permeability. This results in a leaking of fluid from the capillaries, 3rd spacing. We see a 3rd spacing of plasma proteins, fluids, & electrolytes to be lost. -We also see a systemic response of anemia, caused by the direct heat destruction of red blood cells (RBCs); Initially, there is an increased blood flow to the heart, brain, & kidneys, with decreased blood flow to the GI tract. There is an increase in metabolism to maintain body heat, providing for the increased energy needs of the body. -Our goal is 4 our pts. to have a urinary output of (1cc/kg/hr). HESI HINT • Urinary output for infants & children should be 1 to 2 mL/kg/hr.

What Colloid solutions are used? How much fluid do children require to get better? What may occur to children w/ severe burns in terms of nutrition? Most children w/ burns of what percentage will need what? Do we give ABX to its. w/burns? Why or Why not?

-Colloid solutions such as albumin, Plasma-Lyte, or fresh-frozen plasma are useful in maintain- ing plasma volume. However, children with burn injuries usually require fluids in excess of their calculated maintenance and replacement volume. -Hypoglycemia can result from the stress of the burn injury b/c the liver glycogen stores are rapidly depleted. They need a high protein, high calorie diet. -Most children w/ burns in excess of 25% TBSA require supplementation w/ tube feeding. -ABX are usually not administered prophylactically b/c systemic ABX isn't indicated b/c there is decreased circulation to the injured area that prevents delivery of the medication to areas of deepest injury.

Describe Developmental Dysplasia of the Hip (DDH):..........How do we diagnose if a pt. may have this? Describe each test: Barlow, Ortolani, & Galeazzi

-Developmental Dysplasia of the Hip: is a broad term used to describe a spectrum of disorders r/t the abnormal development of the hip (Abnormal development of the femoral head in the acetabulum-<the socket>) . Its basically a dislocation of the hip joint. It can occur at any time during fetal life, infancy, or childhood. -We can Physically diagnosis DDH: by looking to see if their is a palpable hip dislocation on exam via the use of the Ortolani & Barlow tests. They R are most reliable from birth to 4 weeks of age. -Barlow Test: the dislocatable hip is dislocated by adduction & depression of the flexed femur -Ortolani Test: the dislocated hip is reduced by elevation & abduction of the flexed femur -Galeazzi Test: we look 4 an apparent limb length discrepancy d/t a unilateral dislocated hip w/ hip & knee flexed at 90 degrees.

What do pts. who are undergoing the debridement procedure need? What is hydrotherapy used for? How does it work? What is Allograft? What do we need to know about this?

-Débridement is painful & requires analgesia and a sedative before the procedure. -Hydrotherapy is used to cleanse the wound and involves soaking in a tub or showering at least once a day for no more than 20 minutes. Hydrotherapy helps cleanse not only the wound but also the entire body & aids in maintenance of ROM. -Allograft (homograft) skin is obtained from human cadavers that are screened for communicable diseases. Typically, rejection is seen approximately 3 to 4 weeks after application

What emergent care do we provide for pts. undergoing burns continued? How do we calculate TBSA? What should one do if a child or person is on fire?

-Emergency Care Continued: 5. Do NOT break blisters (only specialists). 6. Avoid cold & Ice. 7. Tetanus immunization (q 10 years, but if you need 1 then q 5 years). Ask about DTAP. 8. Don't give the pt. anything by mouth, & establish IV access w/ a large bore catheter -There are two commonly used methods to calculate the total body surface area (TBSA) involved: 1. Palmar Surface 2. Rule of 9's -Place the injured child in a horizontal position & roll the pt. in a blanket, rug, or similar article, w/ care taken not to cover the head & face because of the danger of inhalation of toxic fumes. If nothing is available, the victim should lie down & roll over slowly to extinguish them.

Fluid loss is maximal in minor burns in what time frame?In major burns? What emergent care do we provide for pts. undergoing burns?

-Fluid losses are maximal from 3 to 12 hours post injury in small burns and up to 24 - 48 hours in larger burns. -Emergent Care: 1. Remove anything that is causing the burn to be worst, including jewelry. 2. Wash away whatever caused the pts. burns w/ water. Use tap water for 20 - 30mins to cool a burn. 3. Cover the pt. w/ clean DRY sheets to prevent contamination, decrease pain by eliminating air contact, & prevent hypothermia. 4. No antiseptic preparations. Application of topical ointments, oils, or other home remedies is contraindicated.

As a HESI Hint: Children don't like to receive what? As a result they will do what? Describe the Trendelenburg Sign:...........Describe Legg-Calve-Perthes:...........Who does this condition effect? How does it present itself? This disease is usually what? What might these pts. hx reveal?

-HESI Hint: Children do not like injections & will deny pain to avoid "shots." -Trendelenburg sign: Its when a child stands first on one foot & then on the other (holding onto a chair, rail, or someone's hands) bearing weight on affected hip, pelvis tilts downward on normal side instead of upward, as it would w/ normal stability. -Legg-Calve-Perthes: Is the idiopathic avascular necrosis of the femoral head (IDK no blood flow to the head of the femur & it died). It effects kids age 2 - 12 yrs old. Most cases are bilateral. The dz is usually insidious (gradual), & the hx may reveal only intermittent appearance of a limp on the affected side or a symptom complex.

Read how to properly log roll a pt.

-LOG ROLLING: 1. Usually requires two or more persons, depending on the size of the client. 2. Client is carefully moved on a draw sheet to the side of the bed away from which they are to be turned (moved to the left if they are to face to the right). 3. Client is then turned in a simultaneous motion (log- rolled), maintaining the spine in a straight position. 4. Pillows are arranged for support and comfort, & they assist the client to maintain alignment.

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-Management of fractures: 1. For a Nondisplaced finger fracture= we do "buddy taping" 2. For Metacarpals & thumbs = we do short arm casts 3. & we cast fractured areas + joints above & below -Nursing care for: Casting, traction, ORIF -Pts. in casts are at Risk of developing ischemia & compartment syndrome 1. So we Assess for the five Ps: pain, pallor, pulselessness, parasthesia, paralysis 2. We also Check pulses, color, movement/sensation, temp, edema, pain, & report it immediately *Plus we provide care of the cast, traction devices, and/or surgical sites

When does maximum UVR exposure occur? How do we treat sun burns when they occur? How do we prevent sun burns?

-Maximum UVR exposure occurs at midday (10 AM-4 PM), -Sun Burn Treatment: 1. Place the burned area under a cool tap water soak or immersion of tepid-water bath (temperature slightly below 36.7° C [98° F]) for 20 minutes or until the skin is cool 2. Then apply a bland oil-in-water moisturizing lotion. -Sun Burn Prevention: 1. Place the child in protective clothing 2. Apply Sun block (preferably zinc oxide & titanium dioxide ointments) to exposed areas & areas you think will become exposed like skin folds. -Remember sunscreen agents aren't recommended for infants younger than 6 months. But they can have it applied to small areas of skin like the back of their hands. Use fabrics like cotton 4 protection, shaders, or place in areas of physical shade.

How else do we relieve the discomfort of minor burns? What other effect does this drug have? W/ major burns, when a full-thickness burn encircles the chest, what happens? What may relieve this? For major burns how soon do we have to provide fluid? What solutions are provided during the initial phase of major burn therapy? How else can we tell if a pts. fluid hydration is adequate?

-Minor Burns: A mild analgesic such as acetaminophen is usually sufficient to relieve discomfort; the antipyretic effect of the drug also alleviates the sensation of heat. -Major Burns: When full-thickness burns encircle the chest, constricting eschar may limit chest wall excursion, & ventilation of the child becomes more difficult. Escharotomy of the chest relieves this constriction & improves ventilation. -Also provide fluid w/in the first 24 hrs. Crystalloid solutions R used during this initial phase of therapy. Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, & state of sensorium determine adequacy of fluid resuscitation.

How do we assess to see if a pt. has Scoliosis? (9)

-Nursing Assessment: *Occurs most commonly in adolescent females (10 to 15 years old) 1. Elevated shoulder or hip 2. Head & hips not aligned 3. Adam's Test: While a child is bending forward, a rib hump is apparent. (Ask child to bend forward from the hips w/ arms hanging free, & examine the child 4 a curve of the spine, rib hump, & hip asymmetry.) 4. Shoulder Depression 5. Asymmetry of the Scapulae (unequal) 6. A Curved Spine 7. A Sacral Tilt 8. Asymmetry in distance between the arms & body (unequal) 9. Observe → brace → surgery

What can we do as nurses for pts. w/ Scoliosis in terms of educating pts. about the use of a brace? Does the brace correct the abnormal spinal curvature of the pts. spine?

-Nursing Interventions: 1. Screen all adolescent children, especially females, during growth spurt. B. Prepare child & family for conservative treatment such as the use of a brace. 1. Teach application of brace (Boston, Wilmington or Milwaukee R the most common braces used). 2. Instruct to wear 23 hours a day. 3. Instruct to wear a T-shirt under brace to decrease skin irritation. Instruct to check skin 4 areas for signs of irritation or breakdown. 4. Suggest clothing modifications to camouflage brace. 5. Reinforce prescribed exercise regimen for back & abdominal muscles. 6. Plan w/ adolescent ways of improving self-concept. 7. Teach family that severe, untreated scoliosis can cause respiratory difficulty. -HESI HINT: A brace does not correct the spine's curve in a child with scoliosis; it only stops or slows the progression.

Describe Osteogenesis Imperfecta (OI)

-Osteogenesis imperfecta (OI) is a congenital disease caused by a defect in the gene that produces type 1 collagen, an important building block of bone. It results in Bone fragility & fractures b/c bones very weak & Ligamentous laxity (very bendy). These pts. will be Short in stature. There isn't enough osteoblast so get fractures. Scoliosis Non-Orthopaedic manifestations blue sclera hearing loss brownish opalescent teeth (dentinogenesis imperfecta) increased risk of malignant hyperthermia

What is a positive Ortolani Sign? What are some other ways we can diagnose a pt. w/ Developmental Dysplasia of the Hip for infants (4)? An older child (2)? List some nursing interventions that can be done:...........When should the harness be removed? How long is the Harness worn?

-Other ways we can Diagnose this (INFANTS): 1. A Positive Ortolani sign ("clicking" with abduction) 2. Unequal folds of skin on butt & thigh 3. Limited abduction of the affected hip 4. Unequal leg lengths B. OLDER CHILD 1. A Limp on the affected side 2. Trendelenburg sign -Remember that the Barlow & Ortolani are rarely positive after 3 months of age -Nursing interventions: 1. Apply an abduction device or splint (Pavlik harness; Frejka or von Rosen splint) as rx. Therapy involves positioning legs in a flexed abducted position. The harness should only be removed 4 baths. Its worn continuously until the hip is proved stable on clinical & ultrasound examination, usually in 6 to 12 weeks.

Describe Slipped Capital Femoral Epiphysis (SCFE):.........SCFE usually develops when? Occurs most commonly in who? What is the average age for SCFE? What is this associated w/? There is also a distinct risk of what? List the Symptoms of SCFE:

-SCFE Description: The femoral head slips off growth plate (epiphysis). It develops most frequently shortly b4 or during a period of rapid growth & the onset of puberty. This is more common in boys (Majority are over 95th percentile). Seen in kids between the ages of 9-15 years old. -Its bilateral in 17 to 50% of pts. -Its associated w/ puberty. There is a distinct risk of slippage to contralateral side (occur on other side?) -Symptoms: 1. Painful limp w/o hx of trauma* to hip, knee, groin, or thigh. But they present w/ pain there. 2. Leg held in an externally rotated position * 3. Limited abduction & flexion

How do we care for a pt. we suspect has been poisoned?

-SIRES: 1. Stabilize the child 2. Identify the toxin 3. Reverse its effects 4. Eliminate the substance 5. Support physically & psychologically -1962 Dr. Kempe described the "battered child" -Clues that arouse suspicion Includes: 1. Story doesn't explain injury 2. Inconsistencies or parent blames sibling 3. Long interval between injury & treatment 4. Inappropriate reaction 5. Unrealistic expectations of child

List Symptoms of Legg-Calve-Perthes (4):.............How do we manage pts. w/ Legg-Calve-Perthes?

-Symptoms will also include: 1. PAIN that is worse w/ activity hip, (along the entire thigh, or in the vicinity of the knee joint), 2. LIMITED PASSIVE ROM, 3. Tenderness over groin, 4. Limited abduction & rotation -Management of Legg-Calve-Perthes: 1. Short period of bed rest initially, 2. Ibuprofen, 3. Possible surgery. 4. Non-weight-bearing devices such as abduction braces 5. Worse prognosis > age 6 (Know that About half develop degenerative premature osteoarthritis 6. May need a hip replacement in a few decades.

Describe each type of fracture: (type 1, type 2, type 3, type 4, type 5)............Which 1 is the worst & why?

-Type 1 Fracture: Complete epiphyseal (growth plate) fracture w/ or w/out displacement. -Type 2 Fracture: epiphyseal fracture that goes through the metaphysis that results in a chip fracture of it that can be really small. -Type 3 Fracture: epiphyseal fracture that goes through the epiphysis -Type 4 Fracture: epiphyseal fracture that includes a fracture of both the growth plate & metaphyseal fracture. -Type 5 Fracture: compression fracture of the growth plate. -Type 5 is the worst b/c it will ossify.

What is Xenograft? When should we have burn pts. participate in their care? What are some things we can do to prevent burns?

-Xenograft from a variety of species, most notably pigs, is commercially available. Pigskin dressings are replaced every 1 to 3 days. -Children should begin early to do as much for themselves as possible & to be active participants in their care. -Burn Prevention: 1. Keep hot liquids out of reach (usually found in kitchen & bathroom) 2. Keep dangling table cloths & dangling appliance cords out of reach 3. Baby proof electrical outlets. 4. Reduce water heater thermostats to a maximum of 48.9° C (120° F). 5. Never leave a child unattended in a bath w/out adult supervision. Always test the water b4 placing the kid in the tub or shower. 6. Use caution when removing items from microwave oven & always test the food b4 giving it to kids. 7. Keep potentially hazardous items out of the reach of children; (i.e. a lighter, a match)

Developmental Dysplasia of Hip interventions continued:...........Never place these infants in what?

2. Teach parents about home care. 3. Teach application & removal of device (worn 24 hours a day). 4. Teach skin care & bathing (physician may allow parents to remove device for bathing). Always put an undershirt (or a shirt with extensions that close at the crotch) under the chest straps and put knee socks under the foot and leg pieces to prevent the straps from rubbing the skin. Check frequently (at least two or three times a day) for red areas under the straps & the clothing. Gently massage healthy skin under the straps once a day to stimulate circulation. In general, avoid lotions and powders because they can cake and irritate the skin. Always place the diaper under the straps. Parents are encouraged to hold the infant with a harness and con- tinue care and nurturing activities. -Avoid swaddling w/ legs together, & avoid use of slings (anything that holds the leg together.

Developmental Dysplasia of Hip interventions continued again even more: (care for pts. in Bryant Traction continued) How do we care for its. who will need surgery?

4. Instruct to meet developmental needs of an immobilized infant. 5. Incorporate family in care. 6. Prepare family for spica cast application. -Provide nursing care for a child requiring surgical correction. 1. Perform preoperative teaching of child and family, including cast application. 2. Perform postoperative care. 3. Assess vital signs. 4. Check cast for drainage & bleeding. 5. Perform neurovascular assessment of extremities. 6. Promote respiratory hygiene. 7. Administer narcotic analgesics or morphine either IV (preferred) or IM (Table 5-11). 8. Teach family cast care when child gets home.

Developmental Dysplasia of Hip interventions continued again: (Care for pts. in Bryant Traction)

5. Teach diapering. 6. Teach that follow-up care involves frequent adjustments because of growth. B/c of infants' rapid growth, the straps should be checked in the beginning of therapy & every 1 - 2 weeks 4 adjustments.Teach how to provide care for an infant in Bryant traction (used if splinting is ineffective). Parents are instructed to not adjust the harness. The child should be examined by the practitioner before any adjustment is attempted to make certain the hips are in correct placement. -Care for pts. in a Bryant Traction: 1. Instruct to maintain hips in 90-degree flexion. 2. Instruct to elevate buttocks off bed. 3. Instruct to monitor circulation to feet.

Ilizarov Apparatus

Acts as a bridge, both immobilizing the fracture site and relieving it of stress, while allowing for the movement of the entire limb and partial weight-bearing. The Ilizarov frame is also commonly used to correct deformity through distraction osteogenesis.

Describe what Osteogenesis Imperfecta (OI) is:

Bone fragility and fractures Ligamentous laxity (very bendy) Short stature Scoliosis Non-Orthopaedic manifestations blue sclera hearing loss brownish opalescent teeth (dentinogenesis imperfecta) increased risk of malignant hyperthermia

What type of postoperative care do we provide for pts. who have undergone Scoliosis?

D. Provide postoperative care. 1. Perform frequent neuro checks. 2. Perform Log-roll for 5 days, change position q2hrs 3. Administer IV fluids (IV fluids given until PO) & analgesics as prescribed (usually a PCA epidural. It requires q1h checks). 4. Perform oral hygiene (client NPO). 5. Monitor nasogastric tube & bowel sounds. 6. Assist w/ ambulation, provide body jacket, progressively ambulate. 7. Teach child & family that body jacket will be worn 4 several months until the bone fusion is stable. 8. Pt. discharged w/ brace

Clubfoot (talipes equinovarus)

Non-operative serial manipulation and casting (Ponseti method) 90% success rate Operative soft tissue release & tendon lengthening resistant feet in young children performed at 9-10 months so the child can be ambulatory at one year of age

Child Abuse/Ortho Signs

Red flags Injury inconsistent with history Fractures in infant that is not yet walking Multiple fractures in various stages of healing Posterior rib fractures FYI → frequency of fractures is: humerus > tibia > femur Skeletal survey

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lateral curvature of the spine which is > 10% on x-ray with vertebral rotation idiopathic (most common) congenital skeletal abnormalities neuromuscular (Cerebral Palsy, Spina Bifida) related to neurofibromatosis type I Nursing care: PICU first then pedi unit Foley while epidural in place NG until bowel sounds return IV fluids until po PCA (epidural) requires q1h checks Log-rolling to change position q2h Respiratory care D/C with Brace

How do we prepare our pts. w/ Scoliosis who will undergo surgical correction?

-C. Prepare child and family for surgical correction if required. (pt. goes to PICU 1st then the pediatric unit) 1. Teach child & family log-rolling technique. 2. Teach how to practice respiratory hygiene. 3. Orient child to ICU. 4. Discuss postoperative tubes: Foley (usually has foley while epidural is in place), nasogastric tube is in place until bowel sounds return, & chest tube (if anterior fusion is performed). 5. Obtain a baseline neurologic assessment.