Saunders Peds Neuromuscular

Other findings *developmental dysplasia* of the hip, include an

*apparent SHORT femur* on the *affected side*, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The five Ps of vascular impairment are

1. pain 2. pallor 3. pulselessness 4. paresthesia 5.paralysis. Prompt intervention is critical if neurovascular impairment is to be prevented.

Braces for treatment of scoliosis usually are worn

16 to 23 hours a day. (McGrath says 23) The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, breaks in skin integrity are the client problem that should be included in this child's plan of care. The brace assists with posture, so mobility is not an issue. The brace does not compromise the respiratory status, so oxygenation is not decreased. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace.

The Moro reflex is normally present at birth but is absent by

6 months; if still present at 6 months, there is an indication of neurological abnormality.

The palmar-plantar grasp is present at birth and lessens within

8 months.

a fracture of the bone *across its entire shaft* with some *possible displacement* but *without breaking the skin.*

A *simple fracture* is

An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to Figure.

A Pavlik harness for the treatment of congenital hip dislocation

The nurse is assisting a health care provider (HCP) during the examination of an infant with developmental hip dysplasia. The HCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted?

A palpable click during abduction of the affected hip In the Ortolani maneuver, the examiner abducts both hips. A positive finding is a palpable click on the affected side during abduction. Crying is expected. Asymmetry and reduced range of motion of the affected hip are not positive signs of this maneuver.

superior mesenteric artery syndrome results in

A syndrome of *emesis* and *abdominal distention* similar to that which occurs with *intestinal obstruction* or *paralytic ileus* Postoperative vomiting in children with *body casts* or children who have undergone *spinal fusion* warrants attention because of the possibility of superior mesenteric artery syndrome.

A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position?

Abduction The Pavlik harness consists of chest and shoulder straps and foot stirrups. The device, which is used to correct hip dislocations in infants with developmental dysplasia of the hip, consists of a set of straps that hold the hips in flexion and abduction.

hip spica cast

Applied to trunk, complete leg of affected side, one-half of unaffected leg.

An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain?

Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for not longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

A child has just returned from surgery and has a hip spica cast. What is the nurse's priority action for this client?

Assess the circulatory status. During the first few hours after a cast is applied, the chief concern is swelling, which may cause the cast to act as a tourniquet and obstruct circulation. Therefore, circulatory assessment is a high priority. Elevating the head of the bed of a child in a hip spica cast would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica cast immobilizes the hip and knee. Turning the child from one side to the other at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not a higher priority than checking circulation.

In *developmental dysplasia* of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis.

Asymmetrical and restricted *abduction* of the affected hip, when the child is placed *supine* with the *knees and hips flexed*, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period.

The nurse is reviewing the health care record of an infant suspected of having *unilateral hip dysplasia*. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table is noted in hip dysplasia. Asymmetrical abduction of the affected hip when an infant is placed supine with the knees and hips flexed would also be an assessment finding in hip dysplasia in infants beyond the newborn period. An apparent short femur on the affected side is noted, as well as limited range of motion.

A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem?

Breaks in skin integrity

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the mother. The mother returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy and that the child is agitated and crying loudly. The mother states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred?

Compartment syndrome

Ankle Equinus

Congenital or acquired functional ankle joint sagittal plane motion with less than 10° of available joint dorsiflexion when the foot is in subtalar joint-neutral

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction?

Elevated temp The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature. The remaining options are not specifically associated with osteomyelitis

The pediatric nurse educator provides a teaching session to the nursing staff regarding *juvenile idiopathic arthritis (JIA*). Which action by a nursing staff member in the care of a child with JIA indicates a need for further education? Assesses for joint stiffness in the child Encourages performance of isometric exercises Administers nonsteroidal antiinflammatory medication Emphasizes the importance of rising quickly in the mornings

Emphasizes the importance of rising quickly in the mornings Test-Taking Strategy: Note the strategic words need for *further education* in the question. This phrasing indicates a negative event query and asks you to select an option that is an incorrect statement. Recalling that JIA involves inflammation of the joints will direct you to the correct option.

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

Have the child perform simple isometric exercises during this time."

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for *further instruction*?

I can use lotion or powder around the cast edges to relieve itching."

Parents bring their *2-week-old infant* to a clinic for treatment after a diagnosis of *clubfoot* made at birth. Which statement by the parents indicates a need for *further teaching* regarding this disorder?

I need to bring my infant back to the clinic in +1 month* for a new cast."

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness?

I will watch for any redness or skin irritation where the straps are applied and call the health care provider for red areas." If stabilization of the hip is required, a cast is initially applied. This is kept in place for 3 to 6 months until the hip is stabilized. After this is completed, and if further treatment is required, a Pavlik harness is the treatment of choice next. A Pavlik harness is a removable abduction brace. The brace must be checked every 1 to 2 weeks for adjustment of the straps. The use of double diapering is not recommended for developmental dysplasia of the hip (DDH) because of the possibility of hip extension. Because there are straps applied to the child's skin, it is important to check the skin of the child frequently. Test-Taking Strategy: Focus on the subject, care to the child in a Pavlik harness. Knowing that the child must return to the orthopedic office in 1 to 2 weeks for strap adjustment will allow you to eliminate option 2. Also, knowing that the Pavlik harness is removable will allow you to eliminate option 1 because this states that the harness should be worn continuously. It is also not recommended that double diapering be done with children who are diagnosed with DDH, so this will eliminate option 3

A child sustains a fall at home and is brought to the hospital emergency department by the child's mother. After a radiographic examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding *neurocirculatory assessment* and function.

I'll need to check her skin twice a day at the cast edges." For the first couple of days, I should try to keep her hand higher than her heart most of the time using pillows." "If she seems way too fussy and her arm is painful even after I've given her the pain medication, it might be a problem, and I should call you for help to decide on what is happening."

A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the priority before transferring the child to the hospital emergency department?

Immobilize the arm. When a fracture is suspected, it is imperative that the area be *splinted and immobilized* before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance.

The nursing plan of care for juvenile idiopathic arthritis (JIA) focuses on the status of affected joints.

Isometric exercises and passive range of motion exercises will prevent contractures and deformities. Nonsteroidal antiinflammatory medications are used to treat joint stiffness and pain. The child may need more time than average to begin morning activities.

an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage.

Juvenile idiopathic arthritis

A 1-month-old infant is seen in a clinic and is diagnosed with *developmental dysplasia* of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

Limited range of motion in the affected hip In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which assessment findings should the nurse expect to note in a child who has been diagnosed with JRA? Select all that apply.

Morning stiffness Painful, stiff, and swollen joints Limited range of motion of the joints History of late-afternoon temperature

An alert child, who is crying loudly, is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment?

Neurovascular

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims's position. 4. Notify the health care provider (HCP).

Notify HCP

In a greenstick fracture the bone is partly bent and partly broken.

Only happens in growing kids

It keeps the *hips* and *knees* FLEXED the *hips* ABducted and the *femoral head in the acetabulum*.

Pavlik harness

The nurse in the pediatric unit is preparing for the admission of a child with a dislocated hip. The child will be placed in *Buck's extension traction* preoperatively for short-term immobilization. The nurse prepares to place the child in which type of traction setup? Click on the image to indicate your answer.

Picture #1 Buck's extension traction is a type of skin traction in which the legs are in an extended position. It is used primarily for short-term immobilization, such as in preoperative management of a child with a dislocated hip. A 90- to 90-degree femoral traction (option 2) is used for femur fractures. In this type of traction, the lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the fracture. Russell's traction (option 3) is used for fractures of the femur or for hip and knee contractures. It uses skin traction on the lower leg with a padded sling under the knee. Balanced suspension (option 4) may be used with or without skin or skeletal traction. It is used for femur, hip, or tibial fractures. The balanced suspension suspends the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. In balanced suspension, a Thomas splint extends from the groin to midair above the foot, and a Pearson attachment supports the lower leg.

A child with *cerebral palsy* is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board While lying on the abdomen, the child can move around independently anywhere the child wants to go and can interact with others as desired. Orthoses need to be used all the time to aid locomotion. Children with cerebral palsy (CP) need to be mainstreamed as much as cognitive ability permits to provide for maximum socialization and normalization. Not all children with CP are intellectually challenged.

A child is brought to the emergency department, and diagnostic x-rays of the child reveal that a fracture is present. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. A plaster of Paris cast is applied to the arm. Which instructions should the nurse provide the mother? Select all that apply.

Plaster of Paris is a heavier material than that used in a synthetic cast. It molds easily to the extremity and is less expensive than a synthetic cast. It takes about 24 hours to dry, but drying time could be longer, depending on the size of the cast. Plaster of Paris is not water resistant and will begin to disintegrate when wet. The cast should be elevated on a pillow for the first day to decrease swelling as the cast begins to mold to the arm. As the cast molds, it is imperative that the child can wiggle the fingers because the extremity continues to swell. If the child can wiggle the fingers, adequate motion is present. Color and sensation of the fingers should also be assessed. All of these are important components of a teaching plan for a parent.

The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate?

Report to hcp child's complaint of pins and needles or of the extremity falling asleep needs to be reported to the health care provider. These complaints indicate the possibility of circulatory impairment and paresthesia. Paresthesia is a serious concern because paralysis can result if the problem is not corrected. The five Ps of vascular impairment are pain, pallor, pulselessness, paresthesia, and paralysis. Prompt intervention is critical if neurovascular impairment is to be prevented.

hindfoot varus

Talus and calcaneus almost parallel -> club foot

How to do Ortolani's maneuver

The examiner *abducts the thigh* and applies *gentle pressure forward* over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum.

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace.

The use of lotions or powders should be avoided with a brace because they can become sticky or cake under the brace, causing irritation. The actions in the remaining options are appropriate interventions for the use of a brace on a child.

The nurse has reinforced teaching for a school-age child who was given a brace to wear for the treatment of scoliosis. The nurse determines that the child needs further teaching if the child makes which statement?

This brace will correct my curve." Bracing can halt the progression of most curvatures, but it is not curative for scoliosis.

A complication after surgical treatment of scoliosis is *superior mesenteric artery syndrome*.

This disorder is caused by *mechanical changes* in the position of the child's abdominal contents, resulting from lengthening of the child's body.

A 9-year-old child fractures the *left tibia* along an *epiphyseal line* while using a skateboard. What is the nurse's priority concern during future growth?

Uneven leg growth The epiphyseal line is the area that is responsible for longitudinal bone growth. A fracture affecting this area places the child at risk for uneven future growth if proper healing does not occur. The epiphyses are located at the proximal and distal ends of a bone and are the insertion sites for muscles. The diaphysis is the shaft or main longitudinal portion of a long bone. The metaphysis is an area of flaring of bone, located between the epiphysis and the diaphysis. Paralysis, pressure ulcer, and infection are not priority concerns for future growth. Paralysis and neurovascular status are priority concerns during the immediate period postinjury, but not during future growth.

comminuted fracture type

When *small fragments of bone* are broken from the fracture shaft and lie in the surrounding tissues, the fracture is called comminuted.

The nurse prepares a list of home care instructions for the parents of a child who has a *plaster cast* applied to the left forearm. Which instructions should be included on the list? Select all that apply.

While the cast is drying, the *palms of the hands* are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

A Pavlik harness is

a device that is used to treat congenital hip dislocation. It keeps the hips and *knees flexed*, the *hips abducted*, and the *femoral head in the acetabulum*. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip.

In an oblique fracture

a diagonal line across the bone is noted.

A spiral fracture

a fracture that has a twisted or circular break and affects the length rather than the width. It is seen frequently in child abuse.

Buck's extension traction is

a type of skin traction in which the legs are in an extended position. It is used primarily for *short-term immobilization*, such as in *preoperative* management of a child with a *dislocated hip*.

Babinski's sign is

abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. ( should really be absent by 1yr)

In *developmental dysplasia of the hip*, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to

assess for hip instability and can be done only before 4 weeks of age.

Although resting the extremity is appropriate in an acute exasperation of idiopathic juvenile arthritis

beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by one of the parents indicates an understanding of the use of the harness?

can remove the harness to bathe my infant." The harness should be worn 23 hours a day and can be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.

Skin integrity is a higher priority in a ________ fracture since there is an open wound.

compound

The Pavlik harness is worn

continuously for 3 to 6 months.

isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length

Balanced suspension (option 4) may be used with or without skin or skeletal traction. It is used for

femur, hip, or tibial fractures. The balanced suspension suspends the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. In balanced suspension, a Thomas splint extends from the groin to midair above the foot, and a Pearson attachment supports the lower leg.

Russell's traction (option 3) is used for

fractures of the femur or for hip and knee contractures. It uses *skin traction* on the *lower leg* with a *padded sling* under the knee.

During painful episodes of juvenile idiopathic arthritis,

hot or cold packs and splinting and positioning the affected joint in a neutral position *help reduce the pain*.

The priority assessment for a simple fracture is the neurovascular status in the affected arm. The affected arm should be

immobilized.

Scoliosis is a three-dimensional spinal deformity that usually involves

lateral curvature spinal rotation resulting in rib asymmetry hypokyphosis of the thorax.

Clinical Manifestations of osteomyelitis include

localized pain swelling warmth tenderness unusual odor from the fracture site an elevated temperature.

When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would

maintain the correct amount of weight as prescribed ensure that the weights hang freely check the ropes for fraying and ensure that they are on the pulleys appropriately monitor the neurovascular status of the involved extremity monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

forefoot adduction

movement of the forefoot toward the midline of the body, due to internal rotation of the shank

Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed

not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation.

The most serious complication associated with skeletal traction is

osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture.

Midfoot Supination

outward roll of the foot during normal motion.

Clinical manifestations associated with JRA include *intermittent joint pain* that lasts *longer than 6 weeks* and

painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include 1. malaise 2. fatigue 3. lethargy 4. anorexia 5 weight loss 6. growth problems. A history of a late-afternoon fever with temperature spiking up to 105°F (40.6°C) will also be part of the clinical manifestations.

Compartment syndrome occurs as a result of

pressure buildup within a tissue compartment bound by anatomical structures such as fascia. With a fracture, this pressure increase may occur as a result of the intense inflammatory response or severe bleeding caused by the bone injury, even when diligent nursing care has been provided. Pain disproportionate to the injury despite analgesic administration is the classic sign of compartment syndrome. The nurse should constantly assess for this complication and should instruct the caregiver about the manifestations associated with this complication.

*Clubfoot* is a *complex deformity* of the *ankle and foot* that includes *forefoot adduction* *midfoot supination* *hindfoot varus* and *ankle equinus* the defect may be *unilateral* or *bilateral*. Treatment for clubfoot is

started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in *3 to 6 months*, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

An absent pulse to an extremity of the affected limb after a bone fracture could mean that

the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.

A 90- to 90-degree femoral traction (option 2) is

used for femur fractures. In this type of traction, the lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the fracture.

The pavlik harness It promotes

the development of *muscle* and *cartilage*, resulting in a *stable hip*