Showing posts with label musculoskeletal disorder. Show all posts
Showing posts with label musculoskeletal disorder. Show all posts

DISORDERS OF THE MUSCULOSKELETAL SYSTEM

Thursday, May 22, 2008 | Labels: | 0 Comments  

Spinal Fusion

  1. General information
    1. Fusion of spinous processes with bone graft from iliac crest to provide stabilization of spine
    2. Performed in conjunction with laminectomy
  2. Nursing interventions
    1. Provide pre-op care as for laminectomy.
    2. In addition to post-op care for laminectomy
      1. Position client correctly.
        1. lumbar spinal fusion: keep bed flat for first 12 hours, then may elevate head of bed 20°-30°, keep off back for first 48 hours.
        2. cervical spinal fusion: elevate head of bed slightly.
      2. Assist with ambulation.
        1. time varies with surgeon and extent of fusion.
        2. usually out of bed 3-4 days post-op.
        3. apply brace before getting client out of bed.
        4. apply special cervical collar for cervical spinal fusion.
      3. Promote comfort: client may experience considerable pain from graft site.
    3. In addition to client teaching and discharge planning for laminectomy, advise client that
      1. Brace will be needed for 4 months and lighter corset for 1 year after surgery.
      2. It takes 1 year until graft becomes stable.
      3. No bending, lifting, stooping, or sitting for prolonged periods for 4 months.
      4. Walking without excessive tiring is healthful exercise.
      5. Diet modification will help prevent weight gain resulting from decreased activity.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Discectomy

  1. General information
    1. Excision of inter-vertebral disc.
    2. Indications
      1. Most commonly used for herniated nucleus pulposus not responsive to conservative therapy or with evidence of decreasing sensory or motor status
      2. Also indicated for spinal decompression as with spinal cord injury, to remove fragments of broken bone, or to remove spinal neoplasm or abscess
    3. Spinal fusion may be done at the same time if spine is unstable
  2. Nursing interventions: preoperative
    1. Provide routine pre-op care.
    2. Teach client log rolling (turning body as a unit while maintaining alignment of spinal column) and use of bedpan.
  3. Nursing interventions: postoperative
    1. Provide routine post-op care.
    2. Position client as ordered.
      1. Lower spinal surgery: generally flat
      2. Cervical spinal surgery: slight elevation of head of bed
    3. Maintain proper body alignment; with cervical spinal surgery avoid neck flexion and apply cervical collar as ordered.
    4. Turn client every 2 hours.
      1. Use log-rolling technique and turning sheet.
      2. Place pillows between legs while on side.
    5. Assess for complications.
      1. Monitor sensory and motor status every 2-4 hours.
      2. With cervical spinal surgery client may have difficulty swallowing and coughing.
        1. monitor for respiratory distress.
        2. keep suction and tracheostomy set available.
    6. Check dressings for hemorrhage, CSF leakage, infection.
    7. Promote comfort.
      1. Administer analgesics as ordered.
      2. Provide additional comfort measures and positioning.
    8. Assess for adequate bladder and bowel function.
      1. Monitor every 2-4 hours for bladder distension.
      2. Assess bowel sounds.
      3. Prevent constipation.
    9. Prevent complications of immobility.
    10. Assist with ambulation.
      1. Usually out of bed day after surgery.
      2. Apply brace or corset if ordered.
      3. If client allowed to sit, use straight-back chair and keep feet flat on floor.
  4. Provide client teaching and discharge planning concerning
    1. Wound care
    2. Maintenance of good posture and proper body mechanics
    3. Activity level as ordered
    4. Recognition and reporting of signs of complications such as wound infection, sensory or motor deficits

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Herniated Nucleus Pulposus (HNP)

  1. General information
    1. Protrusion of nucleus pulposus (central part of intervertebral disc) into spinal canal causing compression of spinal nerve roots
    2. Occurs more often in men
    3. Herniation most commonly occurs at the fourth and fifth intervertebral spaces in the lumbar region
    4. Predisposing factors include heavy lifting or pulling and trauma
  2. Medical management
    1. Conservative treatment
      1. Bed rest
      2. Traction
        1. lumbosacral disc: pelvic traction
        2. cervical disc: cervical traction
      3. Drug therapy
        1. anti-inflammatory agents
        2. muscle relaxants
        3. analgesics
      4. Local application of heat and diathermy
      5. Corset for lumbosacral disc
      6. Cervical collar for cervical disc
      7. Epidural injections of corticosteroids
    2. Surgery
      1. Discectomy with or without spinal fusion
      2. Chemonucleolysis
        1. injection of chymopapain (derivative of papaya plant) into disc to reduce size and pressure on affected nerve root
        2. used as alternative to laminectomy in selected cases
  3. Assessment findings
    1. Lumbosacral disc
      1. Back pain radiating across buttock and down leg (along sciatic nerve)
      2. Weakness of leg and foot on affected side
      3. Numbness and tingling in toes and foot
      4. Positive straight-leg raise test: pain on raising leg
      5. Depressed or absent Achilles reflex
      6. Muscle spasm in lumbar region
    2. Cervical disc
      1. Shoulder pain radiating down arm to hand
      2. Weakness of affected upper extremity
      3. Paresthesias and sensory disturbances
    3. Diagnostic tests: myelogram localizes site of herniation
  4. Nursing interventions
    1. Ensure bed rest on a firm mattress with bed board.
    2. Assist client in applying pelvic or cervical traction as ordered.
    3. Maintain proper body alignment.
    4. Administer medications as ordered.
    5. Prevent complications of immobility.
    6. Provide additional comfort measures to relieve pain.
    7. Provide pre-op care for client receiving chemonucleolysis.
      1. Administer cimetidine (Tagamet) and diphenhydramine HCl (Benadryl) every 6 hours as ordered to reduce possibility of allergic reaction.
      2. Possibly administer corticosteroids before procedure.
    8. Provide post-op care for client receiving chemonucleolysis.
      1. Observe for anaphylaxis.
      2. Observe for less serious allergic reaction (e.g., rash, itching, rhinitis, difficulty in breathing).
      3. Monitor for neurologic deficits (numbness or tingling in extremities or inability to void).
    9. Provide client teaching and discharge planning concerning
      1. Back-strengthening exercises as prescribed
      2. Maintenance of good posture
      3. Use of proper body mechanics, how to lift heavy objects correctly
        1. maintain straight spine.
        2. flex knees and hips while stooping.
        3. keep load close to body.
      4. Prescribed medications and side effects
      5. Proper application of corset or cervical collar
      6. Weight reduction if needed

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Total Hip Replacement

  1. General information
    1. Replacement of both acetabulum and head of femur with prostheses
    2. Indications
      1. Rheumatoid arthritis or osteoarthritis causing severe disability and intolerable pain
      2. Fractured hip with nonunion
  2. Nursing interventions
    1. Provide routine pre-op care.
    2. In addition to routine post-op care for the client with hip surgery
      1. Maintain abduction of affected limb at all times with abductor splint or 2 pillows between legs
      2. Prevent external rotation (may vary depending on type of prosthesis and method of insertion) by placing trochanter rolls along leg.
      3. Prevent hip flexion.
        1. keep head of bed flat if ordered.
        2. may raise bed to 45° for meals if allowed.
      4. Turn only to unoperative side if ordered; use abductor splint or 2 pillows between knees while turning and when lying on side.
      5. Assist client in getting out of bed when ordered.
        1. usually on second post-op day.
        2. avoid weight bearing until allowed.
        3. avoid adduction and hip flexion; do not use low chair.
    3. Provide client teaching and discharge planning concerning
      1. Prevention of adduction of affected limb and hip flexion
        1. do not cross legs.
        2. use raised toilet set.
        3. do not bend down to put on shoes or socks.
        4. do not sit in low chairs.
      2. Signs of wound infection
      3. Exercise program as ordered
      4. Partial weight bearing only until full weight bearing allowed

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Fractured Hip

  1. General information
    1. Fracture of the head, neck (intracapsular fracture) or trochanteric area (extracapsular fracture) of the femur
    2. Occurs most often in elderly women
    3. Predisposing factors include osteoporosis and degenerative changes of bone
  2. Medical management
    1. Buck's or Russell traction as temporary measures to maintain alignment of affected limb and reduce the pain of muscle spasm
    2. Surgery
      1. Open reduction and internal fixation with pins, nails, and/or plates
      2. Hemiarthroplasty: insertion of prosthesis (e.g., Austin-Moore) to replace head of femur
  3. Assessment findings
    1. Pain in affected limb
    2. Affected limb appears shorter, external rotation
    3. Diagnostic test: x-ray reveals hip fracture
  4. Nursing interventions
    1. Provide general care for the client with a fracture.
    2. Provide care for the client with Buck's or Russell traction.
    3. Monitor for disorientation and confusion in the elderly client; reorient frequently and provide safety measures.
    4. Perform neurovascular checks to affected extremity.
    5. Prevent complications of immobility.
    6. Encourage use of trapeze to facilitate movement.
    7. Administer analgesics as ordered for pain.
    8. In addition to routine post-op care for the client with open reduction and internal fixation
      1. Check dressings for bleeding, drainage, infection: empty Hemovac and note output; keep compressed to facilitate drainage.
      2. Assess client's LOC.
      3. Reorient the confused client frequently.
      4. Avoid oversedating the elderly client.
      5. Turn client every 2 hours.
      6. Turn to unoperative side only.
      7. Place 2 pillows between legs while turning and when lying on side.
      8. Institute measures to prevent thrombus formation.
        1. apply elastic stockings.
        2. encourage plantarflexion and dorsiflexion foot exercises.
        3. administer anticoagulants such as aspirin if ordered.
      9. Encourage quadriceps setting and gluteal setting exercises when allowed.
      10. Observe for adequate bowel and bladder function.
      11. Assist client in getting out of bed, usually on first or second post-op day.
      12. Pivot or lift into chair as ordered.
      13. Avoid weight bearing until allowed.
    9. Provide care for the client with a hip prosthesis if necessary (similar to care for client with total hip replacement).

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Open Reduction and Internal Fixation

  1. General information
    1. Open reduction of fractures requires surgery to realign bones; may include internal fixation with pins, screws, wires, plates, rods, or nails
    2. Indications include
      1. Compound fractures
      2. Fractures accompanied by serious neurovascular injuries
      3. Fractures with widely separated fragments
      4. Comminuted fractures
      5. Fractures of the femur
      6. Fractures of joints
  2. Nursing interventions: preoperative
    1. Provide routine pre-op care.
    2. Provide meticulous skin preparation to prevent infection.
  3. Nursing interventions: postoperative
    1. Provide routine post-op care.
    2. Maintain affected limb in proper alignment.
    3. Perform neurovascular checks to affected extremity.
    4. Observe for post-op infection.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Fractures

  1. General information
    1. A break in the continuity of bone, usually caused by trauma
    2. Pathologic fractures: spontaneous bone break, found in certain diseases or conditions (osteoporosis, osteomyelitis, multiple myeloma, bone tumors)
    3. Types
      1. Complete: separation of bone into two parts
        1. transverse
        2. oblique
        3. spiral
      2. Incomplete (partial): fracture does not go all the way through the bone, only part of the bone is broken.
      3. Comminuted: bone is broken or splintered into pieces.
      4. Closed or simple: bone is broken without break in skin.
      5. Open or compound: break in skin with or without protrusion of bone.
  2. Medical management
    1. Traction
    2. Reduction
      1. Closed reduction through manual manipulation followed by application of cast
      2. Open reduction
    3. Application of a cast
  3. Assessment findings
    1. Pain, aggravated by motion; tenderness
    2. Loss of motion; edema, crepitus (grating sound), ecchymosis
    3. Diagnostic test: x-ray reveals break in bone
  4. Nursing interventions
    1. Provide emergency care of fractures.
    2. Perform neurovascular checks on affected extremity.
    3. Observe for signs of compartment syndrome (swelling causes an increase within muscle compartment which causes edema and more pressure; irreversible neuromuscular damage can occur within 4 to 6 hours); signs include weak pulse, pallor followed by cyanosis, paresthesias and severe pain.
    4. Observe for signs of fat emboli (respiratory distress, mental disturbances, fever, petechiae) especially in the client with multiple long-bone fractures.
    5. Encourage diet high in protein and vitamins to promote healing.
    6. Encourage fluids to prevent constipation, renal calculi, and UTIs.
    7. Provide care for the client in traction, with a cast, or with open reduction.
    8. Provide client teaching and discharge planning concerning
      1. Cast care if indicated
      2. Crutch walking if necessary
      3. Signs of complications and need to report them

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Osteomyelitis

  1. General information
    1. Infection of the bone and surrounding soft tissues, most commonly caused by S. aureus.
    2. Infection may reach bone through open wound (compound fracture or surgery), through the blood stream, or by direct extension from infected adjacent structures.
    3. Infections can be acute or chronic; both cause bone destruction.
  2. Assessment findings
    1. Malaise, fever
    2. Pain and tenderness of bone, redness and swelling over bone, difficulty with weight bearing; drainage from wound site may be present
    3. Diagnostic tests
      1. CBC: WBC elevated
      2. Blood cultures may be positive
      3. ESR may be elevated
  3. Nursing interventions
    1. Administer analgesics and antibiotics as ordered.
    2. Use sterile technique during dressing changes.
    3. Maintain proper body alignment and change position frequently to prevent deformities.
    4. Provide immobilization of affected part as ordered.
    5. Provide psychologic support and diversional activities (depression may result from prolonged hospitalization).
    6. Prepare client for surgery if indicated.
      1. Incision and drainage of bone abscess
      2. Sequestrectomy: removal of dead, infected bone and cartilage
      3. Bone grafting after repeated infections
      4. Leg amputation
    7. Provide client teaching and discharge planning concerning
      1. Use of prescribed oral antibiotic therapy and side effects
      2. Importance of recognizing and reporting signs of complications (deformity, fracture) or recurrence

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Systemic Lupus Erythematosus (SLE)

  1. General information
    1. Chronic connective tissue disease involving multiple organ systems
    2. Occurs most frequently in young women
    3. Cause unknown; immune, genetic, and viral factors have all been suggested
    4. Pathophysiology
      1. A defect in body's immunologic mechanisms produces autoantibodies in the serum directed against components of the client's own cell nuclei.
      2. Affects cells throughout the body resulting in involvement of many organs, including joints, skin, kidney, CNS, and cardiopulmonary system.
  2. Medical management
    1. Drug therapy
      1. Aspirin and NSAIDs to relieve mild symptoms such as fever and arthritis
      2. Corticosteroids to suppress the inflammatory response in acute exacerbations or severe disease
      3. Immunosuppressive agents such as azathioprine (Imuran), cyclophosphamide (Cytoxan) to suppress the immune response when client unresponsive to more conservative therapy
    2. Plasma exchange to provide temporary reduction in amount of circulating antibodies
    3. Supportive therapy as organ systems become involved
  3. Assessment findings
    1. Fatigue, fever, anorexia, weight loss, malaise, history of remissions and exacerbations
    2. Joint pain, morning stiffness
    3. Skin lesions
      1. Erythematous rash on face, neck, or extremities may occur
      2. Butterfly rash over bridge of nose and cheeks
      3. Photosensitivity with rash in areas exposed to sun
    4. Oral or nasopharyngeal ulcerations
    5. Alopecia
    6. Renal system involvement (proteinuria, hematuria, renal failure)
    7. CNS involvement (peripheral neuritis, seizures, organic brain syndrome, psychosis)
    8. Cardiopulmonary system involvement (pericarditis, pleurisy)
    9. Increase susceptibility to infection
    10. Diagnostic tests
      1. ESR elevated
      2. CBC; anemia; WBC and platelet counts decreased
      3. ANA positive
      4. LE prep positive
      5. Anti-DNA positive
      6. Chronic false-positive test for syphilis
  4. Nursing interventions
    1. Assess symptoms to determine systems involved.
    2. Monitor vital signs, I&O, daily weights.
    3. Administer medications as ordered.
    4. Institute seizure precautions and safety measures with CNS involvement.
    5. Provide psychologic support to client/significant others.
    6. Provide client teaching and discharge planning concerning
      1. Disease process and relationship to symptoms
      2. Medication regimen and side effects
      3. Importance of adequate rest
      4. Use of daily heat and exercises as prescribed for arthritis
      5. Need to avoid physical or emotional stress
      6. Maintenance of a well-balanced diet
      7. Need to avoid direct exposure to sunlight (wear hat and other protective clothing)
      8. Need to avoid exposure to persons with infections
      9. Importance of regular medical follow-up
      10. Availability of community agencies

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Gout

  1. General information
    1. A disorder of purine metabolism; causes high levels of uric acid in the blood and the precipitation of urate crystals in the joints
    2. Inflammation of the joints caused by deposition of urate crystals in articular tissue
    3. Occurs most often in males
    4. Familial tendency
  2. Medical management
    1. Drug therapy
      1. Acute attack: Colchicine IV or PO (discontinue if diarrhea occurs); NSAIDs such as indomethacin (Indocin), naproxen (Naprosyn), phenylbutazone (Butazolidin)
      2. Prevention of attacks
        1. uricosuric agents (probenecid [Benemid], sulfinpyrazone [Anturane]) increase renal excretion of uric acid
        2. allopurinal (Zyloprim) inhibits uric acid formation
    2. Low-purine diet may be recommended
    3. Joint rest and protection
    4. Heat or cold therapy
  3. Assessment findings
    1. Joint pain, redness, heat, swelling; joints of foot (especially great toe) and ankle most commonly affected (acute gouty arthritis stage)
    2. Headache, malaise, anorexia
    3. Tachycardia; fever; tophi in outer ear, hands, and feet (chronic tophaceous stage)
    4. Diagnostic test: uric acid elevated
  4. Nursing interventions
    1. Assess joints for pain, motion, appearance.
    2. Provide bed rest and joint immobilization as ordered.
    3. Administer antigout medications as ordered.
    4. Administer analgesics for pain as ordered.
    5. Increase fluid intake to 2000-3000 ml/day to prevent formation of renal calculi.
    6. Apply local heat or cold as ordered.
    7. Apply bed cradle to keep pressure of sheets off joints.
    8. Provide client teaching and discharge planning concerning
      1. Medications and their side effects
      2. Modifications for low-purine diet: avoidance of shellfish, liver, kidney, brains, sweetbreads, sardines, anchovies
      3. Limitation of alcohol use
      4. Increase in fluid intake
      5. Weight reduction if necessary
      6. Importance of regular exercise

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Osteoarthritis

  1. General information
    1. Chronic, nonsystemic disorder of joints characterized by degeneration of articular cartilage
    2. Women and men affected equally; incidence increases with age
    3. Cause unknown; most important factor in development is aging (wear and tear on joints); others include obesity, joint trauma
    4. Weight-bearing joints (spine, knees, hips) and terminal interphalangeal joints of fingers most commonly affected
  2. Assessment findings
    1. Pain (aggravated by use and relieved by rest) and stiffness of joints
    2. Heberden's nodes: bony overgrowths at terminal interphalangeal joints
    3. Decreased ROM, possible crepitation (grating sound when moving joint)
    4. Diagnostic tests
      1. X-rays show joint deformity as disease progresses
      2. ESR may be slightly elevated when disease is inflammatory
  3. Nursing interventions
    1. Assess joints for pain and ROM.
    2. Relieve strain and prevent further trauma to joints.
      1. Encourage rest periods throughout day.
      2. Use cane or walker when indicated.
      3. Ensure proper posture and body mechanics.
      4. Promote weight reduction if obese.
      5. Avoid excessive weight-bearing activities and continuous standing.
    3. Maintain joint mobility and muscle strength.
      1. Provide ROM and isometric exercises.
      2. Ensure proper body alignment.
      3. Change client's position frequently.
    4. Promote comfort/relief of pain.
      1. Administer medications as ordered: aspirin and NSAIDs most commonly used; intra-articular injections of corticosteroids relieve pain and improve mobility.
      2. Apply heat as ordered (e.g., warm baths, compresses, hot packs) or ice to reduce pain.
    5. Prepare client for joint replacement surgery if necessary.
    6. Provide client teaching and discharge planning concerning
      1. Use of prescribed medications and side effects
      2. Importance of rest periods
      3. Measures to relieve strain on joints
      4. ROM and isometric exercises
      5. Maintenance of a well-balanced diet
      6. Use of heat/ice as ordered

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Rheumatoid Arthritis (RA)


  1. General information
    1. Chronic systemic disease characterized by inflammatory changes in joints and related structures
    2. Occurs in women more often than men (3:1); peak incidence between ages 35-45
    3. Cause unknown, but may be an autoimmune process; genetic factors may also play a role.
    4. Predisposing factors include fatigue, cold, emotional stress, infection.
    5. Joint distribution is symmetric (bilateral); most commonly affects smaller peripheral joints of hands and also commonly involves wrists, elbows, shoulders, knees, hips, ankles, and jaw.
    6. If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis, and bony ankylosis.
  2. Medical management
    1. Drug therapy
      1. Aspirin: mainstay of treatment, has both analgesic and anti-inflammatory effect.
      2. Nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen (Motrin), indomethacin (Indocin), fenoprofen (Nalfon), mefenamic acid (Ponstel), phenylbutazone (Butazolidin), piroxicam (Feldene), naproxen (Naprosyn), sulindac (Clinoril); relieve pain and inflammation by inhibiting the synthesis of prostaglandins
      3. Gold compounds (chrysotherapy)
        1. injectable form: sodium thiomalate (Myochrysine); aurothioglucose (Solganal); given IM once a week; take 3-6 months to become effective; side effects include proteinuria, mouth ulcers, skin rash, aplastic anemia; monitor blood studies and urinalysis frequently.
        2. oral form: auranofin (Ridaura); smaller doses are effective; take 3-6 months to become effective; diarrhea also a side effect with oral form; blood and urine studies should also be monitored.
      4. Corticosteroids
        1. intra-articular injections temporarily suppress inflammation in specific joints.
        2. systemic administration used only when client does not respond to less potent anti-inflammatory drugs.
      5. Methotrexate, Cytoxan given to suppress immune response; side effects include bone marrow suppression
    2. Physical therapy to minimize joint deformities
    3. Surgery to remove severely damaged joints (e.g., total hip replacement; knee replacement)
  3. Assessment findings
    1. Fatigue, anorexia, malaise, weight loss, slight elevation in temperature
    2. Joints are painful, warm, swollen, limited in motion, stiff in morning and after periods of inactivity, and may show crippling deformity in long-standing disease
    3. Muscle weakness secondary to inactivity
    4. History of remissions and exacerbations
    5. Some clients have additional extra-articular manifestations: subcutaneous nodules; eye, vascular, lung, or cardiac problems.
    6. Diagnostic tests
      1. X-rays show various stages of joint disease
      2. CBC: anemia is common
      3. ESR elevated
      4. Rheumatoid factor positive
      5. ANA may be positive
      6. C-reactive protein elevated
  4. Nursing interventions
    1. Assess joints for pain, swelling, tenderness, limitation of motion.
    2. Promote maintenance of joint mobility and muscle strength.
      1. Perform ROM exercises several times a day; use of heat prior to exercise may decrease discomfort; stop exercise at the point of pain.
      2. Use isometric or other exercise to strengthen muscles.
    3. Change position frequently; alternate sitting, standing, lying.
    4. Promote comfort and relief/control of pain.
      1. Ensure balance between activity and rest.
      2. Provide 1-2 scheduled rest periods throughout day.
      3. Rest and support inflamed joints; if splints used, remove 1-2 times/day for gentle ROM exercises.
    5. Ensure bed rest if ordered for acute exacerbations.
      1. Provide firm mattress.
      2. Maintain proper body alignment.
      3. Have client lie prone for 1/2 hour twice a day.
      4. Avoid pillows under knees.
      5. Keep joints mainly in extension, not flexion.
      6. Prevent complications of immobility.
    6. Provide heat treatments (warm bath, shower, or whirlpool; warm, moist compresses; paraffin dips) as ordered.
      1. May be more effective in chronic pain.
      2. Reduce stiffness, pain, and muscle spasm.
    7. Provide cold treatments as ordered; most effective during acute episodes.
    8. Provide psychologic support and encourage client to express feelings.
    9. Assist client in setting realistic goals; focus on client strengths.
    10. Provide client teaching and discharge planning concerning
      1. Use of prescribed medications and side effects
      2. Self-help devices to assist in ADL and to increase independence
      3. Importance of maintaining a balance between activity and rest
      4. Energy conservation methods
      5. Performance of ROM, isometric, and prescribed exercises
      6. Maintenance of well-balanced diet
      7. Application of resting splints as ordered
      8. Avoidance of undue physical or emotional stress
      9. Importance of follow-up care

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Juvenile Rheumatoid Arthritis

  1. General information
    1. Systemic, chronic disorder of connective tissue, resulting from an autoimmune reaction
    2. Results in eventual joint destruction
    3. Affected by stress, climate, and genetics
    4. More common in girls; peak ages 2-5 and 9-12 years
    5. Types
      1. Mono/pauciarticular JRA
        1. fewer than 4 joints involved (usually in legs)
        2. asymmetric; rarely systemic
        3. generally mild signs of arthritis
        4. symptoms may decrease as child enters adulthood
        5. prognosis good
      2. Polyarticular JRA
        1. multiple joints affected
        2. symmetrical symptoms of arthritis, disability may be mild to severe
        3. involvement of temporomandibular joint may cause earaches
        4. characterized by periods of remissions and exacerbations
        5. prognosis poorer
        6. treatment symptomatic for arthritis: physical therapy, ROM exercises, aspirin
      3. Systemic disease with polyarthritis (Still's disease)
        1. explosive course with remissions and exacerbations lasting for months
        2. begins with fever, rash, lymphadenopathy, anorexia, and weight loss
  2. Medical management, assessment findings, and nursing interventions: see Rheumatoid Arthritis, in Unit 4.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Muscular Dystrophy

  1. General information
    1. A group of muscular diseases in children characterized by progressive muscle weakness and deformity
    2. Genetic in origin; biochemical defect is suspected
    3. Types
      1. Pseudohypertrophic (Duchenne type): most frequent type
        1. X-linked recessive
        2. affects only boys
        3. usually manifests in first 4 years
      2. Facioscapulohumeral
        1. autosomal dominant
        2. mild form, with weakness of facial and shoulder girdle muscles
        3. onset usually in adolescence
      3. Limb girdle
        1. autosomal recessive
        2. affects boys and girls
        3. onset usually in adolescence
      4. Congenital
        1. autosomal recessive
        2. onset in utero
      5. Myotonic
        1. autosomal dominant
        2. more common in boys
        3. onset in infancy or childhood, or adult onset
        4. prognosis in childhood form is guarded
    4. Disease causes progressive disability throughout childhood; most children with Duchenne's muscular dystrophy are confined to a wheelchair by age 8-10 years.
    5. Death occurs by age 20 in 75% of clients with Duchenne's muscular dystrophy.
  2. Assessment findings (Duchenne type)
    1. Pelvic girdle weakness is early sign (child waddles and falls)
    2. Gower's sign (child uses hands to push up from the floor)
    3. Scoliosis (from weakness of shoulder girdle)
    4. Contractures and hypertrophy of muscles
    5. Diagnostic tests
      1. Muscle biopsy reveals histologic changes: degeneration of muscle fibers and replacement of fibers with fat.
      2. EMG shows decrease in amplitude and duration of potentials.
    6. Serum enzymes increased, especially CPK
  3. Nursing interventions
    1. Prepare child for EMG and muscle biopsy.
    2. Maintain function at optimal level; keep child as active and independent as possible.
    3. Plan diet to prevent obesity.
    4. Continually evaluate capabilities.
    5. Support child and parents and provide information about availability of community agencies and support groups.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Harrington Rod Insertion

  1. General information
    1. Spinal fusion and installation of a permanent steel rod along spine
    2. Used for moderate to severe curvatures
    3. Usually results in increase in height; positive body image changes
  2. Nursing interventions (see also Discectomy, in Unit 4)
    1. Provide general pre-op teaching and care.
    2. In addition to routine post-op care.
      1. Log roll.
      2. Do not raise head of bed.
      3. Discuss adapting home environment to allow for privacy yet interaction with family during long-term recovery.
      4. Discuss alternate methods of education during recovery period.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Scoliosis

  1. General information
    1. Lateral curvature of the spine
    2. Most commonly occurs in adolescent girls
    3. Disorder has a familial pattern; associated with other neuromuscular disorders
    4. Majority of the time (75% of cases) disorder is idiopathic; others causes include congenital abnormality of vertebrae, neuromuscular disorders, and trauma
    5. May be functional or structural
      1. Nonstructural/functional: "C" curve of spine
        1. due to posture, can be corrected voluntarily and disappears when child lies down
        2. not progressive
        3. treated with posture exercises
      2. Structural/progressive: "S" curve of spine
        1. usually idiopathic
        2. structural change in spine, does not disappear with position changes
        3. more aggressive intervention needed
  2. Medical management
    1. Stretching exercises of the spine for nonstructural changes
    2. Milwaukee brace worn for 23 hours/day for 3 years
    3. Plaster jacket cast
    4. Halo-pelvic or halo-femoral traction
    5. Spinal fusion with insertion of Harrington rod
  3. Assessment findings (structural scoliosis)
    1. Failure of curve to straighten when child bends forward with knees straight and arms hanging down to feet (curve disappears with functional scoliosis)
    2. Uneven bra strap marks
    3. Uneven hips
    4. Uneven shoulders
    5. Asymmetry of rib cage
    6. Diagnostic test: x-ray reveals curvature
  4. Nursing interventions
    1. Teach/encourage exercises as ordered.
    2. Provide care for child with Milwaukee brace
      1. Child wears brace 23 hours/day; is removed once a day for bathing.
      2. Monitor pressure points, adjustments may be needed to accommodate increase in height or weight.
      3. Promote positive body image with brace.
    3. Provide cast/traction care.
    4. Assist with modifying clothing for immobilization devices.
    5. Adjust diet for decreased activity.
    6. Provide diversional activities.
    7. Provide care for child with Harrington rod insertion (see below).
    8. Provide client teaching and discharge planning concerning
      1. Exercises
      2. Brace/traction/cast care
      3. Correct body mechanics
      4. Alternative education for long-term hospitalization/home care
      5. Availability of community agencies

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Osteogenesis Imperfecta

  1. General information
    1. An inherited disorder affecting collagen formation and resulting in pathologic fractures
    2. Types
      1. Osteogenesis imperfecta congenita: autosomal recessive, prognosis poor
      2. Osteogenesis imperfecta tarda: autosomal dominant, less severe form, involvement of varying degrees
    3. Classic picture includes soft, fragile bones; blue sclera; otosclerosis
    4. Severity of symptoms decreases at puberty due to hormone production and child's ability to prevent injury
  2. Medical management
    1. Magnesium oxide supplements
    2. Reduction and immobilization of fractures
  3. Assessment findings
    1. Osteogenesis imperfecta congenita
      1. Multiple fractures at birth
      2. Possible skeletal deformity due to intrauterine fracture
      3. Bones of skull are soft
      4. Occasional intracranial hemorrhage
    2. Osteogenesis imperfecta tarda
      1. Delayed walking, fractures, structural scoliosis as child grows
      2. Lower limbs more frequently affected
      3. Hypermobility of joints
      4. Prone to dental caries
  4. Nursing interventions
    1. Support limbs, do not stretch.
    2. Position with care; use blankets to aid in mobility and provide support.
    3. Instruct parents in bathing, dressing, diapering.
    4. Support parents; encourage expression of feelings of anger or guilt (parents may have been unjustly suspected of child abuse).

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Slipped Femoral Capital Epiphysis

  1. General information
    1. Spontaneous displacement of proximal femoral epiphysis in a posterior and inferior direction
    2. Onset insidious; usually occurs during fast growth period of adolescence (growth hormones weaken epiphyseal plate)
    3. Occurs most often in very tall and very obese adolescents; boys affected more frequently
  2. Medical management
    1. Skeletal traction
    2. Surgical stabilization with pinning
  3. Assessment findings
    1. Limp and referred pain to groin, hip, or knee
    2. Limited internal rotation and abduction of hip
  4. Nursing interventions
    1. Suggest weight reduction program for obese children to decrease stress on bones.
    2. Provide care for the child with a cast or traction.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Legg-Calvé-Perthes Disease

  1. General information
    1. Aseptic necrosis of femoral head due to disturbance of circulation to the area
    2. Primarily affects boys ages 4-10 years
    3. Stages: lasting from 18 months to a few years
      1. Initial stage: may not be distinguishable from transient synovitis
      2. Avascular stage: often the first stage noticed
      3. Revascularization stage: regeneration of vascular and connective tissue
      4. Regeneration stage: formation of new bone
  2. Medical management: goal is to minimize deformity until healing process is completed
    1. Initial bed rest with traction and then an abduction brace
    2. Possible surgery
  3. Assessment findings
    1. Limp, limitation of movement
    2. Pain in groin, hip, and referred to knee; often difficult for child to localize pain
    3. Diagnostic test: x-ray reveals opaque ossification center of head of the femur (softened in avascular stage)
  4. Nursing interventions
    1. Provide care for a child with a cast or brace.
    2. Provide diversional activities.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

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