Transcript Chapter 23 Musculoskeletal Disorders

Chapter 23 Musculoskeletal
Disorders
Review Slides for Children in Casts
and Traction
Review following slides
independently They include content you learned in
NSG 102 and also applies to children
Injuries
Fracture
• Nursing management
– Providing family education
– Preventing fractures
The Immobilized Child
• Immobilization was once thought to be
restorative for patients with illness and injury
• We know now that immobilization has serious
consequences:
– Physical
– Social
– Psychologic
Physiologic Effects of Immobilization
• Muscular system:
– Decreased muscle strength and endurance
– Atrophy
– Loss of joint mobility
• Skeletal system:
– Bone demineralization
– Negative calcium balance
Physiologic Effects of Immobilization (cont’d)
• Metabolism:
– Decreased metabolic rate
– Negative nitrogen balance
– Hypercalcemia
– Decreased production of stress hormones
Physiologic Effects of Immobilization (cont’d)
• Cardiovascular system:
– Decreased efficiency of orthostatic neurovascular
reflexes
– Diminished vasopressor mechanism
– Altered distribution of blood volume
– Venous stasis
– Dependent edema
Physiologic Effects of Immobilization (cont’d)
• Respiratory system:
– Decreased need for oxygen
– Diminished vital capacity
– Poor abdominal tone and distention
– Mechanical or biochemical secretion retention
– Loss of respiratory muscle strength
Physiologic Effects of Immobilization (cont’d)
• Gastrointestinal system:
– Distention caused by poor abdominal muscle tone
– Difficulty feeding in prone position
– Gravitation effect on feces
– Anorexia
Physiologic Effects of Immobilization (cont’d)
• Integumentary system:
– Decreased circulation and pressure leading to
decreased healing capacity
• Urinary system:
– Alteration of gravitational force
– Difficulty voiding in supine position
– Urinary retention
– Impaired ureteral peristalsis
Psychologic Effects of Immobilization
• Diminished environmental stimuli
• Altered perception of self and environment
• Increased feelings of frustration, helplessness,
anxiety
• Depression, anger, aggressive behavior
• Developmental regression
Effect on Families
• Extended periods of immobilization:
– Logistical management of sick child
– Need for family support and home care assistance
• Coping skills
Traumatic Injury
• Soft-tissue injury: injuries to muscles,
ligaments, and tendons
– Sports injuries
– Mishaps during play
Sites of Injuries
FIG. 31-1 Sites of injuries to bones, joints, and soft tissues.
Contusions
• Damage to soft tissue,
subcutaneous tissue, and muscle
• Escape of blood into tissues—
ecchymosis—causing black and
blue discoloration
• Swelling, pain, disability
• Crush injuries
Dislocations
• Occur when force of stress on ligament is
sufficient to displace normal position of
opposing bone ends or bone ends to socket
• Pain increases with active or passive
movement of affected extremity
• More common in Down syndrome
• Hip dislocation: potential loss of blood supply
to head of femur
What Are Sprains and Strains?
– Sprains and strains are among the most common
injuries people encounter, ranging from twisted
ankles to aching backs.
– A sprain is a stretching or tearing of ligaments, the
tough, fibrous bands of tissue that connect bones to
one another at a joint.
– A strain is a stretching or tearing of muscle tissue,
commonly called a pulled muscle.
ACL Injury
Nursing care management
Assessment of Fractures: The 5 Ps
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Pain and point of tenderness
Pulse–distal to the fracture site
Pallor
Paresthesia–sensation distal to the
fracture site
• Paralysis–movement distal to the fracture
site
Types of Fractures
• Compound or open: fractured bone
protrudes through the skin
• Complicated: bone fragments have
damaged other organs or tissues
• Comminuted: small fragments of
bone are broken from fractured
shaft and lie in surrounding tissue
• Greenstick: compressed side of bone
bends, but tension side of bone
breaks, causing incomplete fracture
Types of Fractures
FIG. 31-2 Types of fractures in children.
Clinical Manifestations of Fracture
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•
•
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Generalized swelling
Pain or tenderness
Diminished functional use
May have bruising, severe muscular rigidity,
crepitus
Common Medical Treatments
• External fixation
– Caring for the child with an external fixator
– Providing pin care (pg. 845 in text)
Common Medical Treatments
• Casts
– Cast application
– Caring for the child with a cast
– Cast removal
• Traction
– Caring for the child in traction
– Preventing complications
The Child in a Cast
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Cast application techniques
Nursing considerations
Cast care at home
Cast removal
Skin care
Applying the cast
Care of the Child with a Cast
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A regular (non-waterproof) cast becomes firm to the touch within 10-15 minutes
after it is put on, but for the first two hours it is soft and can easily be dented or
cracked. If child has a walking cast (weight-bearing cast), he/she should not walk
on it for two hours after it is applied.
An arm or leg cast can be protected with a large plastic bag during bathing.
Cover cast with the bag and tape the opening shut. Even with a cast covered,
your child should not place the covered cast in the water. Special plastic covers can
also be bought at special stores (check with the orthopaedic nurse) but they too
can leak when placed underwater. It may be easier for your child to take sponge
baths while the cast is on.
If the cast becomes soiled it can be cleaned with a slightly damp washcloth and a
cleanser. Your child should not put clothing over the cast until it dries.
Protect
the cast by covering it when your child eats or drinks. If a cast gets wet,
immediately dry it with a blow dryer on the cold/cool setting. Children can be
burned with a blow dryer on the warm or hot setting. You can also use a vacuum
cleaner with an upholstery attachment. The vacuum will pull air through the cast
which is porous.
Waterproof Cast
• The only cast that can go into water is a Gore-Tex" cast. It can get
completely wet in the bath, shower, sprinkler, rain, ocean, or pool. There is
no need to dry the cast, but it should be rinsed after being in the ocean,
pool or in soapy water. Unfortunately, waterproof casts are not for all
types of fractures, and can't be used when skin pins are in place under the
cast, or for recently manipulated fractures.
• It is normal for the fingers/toes to appear slightly darker than the opposite
side for the first 30 minutes after cast application.
Spica Casts
Circulation Checks
• When there is a cast in place, it is important to
check the function of the nerves and blood
vessels.
– CRT - child's fingers and toes should be pink and
feel warm to the touch. A gentle squeeze should
cause the finger to blanch (turn white) followed by
a return of color when released.
– child should be able to feel all sides of his/her
fingers when touched.
– child should also be able to wiggle his/her toes or
fingers.
Skin Care
•
Child with a large cast,
–
changing his/her position is important. This will prevent constant pressure on any one
skin area.
– Turn the child every two hours during the day and as often as you can at night.
– It also helps to put the child's casted arm or leg up on a pillow.
•
Check child's skin every 4 hours inpatient, every day at home
– . Press skin back around all edges of the cast. Use a flashlight to give more light and
carefully look under the cast for reddened areas.
– Feel for blisters or sores under the edges of the cast. Rub the skin under the edges of the
cast with rubbing alcohol three to four times a day. This will help toughen it. If the skin
becomes cracked or very dry, stop using the alcohol until it is clear.
– Do not use lotions or powders on the skin. These tend to cake and will soften rather than
toughen the skin. This may injure the skin.
•
Do not allow child to stick any object under his/her cast, such as a pencil, or a coat
hanger.
– Call your doctor about unbearable itching. Children's Benadryl" can help with the itching
and is available at drug stores without a prescription.
Nursing considerations
• Careful observations of skin &
circulation: children grow
quickly!
• Teaching parents care of child
• Encourage parents to provide
child with a normal life to aide
growth and development
When to Call the Doctor
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If toes or fingers are cold to touch, appear pale, or blue.
If child complains of tingling and/or numbness of toes or fingers.
If child cannot move toes or fingers.
If toes or fingers become very swollen.
If your child complains of rubbing or burning under the cast. This can be a sign of
a pressure sore (especially over the heel or ankle).
If there is a foul smell from the cast or if staining of the cast occurs that was not
present when the child went home. This may be a sign of a pressure sore and
should be checked by your doctor.
If there is a breakdown of skin under the edge of the cast.
If the cast is too loose or too tight.
If the cast breaks, becomes soft or cracks, or wears out prematurely.
If the cast is soaked (non-waterproof) and does not dry with a vacuum or blow
dryer on the cold setting
Removing the cast – Very Noisy!
Removing the Cast from a Child
•
http://www.jbjs.org.uk/cgi/reprint/83-B/3/388.pdf
•
Study done in Tel Aviv, Israel Journal of Bone and Joint
Surgery April 2001
Summary of Article:
– Child with cardiac problems died after removal of cast
for club foot
– Researchers identified sound of saw as source of anxiety
in children
– 20 children in study: 10 used protective headphones
during cast removal, 10 did not
– Saw sound measured in decibles and equal to loud
shout
– Heart rates of children recorded Before-During-After
cast removal
– Results:
•
• Children without hearing protectors: mean increase by
30% up to 131 bpm
• Children with hearing protectors: mean increase by :
11% up to 11 bpm103
• No EKG changes
• Recommendations:
• Use hearing protectors in all children, especially those with
cardiac histories
• Use quiet saw
Would they pass as Part of Uniform?
Teach Crutch Walking to Child with Lower Extremity
Cast
The Child in Traction
• Traction: extended pulling force may be used:
– To provide rest for an extremity
– To help prevent or improve contracture deformity
– To correct deformity
– To treat dislocation
– To allow position and alignment
– To provide immobilization
– To reduce muscle spasms (rare in children)
Traction: Essential Components
• Traction: forward force produced by attaching
weight to distal bone fragment
– Adjust by adding or subtracting weights
• Counter-traction: backward force provided by
body weight
– Increase by elevating foot of bed
• Frictional force: provided by patient’s contact
with the bed
Bone Alignment
FIG. 31-5 Application of traction to maintain bone
alignment.
Types of Traction
• Manual traction: applied to body part by the
hand placed distally to fracture site
• Skin traction: pulling mechanisms are
attached to skin with adhesive material or
elastic bandage
• Skeletal traction: applied directly to skeletal
structure by pin, wire, or tongs inserted into
or through diameter of bone distal to fracture
Child in Traction
Cervical Traction
• Crutchfield or Barton tongs
• Inserted through burr holes in
skull with weights attached to
the hyperextended head
• As neck muscles fatigue,
vertebral bodies gradually
separate so the spinal cord is no
longer pinched between
vertebrae
• Halo traction can be applied in
some cases
Nursing Care Management for Traction
• Assessing patient in traction
– Must know purpose of traction and understand basic principles of
traction
• Skin care issues
– Overall skin assessment and care to prevent breakdown
– Pin care (pg. 848 in text)
• Assess site every 4 hours for bleeding, inflammation or infection
• Clean skeletal pin sites with 2mg/ml chlorhexidine solution (Best practice care by
NAON)
• Teach family pin site care, S&S to observe
• Pressure reduction devices: air mattress
• Pain management and comfort
– Especially needed initially due to pulling on tired muscles
– Analgesics (opioid and non-opioid) and muscle relaxants
Examples of Pinning to Treat Fractures
Distraction
• Process of separating
opposing bone to
encourage
regeneration of new
bone in created space
• Can be used when
limbs are unequal in
length and new bone
is needed to elongate
shorter limb