1 Chapter 23 Musculoskeletal DisordersReview Slides for Children in Casts and Traction

2 Review following slides independently -They include content you learned in NSG 102 and also applies to children

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4 Injuries Fracture Nursing management Providing family educationPreventing fractures

5 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 5

6 Physiologic Effects of ImmobilizationMuscular system: Decreased muscle strength and endurance Atrophy Loss of joint mobility Skeletal system: Bone demineralization Negative calcium balance 6

7 Physiologic Effects of Immobilization (cont’d)Metabolism: Decreased metabolic rate Negative nitrogen balance Hypercalcemia Decreased production of stress hormones 7

8 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 8

9 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 9

10 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 10

11 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 11

12 Psychologic Effects of ImmobilizationDiminished environmental stimuli Altered perception of self and environment Increased feelings of frustration, helplessness, anxiety Depression, anger, aggressive behavior Developmental regression 12

13 Effect on Families Extended periods of immobilization: Coping skillsLogistical management of sick child Need for family support and home care assistance Coping skills 13

16 Sites of Injuries FIG Sites of injuries to bones, joints, and soft tissues. 16

17 Contusions Damage to soft tissue, subcutaneous tissue, and muscleEscape of blood into tissues—ecchymosis—causing black and blue discoloration Swelling, pain, disability Crush injuries 17

18 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 18

19 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.

20 ACL Injury

21 Nursing care management Assessment of Fractures: The 5 PsPain 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 21

22 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 22

23 Types of Fractures FIG. 31-2 Types of fractures in children. 23

24 Clinical Manifestations of FractureGeneralized swelling Pain or tenderness Diminished functional use May have bruising, severe muscular rigidity, crepitus 24

25 Common Medical TreatmentsExternal fixation Caring for the child with an external fixator Providing pin care (pg. 845 in text)

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28 Common Medical TreatmentsCasts Cast application Caring for the child with a cast Cast removal Traction Caring for the child in traction Preventing complications

29 The Child in a Cast Cast application techniques Nursing considerationsCast care at home Cast removal Skin care 29

31 Care of the Child with a CastA regular (non-waterproof) cast becomes firm to the touch within 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.

32 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.

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34 Spica Casts

35 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.

36 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.

37 Nursing considerationsCareful 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

38 When to Call the Doctor 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

40 Removing the Cast from a Child 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

41 Would they pass as Part of Uniform?The child may want to play sports, even with a cast, and will be very disappointed when told they cannot.

43 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) 43

44 Traction: Essential ComponentsTraction: 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 44

45 Bone Alignment FIG. 31-5 Application of traction to maintain bone alignment. 45

46 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 46

48 Cervical Traction Crutchfield or Barton tongsInserted 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 48

49 Nursing Care Management for TractionAssessing 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 49

50 Examples of Pinning to Treat Fractures

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