Nursing Management
Administer medications as ordered and teach families about their use; instruct them to monitor for side effects.
Educate the family about the importance of maintain- ing the medication regimen in order to prevent calcino- sis (calcium deposits) and joint deformity in the future.
Encourage compliance with physical therapy regimens.
Ensure that children are excused from physical educa- tion classes while the disease is active.
The nurse reinforces and carries out the exercise plans and adaptive equipment use as prescribed by the physical or occupational therapist in order to maintain neuromuscular function and to prevent complications.
Nursing management of a child with myelomenin- gocele focuses on preventing infection, promoting bowel and urinary elimination, promoting ad- equate nutrition, preventing latex allergy reaction, maintaining skin integrity, providing education and support to the family, and recognizing complica- tions, such as hydrocephalus or increased ICP, as- sociated with the disorder.
Cerebral palsy may result in signiicant motor impairment. Children with cerebral palsy require ongoing physical therapy as well as nutritional intervention.
Boys with Duchenne muscular dystrophy initially learn to walk but later lose this ability.
Respiratory compromise occurs in muscular dys- trophy and spinal muscular atrophy and eventually leads to death.
Children with spinal cord injury require intense nursing management and lengthy rehabilitation to maintain or regain function.
Children with neuromuscular disorders often suf- fer depression related to the chronic nature of the disorder.
School attendance and participation in activities such as the Special Olympics are important for children with neuromuscular dysfunction.
References
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American Academy of Pediatrics. (2012). Clean intermittent catheter- ization. Retrieved March 20, 2012, from http://www.healthychildren .org/English/health-issues/conditions/chronic/Pages/Clean-Intermit tent-Catheterization.aspx
Arnon, S. S. (2011). Botulism (Clostridium botulinum). In: R. M. Kliegman, B. F. Stanton, St. Geme, J. W., Schor, N. F., & R. E. Behrman (Eds.), Nelson’s textbook of pediatrics (19th ed., pp. 987–991). Philadelphia: Saunders.
Bozic, D., & Daniels, C. (2009). AboutKidsHealth clean intermittent catheterization (CIC): Step by step instructions for boys. Retrieved June 28, 2011, from http://www.aboutkidshealth.ca/HealthAZ/
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• Listlessness
• Generalized weakness
• Weak cry
Common signs and symptoms in older children reported during the health history might include:
• Double vision
• Blurred vision
• Drooping eyelids
• Dificulty swallowing
• Slurred speech
• Muscle weakness
Physical Examination and Laboratory and Diagnostic Tests
Assess for a diminished gag relex, which is indicative of botulism. Diagnostic tests include cultures of stool and serum. Botulism is a rare disease and is dificult to diag- nose since its symptoms are similar to those of other neuromuscular diseases. Therefore, assessment may include diagnostic tests to help rule out other diseases, such as Guillain-Barré syndrome, stroke, and myasthe- nia gravis.
Nursing Management
Treatment is mainly supportive and focuses on maintain- ing respiratory status and nutritional status. If ordered, administer botulinum toxin early in the disease to reduce its severity and progression.
KEY CONCEPTS
Muscles, tendons, ligaments, and cartilage are all present and functional at birth, though intentional, purposeful movement develops only as the infant matures.
The spine is very mobile in the newborn and in- fant, especially the cervical spine region, resulting in a high risk for cervical spine injury.
The nurse’s role in laboratory and diagnostic test- ing for neuromuscular disorders is mainly that of educating the child and family about and preparing the child for the test or procedure.
Assessment of range of motion and muscle tone is critical in the child with a neuromuscular disorder.
Hypertonia or hypotonia is an abnormal inding in the infant or child.
Determining attainment of developmental mile- stones and subsequent progression or loss of those milestones is useful in distinguishing various neu- romuscular disorders.
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limb-girdle muscular dystrophy (LGMD); facioscapulohumeral mus- cular dystrophy (FSH or FSHD) (also known as Landouzy-Dejerine);
myotonic dystrophy (MMD) (also known as DM or Steinert disease);
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Sivadon-Tardy, V., Orlikowski, D., Porcher, R., Sharshar, T., Durand, M. C., Enouf, V., et al. (2009). Guillain-Barré syndrome and inlu- enza virus infection. Clinical Infectious Diseases, 48(1), 48–56. doi:
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CHAPTER W O R K S H E E T
1624
CRITICAL THINKING EXERCISES
1. A 5-year-old girl, diagnosed with myelomeningocele, is admitted to the hospital for a corrective surgical procedure. Choose four questions from below that the nurse should ask when obtaining the health history that would assist in planning the child’s care.
a. What is the child’s current mobility status?
b. Is there a family history of myelomeningocele?
c. What is the child’s genitourinary and bowel func- tion and regimen?
d. Does this child have a history of hydrocephalus with presence of shunt?
e. Does she have known latex sensitivity?
f. Were there any complications during the preg- nancy or birth of this child?
g. Did the mother take prenatal folic acid supplementation?
2. Based on the case in the above question, develop a nursing care plan for the child with myelomeningocele.
3. A 5-year-old child is admitted to the pediatric unit with a history of cerebral palsy sustained at birth. The child is admitted for a scheduled tendon lengthening pro- cedure. Based on your knowledge about the effects of cerebral palsy, list three priorities to focus on when planning her care. Compare this to a child admitted for surgical correction of a broken femur with no signii- cant past medical history.
STUDY ACTIVITIES
1. In the clinical setting, compare the growth of a child with muscular dystrophy, spinal muscular atrophy, or cerebral palsy to the growth of a similar-age child who has been healthy. What differences or similarities do you ind? What are the explanations for your indings?
2. Identify the role of the registered nurse in the multi- disciplinary care of the child with a debilitating neuro- muscular disorder.
3. In the clinical setting, interview the parent of a child with Duchenne muscular dystrophy, myelomeningo- cele, spinal muscular atrophy, or severe cerebral palsy.
Determine the parent’s feelings about the ongoing care that he or she is responsible for. Relect upon this interview in your clinical journal.
4. In the clinical setting, compare the cognitive abilities of two children with a severe neuromuscular disorder.
What are the reasons for the similarities or differences that you ind?
MULTIPLE CHOICE QUESTIONS
1. A boy with Duchenne muscular dystrophy is admitted to the pediatric unit. He has an ineffective cough. Lung auscultation reveals diminished breath sounds. What is the priority nursing intervention?
a. Apply supplemental oxygen.
b. Notify the respiratory therapist.
c. Monitor pulse oximetry.
d. Position for adequate airway clearance.
2. A 7-year-old child with cerebral palsy has been admit- ted to the hospital. Which information is most impor- tant for the nurse to obtain in the history?
a. Age that the child learned to walk
b. Parents’ expectations of the child’s development c. Functional status related to eating and mobility d. Birth history to identify cause of cerebral palsy 3. The nurse is caring for a 2-year-old with myelome-
ningocele. When teaching about care related to neu- rogenic bladder, what response by the parent would indicate that additional teaching is required?
a. “Routine catheterization will decrease the risk of infection from urine staying in the bladder.”
b. “I know it will be important for me to catheterize my child for the rest of her life.”
c. “I will make sure that I always use latex-free catheters.”
d. “I will wash the catheter with warm soapy water after each use.”
4. The nurse is caring for a child with cerebral palsy who requires a wheelchair to attain mobility. Which intervention would help the child achieve a sense of normality?
a. Encourage follow-through with physical therapy exercises.
b. Restrict the child to a special needs classroom.
c. Encourage after-school activities within the limits of the child’s abilities.
d. Ensure the school is aware of the child’s capabilities.
5. What is the priority nursing intervention for the child recently admitted with Guillain-Barré syndrome?
a. Perform range-of-motion exercises.
b. Take temperature every 4 hours.
c. Monitor respiratory status closely.
d. Assess skin frequently.
45
Nursing Care of the Child With a
Musculoskeletal Disorder
KEY TERMS compartment
syndrome epiphysis external ixation immobilize kyphosis lordosis ossiication traction
Trendelenburg gait
Words of Wisdom
Nursing care that helps children to take wobbly steps, run, jump, fall, and get up again provides life itself in a child’s world.
W O W
Dakota Dawes, 2 years old, is brought to the clinic by his mother.
She states, “Last night Dakota said his arm hurt, but he didn’t have any complaints during the day. Today when he was playing I noticed he wasn’t using his right arm.”
Learning Objectives
Upon completion of the chapter, you will be able to:
1. Deine the key terms used in this chapter.
2. Compare the anatomy and physiology of the musculoskeletal system in children versus adults.
3. Identify nursing interventions related to common laboratory and diagnostic tests used in the diagnosis and management of musculoskeletal disorders.
4. Identify appropriate nursing assessments and interventions related to medications and treatments for common childhood musculoskeletal disorders.
5. Distinguish various musculoskeletal disorders occurring in childhood.
6. Devise an individualized nursing care plan for the child with a musculoskeletal disorder.
7. Develop child/family teaching plans for the child with a musculoskeletal disorder.
8. Describe the impact of chronic musculoskeletal disorders on the growth and development of children.
Musculoskeletal
disorders in children may occur as a congenital malformation or a genetic disorder that is present from birth but may not be identiied until later in childhood or adolescence. Other disorders are devel- opmental and still others result from trauma. Infants and young children have resilient soft tissue, so sprains and strains are less common in this age group. Older school- age children and adolescents often participate in sports, resulting in an increased risk of injuries such as sprains, fractures, and torn ligaments.The immobility associated with most musculoskel- etal disorders may affect the child’s development and acquisition of motor skills, leading to motor dysfunction.
Understanding the most common responses to these disorders gives the nurse the foundation required to plan care for any child with any musculoskeletal disorder.