Care of the child with a musculoskeletal disorder in- cludes assessment, nursing diagnosis, planning, inter- ventions, and evaluation. There are a number of general concepts related to the nursing process that may be applied to musculoskeletal dysfunction in children.
The nursing care of immobilized children is similar to that of adults, yet developmental and age-appropriate effects must be taken into account. Prevention of com- plications is a key nursing function. Nursing Care Plan 45.1 gives interventions related to prevention of com- plications. Particular care related to casts, traction, and ixators is discussed below.
Treatment Explanation Indications Nursing Implications Traction Application of a pulling force
on an extremity or body part
Fracture reduction, dis- locations, correction of deformities
To maintain even, constant traction:
• Ensure weights hang free at all times and ropes remain in the pulley grooves.
• Keep weights out of child’s reach.
• Maintain prescribed weight.
• Elevate head or foot of bed only with physician order.
Monitor for complications:
• Perform neurovascular checks at least every 4 hours.
• Assess for skin impairment.
Casting Application of plaster or iber- glass material to form a rigid apparatus to immobilize a body part
Fracture reduction, dis- locations, correction of deformities
Assess frequently for neurovascular com- promise, skin impairment at cast edges.
Protect cast from moisture.
Teach family how to care for cast at home.
Splinting Temporary stiff support of injured area
Temporary fracture reduction, immobiliza- tion and support of sprains
Similar to cast care. Some splints are removable and are replaced when the child is up out of bed.
Teach family appropriate use of splints.
Fixation Surgical reduction of a fracture or skeletal deformity with an internal or external pin or ixa- tion device
Fractures, skeletal deformities
No additional care for internal ixation External ixation: perform pin care as
prescribed by the surgeon.
Assess for excess drainage or pin slippage, notifying physician or nurse practitioner if this occurs.
Velcro or snaps on sleeves and pant legs help with dressing.
Cold therapy Application of ice bags, com- mercial cold packs, or cold compresses
Most often used in acute injuries to cause vasoconstriction, thereby decreasing pain and swelling
Apply for 20 to 30 minutes, then remove for 1 hour, and then reapply for 20 to 30 minutes.
Discontinue when numbness occurs.
Place a towel between the cold pack and the skin to prevent thermal injury.
Crutches Ambulatory devices that trans- fer body weight from lower to upper extremities
Used whenever weight bearing is contraindi- cated
Top of crutch should reach 2 to 3 inger- breadths below the axillae to prevent nerve palsy.
Teach child appropriate ambulation with crutches or reinforce teaching if per- formed by physical therapist.
Physical therapy, occupational therapy
Physical therapy focuses on attainment or improvement of gross motor skills. Occu- pational therapy focuses on reinement of ine motor skills, feeding, and activities of daily living.
Restore function after injury or surgery; pro- mote developmental activities when limb use is compromised, as in limb deiciency
Provide follow-through with prescribed exercises or supportive equipment.
Success of therapy is dependent upon continued compliance with the pre- scribed regimen.
Ensure adequate communication exists within the interdisciplinary team.
Orthotics, braces
Adaptive positioning devices specially itted for each child by the physical or occupa- tional therapist or orthotist.
Used to maintain proper body or extremity alignment, improve mobility, and prevent contractures.
Used to immobilize a body part or prevent deformity through positioning. Used to treat developmental dysplasia of the hip and scoliosis; also may be used for a period of time after cast removal.
Provide frequent assessments of skin covered by the device to avoid skin breakdown.
Cotton undergarment worn under the brace helps to maintain skin integrity.
Follow the therapist’s schedule of recom- mended “on” and “off” times.
Encourage families to comply with use.
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Assessment
Assessment of musculoskeletal dysfunction in children includes health history, physical examination, and labo- ratory and diagnostic testing.
be signiicant for musculoskeletal congenital anomaly or orthopedic injury during the birthing process. Breech de- livery may be associated with developmental dysplasia of the hip. Determine history related to attainment of devel- opmental milestones, such as walking and whether or not the child participates in sports. Inquire about the child’s usual level of physical activity, participation in sports, and use of protective equipment. Family history may be posi- tive for orthopedic problems. When eliciting the history of the present illness, inquire about the following:
• Limp or other changes in gait
• Recent trauma (determine the mechanism of injury)
• Recent strenuous exercise
• Fever
• Weakness
• Alteration in muscle tone
• Areas of redness or swelling Remember Dakota, the 2-year-old with right
arm pain and refusal to use his arm? What ad- ditional health history and physical examina- tion assessment information should the nurse obtain?
Health History
The health history consists of the past medical history, fam- ily history, and history of present illness (when the symp- toms started and how they have progressed), as well as treatments used at home. The past medical history might
DRUG GUIDE 45.1 COMMON DRUGS FOR MUSCULOSKELETAL DISORDERS
Medication Actions Indications Nursing Implications
Benzodiazepines (diazepam, loraz- epam)
Antianxiety drugs that also have the effect of skeletal muscle relax- ation
Treatment of muscle spasms associated with traction or casting
Monitor sedation level.
May cause dizziness
Paradoxical excitement may occur.
Assess for improvements in spasms.
Acetaminophen Blocks pain impulses in response to inhibition of prostaglandin synthesis
Relief of mild pain if used alone, moderate or severe pain if used with a narcotic analgesic
Often combined with a narcotic such as codeine or oxycodone for increased analgesic effect
Monitor pain levels and response to medication.
Narcotic analgesics Act on receptors in the brain to alter perception of pain
Relief of moderate to severe pain associated with injuries, orthope- dic procedures
Assess pain location, quality, intensity, and duration.
Assess respiratory rate prior to and periodically after administration.
Monitor sedation level.
May cause nausea, vomiting, constipation, pupil constriction
Nonsteroidal anti- inlammatory drugs (NSAIDs: ibuprofen, ketorolac)
Inhibit prostaglandin syn- thesis, having a direct inhibitory effect on pain perception and result- ing in antinlammatory and antipyretic activities
Relief of mild to moder- ate pain, treatment of Legg-Calvé-Perthes disease
Monitor for nausea, vomiting, diarrhea, and constipation.
Administer with water or food to decrease GI upset.
Bisphosphonate:
IV—pamidronate, zoledronic acid;
oral—alendronate, risedronate
Increase bone mineral density
Decrease incidence of fractures in moderate to severe osteogenesis imperfecta
IV: given at 4-month intervals, causes a decrease in serum calcium level, inluenza-like reaction with irst IV dose
Oral: side effects include heartburn, regurgita- tion, and upper abdominal discomfort.
GI, gastrointestinal; IV, intravenously.
Adapted from Karch, A. (2010). 2010 Lippincott’s nursing drug guide. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Taketomo, C. K., Hodding, J. H., & Kraus, D. M. (2010). Lexi-comp’s Drug Reference Handbook: Pediatric &
Neonatal Dosage Handbook (18th ed.). Hudson, OH: Lexi-comp, Inc.
who has achieved the developmental skill of walking.
Note refusal to walk, limping, in-toeing, out-toeing, or foot slap. Inspect injured joints for ecchymosis or swelling. In the injured extremity, note the color of the ingertips or toes. Observe spontaneous range of mo- tion. Perform scoliosis screening to determine spinal alignment. Note symmetry of thigh folds.
PALPATION
Palpate the clavicles in the newborn or young infant for tenderness or a bump that indicates callus formation
Physical Examination
Physical examination of the musculoskeletal system consists of inspection, observation, and palpation.
INSPECTION AND OBSERVATION
Observe the child’s posture and alignment of the trunk.
Inspect the extremities for symmetry and positioning and for absence, duplication, or webbing of any digits.
Note any obvious extremity deformity or limb-length discrepancy. Inspect the skin for redness, warmth, bruises, and puncture sites. Observe gait in the child
Short-arm cast Long-arm cast Shoulder spica cast
Long-leg cast Short-leg cast Long-leg hip spics cast One and a half hip spics cast
Abduction boots FIGURE 45.4 Selected casts used in children.
COMPARISON CHART 45.1 SKIN VERSUS SKELETAL TRACTION
Skin Traction Skeletal Traction
Application of force To the skin via strips or tapes secured with Ace bandages or traction boots
To the body part directly by ixation into or through the bone
Length of treatment Usually limited Allows for longer periods of traction
Amount of force Less More
Nursing goals, interventions, and evaluation for the child with musculoskeletal dysfunction are based on the nursing diagnoses (see Nursing Care Plan 45.1).
Nursing Care Plan 45.1 may be used as a guide in plan- ning nursing care for the child with a musculoskeletal disorder. The care plan includes many nursing diagno- ses that are applicable to the child or adolescent. Chil- dren’s responses to musculoskeletal dysfunction and its treatment will vary, and nursing care should be indi- vidualized based on the child’s and family’s responses to illness.
The nursing care of immobilized children is similar to that of adults, but developmental and age-appropriate effects must be taken into account. Prevention of com- plications is a key nursing function. Refer to Nursing Care Plan 45.1 for interventions related to prevention of complications. Additional information about nursing care related to certain disorders will be included later in the chapter as it relates to speciic disorders. Refer to Chapter 36 for nursing interventions related to pain management. Particular care related to casts, traction, and external ixation is discussed below.
with clavicle fracture. Perform active range of motion to determine if a joint position is ixed (e.g., clubfoot). Pal- pate the affected joint or extremity to detect warmth or tenderness. In the injured child or the child with a cast or splint, thoroughly assess the neurovascular status of the affected extremities. Palpate the ingers or toes for warmth. Determine the capillary reill time. Note the presence of sensation or motion. Evaluate muscle strength. Palpate pulses distal to the injury, noting their strength and quality. Perform the Ortolani and Barlow maneuvers (see section on developmental dysplasia of the hip later in this chapter) to assess for developmen- tal dysplasia of the hip.
Take Note!
Assess the injured site last, and do so gently.
Laboratory and Diagnostic Testing
Common Laboratory and Diagnostic Tests 45.1 explains the laboratory and diagnostic tests most commonly used when considering musculoskeletal disorders. The tests can assist the physician or nurse practitioner in diagnos- ing a disorder and/or be used as guidelines in determin- ing ongoing treatment. Some of the tests are obtained by laboratory or nonnursing personnel, while others might be obtained by the nurse. In either instance the nurse should be familiar with how the tests are obtained, what they are used for, and normal versus abnormal results.
This knowledge will also be necessary when providing child and family education related to the tests.