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.
Nursing Diagnoses, Goals,
COMMON LABORATORY AND DIAGNOSTIC TESTS 45.1
Test Explanation Indications Nursing Implications
Radiographs Radiographic image;
usually two views are obtained of the affected extremity (lateral and anteropos- terior)
To detect fractures and other anomalies
Child must cooperate and hold still.
Enlist the family’s help in calming the child.
Ultrasound Use of sound waves to locate the depth and structure within soft tissues and luid
To diagnose toxic synovitis, Legg-Calvé-Perthes dis- ease, slipped capital femo- ral epiphysis, osteomyelitis, fractures, ligament or soft tissue injuries
Monitoring and follow-up of fractures and remodeling
Better tolerated by nonsedated chil- dren than CT or MRI
Can be performed with a portable unit at bedside
Computed tomog- raphy (CT)
Noninvasive x-ray study that looks at tissue density and structures.
Images a “slice” of tissue
To evaluate the extent of osteomyelitis, Legg-Calvé- Perthes disease, or slipped capital femoral epiphysis or to rule out other problems
Machine is large and can be frighten- ing to children. Procedure can be lengthy and child must remain still.
If unable to do so, sedation may be necessary. If performed with contrast medium, assess for allergy. Encour- age luids after the procedure if not contraindicated.
Magnetic resonance imaging (MRI)
Based on how hydrogen atoms behave in a magnetic ield when disturbed by radiofre- quency signals. Does not require ionizing radiation. Provides a 3D view of the body part being scanned
To assess hard and soft tissue, as well as bone mar- row; to evaluate extent of osteomyelitis, Legg-Calvé- Perthes disease, or slipped capital femoral epiphysis;
or to rule out other prob- lems
Remove all metal objects from the child. Child must remain motionless for entire scan; parent can stay in room with child. Younger children will require sedation in order to be still. A loud thumping sound occurs inside the machine during the scan procedure, and this can be frighten- ing to children.
Arthrography Multiple radiographic images of a joint after direct injection with a radiopaque substance
To assess ligaments, muscles, tendons, and cartilage, particularly after injury
Should not be performed if joint infection is present. The joint should be rested for 12 hours. Apply cold therapy afterward and assess for swelling and pain. Crepitus may be present in the joint for 1 to 2 days after procedure.
Complete blood count
Evaluates hemoglobin and hematocrit, white blood cell count, platelet count
To evaluate hemoglobin and hematocrit with fracture with potential bleeding.
To determine infection in osteomyelitis, septic arthri- tis, and toxic synovitis
Normal values vary according to age and gender. White blood cell count differential is helpful in evaluating for infection. May be affected by myelo- suppressive drugs
Erythrocyte sedimentation rate
Nonspeciic test used to determine presence of infection or inlamma- tion
To evaluate for osteomyelitis or septic arthritis
Send sample to laboratory immedi- ately; if allowed to stand for longer than 3 hours, may produce falsely low result
C-reactive protein Measures acute-phase reactant protein indicative of inlamma- tory process
To evaluate for osteomyelitis or septic arthritis
Anti-inlammatory drugs may cause decreased levels. More sensitive and rapidly responsive than erythrocyte sedimentation rate
(continued)
• Pale or blue color
• Skin coolness
• Numbness or tingling
• Prolonged capillary reill
• Decreased pulse strength (or absence of pulse) Notify the physician or nurse practitioner of changes in neurovascular status or odor or drainage from the cast.
Fiberglass casts usually have a soft fabric edge, so they usually do not cause skin rubbing at the edges of the cast. On the other hand, plaster casts require special treatment of the cast edge to prevent skin rubbing. This may be accomplished through a technique called pet- aling: cut rounded-edge strips of moleskin or another soft material with an adhesive backing and apply them to the edge of cast, as shown in Figure 45.6.
and will cause a very warm feeling inside the cast, so warn the child that it will begin to feel very warm.
Plaster requires 24 to 48 hours to dry. Take care not to cause depressions in the plaster cast while drying, as those may cause skin pressure and breakdown. Instruct the child and family to keep the cast still, positioning it with pillows as needed.
Caring for the Child With a Cast
Perform frequent neurovascular checks of the casted extremity to identify signs of compromise early. These signs include:
• Increased pain
• Increased edema
COMMON LABORATORY AND DIAGNOSTIC TESTS 45.1 (continued)
Test Explanation Indications Nursing Implications
Blood culture To determine presence of bacteria in blood
May be positive with septic arthritis or osteomyelitis
Transport specimen to laboratory within 30 minutes. Avoid skin contamination of specimen while obtaining it. Cultures should usually be drawn before starting antibiotics, as partial antibiotic treatment may result in negative culture.
Joint luid aspiration (arthrocentesis)
Aspirated joint luid is examined for presence of pus and white blood cells; culture is per- formed.
To evaluate for septic arthritis
Use cold therapy to decrease swelling after aspiration.
Apply pressure dressing to prevent hema- toma formation or luid re-collection.
Assess for fever and joint pain or edema, which may indicate infection.
Positive luid culture indicates a bacterial infection in the joint. May also be used to relieve pressure in the joint space
Adapted from Fischbach, F. T., & Dunning III, M. B. (2009). A manual of laboratory and diagnostic tests (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
FIGURE 45.5 Assist with cast application by distracting or comforting the child.
To petal a cast:
1.
2.
3.
4.
Cut several strips of adhesive tape or moleskin three to four inches in length. Use one inch tape for smaller areas (e.g., infant's foot) and two inch tape for larger areas (e.g., adolescent's waist).
Round one end of each strip to keep the corners from rolling.
Apply the first strip by tucking the straight end inside the cast and by bringing the rounded end over the cast edge to the outside.
Repeat the procedure, overlapping each additional strip, until all rough edges are completely covered.
FIGURE 45.6 Petaling the cast.
Overview for the Child With a Musculoskeletal Disorder
NURSING DIAGNOSIS: Impaired physical mobility related to injury, pain, or weakness as evidenced by inability to move an extremity, to ambulate, or to move without limitations
Outcome Identification and Evaluation
Child will engage in physical activities within limits of injury or disease: child will assist with transfers and positioning in bed and/or participate in prescribed bed exercises.
Intervention: Maximizing Physical Mobility NURSING CARE PLAN 45.1
• Assess child’s ability to move based on injury or disease and within limits of prescribed treatment to determine baseline.
• Prior to prescribed exercise or major position changes, ensure that pain medication is given:
relief of pain increases child’s ability to tolerate and participate in activity.
• Use passive and active range-of-motion exercises and teach child and family how to perform them to facilitate joint mobility and muscle development (active ROM) and to help increase mobility (within limits of restrictions related to injury or prescribed treatment).
• Collaborate with physical therapy and occupational therapy as needed to provide child and family with appropriate exercises and methods to promote mobility. Support therapy activities by using same equipment and technique to help rehabilitate musculoskeletal deficits, improve mobility, and allow for maximum functioning.
• Praise accomplishments and emphasize child’s abilities to improve self-esteem and encourage feelings of confidence and competence.
• Teach child and family necessary care related to mobility issues so the family can continue with these measures at home.
NURSING DIAGNOSIS: Risk for constipation related to immobility and/or use of narcotic analgesics
Outcome Identification and Evaluation
Child will demonstrate adequate stool passage, will pass soft, formed stool every 1 to 3 days without straining or other adverse effects.
Intervention: Promoting Appropriate Bowel Elimination
• Assess usual pattern of stooling to determine baseline and identify potential problems with elimination.
• Palpate for abdominal fullness and auscultate for bowel sounds to assess for bowel function and pres- ence of constipation.
• Encourage iber intake to increase frequency of stools.
• Ensure adequate luid intake to prevent formation of hard, dry stools.
• Encourage activity within child’s limits or restrictions as even minimal activity increases peristalsis.
NURSING DIAGNOSIS: Self-care deicit related to immobility as evidenced by inability to perform hygiene care and transfer self independently
Outcome Identification and Evaluation
Child will demonstrate ability to care for self within age parameters and limits of disease:
child is able to feed, dress, and manage elimination within limits of injury or disease and age.
(continued)
Overview for the Child With a Musculoskeletal Disorder
(continued)Intervention: Maximizing Self-Care NURSING CARE PLAN 45.1
• Introduce child and family to self-help methods as soon as possible to promote independence from the beginning.
• Encourage family and staff to allow child to do as much as possible to allow child to gain confidence and independence.
• Collaborate with physical therapy and occupational therapy as needed to provide child and family
with appropriate tools to modify environment and methods to promote transferring and self-care to allow for maximum functioning.
• Praise accomplishments and emphasize child’s abilities to improve self-esteem and encourage feelings of confidence and competence.
• Balance activity with periods to rest to reduce fatigue and increase energy available for self-care.
NURSING DIAGNOSIS: Risk for impaired skin integrity related to immobility, casting, traction, use of braces or adaptive devices
Outcome Identification and Evaluation
Child’s skin will remain intact, without evidence of redness or breakdown.
Intervention: Promoting Skin Integrity
• Monitor condition of entire skin surface at least daily to provide baseline and allow for early identification of areas at risk.
• Avoid excessive friction or harsh cleaning products that may increase risk of breakdown in child with susceptible skin.
• Keep child’s skin free from stool and urine to decrease risk of breakdown.
• Keep linen clean, dry, and free from food crumbs and wrinkles to prevent pressure areas from forming.
• Change child’s position frequently to decrease pressure on susceptible areas.
• Monitor condition of skin affected by braces or adaptive equipment frequently to prevent skin breakdown related to poor fit.
For the child in traction:
• Pad bony prominences with cotton padding before applying traction to protect skin from injury.
• Gently massage child’s back and sacrum with lotion to stimulate circulation.
For the child in a spica cast:
• Apply plastic wrap to the perineal edges of the cast to prevent soiling of cast edges, which can contribute to cast breakdown.
• Use a fracture bedpan to facilitate toileting without soiling cast.
• For the child still in diapers, tuck a smaller diaper under the perineal edges of cast and cover with a larger diaper to prevent cast soiling.
NURSING DIAGNOSIS: Deicient knowledge related to cast care, activity restrictions, or other pre- scribed treatment as evidenced by verbalization, questions, or actions demonstrating lack of under- standing regarding child’s condition or care
Outcome Identification and Evaluation
Child and family will demonstrate accurate understanding about condition and course of treatment through verbalization and return demonstration.
Overview for the Child With a Musculoskeletal Disorder
(continued)NURSING CARE PLAN 45.1
• Assess child’s and family’s willingness to learn:
child and family must be willing to learn for teaching to be effective.
• Provide teaching at an appropriate level for the child and family (depends on age of child, physical condition, memory) to ensure understanding.
• Teach in short sessions: many short sessions are more helpful than one long session.
• Repeat information to give family and child time to learn and understand.
• Provide reinforcement and rewards to facilitate the teaching/learning process.
• Use multiple modes of learning involving many senses (provide written, verbal, demonstration, and videos) when possible: child and family are more likely to retain information when presented in different ways using many senses.
NURSING DIAGNOSIS: Risk for delayed development related to immobility, alterations in extremities
Outcome Identification and Evaluation
Development will be enhanced: child will make continued progress toward developmental milestones and will not show regression in abilities.
Intervention: Promoting Development
• Screen for developmental capabilities to determine child’s current level of functioning.
• Offer age-appropriate toys, play, and activities (including gross motor) to encourage further development.
• Perform exercises or interventions as prescribed by physical or occupational therapist:
repeat participation in those activities helps to promote function and acquisition of developmental skills.
• Provide support to families: immobility and extremity deficits may lead to slow progress in achieving developmental milestones, so ongoing motivation is needed.
Intervention: Providing Child and Family Teaching
Take Note!
If a cast is lined with Gore-Tex do not petal it.
Position the child with the casted extremity ele- vated on pillows. Ice may be applied during the irst 24 to 48 hours after casting if needed. Teaching the child to use crutches is an important nursing intervention for any child with lower extremity immobilization so that the child can maintain mobility (Fig. 45.7). Provide home care instructions to the family about cast care.
(See Teaching Guidelines 45.1.)
Take Note!
Persistent complaints of pain may indicate com- promised skin integrity under the cast.
FIGURE 45.7 Reinforce appropriate crutch walking for children with lower extremity immobilization.
FIGURE 45.8 The loud noise of the cast saw may frighten the child.
Assisting With Cast Removal
Children may be frightened by cast removal. Prepare the child using age-appropriate terminology:
• The cast cutter will make a loud noise (Fig. 45.8).
• The skin or extremity will not be injured (demon- strate by touching the cast cutter lightly to your palm).
• The child will feel warmth or vibration during cast removal.
Teaching Guidelines 45.2 gives instructions related to skin care after cast removal.
Teaching Guidelines 45.1
HOME CAST CARE
• For the irst 48 hours, elevate the extremity above the level of the heart and apply cold therapy for 20 to 30 minutes, then off 1 hour, and repeat.
• Assess for swelling, and have the child wiggle the ingers or toes hourly.
• For itching inside the cast:
• Never insert anything into the cast for the pur- poses of scratching.
• Blow cool air in from a hair dryer set on the lowest setting or tap lightly on the cast.
• Do not use lotions or powders.
• Protect the cast from wetness.
• Apply a plastic bag around cast and tape securely for bathing or showering. Continue to avoid placing the cast directly in water (unless it is Gore-Tex lined).
• Cover it when your child eats or drinks.
• If a cast become soiled it can be wiped clean with a slightly damp clean cloth.
• If the cast gets wet, dry it with a blow dryer on the cold setting (if warm setting is used the child could get burned).
• If the child has a large cast, change position every 2 hours during the day and while sleeping change position as often as possible.
• Check the skin for irritation.
• Press the skin back around edges of the cast.
• Use a lashlight to look for reddened or irritated areas.
• Feel for blisters or sores.
• Call the physician or nurse practitioner if:
• The casted extremity is cool to the touch, pale, blue, or very swollen.
• The child cannot move the ingers or toes.
• Severe pain occurs when the child attempts to move the ingers or toes.
• Persistent numbness or tingling occurs.
• Drainage or a foul smell comes from under the cast.
• Severe itching occurs inside the cast.
• The child runs a fever greater than 101.5°F for longer than 24 hours.
• Skin edges are red and swollen or exhibit break- down.
• Child complains of rubbing or burning under cast.
• The cast gets wet or is cracked, split, or softened.
Adapted from Bowden, V. R., & Greenberg, C. S. (2008). Pediatric nursing procedures. Philadelphia: Lippincott Williams & Wilkins; and American Academy of Family Physicians. (2010). Cast care. Retrieved July 12, 2012, from http://familydoctor.org/online/famdocen/home/healthy/
firstaid/after-injury/094.html
Teaching Guidelines 45.2
SKIN CARE AFTER CAST REMOVAL
• Brown, laky skin is normal and occurs as dead skin and secretions accumulate under the cast.
• New skin may be tender.
• Soak with warm water daily.
• Wash with warm soapy water, avoiding excessive rubbing, which may traumatize the skin.
• Discourage the child from scratching the dry skin.
• Apply moisturizing lotion to relieve dry skin.
• Encourage activity to regain strength and motion of extremity.
Notify the physician or nurse practitioner immediately if these signs of compartment syndrome occur: extreme pain (out of proportion to the situation), pain with passive range of motion of digits, distal extremity pallor, inability to move digits, or loss of pulses.
Caring for the Child With an External Fixator
Care of an external ixator involves maintaining skin integrity, preventing infection, and preventing injury.
Routine neurovascular and skin assessment is essential.
Skin care is similar to a child in skeletal traction and includes pin care daily. Elevation of the extremity can help prevent swelling. The ixator may be moved by grasping the frame, as the ixator can tolerate ordinary movement. Encourage weight bearing as prescribed.
Provide appropriate education to the child and family.
Encourage the child to look at the apparatus. Teach the child not to pick or manipulate the pins. Baggy or loose clothing can be worn over the device. Velcro sewn into the seams can be helpful and allows clothes to slip over the device.
Providing Pin Care
Whether pins are inserted for skeletal traction or as part of an external ixator (see section on fractures), keeping the pin sites clean is important to prevent infection. (See Evidence-Based Practice 45.1.) Clean- ing of the pin sites prevents infection by promoting comfort and preventing healing skin from adhering to the metal pin. Notify the orthopedic surgeon if signs of pin site infection are present or if pin slippage occurs.
Caring for the Child in Traction
Nursing care of the child in any type of traction fo- cuses not only on appropriate application and mainte- nance of traction but also on promoting normal growth and development and preventing complications (see Table 45.1). Apply skin traction over intact skin only so that the pull of the traction is effective. Prepare the skin with an appropriate adhesive before applying the traction tapes to ensure that the tapes adhere well, pre- venting skin friction. After application of the traction tapes, apply the elastic bandage or use the foam boot.
Attach the traction spreader block and then apply the prescribed amount of weight via a rope attached to the spreader block. Ensure that the rope moves without obstruction and that the weights hang freely without touching the loor.
In skeletal traction, apply weight via ropes at- tached to the skeletal pins. Treat the pin sites as surgi- cal wounds (see section on pin site care). Protect the exposed ends of the pins to avoid injury. Whether skin or skeletal traction is used, be sure that constant and even traction is maintained.
Take Note!
Avoid sudden bumping or movement of the bed: this can disturb traction alignment and cause addi- tional pain to the child as the weights are jostled.
Preventing Complications
Refer to Nursing Care Plan 36.1 for interventions re- lated to pain management and Nursing Care Plan 45.1 for interventions related to the prevention of compli- cations of immobility such as skin integrity impair- ment. To prevent contractures and atrophy that may result from disuse of muscles, ensure that unaffected extremities are exercised. Assist the child to exercise the unaffected joints and to use the unaffected extrem- ity if this does not disrupt traction alignment. Promote use of a trapeze if not contraindicated to involve the child in repositioning and assist with movement. En- courage deep-breathing exercises to prevent the pul- monary complications of long-term immobilization.
Promote normal growth and development by:
• Placing age-appropriate toys within the child’s reach
• Encouraging visits from friends
• Providing diversional activities such as drawing, col- oring, or video games (Fig. 45.9)
Take Note!
Ongoing, careful neurovascular assessments are critical in the child with a cast or in skeletal traction.
FIGURE 45.9 Provide age-appropriate diversional activities and schoolwork for children conined to bed in traction.