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ATI Pedi Book Ch 29 Neuromusculoskeletal/Chronic
Terms in this set (112)
Parts affected by neuromusculoskeletal disorders
Brain, muscles, joints, skeletal structures.
Nonprogressive impairment of motor function, especially of muscle control, coordination, posture. Cause unknown. Tend to develop contractures.**** May cause abnormal perception and sensation; visual, hearing, and speech impairment; seizures; cognitive disability. Manifests differently in each child. Severity differs.
Risk factors for cerebral palsy
Cause unknown. Brain anomalies, cerebral infections, head trauma (shaken baby), anoxia to brain. Maternal chorioamnionitis. Prematurity. Multiple births. Extremely low or very low birth weight. Inability of placenta to provide O2 and nutrients. Interruption of O2 delivery at birth. Kernicterus from high neonatal bilirubin.
Manifestations of cerebral palsy
Failure to meet developmental milestones. Persistent primitive reflexes. Gagging or choking with feeding, poor suck. Tongue thrust. Poor head control. Asymmetric crawl.**** Rigid posture and extremities, abnormal posturing. Hyperreflexia. Vision or hearing impairment. Seizures. Impaired social relations. Findings associated with specific types of cerebral palsy.
Types of cerebral palsy
Dyskinetic (nonspastic, extrapyramidal).
Ataxic (nonspastic, extrapyramidal).****
Manifestations of spastic cerebral palsy
Hypertonicity (muscle tightness or spasticity). Increased DTRs, clonus. Poor control of motion, balance, posture. Impaired fine and gross motor skills. May present in all or some extremities. Affected limbs may be shorter and thinner. Gait may be crouched with scissoring motion of legs, intoeing, and tiptoeing.
All four limbs affected.
Similar parts of body affected.
Three limbs affected.
One limb affected.
One side of body affected.
2 types of dyskinetic cerebral palsy
Manifestations of athetoid cerebral palsy
Involuntary jerking movements that appear slow, writhing, and wormlike, involving trunk, neck, face, and tongue.
Manifestations of dystonic cerebral palsy
Slow twisting movements that affect trunk and extremities with abnormal posturing from muscle contractions.
Manifestations of ataxic cerebral palsy
Wide-based gait. Difficulty with coordination. Poor ability with repetitive movement. Difficulty with quick or precise movement (writing, buttoning shirt). Shakiness. Low muscle tone.
Diagnostic procedures for cerebral palsy
Complete neurologic assessment.
MRI to evaluate structures or abnormal areas located near bone. (May need sedation.)
Metabolic and genetic testing.
Nursing care for cerebral palsy
Interventions to fit client's developmental level rather than age. Maintain airway. Suction equipment available. Suction oral secretions as needed.**** Individualize care. Monitor developmental milestones. Speech and hearing evaluations if needed. Promote independence as much as possible. Support self-esteem and body image. Family support. Referrals for resources. Communicate with child directly, but include parents as needed. Augmented communication devices as needed. Include family in care during hospitalization. Monitor for pain, especially muscle spasm. Pain/spasm meds as prescribed. Adequate nutrition. Skin care. Rest periods as needed.
How family can be involved in hospital care of cerebral palsy patient
Ask about routine care and have family provide if appropriate. Have family verify client's needs if communication is impaired.
Nutrition measures for cerebral palsy
Assess for aspiration in severely disabled children. Determine ability to take PO. Ascertain correct positioning for feeding. Use head positioning and manual jaw control as needed. Supply foods as eaten at home when possible. Supplements as prescribed. G-tube feeding as prescribed. Maintain weight/height chart.
Skin care for cerebral palsy
Assess skin under any splints and braces. Turn to keep pressure off bony prominences. Keep skin clean and dry.
Medications for cerebral palsy
Baclofen (Lioresal), a centrally acting skeletal muscle relaxant that decreases spasm and severe spasticity. May be on baclofen pump (reservoir in abdomen with catheter that delivers med intrathecally).
Diazepam (Valium), a skeletal muscle relaxant used to decrease spasm and severe spasticity.
Botulinum toxin A (Botox), which reduces spasticity in specific muscle groups, used primarily for clients with only lower extremity spasticity.
Antiepileptics to control seizures.****
Can someone with cerebral palsy be independent and live a normal adult life or with they be dependent on care takers for the rest of their life?
Can be independent.****
Nursing considerations for baclofen
Oral or intrathecal via special surgically implanted pump. Monitor effectiveness. Monitor for muscle weakness, increased fatigue or less common adverse effects like diaphoresis and constipation. Educate family about expected response, adverse effects, and when to call provider.
Nursing considerations for diazepam
Only for older children and adolescents. Monitor for drowsiness and fatigue. Educate family about expected response, adverse effects, and when to call provider.
Nursing considerations for botulinum toxin A
Monitor for temporary weakness. Teach family that onset is 24-72 hours, peak is 2 weeks, and it lasts 3-6 months.
Teamwork and collaboration for cerebral palsy
Speech, recreational, and physical therapy. Education and medical specialists. Refer for technical aids to assist with coordination, speech, mobility, increased level of independence. May need voice-activated wheelchair. May need surgery such as tendon release to correct contractures or other spastic deformity.
Post-discharge education for cerebral palsy
Reinforce plan of care. Reinforce need for rest periods. Feeding schedule and techniques. Adherence to medical regimen. Regular dental care. Encourage parents to provide developmental stimulation. Wound care if needed. Ankle-foot orthoses if prescribed. Self urinary catheterization if needed. Pulmonary hygiene techniques. Coordinate interdisciplinary team. Help family identify resources such as respite care. Suggest support group for cerebral palsy.
Complications of cerebral palsy
Potential for injury.
Nursing actions for aspiration in cerebral palsy
Keep head elevated. Keep suction available if thick oral secretions or difficulty swallowing. Educate family about feeding techniques to decrease aspiration risk. Encourage CPR classes.
Nursing actions for injury risk in cerebral palsy
Raise bed rails to prevent falls. Pad bed rails and wheelchair arms. Secure child in mobility devices like wheelchairs. Encourage adequate rest to prevent injuries from fatigue. Encourage helmets, seat belts, other safety equipment. Educate family about safety equipment.
Failure of osseous spine to close during development. A form of congenital neural tube defect.****
Spina bifida occulta
Mostly affects lumbosacral area and is not visible.****&
Spina bifida cystica
Has visible sac protrusion.****
Types of spina bifida cystica
Meningocele: Sac contains spinal fluid and meninges.
Myelomeningocele: Sac includes meninges, spinal fluid, and nerves.****
Positioning baby with spina bifida
Place prone to protect sac.****
Risk factors for spina bifida
Drugs taken during pregnancy. Maternal malnutrition. Insufficient folic acid during pregnancy. Radiation or chemicals during pregnancy.**** Obesity, diabetes mellitus, hyperthermia, low vitamin B12 during pregnancy.
What determines severity of spina bifida
Size and location of defect.****
Subjective data for spina bifida
Assess prenatal history. Family history of neural tube defects.
Physical assessment findings with spina bifida
Protruding sac midline of the osseous spine. Dimpling in the lumbosacral area.
Prenatal testing for spina bifida
Alpha-fetoprotein between 16 and 18 weeks of gestation indicates possible neural tube defect. Amniocentesis done following elevated alpha-fetoprotein to detect anencephaly or myelomeningocele.
Ultrasound may show defect.
Lab tests and diagnostic procedures for spina bifida in newborn
Infant blood tests: Blood cultures to determine causative pathogen if appropriate.
MRI, ultrasound, and CT to evaluate spinal cord and brain.
Medical management of spina bifida
Closure of meningomyelocele immediately, may even be done prenatally.****
Nursing care for spina bifida
Assess for parent-infant attachment. Assess the sac. Routine newborn assessment. Assess level of neurologic involvement. Accurate output measurements. Head circumference and fontanels.
Teamwork and collaboration for spina bifida
Neurosurgery, neurology, urology, orthopedics, PT, OT, social services.
Surgical intervention for spina bifida
Closure of myelomeningocele sac is done as soon as possible (usually 24-48 hours after birth) to prevent complications of injury and infection.
Preoperative nursing actions for spina bifida surgery
Prepare family for surgery. Protect sac from injury. Place infant in warmer without clothing. Apply sterile moist nonadherent dressing with NS on sac and change q.2h. Inspect sac for leaks and irritation. Assess for infection (fever, irritability, lethargy). Position infant prone, legs flexed, hips abducted. IV antibiotics as prescribed. No rectal temperatures. Avoid cuddling or putting pressure on sac.
Postoperative nursing actions for spina bifida surgery
Vital signs. I&O. Assess for infection. Pain management. Incision care. Assess for CSF leak. Maintain prone until other positions prescribed. Resume oral feeds. Provide ROM to extremities.
Care of spina bifida after discharge
Teach postoperaitve care at home. Depending on disability, teach ROM techniques. Assess head circumference. Assess skin integrity. Assess for allergies like latex. Assess cognitive development. Assess bladder and bowel function. Assess motor development. Monitor for infections. Address body image concerns. Support for family. Assist client with independence. Assist family in obtaining equipment, services.
Complications of spina bifida
Skin ulceration caused by prolonged pressure in one area.
Latex allergy (may have high risk).
Increased intracranial pressure caused by hydrocephalus or shunt malfunction. May need shunt or shunt revision.
Bladder issues. Spasm or flaccidity.
Orthopedic issues including clubfoot, scoliosis, other malformations of feet and legs.
Nursing actions for skin ulceration in spina bifida
Monitor for skin breakdown. Reposition frequently. Monitor skin under splints and braces. Teach family to monitor skin integrity.
Allergies associated with latex allergy
Bananas, avocados, kiwi, chestnuts.
Nursing actions for latex allergy
Assist with allergy testing. Reduce exposure. Educate family to avoid latex. Provide list of items that may contain latex. Teach signs and symptoms of allergy to report. Instructions for EpiPen.
Common items that contain latex
Disposable diapers, cleaning or kitchen gloves, elastic in clothing.
Manifestations of increased intracranial pressure in infants
High-pitched cry, lethargy, vomiting, bulging fontanels, widening cranial suture lines, increased head circumference.
Manifestations of increased intracranial pressure in children
Headache, lethargy, nausea, vomiting, double vision, decreased school performance, decreased level of consciousness, seizures.
Nursing actions for increased intracranial pressure
Prepare for surgery for shunt or shunt revision. Use gentle movements when performing ROM. Minimize environmental stress. Assess and manage pain. Teach manifestations of hydrocephalus and shunt malfunction and when to call provider.
Nursing actions for bladder issues with spina bifida
Monitor for signs of bladder dysfunction. Monitor for bladder infection. Monitor for bleeding. Prepare for surgery if needed. If vesicostomy, teach stoma care.
Nursing actions for orthopedic issues with spina bifida
Monitor for infection. Pain meds. Prepare for surgery if needed. Cast care if needed. Monitor for neurosensory deficits. Educate family about signs of infection, cast and splint care.
Chromosomal abnormality (trisomy 21).****
Medical issues that may accompany Down syndrome
Congenital heart malformations, hypotonicity, immune dysfunction, thyroid dysfunction, leukemia.
Risk factor for Down syndrome
Maternal age greater than 35.****
Physical manifestations of Down syndrome
Upward outward eye slant. Small nose, depressed nasal bridge. Small ears, short pinna. Protruding tongue.**** High-arched narrow palate. Short broad neck. Shortened rib cage. Possible heart defect. Protruding abdomen. Broad short feet and hands. Stubby toes and fingers. Transverse palmar crease. Large space between big and second toe with plantar crease. Short stature. Hyperflexibility, hypotonia. Separated sagittal suture. Enlarged anterior fontanel. Small round head. Flattened forehead.
Diagnostic procedures for Down syndrome
Prenatal: Alpha-fetoprotein in maternal serum.
Infant: Chromosome analysis and echocardiography.
Nursing care for Down syndrome
Support family. Appropriate referrals. Assist parents in holding and bonding with infant. Manage secretions and prevent URI. Listen to concerns of parents and discuss ethical dilemmas regarding treatment for physical defects. Standard post-op care for any surgery: Wound care, respiratory care, pain management. Teach post-op and home care management. Reinforce treatment plan.
Surgical infants for Down syndrome
Depends on associated congenital anomalies. May need to correct cardiac defects or strabismus.
Ongoing care for Down syndrome
Teach family to manage secretions. Rinse mouth after feedings. Use cool mist to moisturize secretions. Change infant's position frequently. Pulmonary hygiene with postural drainage/percussion. Feeding strategies to accommodate protruding tongue. Skin care and moisturizing creams. Diet high in fiber and fluid to prevent constipation. Monitor calories to prevent obesity. Regular healthcare visits. Monitor milestones. Plot height and weight on Down syndrome growth chart. Prepare for surgery if indicated. Evaluate eyesight and hearing frequently. Frequent TFTs. Assess for atlantoaxial instability. Teach family to prevent complications.
Signs of atlantoaxial instability
Neck pain, weakness, torticollis.
Down syndrome complications
Respiratory infections. Common due to decreased muscle tone and poor drainage of mucus because of hypotonicity and underdeveloped nasal bone. Also, mouth breathing dries mucous membranes and increases risk.
Nursing actions for respiratory infections in Down syndrome
Rinse mouth with water after feeding and at other times when it is dry. Cool mist humidification. Clear nasal passages with bulb syringe. Encourage exercise in older children. Good hand hygiene. Frequent repositioning to promote respiratory function. Postural drainage and percussion. Routine immunizations. Seek healthcare at earliest sign of infection. Reinforce antibody schedule if prescribed.
Juvenile idiopathic arthritis
Chronic autoimmune inflammatory disease affecting joints and other tissues****. Chronic inflammation of synovium leads to wear and damage to articular cartilage. Rarely life-threatening. May subside with time, but can leave residual joint damage and deformity. Multiple classifications with or without rheumatoid factor.
Risk factors for juvenile idiopathic arthritis
Immunogenic susceptibility. Environmental triggers.
Manifestations of juvenile idiopathic arthritis
Joint swelling, stiffness, redness, warmth that are worse in morning or after naps. Mobility limitation. Fever. Rash. Limp in the morning. Enlarged lymph nodes. Delayed growth.
Lab tests for juvenile idiopathic arthritis
ESR may or may not be elevated.
CBC may have increased WBC, especially during exacerbation.
Antinuclear antibodies (ANA), may indicate uveitis.****
Rheumatoid factor rarely detected in children.
Anticyclic citrullinated peptide (anti-CCP) antibodies.
Eye inflammation, very red painful eyes, may lead to permanent vision loss.****
Significance of anticyclic citrullinated peptide (anti-CCP) antibodies
In juvenile idiopathic arthritis, can be detected before symptoms start.
Significance of antinuclear antibodies (ANA) in juvenile idiopathic arthritis
Indicate increased risk for uveitis.****
Diagnostic procedures for juvenile idiopathic arthritis
Radiographic studies for baseline comparison.
Slit lamp examination to detect uveitis.
X-ray findings for juvenile idiopathic arthritis
Increased synovial fluid in joint which causes soft tissue swelling or widening of joint. Later findings: Osteoporosis and narrow joint spaces.
Nursing care of juvenile idiopathic arthritis
Teach parents to apply splints at night to decrease pain and flexion deformities. Encourage use of electric blankets for comfort. Apply heat or moist packs to affected joints prior to exercise. Encourage to adhere to treatment regimen. Encourage self care and participation in an exercise program with full ROM.**** Relaxation techniques and nonpharmacologic pain management. Pain meds and assess response. Support group. Encourage PT and activity as tolerated. Proper positioning during sleep. Firm mattress. No pillows under knees. No pillow or flat pillow for head. Warm baths. Alternate means to meet developmental needs during exacerbation. Give adequate time. Well-balanced diet. Adequate fluids. Encourage school participation and contact with peers. Collaborate with school nurse. Teach family that illness worsens exacerbations. Routine followup and regular eye exams.
Medications for juvenile idiopathic arthritis
NSAIDs: Ibuprofen (Motrin), naproxen (Naprelan), tolmetin (Tolectin). To control pain and inflammation.
Methotrexate (Rheumatrex) to slow joint degeneration and progression when NSAIDs do not work alone.
Corticosteroids: Prednisone (Deltasone) for life-threatening complications, severe arthritis, uveitis.
Etanercept (Enbrel): DMARD used when methotrexate is not effective.****
Nursing considerations for NSAIDs
Take as directed. Take with food to minimize GI upset. Report changes in stool, GI discomfort, increase in bruising.
Methotrexate (Rheumatrex) class
Cytotoxic disease-modifying antirheumatic drug (DMARD).
Nursing considerations for methotrexate
Monitor LFTs and CBC regularly (hepatotoxicity and myelosuppression). Teach adolescents to avoid alcohol. Birth control to avoid birth defects while taking it.
Nursing considerations for corticosteroids in juvenile idiopathic arthritis
Eye solution, oral, IV, or injected into intraarticular space. Lowest effective dose for short-term therapy and then taper. Advise family that weight gain, especially in face, is common.**** Monitor height and weight. Alteration in growth is long-term complication. Avoid exposure to infectious agents. Healthy eating habits.
Etanercept (Enbrel) class
Tumor necrosis factor alpha receptor blocker. Disease-modifying antirheumatic drug (DMARD).
Nursing considerations for etanercept
Give subcutaneously once or twice weekly. Potential for allergic reactions. Avoid exposure to infectious agents.
Teamwork and collaboration for juvenile idiopathic arthritis
PT, OT, ophthalmology, dentist, dietitian, social worker, school nurse.
Complications of juvenile idiopathic arthritis
Joint deformity, functional disability.
Nursing actions for joint deformity and disability in juvenile idiopathic arthritis
Individualized therapeutic care plan. Advocate for child when treatments not working. Encourage adherence to treatment regimen. Encourage self-care and active participation in exercise program.
Group of inherited disorders with progressive degeneration of symmetric skeletal muscle groups. Onset, pace of progression, and affected muscle groups depend on type.****
3 common types of muscular dystrophy
Most common form of muscular dystrophy
Typical age of onset of Duchenne MD
Age 3-7 years.****
Duchenne muscular dystrophy
X-linked recessive. Onset between age 3 and 7. Progressive disease. Life expectancy currently early adulthood.
Facioscapulohumeral muscular dystrophy
Autosomal dominant. Progression is slow. Normal lifespan.
Limb girdle muscular dystrophy
Autosomal dominant or recessive and heterogeneous. Appears late in childhood. Slow progression.
Risk factors for Duchenne muscular dystrophy
Family genetic history.
Manifestations of Duchenne muscular dystrophy
Fatigue. Muscle weakness beginning in lower extremities. Unsteady gait with waddle. Lordosis. Delayed motor skill development. Frequent falls. Difficulty getting out of bed, rising from sitting, climbing stairs. Progressive difficulty walking, possible loss of ability to walk by age 12.**** Learning difficulties. Mild cognitive delays that do not worsen with disease. Progressive muscle atrophy. Respiratory and cardiac difficulties usually start by age 20.
Lab tests for Duchenne muscular dystrophy
Serum polymerase chain reaction (PCR) to detect dystrophin gene mutation.
Serum CK elevated, can be elevated before clinical presentation.
Diagnostic procedures for Duchenne muscular dystrophy
Nursing care for Duchenne muscular dystrophy
Genetic counseling. Monitor ability to perform ADLs, respiratory function, cardiac function, understanding of long-term effects, coping and support. Maintain optimum physical function as long as possible. Maintain respiratory function. Adequate fluid intake. Adequate nutrition. Routine physical exams and immunizations. Facilitate discussion of end-of-life decisions when appropriate.
Strategies for maintaining physical function in Duchenne muscular dystrophy
Encourage independence in ADLs as long as possible. ROM exercises. Appropriate physical activities. Include stretching exercise, strength and muscle training, breathing exercises. Proper body alignment. Frequent repositoining to prevent skin breakdown. Splints and braces as prescribed.
Strategies for maintaining respiratory function in Duchenne muscular dystrophy
Incentive spirometry. Positioning to enhance lung expansion. Teach client to use mechanical cough device. O2 as prescribed. Noninvasive ventilation as prescribed.
Medications in Duchenne muscular dystrophy
Corticosteroids: Prednisone (Deltasone) to increase muscle strength.
Amino acid, vitamin, mineral supplements.
Nursing considerations for corticosteroids in Duchenne muscular dystrophy
Monitor for infections and adverse effects. Education: Avoid potentially infectious agents. Healthy eating habits. Adverse effects and when to notify provider.
Teamwork and collaboration in Duchenne muscular dystrophy
Neurologist, genetic counselor, PT, OT, respiratory therapy, dietitian, social worker, school teacher. As disease progresses, respite care, long-term care, home healthcare. Support groups.
Surgical interventions for Duchenne muscular dystrophy
May need release or repair of contractures, G-tube, or tracheostomy.
Complications of Duchenne muscular dystrophy
Respiratory compromise due to inability of respiratory muscles to maintain respirations.
Nursing actions for respiratory compromise in Duchenne muscular dystrophy
Help child turn hourly or more frequently. DB&C. Suction. O2 as prescribed. Intermittent positive pressure ventilation and mechanically assisted cough device. Antibiotics as prescribed. Discuss mechanical ventilation options with parents.
True or false: Oxybutinin is used for painful muscle spasms in cerebral palsy
False. ATI is looking for skeletal muscle relaxants, not treatment for neurogenic bladder (bladder muscle spasm).
True or false: Use a firm mattress for children with juvenile idiopathic arthritis
True or false: A child with Down syndrome will have large, set back ears.
False. Small features with small ears and short pinna.
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