The Child with Musculoskeletal or Articular Dysfunction Chapter
39
Slide 2
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 2 Emergency Management ABCs Spinal
cord injury EMS/BLS/ALS Systematic head-to-toe assessment
Slide 3
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 3 The Immobilized Child
Immobilization was once thought to be restorative from illness and
injury We know now that immobilization has serious consequences
Physical Social Psychologic
Slide 4
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 4 Physiologic Effects of
Immobilization Muscular system Decreased muscle strength and
endurance Atrophy Loss of joint mobility Skeletal system Bone
demineralization Negative calcium balance
Slide 5
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 5 Physiologic Effects of
Immobilization
Slide 6
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 6 Physiologic Effects of
Immobilization (cont.) Metabolism Decreased metabolic rate Negative
nitrogen balance Hypercalcemia Decreased production of stress
hormones
Slide 7
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 7 Physiologic Effects of Immobility
(cont.) Cardiovascular system Decreased efficiency of orthostatic
neurovascular reflexes Diminished vasopressor mechanism Altered
distribution of blood volume Venous stasis Dependent edema
Slide 8
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 8 Physiologic Effects of Immobility
(cont.) Respiratory system Decreased need for oxygen Diminished
vital capacity Poor abdominal tone and distention Mechanical or
biochemical secretion retention Loss of respiratory muscle
strength
Slide 9
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 9 Physiologic Effects of Immobility
(cont.) GI system Distention caused by poor abdominal muscle tone
Difficulty feeding in prone position Gravitation effect on feces
Anorexia
Slide 10
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 10 Physiologic Effects of
Immobility (cont.) 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
Slide 11
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 11 Effects of Immobility on
Neurosensory System Loss of innervation If nerve tissue is damaged
by pressure If circulation to nerve tissue is interrupted Effects
of improper positioning Sensory and perceptual deprivation
Slide 12
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 12 Tissue Breakdown
Slide 13
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 13 Psychologic Effects of
Immobility Diminished environmental stimuli Altered perception of
self and environment Increased feelings of frustration,
helplessness, anxiety Depression, anger, aggressive behavior
Developmental regression
Slide 14
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 14 Immobilized Child
Slide 15
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 15 Effect on Families Extended
periods of immobilization Logistical management of sick child Need
for family support and home care assistance Coping skills Coping
skills
Slide 16
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 16 Mobilization Devices Orthotics
and prosthetics Nursing considerations Crutches and canes
Wheelchairs
Slide 17
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 17 Orthotics
Slide 18
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 18 Knee-Ankle-Foot Orthosis
Slide 19
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 19 Thoracolumbosacral Orthosis
Slide 20
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 20 Rear-Rolling Walker
Slide 21
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 21 Gait Walker with Suspension
Belts
Slide 22
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 22 Epiphyseal Injuries Weakest
point of long bones is the cartilage growth plate (epiphyseal
plate) Frequent site of damage during trauma May affect future bone
growth Treatment may include open reduction and internal fixation
to prevent growth disturbances
Slide 23
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 23 Fractures Common injury in
children Methods of treatment different in pediatrics than in older
adult population Rare in infants, except with MVC Clavicle most
frequently broken bone in child, especially younger than age 10
School age: bike, sports injuries
Slide 24
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 24 Types of Fractures Compound or
open: fractured bone protrudes through the skin Complicated: bone
fragments have damaged other organs or tissues
Slide 25
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 25 Types of Fractures (cont.)
Comminuted: small fragments of bone are broken from the fractured
shaft and lie in surrounding tissue Greenstick: compressed side of
bone bends, but tension side of bone breaks, causing incomplete
fracture
Slide 26
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 26 Fracture Types
Slide 27
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 27 Clinical Manifestations of
Fracture Generalized swelling Pain or tenderness Diminished
functional use May have bruising, severe muscular rigidity,
crepitus
Slide 28
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 28 Bone Healing and Remodeling
Typically rapid healing in children Neonatal period2 to 3 weeks
Early childhood4 weeks Later childhood6 to 8 weeks Adolescence8 to
12 weeks
Slide 29
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 29 Time Devoted to Phases of Bone
Healing
Slide 30
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 30 Assessment of Fractures: The
Five Ps Pain and point of tenderness Pulsedistal to the fracture
site Pallor Paresthesiasensation distal to the fracture site
Paralysismovement distal to the fracture site
Slide 31
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 31 The Child in a Cast Cast
application techniques Nursing considerations Cast care at home
Cast removal Skin care
Slide 32
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 32 Cast Types
Slide 33
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 33 Spica Cast with Hip
Abductor
Slide 34
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 34 Young Children Come to Regard
Casts as Part of Their Body
Slide 35
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 35 The Child in Traction Traction:
extended pulling force may be used to: Provide rest for an
extremity Help prevent or improve contracture deformity Correct a
deformity Treat a dislocation Allow position and alignment Provide
immobilization Reduce muscle spasms (rare in children)
Slide 36
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 36 Traction: Essential Components
Traction: forward force produced by attaching weight to distal bone
fragment Adjust by adding or subtracting weights Countertraction:
backward force provided by body weight Increase by elevating foot
of bed Frictional force: provided by patients contact with the
bed
Slide 37
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 37 Application of Traction for
Maintaining Equilibrium
Slide 38
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 38 Types of Traction Manual
traction: applied to the body part by the hand placed distally to
the fracture site Skin traction: pulling mechanisms are attached to
the skin with adhesive material or elastic bandage Skeletal
traction: applied directly to skeletal structure by pin, wire, or
tongs inserted into or through the diameter of the bone distal to
the fracture
Slide 39
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 39 Cervical Traction Crutchfield or
Barton tongs Inserted through burr holes in skull with weights
attached to the skull with weights attached to the hyperextended
head hyperextended head As neck muscles fatigue, vertebral bodies
gradually separate so the spinal cord no longer pinched between
vertebrae Halo traction can be applied in some cases
Slide 40
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 40 Nursing Considerations Assessing
the patient in traction Skin care issues Pain
management/comfort
Slide 41
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 41 Distraction Process of
separating opposing bone to encourage regeneration of new bone in
the created space Can be used when limbs are unequal in length and
new bone is needed to elongate the shorter limb
Slide 42
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 42 External Fixation Ilizarov
external fixator Permits limb lengthening by manual distraction by
manual distraction Nursing considerations
Slide 43
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 43 Internal Fixation ORIF (surgical
intervention) Preoperative preparation Postoperative complications
Infection Neurovascular compromise
Slide 44
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 44 Fracture Complications
Circulatory impairment Nerve compression syndromes Compartment
syndromes Volkmann contracture Epiphyseal damage
Slide 45
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 45 Fracture Complications (cont.)
Nonunion/malunion Infection Kidney stones from increased free CA++
Pulmonary emboli
Slide 46
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 46 Amputation Congenital or
traumatic Potential for reattachment of amputated part Nursing
considerations
Slide 47
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 47 Amputation (cont.) Surgical
amputation Surgical repair of severed limb Prosthetics Pain
management/phantom pain Nursing considerations
Slide 48
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 48 Therapeutic Management
Prosthetics as early as possible Early prosthetics encourage
maximum exploration and development in infancy Phocomelic digits
may be surgically modified, preserved, and reattached for use with
prosthetics
Slide 49
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 49 Injuries and Health Problems
Related to Sports Participation Preparation for sports AAP
classification of sports according to strenuousness and probability
of collision AAP guidelines for inclusion or exclusion from
specific sports based on medical and/or surgical condition of
child
Slide 50
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 50 Football is Strenuous Collision
Sport
Slide 51
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 51 Traumatic Injury Soft tissue
injury: injuries to muscles, ligaments, and tendons Sports injuries
Mishaps during play
Slide 52
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 52 Contusions Damage to soft
tissue, subcutaneous tissue, and muscle Escape of blood into
tissuesecchymosis black-and-blue discoloration Swelling, pain,
disability Crush injuries
Slide 53
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 53 Dislocations Occurs when the
force of stress on the ligament is great enough to disrupt the
normal position of the opposing bone ends or the bone end and its
socket Pain increases with active or passive movement of the
affected extremity More common in Down syndrome Hip dislocation:
potential loss of blood supply to head of femur
Slide 54
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 54 Sprains Trauma to a joint from
ligament partially or completely torn or stretched by force May
have associated damage to blood vessels, muscles, tendons, and
nerves Presence of joint laxity as indicator of severity Rapid
onset of swelling with disability
Slide 55
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 55 Sites of Injuries to Bones,
Joints, and Tissues
Slide 56
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 56 Strains A microscopic tear to
musculotendinous unit Similar to sprain Swollen, painful to touch
Generally incurred over time
Slide 57
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 57 Stress Fractures Occur as result
of repeated muscle contraction Often seen in repetitive
weight-bearing sports (running, gymnastics, basketball) Tibial
fracture most common Symptoms Therapeutic management
Slide 58
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 58 Gymnastics is Strenuous
Limited-Contact Sport
Slide 59
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 59 Therapeutic Management of Sports
Injuries RICE: Rest the injured part Ice immediately (max 30
minutes at a time) Compression with wet elastic bandage Elevation
of the extremity Immobilization and support (casts or splints as
appropriate to injury)
Slide 60
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 60 Correct and Incorrect Methods
for Elevating a Lower Extremity
Slide 61
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 61 Therapeutic Management of Sports
Injuries (cont.) ICES Ice, Compression, Elevation, Support
Alleviate repetitive stress Rest as primary therapy Usually means
reduced activity and alternative exercises, not bedrest
Slide 62
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 62 Heat Injury/Illness
Susceptibility of infants and children Heat cramps Heat exhaustion
Heatstroke Therapeutic interventions
Slide 63
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 63 Underwater Sports-Related
Injuries Near-drowning is primarily a respiratory and neurologic
problem Ear injuries when middle ear pressures unequalized
Diving-related concerns Sports and accidental drowning Risk
elevated with alcohol use
Slide 64
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 64 Health Concerns Associated with
Sports Nutrition Water and electrolytes Minerals Glycogen
Weight
Slide 65
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 65 Considerations for the Female
Athlete Female athlete triad Amenorrhea Osteoporosis Eating
disorders -to stay in weight range -to stay in weight range
Slide 66
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 66 Drug Use by Athletes Ergogenic
aids Amphetamines Anabolic steroids Nutritional aids
Life-threatening risks
Slide 67
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 67 Sudden Death Also called
instantaneous death: death occurs within minutes or within 24 hours
of the episode Sports with high inherent risk for death
Unrecognized underlying medical problems Idiopathic hypertrophic
subaortic stenosis Present with chest pain, dizziness, prominent
pulses, murmur at left sternal border Sports environment
Slide 68
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 68 Nurses Role in Sports for
Children and Adolescents Evaluation for activities Prevention of
injury Treatment of injuries Rehabilitation after injuries
Instruction to student and parents
Slide 69
MUSCULOSKELETAL DYSFUNCTION
Slide 70
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 70 Torticollis Wry neck Congenital
or acquired limited neck motion with neck flexed to affected side
Long-term effects Physical therapy Nursing considerations
Slide 71
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 71 Slipped Femoral Capital
Epiphysis (SFCE) Spontaneous displacement of the proximal femoral
epiphysis in a posterior and inferior direction Occurs shortly
before or during accelerated growth periods or puberty Usually
idiopathic, multifactorial Obesity, puberty hormone changes, bone
changes
Slide 72
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 72 SFCE (cont.) Clinical
manifestations Episode of trauma with acute displacement Gradual
displacement without definite injury Intermittent displacement (or
combination of all) Therapeutic management Nursing
considerations
Slide 73
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 73 Lordosis Accentuation of the
cervical or lumbar curvature beyond physiologic limits May be
secondary complication of trauma or idiopathic May occur with
flexion contractures of hip, congenital dislocated hip In obese
children abdominal fat alters center of gravity, causing
lordosis
Slide 74
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 74Kyphosis Abnormally increased
convex angulation in the curvature of the thoracic spine Most
common form is postural Can result from TB, arthritis,
osteodystrophy, or compression fracture
Slide 75
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 75 Scoliosis The most common spinal
deformity Complex spinal deformity in three planes Lateral
curvature Spinal rotation causing rib asymmetry Thoracic
hypokyphosis May be congenital or develop during childhood
Slide 76
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 76 Severe Scoliosis
Slide 77
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 77 Scoliosis (cont.) Multiple
potential causes; most cases idiopathic Generally becomes
noticeable after preadolescent growth spurt May have complaint of
ill-fitting clothes School screening controversial
Slide 78
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 78 Diagnostic Evaluation Standing
radiographs to determine degree of curvature Asymmetry of shoulder
height, scapular or flank shape, or hip height Often have a primary
curve and a compensatory curve to align head with gluteal
cleft
Slide 79
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 79 Therapeutic Management Treatment
goal: keep head of femur in acetabulum Containment with various
appliances and devices Rest, no weight bearing initially Surgery in
some cases Home traction in some cases
Slide 80
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 80 TLSO Brace
Slide 81
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 81 Clinical Manifestations
Insidious onset, may have history of limp, soreness or stiffness,
limited ROM, vague history of trauma Pain and limp most evident on
arising and at end of activity Diagnosed by x-ray
Slide 82
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 82 Therapeutic Management Team
approach to treatment Bracing Exercise Surgical intervention for
severe curvature (instrumentation and fusion) Harrington rods
L-rods
Slide 83
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 83 Nursing Considerations Concerns
of body image Concerns of prolonged treatment of condition
Preoperative care Postoperative care Family issues
Slide 84
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 84 Osteomyelitis Inflammation and
infection of bony tissue May be caused by exogenous or hematogenous
sources Infectious agent invades the bone following penetrating
wound, open fracture, contamination in surgery, or secondary
extension from an abscess or burn
Slide 85
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 85 Hematogenous Osteomyelitis
Preexisting infection spreads to bone Source may be skin
infections, URI, abscessed teeth, pyelonephritis, etc. Any organism
can cause osteomyelitis Infective emboli travel to arteries in the
bone metaphysis, causing abscess formation and bone
destruction
Slide 86
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 86 Osteomyelitis Signs and symptoms
begin abruptly; resemble symptoms of arthritis and leukemia Marked
leukocytosis Bone cultures obtained from biopsy or aspirate Early
x-rays may appear normal Bone scans for diagnosis
Slide 87
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 87 Therapeutic Management of
Osteomyelitis May have subacute presentation with walled- off
abscess rather than a spreading infection Prompt, vigorous IV
antibiotics for extended period (3 to 4 weeks or up to several
months) Monitor hematologic, renal, hepatic responses to
treatment
Slide 88
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 88 Nursing Considerations Complete
bedrest and immobility of limb Pain management concerns Long-term
IV access (for antibiotic administration) Nutritional
considerations Long-term hospitalization or home therapy
Psychosocial & school needs
Slide 89
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 89 Juvenile Rheumatoid Arthritis
(JRA) Also called juvenile chronic arthritis or idiopathic
arthritis of childhood Possible causes Peak ages: 1 to 3 years and
8 to 10 years Often undiagnosed Actually a heterogenous group of
diseases Pauciarticular onset (involves 4 joints) Pauciarticular
onset (involves 4 joints) Polyarticular onset (involves 5 joints)
Polyarticular onset (involves 5 joints) Systemic onset (high fever,
rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)
Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis,
pleuritis, lymphadenopathy)
Slide 90
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 90 JRA (cont.) Actually a
heterogenous group of diseases Pauciarticular onset (involves 4
joints) Polyarticular onset (involves 5 joints) Systemic onset
(high fever, rash, hepatosplenomegaly, pericarditis, pleuritis,
lymphadenopathy)
Slide 91
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 91 JRA (cont.) 90% children have
negative rheumatic factor Symptoms may burn out and become inactive
Chronic inflammation of synovium with joint effusion, destruction
of cartilage, and ankylosis of joints as disease progresses
Slide 92
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 92 Symptoms of JRA Stiffness
Swelling Loss of mobility in affected joints Warm to touch, usually
without erythema Tender to touch in some cases Symptoms increase
with stressors Growth retardation
Slide 93
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 93 Diagnostic Evaluation of JRA No
definitive diagnostic tests Elevated sedimentation rate in some
cases Antinuclear antibodies common but not specific for JRA
Leukocytosis during exacerbations Diagnosis based on criteria of
American College of Rheumatology
Slide 94
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 94 American College of Rheumatology
Diagnostic Criteria Age of onset younger than 16 years One or more
affected joints Duration of arthritis more than 6 weeks Exclusion
of other forms of arthritis
Slide 95
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 95 JRA: Therapeutic Management No
specific cure Goals of therapy: preserve function, prevent
deformities, and relieve symptoms Iridocyclitis/uveitis
Inflammation of iris and ciliary body Unique to JRA Requires
treatment by ophthalmologist
Slide 96
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 96 JRA: Pharmacology NSAIDs SAARDs
Corticosteroids Cytotoxic agents Immunomodulators
Slide 97
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 97 JRA: Management Therapy
individualized to child PT, OT Nutrition, exercise Splinting
devices Pain management Prognosis Nursing considerations
Slide 98
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 98 The Child with Neuromuscular or
Muscular Dysfunction Chapter 40
Slide 99
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 99 Neuromuscular Dysfunction Terms
to understand Myopathy Upper motor neurons Lower motor neurons
Motor unit Pyramidal Extrapyramidal
Slide 100
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 100 Classification and Diagnosis
Upper motor neuron lesions Weakness/spasticity Increased DTRs and
abnormal superficial reflexes Primarily cerebral palsy Lower motor
neuron lesions Weakness, atrophy of skeletal muscles, hypotonia
Usually symmetric Gradual or sudden onset indicates causation
Slide 101
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 101 Site of Origin of Neuromuscular
Disorders
Slide 102
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 102 Classification (cont.) Diseases
of anterior horn cells Neuropathies Neuromuscular junction disease
Diseases of muscles
Slide 103
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 103 Diagnostic Tools EMG Nerve
conduction velocity Muscle biopsy Serum enzyme measurement/CPK
Slide 104
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 104 Cerebral Palsy (CP)
Characterized by early onset and impaired movement and posture
Incidence 1.5 to 3 per 1000 live births Most common permanent
physical disability in childhood
Slide 105
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 105 CP: Etiology Intrauterine
hypoxia/asphyxia Intrapartum asphyxia 12% to 23% of CP occurs in
term infants with intrapartum asphyxia 12% to 23% of CP occurs in
term infants with intrapartum asphyxia Postnatal Often no
identifiable immediate cause
Slide 106
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 106 CP: Etiology (cont.) Preterm
birth of ELBW and VLBW is single most important determinant of CP
Anoxiamost common cause of brain damage whenever it occurs
Slide 107
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 107 Types of CP Spastic
Athetoid/dyskinetic Ataxic Mixed/dystonic
Slide 108
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 108 Types of CP (cont.) Spastic
Most common clinical type Presents as hypotonia most often
Slide 109
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 109 Types of Spastic CP
Quadriparesis (tetraparesis) Four extremities involved/severe
disability Speech and swallowing difficulties Tongue protrusion
(incomplete) Labile emotions in some patients
Slide 110
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 110 Types of CP (cont.) Diplegia
Monoplegia Triplegia Paraplegia
Slide 111
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 111 Possible Motor Signs of CP Poor
head control after age 3 months Stiff or rigid limbs Arching
back/pushing away Floppy tone Unable to sit without support at age
8 months Clenched fists after age 3 months
Slide 112
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 112 Possible Behavioral Signs of CP
Excessive irritability No smiling by age 3 months Feeding
difficulties Persistent tongue thrusting Frequent gagging or
choking with feeds
Slide 113
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 113 Therapeutic Management General
concepts Mobilization Surgical interventions Medications Technical
aids
Slide 114
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 114 Child Ambulating with an
Assistive Device
Slide 115
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 115 Cerebral Palsy and IQ Wide
variation 70% of CP patients have normal IQ Difficult to assess
Rigid, atonic, and quadriparetic CP have highest incidence of
profound impairment
Slide 116
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 116 Therapeutic Management:
Therapies, Education, Recreation PT Functional and adaptive
training (OT) Speech therapy Recreation Normalization Family
support
Slide 117
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 117 Muscular Dystrophies (MDs)
Largest group of muscular diseases in children All have genetic
origin with gradual degeneration of muscle fibers, progressive
weakness, and wasting of skeletal muscles All have increasing
disability and deformity with loss of strength
Slide 118
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 118 Initial Muscle Groups Involved
in MDs
Slide 119
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 119 Duchenne Muscular Dystrophy
(DMD) Also called pseudohypertrophic muscular dystrophy Most severe
and most common of the MDs in childhood X-linked inheritance
pattern; one third are fresh mutations Incidence: 1 in 3500 male
births
Slide 120
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 120 Characteristics of DMD Onset
between ages 3 and 5 years Progressive muscle weakness, wasting,
and contractures Calf muscles hypertrophy in most patients
Progressive generalized weakness in adolescence Death from
respiratory or cardiac failure
Slide 121
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 121 Diagnostic Evaluation of DMD
Suspected based on clinical appearance Confirmation by EMG, muscle
biopsy, and serum enzyme measurement Serum CPK and AST levels high
in first 2 years of life, before onset of weakness; levels diminish
as muscle deterioration continues
Slide 122
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 122 DMD: Clinical Manifestations
Waddling gait, frequent falls, Gower sign Lordosis Enlarged
muscles, especially thighs and upper arms Profound muscular atrophy
in later stages Mental deficiency common
Slide 123
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 123 Therapeutic Management of DMD
No effective treatment has been established Primary goal: maintain
function in unaffected muscles as long as possible Keep child as
active as possible ROM, bracing, performance of ADLs, surgical
release of contractures prn Genetic counseling for family
Slide 124
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 124 DMD: Nursing Considerations
Help child and family cope with chronic, progressive, debilitating
disease Help design a program to foster independence and activity
as long as possible Teach child self-help skills Arrange for
appropriate health care assistance as childs needs intensify (home
health, skilled nursing facility, respite care for family,
etc.)
Slide 125
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 125 Guillain-Barr Syndrome (GBS)
Also called infectious polyneuritis An acute demyelinating
polyneuropathy with progressive paralysis Children less often
affected than adults Occurrence in children most often between ages
4 and 10 years
Slide 126
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 126 GBS: Pathophysiology
Immune-mediated disease Often associated with viral or bacterial
infection or administration of vaccines Inflammation and edema in
spinal and cranial nerves progresses to impaired nerve conduction,
then partial or complete paralysis of involved muscles
Slide 127
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 127 GBS: Diagnostic Evaluation
Based on paralytic manifestation and/or EMG findings CSF may have
increased protein concentration; other labs WNL Symmetric paralysis
is part of the differential diagnosis
Slide 128
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 128 Clinical Manifestations of GBS
Initially: muscle tenderness, paresthesia, muscle weakness
Paralysis rapidly ascends from lower extremities; may involve
trunk, arms, face Flaccid paralysis, loss of reflexes Intercostal
and phrenic nerve involvement Frequently urinary incontinency or
retention and constipation
Slide 129
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 129 Therapeutic Management of GBS
Treatment is symptomatic Possibly steroids, IV immunoglobulin, and
plasmapheresis Respiratory support
Slide 130
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 130 GBS Prognosis: Better outcomes
associated with younger ages; most patients have complete recovery
Most patients have muscle function begin to return 2 days to 2
weeks after onset of symptoms, but prolonged period to complete
recovery Most deaths due to respiratory failure
Slide 131
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 131 GBS: Nursing Considerations
Supportive care Observe for early signs of respiratory
distress/difficulty swallowing Focus on prevention of complications
Support for child and family
Slide 132
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 132 Tetanus Also called lockjaw An
acute, preventable, and often fatal disease Caused by exotoxin of
Clostridium tetani Characterized by muscle rigidity involving the
masseter and neck muscles
Slide 133
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 133 Four Requirements for
Developing Lockjaw Presence of tetanus spores or vegetative forms
of the bacillus Injury to the tissues Wound conditions that
encourage multiplication of the organism A susceptible host
Slide 134
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 134 Tetanus Spores are found in
soil, dust, and GI tract of humans and animals Bacteria enter body
through wound, especially puncture or crush wound or burn May enter
through scratch, bee sting, thorn, or needle prick Exposure greater
during outdoor activities
Slide 135
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 135 Pathophysiology of Tetanus
Exotoxin spreads from wound to CNS by way of neurons or bloodstream
Toxin becomes fixed on nerve cells of brainstem and spinal cord
Toxin produces muscle stiffness
Slide 136
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 136 Clinical Manifestations of
Tetanus Initially: progressive stiffness and tenderness of neck and
jaw muscles, difficulty in opening the mouth, facial muscle spasm
Progressive: opisthotonos, difficulty swallowing, laryngospasm, and
tetany of respiratory muscles Rigid abdominal and limb muscles
Slide 137
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 137 Clinical Manifestations of
Tetanus (cont.) Respiratory: accumulated secretions, atelectasis,
pneumonia, respiratory arrest Patient anxious but alert; mentation
unaffected Rapid HR, diaphoresis, mild or absent fever Incubation:
3 to 10 days Mortality approximately 30%; usually fatal in
newborn
Slide 138
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 138 Therapeutic Management of
Tetanus Prevention by tetanus toxoid or tetanus antitoxin after
exposure Treatment of wounds contaminated with dirt, feces, soil,
saliva, puncture wounds, avulsions, crushing, burns, and frostbite
should include tetanus immune globulin if patient inadequately
immunized
Slide 139
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 139 Therapeutic Management of
Tetanus (cont.) ICU for constant observation and respiratory
support availability Monitor fluid and electrolyte status Tetanus
immune globulin therapy to neutralize toxins Wound care to decrease
organism proliferation Muscle relaxants, sedatives, pancuronium
(Pavulon)
Slide 140
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 140 Nursing Considerations Control
environmental stimuli Careful monitoring of respiratory status
Attempt to reduce anxiety of child and family
Slide 141
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 141 The Child with Renal
Dysfunction Chapter 30
Slide 142
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 142 Renal Structure and Function
Primary responsibility of kidney is to maintain the composition and
volume of the body fluids in equilibrium
Slide 143
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 143 Major Functions of Nephron
Components
Slide 144
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 144 Renal System Assessment
Physical assessment Palpation, percussion Health history Previous
UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer
Medications: antibiotics, anticholinergics, antispasmodics Urologic
instrumentation Urinary hygiene Patterns of elimination
Slide 145
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 145 Urinary Tract Infection:
Nursing Assessment Nausea, vomiting, anorexia, chills, nocturia,
urinary frequency, urgency Suprapubic or lower back pain, bladder
spasms, dysuria, burning on urination
Slide 146
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 146 Urinary Tract Infection Nursing
Assessment (Cont.) Objective data Fever Hematuria; foul-smelling
urine; tender, enlarged kidney Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
Slide 147
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 147 Diagnostic Studies UA Urine
C&S BUN Creatinine KUB IVP VCG/VCUG Renal scan Cystogram
Retrograde pyelogram Ultrasound CT MRI Renal arteriogram
Slide 148
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 148 Normal Urinalysis pH 5 to 9 Sp
gr 1.001 to 1.035 Protein
Slide 149
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 149 Normal Characteristics of Urine
Color range Clear Newborn production about 1 to 2 ml/kg/hr Child
production about 1 ml/kg/hr
Slide 150
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 150 Urinary Tract Infection (UTI)
Is it really that serious? Concept of asymptomatic bacteria in
urinary tract
Slide 151
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 151 UTI: Causes Escherichia coli
most common pathogen Streptococci Staphylococcus saprophyticus
Occasionally fungal and parasitic pathogens
Slide 152
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 152 UTI: Classification Upper tract
involves renal parenchyma, pelvis, and ureters Typically causes
fever, chills, flank pain Lower tract involves lower urinary tract
Usually no systemic manifestations
Slide 153
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 153 UTI: Classification (Cont.)
Lower tract: Cystitis Urethritis Upper tract: Pyelonephritis VUR
Glomerulonephritis
Slide 154
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 154 UTI: Classification (Cont.)
Uncomplicated infection Complicated infections Stones Obstruction
Catheters Diabetes or neurologic disease Recurrent infections
Slide 155
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 155 Types of UTIs Recurrentrepeated
episodes Persistentbacteriuria despite antibiotics Febriletypically
indicates pyelonephritis Urosepsisbacterial illness; urinary
pathogens in blood
Slide 156
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 156 UTI: Etiology and
Pathophysiology Physiologic and mechanical defense mechanisms
maintain sterility Emptying bladder Normal antibacterial properties
of urine and tract Ureterovesical junction competence Peristaltic
activity
Slide 157
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 157 UTI: Etiology and
Pathophysiology (Cont.) Alteration of defense mechanisms increases
risk of UTI Organisms usually introduced via ascending route from
urethra Less common routes Bloodstream Lymphatic system
Slide 158
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 158 UTI: Etiology and
Pathophysiology (Cont.) Contributing factor: urologic
instrumentation Allows bacteria present in opening of urethra to
enter urethra or bladder Sexual intercourse promotes milking of
bacteria from perineum and vagina May cause minor urethral
trauma
Slide 159
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 159 UTI: Etiology and
Pathophysiology (Cont.) UTIs rarely result from hematogenous route
For kidney infection to occur from hematogenous transmission, must
have prior injury to urinary tract Obstruction of ureter Damage
from stones Renal scars
Slide 160
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 160 UTI: Etiology and
Pathophysiology (Cont.) UTI is a common nosocomial infection Often
Escherichia coli Seldom Pseudomonas Urologic instrumentation common
predisposing factor
Slide 161
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 161 UTI: Clinical Manifestations
Symptoms Dysuria Frequent urination (>q2h) Urgency Suprapubic
discomfort or pressure
Slide 162
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 162 UTI: Clinical Manifestations
(Cont.) Urine may contain visible blood or sediment (cloudy
appearance) Flank pain, chills, and fever indicate infection of
upper tract (pyelonephritis) Pediatric patients with significant
bacteriuria may have no symptoms or nonspecific symptoms like
fatigue or anorexia
Slide 163
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 163 Pediatric Manifestations
Frequency Fever in some cases Odiferous urine Blood or blood-tinged
urine Sometimes no symptoms except generalized sepsis
Slide 164
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 164 UTI: Diagnostic Studies
Dipstick Microscopic urinalysis Culture
Slide 165
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 165 UTI: Diagnostic Studies (Cont.)
Clean-catch is preferred U-bag for collection from child Specimen
obtained by catheterization or suprapubic needle aspiration has
more accurate results May be necessary when clean-catch cannot be
obtained
Slide 166
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 166 UTI: Diagnostic Studies (Cont.)
Sensitivity testing determines susceptibility to antibiotics
Imaging studies for suspected obstruction IVP or abdominal CT
Slide 167
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 167 UTI Collaborative Care: Drug
TherapyAntibiotics Uncomplicated cystitis: short-term course of
antibiotics Complicated UTIs: long-term treatment
Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin
Amoxicillin
Slide 168
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 168 UTI Collaborative Care: Drug
Therapy (Cont.) Cephalexin Others Gentamycin, carbenicillin ++
Pyridium (OTC) Combination agents (e.g., Urised) used to relieve
pain Preparations with methylene blue tint
Slide 169
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 169 UTI Collaborative Care: Drug
Therapy for Repeated UTIs Prophylactic or suppressive antibiotics
TMP-SMX administered every day to prevent recurrence or single dose
prior to events likely to cause UTI
Slide 170
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 170 Vesicoureteral Reflux (VUR)
Retrograde flow of bladder urine into the ureters Increases
potential for infection Primary vs. secondary reflux
Slide 171
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 171 Acute Pyelonephritis: Etiology
and Pathophysiology Inflammation caused by bacteria, fungi,
protozoa, or viruses infecting kidneys Urosepsis: systemic
infection from urologic source Can lead to septic shock and death
in 15% of cases
Slide 172
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 172 Acute Pyelonephritis: Etiology
and Pathophysiology (Cont.) Usually infection is via ascending
urethral route Frequent causes Escherichia coli Proteus Klebsiella
Enterobacter
Slide 173
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 173 Acute Pyelonephritis Etiology
and Pathophysiology (Cont.) Preexisting factor (usually)
Vesicoureteral reflux Dysfunction of lower urinary tract function
Obstruction Obstruction Stricture Stricture
Slide 174
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 174 Acute Pyelonephritis: Etiology
and Pathophysiology (Cont.) Commonly starts in renal medulla and
spreads to adjacent cortex Recurring episodes lead to scarred,
poorly functioning kidney and chronic pyelonephritis
Slide 175
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 175 Acute Pyelonephritis: Clinical
Manifestations Vary from mild to classic and very severe Presenting
symptoms N/V, anorexia, chills, nocturia, frequency, urgency
Suprapubic or low back pain, dysuria Fever, hematuria,
foul-smelling urine Costovertebral tenderness Symptoms often
subside in a few days, even without therapy Bacteriuria and pyuria
still persist
Slide 176
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 176 Acute Pyelonephritis:
Diagnostic Studies Urinalysis WBC casts CBC Imaging studies (IVP or
CT) Ultrasound
Slide 177
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 177 Acute Pyelonephritis:
Collaborative Care Hospitalization Parenteral antibiotics Relapses
treated with 6-week course of antibiotics Reinfections treated as
individual episodes or managed with long-term therapy Prophylaxis
may be used for recurrence
Slide 178
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 178 Types of Glomerulonephritis
Most are postinfectious Pneumococcal, streptococcal, or viral May
be distinct entity or May be a manifestation of systemic disorder
SLE Sickle cell disease Others
Slide 179
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 179 Glomerulonephritis Symptoms
Generalized edema due to decreased glomerular filtration Begins
with periorbital Progresses to lower extremities and then to
ascites HTN due to increased ECF
Slide 180
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 180 Glomerulonephritis Symptoms
(Cont.) Oliguria Hematuria Bleeding in upper urinary tract smoky
urine Proteinuria Increased amount of protein = increase in
severity of renal disease
Slide 181
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 181 Acute Poststreptococcal
Glomerulonephritis (APSG) Is a noninfectious renal disease
(autoimmune) Onset 5 to 12 days after other type of infection Often
group A -hemolytic streptococci Most common in children 6 to 7
years old Uncommon in younger than 2 years old Can occur at any
age
Slide 182
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 182 DIAGNOSING APSG
Slide 183
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 183 Prognosis 95%rapid improvement
to complete recovery 5% to 15%chronic glomerulonephritis
1%irreversible damage
Slide 184
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 184 Nursing Management of APSG
Manage edema Daily weights Accurate I&O Daily abdominal girth
Nutrition Low-sodium, low to moderate protein Susceptibility to
infections Bed rest is not necessary
Slide 185
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 185 Nephrotic Syndrome Most common
presentation of glomerular injury in children Characteristics:
Proteinuria Hypoalbuminemia Hyperlipidemia Edema Massive urinary
protein loss
Slide 186
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 186 Types of Nephrotic Syndrome
Minimal change nephrotic syndrome (MCNS) Also called: Idiopathic
nephrosis Idiopathic nephrosis Nil disease Nil disease
Uncomplicated nephrosis Uncomplicated nephrosis Childhood nephrosis
Childhood nephrosis Minimal lesion nephrosis Minimal lesion
nephrosis Congenital nephrotic syndrome Secondary nephrotic
syndrome
Slide 187
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 187 Changes in Nephrotic Syndrome
Glomerular membrane Normally impermeable to large proteins Becomes
permeable to proteins, especially albumin Albumin lost in urine
(hyperalbuminuria) Serum albumin decreases (hypoalbuminemia) Fluid
shifts from plasma to interstitial spaces Hypovolemia Hypovolemia
Ascites Ascites
Slide 188
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 188 Nephrotic Syndrome
Slide 189
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 189 Nephrotic Syndrome (Cont.)
Edema phase Remission phase Prognosis
Slide 190
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 190 Nephrotic Syndrome Management
Supportive care Diet Low to moderate protein Sodium restrictions if
large amount of edema Steroids 2 mg/kg divided into BID doses
Prednisone drug of choice (cheapest and safest) Immunosuppressant
therapy (Cytoxan) Diuretics
Slide 191
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 191 Family Issues Chronic condition
with relapses Developmental milestones Social isolation Lack of
energy Immunosuppression/protection Change in appearance due to
edemaself-image
Slide 192
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 192 Nursing Interventions Aseptic
technique during catheterizations Avoid unnecessary catheterization
and early removal of indwelling catheters Prevents nosocomial
infections Wash hands before and after contact Wear gloves for care
of urinary system
Slide 193
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 193 Nursing Interventions (Cont.)
Nursing Interventions (Cont.) Routine and thorough perineal care
for all hospitalized patients Avoid incontinent episodes by
answering call light and offering bedpan at frequent intervals
Slide 194
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 194 Nursing Interventions (Cont.)
Ensure adequate fluid intake (patient with urinary problems may
think will be more uncomfortable) Dilutes urine, making bladder
less irritable Flushes out bacteria before they can colonize Avoid
caffeine, alcohol, citrus juices, chocolate, and highly spiced
foods Potential bladder irritants Potential bladder irritants
Slide 195
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 195 Nursing Interventions (Cont.)
Discharge to home instructions Follow-up urine culture Recurrent
symptoms typically occur in 1 to 2 weeks after therapy Encourage
adequate fluids even after infection Low-dose, long-term
antibiotics to prevent relapses or reinfections Explain rationale
to enhance compliance
Slide 196
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 196 Renal Tubular Disorders Renal
tubular acidosis Proximal tubular acidosis (type II) Distal tubular
acidosis (type I)
Slide 197
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 197 Nephrogenic Diabetes Insipidus
(NDI) Major disorder associated with a defect in ability to
concentrate urine Distal tubules and collecting ducts are
insensitive to action of ADH (vasopressin) X-linked recessive
inheritance
Slide 198
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 198 Clinical Manifestations of
Diabetes Insipidus Newborn: vomiting, fever, failure to thrive,
hypernatremia Copious amounts of dilute urine
Slide 199
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 199 Therapeutic Management Fluid
management (management of extreme thirst in child) Pharmacologic
interventions
Slide 200
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 200 Hemolytic-Uremic Syndrome
Pathophysiology Diagnostic evaluation Therapeutic management
Prognosis Nursing considerations
Slide 201
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 201 Renal Failure Acute renal
failure (ARF) Chronic renal failure (CRF)
Slide 202
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 202 Acute Renal Failure (ARF)
Definition: kidneys suddenly unable to regulate the volume and
composition of urine Not common in children Principal feature is
oliguria Associated with azotemia, metabolic acidosis, and
electrolyte disturbances Most common pathologic cause: transient
renal failure resulting from severe dehydration
Slide 203
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 203 ARF (Cont.)
Pathophysiologyusually reversible Diagnostic evaluation Therapeutic
management Nursing considerations
Slide 204
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 204 Complications of ARF
Hyperkalemia Hypertension Anemia Seizures Hypervolemia Cardiac
failure with pulmonary edema
Slide 205
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 205 Chronic Renal Failure (CRF)
Begins when diseased kidneys cannot maintain normal chemical
structure of body fluids Clinical syndrome called uremia
Slide 206
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 206 Potential Causes of CRF
Congenital renal and urinary tract malformations VUR associated
with recurrent UTIs Chronic pyelonephritis Chronic
glomerulonephritis
Slide 207
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 207 CRF Pathophysiology Diagnostic
evaluation Therapeutic management Manage diet, hypertension,
recurrent infections, seizures Nursing considerations
Slide 208
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 208 Renal Replacement Therapy
Dialysis types Hemodialysis Peritoneal dialysis Hemofiltration
Slide 209
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 209 Hemodialysis Requires creation
of a vascular access and special dialysis equipment Best suited for
children who can be brought to facility 3 times per week for 4 to 6
hours Achieves rapid correction of fluid and electrolyte
abnormalities
Slide 210
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 210 Child Receiving
Hemodialysis
Slide 211
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 211 Diversional Activities Lessen
Boredom During Hemodialysis
Slide 212
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 212 Peritoneal Dialysis Abdominal
cavity acts as semipermeable membrane for filtration Can be managed
at home in some cases Warmed solution enters peritoneal cavity by
gravity; remains for period of time before removal
Slide 213
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 213 Continuous Venovenous
Hemofiltration Uses technique for ultrafiltration of blood
continuously at a very slow rate Works with the fluid overload in
postoperative period Successful alternative for critically ill
children who might not survive rapid volume changes of hemodialysis
and/or PD
Slide 214
Mosby items and derived items 2007, 2003 by Mosby, Inc., an
affiliate of Elsevier Inc.Slide 214 Transplantation From living,
related donor From cadaver donor Primary goal is long-term survival
of grafted tissue Role of immunosuppressant therapy Rejection
Prognosis