Alternation In Mobility / Neuromuscular, Muscoskeletalk & Pressure Ulcer Handout Flashcards
1
Q
> 50% of pressure ulcers in neonates/kids are due too..
A
Equipment pressure injury
2
Q
Hihh risk conditions for pressure ulcers in peds…
A
Spinal Bifida/ Cerebral palsey
3
Q
How often skin assessment in peds
A
Daily
Medicare will not reimbursement stage III or IV unless present upon arrival
4
Q
Site most likely fir pressure ulcer
Small child
Older child
A
Small = Occiput
Older = Sacral
5
Q
Brain & spinal cord myelination is incomplete at birth describe how process of myelination…
A
Cephalocaudal - Head - toe and
Inwards outward
6
Q
Hypertrophy…
A
Muscle growth
7
Q
Epiphyseal plates…
A
Growth plates in long bones.
8
Q
Cast are applied after swelling has decreased to avoid…
A
Compartment syndrome
9
Q
Cast will require Stockinette/ padding to avoid injury.
Removed with…
A
Cast saw
Vibrates but cannot cut skin
10
Q
Do this if skin under cast is itchy…
A
Cool hair dryer setting
11
Q
When to elevate extremity in a cast…
A
First 1 or 2
12
Q
Teach SS of compartment syndrome…
A
5 Ps
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
13
Q
Therapeutic tech to apply a pulling force to a part of the body (Bones, Joints, Muscles)
A
Traction
14
Q
Traction
Therapeutic tech to apply a pulling force to a part of the body (Bones, Joints, Muscles)
Goal….
A
Alignment broken bones / dislocated joints
Reduce muscle spamsm
Correct deformities
Relief of pressure on nerves
Immobilize limb before or after surgery
15
Q
Neurovascular checks for 5 Ps how often for pt in traction…
A
1-2 initially
16
Q
Traction Setup.
Ensure the weights rest on the floor at all times.
T ir F
A
F
They must hang freely
17
Q
Complications frequent with traction…(4)
A
Constipation
DVT
Urine retention
Pressure ulcers
18
Q
External fixation purpse…
A
Pins & screws inserted into bone and connected to wire frame outside the body to stablize bone while it heals
19
Q
Benefits of external fixation ….
A
Stabilize complex / open fractures
Allows soft tissue healing- burns, wounds, infections
Temp stability b4 surgery
Correct bone deformities
Maintain alignment after surgery
20
Q
Pin site cleaning for external fixation…
Type of technique…
Type of cleaner….
A
Sterlie tech
Chlorhexidine
21
Q
Muscoskeletal assessment.
Inspection…
Palpation…
ROM…
Strength Test…
A
Inspection; Swelling, bruising, redness, asymmetrical / Muscle Wasting
Palpation: tenderness, warmth, crepitus, masses
ROM: Active & passive
Strength; Push / Pull 1 - 5
22
Q
Neurovascular assessment consists of circulation, sensation, motion.
Critical after injury, surgery, casting
Describe assessment…
A
6 P’s
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Pressure
23
Q
Spina bifida occulta occurs when the vertebrae fail to completely close around the spinal cord.
Nerves usually Uneffected
What does it look like…
A
Dimple on lower back
Small tuft of hair
Birthmark
Lipoma (small fatty lump)
Dermal pit
24
Q
Clinical Significance of spina bifida occulta…
A
Mostly asymptomatic
Rarely Tethered Cord Syndrome- spinal cord is abnormally stretched
Back pain
Leg weakness
Bowle / bladder
Change in Gait
25
Meningocele....
Moderate form of spina bifida
Meninges protrude through vertebrate DONT CONTAIN SPINAL CORD TISSUE
26
CSF- filled sac visible on back near lumbar or sacral area.
Spinal cord remains in place & neurological function is preserved
Sac breaks = Medical Emergency
Meningocele
27
Meningocele is a CSF filled sac located on the lower back
Neurological function often intact
Pre op care:
Protect the sac
Dressing...
Posistion...
Diapers....
Monitor for this serious problem...
Saline soaked non-adherent bandage
Prone posistion
Diaper under the sac
Monitor for meningitis
28
Myelomeningocele....
Most severe spina bifida
Meninges & spinal cord / nerves protrude through opening in vertebrea
29
Myelomeningocele
Neurological defects below level of lesion
Physical findings
Visible sac at birth
Lower limbs...
Bowles/bladder....
Clubfoot, dislocated hips, ortho deformities
Hydrocephalus....
Lower limbs = Flaccid paralysis
Incontinence
Hydrocephalus 80 -90%
30
Posistion for myelomeningocele
Posistion...
Head...
Diapers...
SAC Care
Type of allergy common among this population...
Posistion: Prone / hips slightly flexed, legs abducted with pad
Head turned to 1 side
Dint use diapers
SAC Care
Saline soaked bandage
Latex allergy
31
Labs & Screening for myelomeningocele
Maternal AFP...
Amniocentesis...
Parental screening for neural tube defects
Amniocentesis can detect levels of AFP
32
Spina bifida occulta
Meningocele
Myelomeningocele
External appearance & problems involved with disorder...
Spina bifida occulta
Red, dimples, tuft of hair - incomplete close of vertebrae- Back / leg pain
Meningocele:
Visible CSF filled sac & Meninges
Neurological issues rare.
Myelomeningocele
Large CSF, Meninges, nerves in a sac on lower back.
Hydrocephalus common
Parálisis, sensory loss, bowel / bladder dysfunction
33
Talipes Equinovarus (Club Foot) is a defect in which one or both feet are twisted out of posistion.
Define
Cavus...
Adduction...
Varus...
Equinus...
Cavus High Arch
Adduction Forefoot turns inwards
Varus heel turns inwards
Equinus Tip Toe posistion
34
Gold standard for treating Club Foot...
Ponseti Method
Serial casting started soon after birth
Gentle manipulation of foot followed by long leg casting
Chnge casting weekly for 6 - 8 weeks
35
Osteogenesis imperfecta....
Brittle bone disease
Break easily due to defect in tyoe 1 collagen
Inherited Autosomal Dominate (most common) or Autosomal Recessive
Type 1 Mild
Tyoe 2 lethal at birth
36
Osteogenisis imperfecta
Blue sclerae...
Hearing loss...
Short statue
Joint laxity
Spinal curvature...
Family history
Collagen in eyes give a blue tint
Hearing loss due to abnormal ossicles
Kyphosis / Scoliosis
37
Medications for osteogenisis imperfecta...
Bisphosphonates (pamidronate)
Improves bone density
38
Femoral head and acetabulum are misaligned or unstable...
Dev Dysplasia of the Hip
39
Risk of development Dysplasia of the hip.
Birth order...
Male / Female...
Birth posistion...
Family history...
Oligohydramnios....
Swaddling tight...
First born risk - less uterine space
Female x 5 odds due to maternal hormone
Breech posistion
Genetic predisposición
Low amniotic fluid can restrict movement
Swaddling with hips extended & adducted
40
Development Dysplasia of the hip
Clunk heard as femoral head is reduced into acetabulum.
Hip dislocation when adduct3d and pushed posteriorly
Barlow sign
Ortolani sign
Clunk heard as femoral head is reduced into acetabulum - Ortolani sign
Hip dislocation when adduct3d and pushed posteriorly - Barlow sign
41
Infants:
Positive Ortolani/ Barlow signs
Asymmetrical gluteal / thigh folds
Limited hip abduction
Leg length discrepancy
Older Chillin
Limping/ Tip toe walker
Trendelburg sign: Pelvis dips on unaffected side when standing on affected leg
Hip pain (less common)
Hip Dysplasia
42
Treatment for Development Hip Dysplasia
New born - 6 months....
6 - 18 months....
>18 months...
New born - 6 months: Pavlik harness: Keeps hips flexed and ABDUCTED (23 - 24 Hrs Daily)
6 - 18 months: closed reduction/ Spica cast
>18 months: Open Surgical reduction, possible osteoporosis, casting
43
Pavlik Harness Considerations
When to adjust straps...
Wher3 to wear harness in relation to diaper...
Adjust only with providers blessing
Wear over diaper, undershirt, under straps to protect skin
44
Muscle fibers are gradually replaced by fat & connective tissue in this progressive genetic disorder that leads to muscle weakness/ degeneration....
Muscular dystrophy (group of genetic disorders)
45
The most common & severe progressive/ genetic disorder that replaces muscle tissue with fat / connective tissue...
Duchenne Muscular Dystrophy
46
MD is an X linked recessive disorder.
Which population is most affected by this disease...
Boys
Girls are carriers
47
When do symptoms appear for MD...
2 - 5 yrs
48
Gowers sign...
MD
Chold uses hands to Walk Up thighs to stand from floor
49
MD Progressive muscle degeneration
Begins in this area....
Describe gait...
Enlargement of...
Loss of ambulation by age...
Can lead to heart / ling failure
Some cases Mild Cognitive Delay
Begins in Pelvis & Shoulder Gridles & move up
Waddling Gait
Enlargement of Calves
Loss of ambulation by age 10 - 12
50
MD - Respiratory support
Teach use of...
Eventually use of...
Cough assist device
Bipap
51
Medications for MD
(3)
Corticosteroids
ACE Inhibitors/ beta-blockers
52
Non-progressive disorder of muscle, movements, muscle tone, posture caused by Damage to Develpong Brain - before or during birth...
Cerebral Palsey
53
Cerebral Palsy is a non-progressive disorder that affects movement, muscle tone, or posture and is caused by damage to developing brain.
Timing (Pre, Peri, Post - Natal)
Birth Asphyxia, premature , low birth weight, birth trauma
TBI, Meningitis, encephalitis, stroke, kernicterus
Brain malformation, Intrauterine infection (CMV, Rubella), maternal drug used, placenta insufficiency
Perinatal
Birth Asphyxia, premature , low birth weight, birth trauma
Postnatal
TBI, Meningitis, encephalitis, stroke, kernicterus
Pernatal
Brain malformation, Intrauterine infection (CMV, Rubella), maternal drug used, placenta insufficiency
54
Duchene MD
Spastic (Most Common)
Dyskinetic/ Athetoid
Ataxic
Mixed
Spastic (Most Common)
Stiff muscles, jerky, tight joints, can affect just 1 limb / side or everything
Dyskinetic/ Athetoid
Involuntary movements esp in face and tongue / drooling & speech issue
Ataxic
Poor balance, unsteady gait, difficulty with depth perception/ coordination
Mixed
Combined disorders esp Spastic & athetoid
55
Medications for MD
For spasiticy...
Targeted muscle relief...
Seizures....
For spasiticy: Baclofen / Diazepam
Targeted muscle relief: Botox
Seizures: Anticonvulsants
56
Slipped Capital Femoral Epiphysis....
Head of femur slips off growth plate (epiphysis) at the hip joint.
Like a scoop of ice cream slipping off a cone
MEDICAL EMERGENCY- Risk of Avascular Necrosis
57
Describe population most at risk....
10 - 16 yrs
Boys
Fat
Black / latino
Endocrine disorder, trauma, fam history
58
Treatment Slipped Capital Femoral Epiphysis
Immediate....
Surgery...
Bilateral fixation maybe considered if hips are at high risk
Crutches / wheel chair until surgery
In-situ pinning (metal screw holds head of femur in place)
59
Lateral side to side curvature of the spine >10 ° often with vertebral rotation...
Scoliosis
60
This disease can be Structrual (Permanent) or non-Structrual (Temp. Due to posture)
Usually becomes noticeable during growth periods...
Scoliosis
61
Scoliosis 3 variations
Idiopathic
Congenital
Neuromuscular
abnormal spinal formation in utero
Relat3d to Neuromuscular diseases (CP / MD)
Unknown cause, more common in girls
Idiopathic: Unknown cause, more common in girls
Congenital: abnormal spinal formation in utero
Neuromuscular: Relat3d to Neuromuscular diseases (CP / MD)
62
Non surgical Therapeutic Management
<25°
25 - 45°
<25°
Observation & regular X-rays monitor
25 - 45°
Bracing (Boston Brace) stops progression. Worn 16 - 23 hrs daily.
63
Surgical management of scoliosis
Spinal fusion with rods & screws
____ ° of spinal curvature needed.
45 - 50
64
Post op for scoliosis surgery
Log rolling for how long...
No bending, twisting, lifting >10lbs....
No gym / pe...
Avoid prolonged sitting...
Log roll 2 days post op
Bending, twisting, lifting, >10lbs
6 - 12 weeks up to 6 months
Gym/ PE 6 months
Sitting first few weeks
65
Pain management post scoliosis surgery...
Neurovascular checks lower extremities
Respiratory...
Eliminating...
Psychosocial support
PCA / IV opiods
Incentives spirometry / assess lung sounds
Constipation/ give stool softeners
66
5 types of growth plate fractures
Straight
Above
Lower
Through
Rammed
Worst prognosis Often leads to growth arrest
Through growth plate & metaphysis. Most common type Good prognosis
Through growth plate & epiphysis. Can affect joint & mod risk to growth
Across the growth plate. Good prognosis
Through metaphysis, physis, epiphysis. Can lead to growth disturbances. Requires surgery
Straight
Across the growth plate. Good prognosis
Above
Through growth plate & metaphysis. Most common type Good prognosis
Lower
Through growth plate & epiphysis. Can affect joint & mod risk to growth
Through
Through metaphysis, physis, epiphysis. Can lead to growth disturbances. Requires surgery
Rammed
Worst prognosis Often leads to growth arrest
67
List 5 types of growth plate fractures in order from least to most serious...
Straight 1
Above 2
Lower 3
Through 4
Rammed 5
68
Types of fractures
Simple (closed)
Compound (open)
Comminuted
Greenstick
Bone breaks but skin not broken. Cast / splint treatment
Bone breaks into 3 more pieces. Surgical intervention to realign Bone.
Bone bends and cracks but doesn't break completely. Common in children due to more flexible bones
Bone breaks & pierces skin. Requires surgery & antibiotics
Simple (closed)
Bone breaks but skin not broken. Cast / splint treatment
Compound (open)
Bone breaks & pierces skin. Requires surgery & antibiotics
Comminuted
Bone breaks into 3 more pieces. Surgical intervention to realign Bone.
Greenstick
Bone bends and cracks but doesn't break completely. Common in children due to more flexible bones
69
Suspicious fractures.... (7)
Not yet walking
Multiple with various stage of healing
Ribs / sternum
Both arms / legs
Spiral fractures
Skull / femur
Lying ass parents
70
Complication of fractures
Fat embolism
SS
Respiratory distress
Confusion
Requires supportive care
71
Complications of fractures
Osteomyelitis...
Bone infection- often after an open fracture
72
Juvenile idiopathic arthritis
Autoimmune disorder where immune system attacks body's joints. <16 yrs
Chronic pain lasting >____ weeks
Morning Stiffness, may improve throughout the day.
Labs:
ESR & CRP...
Positive ANA...
Rheumatoid factor (RF)...
>6 weeks
Labs:
ESR & CRP Both elevated
Positive ANA sometimes
RF negative
73
Type of juvenile idiopathic arthritis
Oligoarticular JIA (Def, Joints, Prognosis, Management)
Polyarticular JIA (Def, Joints, Prognosis, Management)
Systemic JIA (Def, Symptoms, Joints, Prognosis, Management)
Oligoarticular JIA
Def <4 JOINTS
Joints: Knee, ankel, wrist
Prognosis Good but can lead to eye problems
Management: Disease-modifying antirheumatic drugs (DMARDs) & biologics for eye protection
Polyarticular
Def: >5 typically symmetrical
Joints: Hands, Wrist, Knee, Feet
Prognosis: more likely Joint Damage & long-term disability
Management: DMARD, Biologics, NSAIDS
Systemic JIA
DEF: Affects multiple systems & Joints
Symptoms: Fever (evening), Rash (salmon colored/ sporadic), Enlarged Lymph nodes/ spleen, inflammation Heart, Lungs, liver
Prognosis: Severe & potential life threatening
Management: High doses corticosteroids & biologics
74
Methotrexate...
First line DMARD for Polyarticular/ Systemic JIA
75
Management of Juvenile Idiopathic Arthritis
(6)
Meds: NSAID, DMARD,Biologics, Corticosteroids, methotrexate
PT: Exercise/ ROM
Orthotic Support: Splints & Braces
Eye care: eye exams esp Oligoarticular JIA- due to risk of uveitis (eye wall)
Surgery
Psychosocial
76
In infants the spine is very mobile which can increase odds of injury...
True
77
Lordosis, kyphosis, scoliosis
Describe...
Lordosis: inwards curve of lower spine
Kyphosis: Hunch back
Scoliosis: James Schmolen : Curvature of spine atleast 10°
78
Damage to the epiphysis may have this effect on the child....
Decreased growth
79
Difference between
X ray
Fluoroscopy
Myelography
X ray: Must hold still
Fluoroscopy: Creates photos during movement
Myelography: Visualize neurotube defects
80
Gold standard for diagnosis of neuro
81
Gold standard to detect neural tube defects...
MRI/CT
Can look at both hard & soft surfaces
82
Which lab result most accurately reflects muscle damage...
CK
83
Type of diet for immobilized pts...
High calorie/ high protein
84
Examples of skin traction devices...
Ace wrap
Kinesiology tape
85
Straight/ Running traction
Balanced suspension traction
Provide counter balance to Force of traction, Can change posistion slightly, extremity is ELEVATED
Force of weight pull extremities in 1 direction. Allows for extremity to rest on bed
Straight/ Running traction
Force of weight pull extremities in 1 direction. Allows for extremity to rest on bed
Balanced suspension traction
Provide counter balance to Force of traction, Can change posistion slightly, extremity is ELEVATED
86
Russell traction...
Skin traction to put joint back in place
87
Myelomeningocele is often detectable by US during these weeks of preggers...
16 - 18 wks
88
Describe club foot appearance...
Inwards & upwards
Golf club
89
Serial casting called the Ponseti method can last up to 12 weeks and is ised to help...
Club foot
90
How long after receiving the Ponseti serial casting method will a child need to wear Ankle, Foot, Orthopedic boots...
Several years possible
91
Osteogenisis imperfecta causes Porous bones, hypermobile joints, and connective tissue issues.
How does one get brittle bine disease...
Autosomal Dominate defects of the collagen type 1 gene
92
Bisphosphonates are given to Osteogenisis imperfecta to strengthen bines
Give 2 nursing care interventions...
Scoop instead of lift
Don't lift legs to change diapers
AVOID BP CUFF
93
Subluxation...
Partial dislocation
94
Maternal hormones may lead to laxity of ligaments (very flexible) in females causing this problem...
Hip Dysplasia
95
Unequal folds of skin
Unequal knee height
Limited abduction
Trendelburg sign
Problem....
Developmental Hip Dysplasia
96
Genetic mutation causes decreased/absent muscle protein dystrophin...
MD
97
Muscle Wasting/ Pseudohypertrophy
Waddling Gait
Lordosis (Saddle Back)
Growers sign
Associated with...
MD
98
Medications for MD...
A (X linked recessive) affects boys progressive illness
Corticosteroids
Ca & D vitamin
Antidepressants
Ace & beta blockers
99
Mechanically assisted cough machine maybe used with...
MD
100
CP has 2 neurological comorbidities...
Seizures & hydrocephalus
101
Class: Muscle relaxant; GABA agonist
Use:
Treats spasticity (especially in cerebral palsy, spinal cord injury, multiple sclerosis)
Can be oral or intrathecal (pump)
Baclofen
102
Baclofen pump has an intrathecal delivery
Explain medication...
Explain intrathecal...
Baclofen Muscle Relaxant used in CP
Intrathecal = in CSF in spine
103
Selective Dorsal Rhizotomy....
A neurosurgical procedure used to reduce spasticity (muscle tightness) in children, commonly with cerebral palsy (especially spastic diplegia).
Involves cutting selected sensory nerve rootlets in the spinal cord that are sending abnormal signals to the muscles
104
Botulin Toxins
Anticholinergic
Baclofen, danteolene, diazepam
Prescribed for...
CP
105
Slipped Capital Femoral Epiphysis
Passive ROM can help...
False.
It will mess them up
106
Legg-Calve-Perches Disease
Avascular necrosis of femoral head
Painless
Common in boys 4 - 8 yrs
Treatment....
Exercise....
Surgery...
Treatment:
NSAIDS
Limit activity
Exercise: Low Impact
Surgery: Not often unless >8yrs
107
What is a TLSO Brace?
Used for Scoliosis
A rigid back brace that supports the thoracic, lumbar, and sacral spine.
Commonly used to immobilize the spine after surgery, injury, or to treat spinal deformities.
108
Scoliosis >45° may require...
Spinal fusion
109
Scoliosis surgery is 5 - 8 hrs long
How does the HCP lengthen the rods...
Magnetic Expansion Control Rod
110
Post op Scoliosis care
RN helps pt to ambulate with in first 24hrs...
False
PT helps with the first ambulation
111
Spiral fractures are common injuries in children...
False
They are associated with abuse
112
Salter-Harris classification...
Used to classify fractures in Growth Plate
113
Juvenile Idiopathic arthritis
Autoimmune disorder Antibodies attack joints
Inflammation, warmth, Stiffness with activity...
False
With Inactivity
114
Methotrexate is...
Antirheumatic drugs used for Juvenile Idiopathic arthritis
115
Fever
Rash
Enlargement of spleen / lymph nodes
Anemia
Fatigue
Problem....
JIA
116
