Nursing Care: Alterations of Musculoskeletal and Neuro Systems

Neuro Exam: VS
~RR (short, shallow)
~HR (up or down)
~BP (elevate)

*Cushing Triad* – all 3 change (brainstem involvement)

Neuro Exam: Eyes
Pupil size/reaction
~Fixed and dilated (abnormal finding)
~Asymmetrical (abnormal finding)

Eye movements (Doll’s Eyes)

Neuro Exam: Motor Function
Spontaneous Activty
Purposeful and symmetrical movements (seizure activity)
Response to pain (absence of response)

Most disappear between 6-9 months

Neuro Exam: Drainage
From the nose or ears
Look for Bleeding and Clear Fluid

Neurologic Exam: Diagnostic Procedures
Lab Testing
Lumbar Puncture
Auditory and Visual Evoked Potentials

an alert cognitive state in which you have cognitive power

a state lacking normal awareness of the self or environment greater than 6 hours

Imbalance in the production/absorption of CSF (Passive dilation of the ventricles and pressure on tissues)

Hydrocephalus: Causes
Impaired absorption of CSF fluid

*Genetic*: Spina Bifida

~Intraventricular hemorrhage
~Traumatic head injury

S/S: Hydrocephalus

Head circumference:
Crosses 1-2 grids in growth chart
Bulging fontanels
Distended scalp veins
Thin scalp skin

Treatment: Hydrocephalus
Relieve pressure
VP Shunt
EVD (external ventricular drainage)

Ventriculoperitoneal Shunt
Comprised of shunt, catheter and valve placed in ventricle and that drains into peritoneal cavity

~Mechanical failure

Hydrocephalus: Nursing Postop
Routine Care
Supine Position or HOB elevated

Assess for s/s Increased ICP
~head circumference
~pupil dilation
~BP alterations

Abdominal Distention
~Post-Op ileus

Advance diet as tolerated
Strict I/O (Daily weight)

PostOp N/M: Hydrocephalus
↓ responsiveness
~Local inflammation

Wound Care
Emotional support

Hydrocephalus: Prognosis
~Rate in which it develops
~Duration of increased intracranial pressure
~Frequency of complications

Long term complications
Neurological disabilities = 50%

Head Injury
Leading cause of death in children

Causes of Brain Damage:
Bicycle injuries
Sports-related trauma

Head Injury: General Characteristics
~Directly related to FORCE (severe blow causes diffuse swelling)
~Younger children more vulnerable (larger head, thinner softer skull, insufficient musculoskeletal support)
~Acceleration (Coup – point of impact, countrecoup – rebound effect)

Head Injury: Complications
~Neuronal dysfunction: altered mental status

S/S: Confusion, Amnesia, Vomiting, Dizziness


Complications: Head Injury
Contusion and laceration (bruising and tearing of tissue)
~Epidural (outer) hemorrhage (dura-skull)
~Subdural (inner) hemorrhage (dura – cerebrum)
~Cerebral edema (anoxia and herniation)

S/S: Head Injury
Scalp swelling
Well vasculated
Loss of Consciousness
HA or Irritability

Head Injury: Home Management
Check child every 2 hours
F/U with primary care physician in 1-2 days
Diet as tolerated
Observe I/O status
Tylenol for pain

Head Injury: Acute Care
VS Q 2 hrs
Neuro Checks Q 2 hrs
NPO till gag reflex present
I/O balance
Pain Management
↓ cerebral edema
Safety (side rails up)
Quiet, dark environment

Acute inflammation of meninges (Bacterial)

Transmission: Nasopharynx

Patho: Meningitis
Vascular dissemination from a focus of infection elsewhere:

WBC accumulation
Tissue damage

S/S: Meningitis Bacterial
Abrupt onset:
~Altered sensation
~*Nuchal rigidity*
~*Petechiae/purpuric rash (meningococcal infx)*

S/S: Meningitis Viral
Abrupt or gradual

GI s/s
1-2 days later (neuro alterations)

Diagnosis: Meningitis
Lumbar puncture (sedation and monitor VS)
HOB Flat
Encourage fluids
Neuro check
Drainage at injection site
Inability to void

Two Telltale Signs: Meningitis
Brudzinski’s – Severe *neck* stiffness causes a patient’s hips and knees to flex when the neck is flexed.

Kernig’s – Severe stiffness of the *hamstrings* causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Treatment: Meningitis
Reduce increased ICP
Pain Relief

Antibiotic Therapy
Manage Shock
Control Seizures
Monitor Hearing

a chronic neurological condition characterized by recurrent episodes of seizures of varying severity (abnormal electrical discharge)

Most commonly treated neurologic alteration in children

S/S: Epilepsy
Altered LOC
Involuntary movements
Changes in Perception

Diagnosis: Epilepsy
*EEG best tool*:
Auditory/Visual Provoked

Risk Factors
Intellectual disabilities
Cerebral Palsy

Complex Partial Epilepsy
Start out in partial (alert and involuntary movement) and then goes into disorientation stage and then a recovery phase


Petite Mal
A mild form of epilepsy

Twitching eyelid
Smacking Lip

Myoclonic Seizure
Sudden brief involuntary single or multiple contractions of muscles

Pertaining to alternate contraction and relaxation of muscles

state of continuous muscular contraction

Tonic-Clonic Seizure
Violent, involves the total body and usually is preceded by an “aura” – a brief warning sign

Atonic Seizure
Pt has complete loss of muscle tone and falls to the ground; *Drop Attack*

Epilepsy Treatment: Goal
Identify cause (if possible)
Pharmacology management w/ minimal side effects

Epilepsy Treatment: Pharmacology
Raises neuronal excitability threshold
1-3 medications (the less the better) max dose before you start on another med
Serum monitoring
Discontinued when seizure-free for 2 years

Epilepsy Treatment: Ketogenic Diet
High fat
↓ Low carb
Adequate protein (changes energy source – ketones)

25% success

Epilepsy Treatment: Vagus Nerve Stimulation
Implanted device
Left vagus nerve (cranial nerve X)
Activated by magnets

Epilepsy Treatment: Surgery
Removal of causative agent (hematoma, tumor, lesion)

Epileptogenic area
~Incapacitating, refractory seizures
~Failure of >3 meds

N/M: Epilepsy
Observe and document event
~Behaviors preceding
~Characteristics of the Episode
~Do Not Define

~Lie flat
~Do Not Restrain
~Risk of Aspiration
~Risk of airway obstruction

Remain Calm
Stay w/ Child (press call light)
Isolate child
Teaching and Support (rectal meds)

Status Epilepticus
A condition in which there are continuing attacks of epilepsy *without* intervals of consciousness

Last more than 30 monutes

N/M: Status Epilepticus
ABCs of life support
IV access
Rectal diazepam (safe Rx)
Hyperthermia (increased motor activity)
HTN (BP may be elevated)
Recovery Position

Febrile Seizures
This is a generalized seizure that usually occurs when a child’s temperature rises rapidly to above 101.8. The seizure is general *tonic-clonic* movements lasting less than 15 minutes (usually 1-2 minutes).

More prevalent in *boys*

Cerebral Palsy
a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by increased muscular tone, reduced muscular tone and fluctuating tone

Cerebral Palsy: Causes
Intauterine event (infx. meds, abnormal placental attachment)
Birthing difficulties
Postnatal (Infx and Trauma)

Spastic Cerebral Palsy
70 to 80 % of patients and is characterized by stiff or permanently contracted muscles

*Walks on toes*
*Scissor Gait*

Athetoid Cerebral Palsy
affects 10 to 20 percent of patients. uncontrolled, slow, writhing movements in all extremities
Poor swallowing drooling facial grimacing

Ataxic Cerebral Palsy
Typically they have an unsteady gait, muscle weakness, a lack of coordination and problems with depth perception and balance

Mixed Cerebral Palsy
occurs when patient has symptoms of 2+but most common is spastic/ athetoid forms .

Treatment: Cerebral Palsy
No cure

Symptomatic Relief
~Baclofen pump
~Oral muscle relaxants
~ROM exercises
~Orthopedic surgery
~Developmental interventions

Duchenne’s Muscular Dystrophy
Most common and severe progressive degenerative disease; This is an inherited *sex linked recessive disease (Mom to Son)*. It is characterized by an absence of muscle protein dystrophin

symmetric skeletal muscle groups. Is a progressive weakness & atrophy as it continues. Muscle wasting, from the bottom up. Ultimately fatal. Most children wheelchair bound by 12, death from respiratory paralysis during adolescence.

Duchenne’s Muscular Dystrophy
Inability to support muscle fibers *(muscle fiber degeneration)*
~Fat and connective tissue replacement

S/S: Duchenne’s Muscular Dystrophy
Frequent falls
*Large calf muscles*
Weakness in Lower Muscles
*Waddling gait*
*Gower’s Sign*

Rapid Progression

Duchenne’s Muscular Dystrophy: Mortality
Late adolescent (early 20s)
Weakened thoracic muscles
~Tachycardia (cardiomyopathy)
~Dyspnea (respiratory infx)

Duchenne’s Muscular Dystrophy: Diagnosis
Muscle biopsy
Nerve Conduction Velocity
Creatine Kinase

Duchenne’s Muscular Dystrophy: Treatment
No cure
~Orthopedic surgery
~Pulmonary toileting

Emotional Support
Genetic Screening

Neural Tube Defects
malformations of the brain, spinal cord, or both during embryonic development that often result in lifelong disability or death

Failure of the neural tube to close at 1 month gestation

Neural Tube Defects: Causes
Environmental (Folic Acid)

~Alpha-fetoprotein (amniocentesis)
~CT scans

Spina Bifida
A congenital defect that occurs during early pregnancy when the spinal canal fails to close completely around the spinal cord to protect it

*Absent* cerebral hemispheres (brainstem present)

a congenital herniation of brain tissue thru a gap in the skull

Hernial protrusion of saclike cyst containing meninges, spinal fluid and a portion of the spinal cord with its nerves

S/S: Neural Tube Defects
Lower lumbar/sacral
~Tuft hair
~Port wine nevi

Bowel/bladder dysfunction

Complications: Neural Tube Defects
↓ motor activity
Musculoskeletal alterations
Neurogenic Bladder/Bowel
CNS Infx (hydrocephalus)
*Latex Allergy*

Treatment: Neural Tube Defects
Immediate surgical closure within 48 hours

Risk of Infx
Spinal Cord/Nerve damage

VP Shunt

Neural Tube Defects: Nursing PreOp
Cover sac with warmed, saline soaked sterile dressings

Assess: leakage of sac, infx, CNS alterations
Support: bowel/bladder function (keep fluid off sac)

*Assess for hydrocephalus*
Emotional Support

Neural Tube Defects: Nursing PostOp
Skin Care
Postop complications
Head circumference
ROM exercise
Intermittent catheterization
Assistive devices

More common in children and older adults

Variations of child
~Heal faster
~Traumatic cause
~Rare in infant (abuse, osteogenesis imperfecta)

Most common

Growth plates
Weakest part of bone
Goal of aggressive treatment: prevent growth disturbances

Muscles around fracture contract to anatomically splint area = muscle rigidity (muscles protecting bone)

Muscle relaxation (traction and pharmacology)

S/S: Fractures
Splinting affected area
Limited activity

Treatment: Fractures
End to end apposition (traction/immobilization)

Displaced (ORIF = Open Reduction and Internal Fixation)

Rarely need physical therapy (Children are naturally active)

Fractures: Acute Care Settings
ORIF Necessary

Supracondylar (elbow fracture)

Fractures: Nursing PreOp
Emotional support
Pain management

Compartment Syndrome – swelling in area that constricts blood flow to the area

Fat Embolism
condition in which fat globules are released from the marrow of the broken bone into the bloodstream, migrate to the lungs and cause pulmonary hypertension

N/M: PostOp Fractures
Promote casting drying (7 mins-48 hours)
Cast petaling
Elevate extremity
Tissue ischemia
Pain relief (itching – cool air via blow dryer)
Cast Care

Fractures: Traction
Elongate muscles (reduce muscle spasms)
Position bone (prevent deformity)

Types: Skin (foam rubber straps) and Skeletal (pins in bones)

N/M: Traction
Pain (Opioids and Muscle Relaxants)
Adequate Nutrition (encourage fluids)
Regular bowel movements
System evaluation
Skin Care (Pin Care)

Developmental Dysplasia of the Hip
Disformation that causes subluxation or full dislocation that causes hip instability

Risk Factors: DDH
~*Breech* position and/or delivery
~*Females* > Males
~Has to do with *carrying position* (rare in african Americans babies but common in *Indian babies*

Ortolani/Barlow testing (lifting legs up and rotating hips out)
Shortening of limb
Assymmetrical thigh/gluteal folds

Treatment: Developmental Dysplasia of the Hip
Pavlik harness (immobilize them)
~abduct position
~24 hours/day
~3-5 months
~delayed developmental milestones
~skin breakdown

Spica Cast
~3-6 months

~Applying device (teaching parents)
~Skin care (sponge bath)
~Therapeutic touch
~Stroller/ car seat

Legg-Calve Perthes Disease
Early elementary and more prevalent in boys; Infection or trauma of the hip area which causes poor circulation to the femoral head and causes it to die off

S/S: Legg-Calve Perthes Disease
Soreness and Stiffness
Hip and Knee pain at the *end of the day*

Treatment: Legg-Calve Perthes Disease
Immobilize and Rest Area
Non-weight bearing
~Bed Rest
Therapy (PT/OT)

Surgical Reconstruction (Severe cases)

Slipped Capital Femoral Epiphysis (SCFE)
Idipoathic or obesity probable; Femur head popping out of hip joint (vascular compromise causing necrosis of tissue)

Thigh and Knee Pain
*Trendelenburg* Test

Treatment: SCFE
Non-weight bearing
Surgical Pinning
Spica Cast

Idiopathic formation; Lateral Curvature, Spinal Rotation or Thoracic Hypokyphosis

Classified by age onset:
*Adolescent (more common) s/s seen during growth spurts*

Diagnosis: Scoliosis
Forward Bend Test (Symmetrical Position)
~Rib Cage

>10 degree curvature (referal for xray)

Treatment: Scoliosis
Bracing (10-40 degree curvature)
~23 hours/day (OFF for ADL and bathing)
~Exercise (strengthen spine and abdominal muscles) non-contact sports
~Surgery (More than 40 degree)
Spinal fusion

N/M: Scoliosis
Maintain spine alignment (LOG ROLL)
Skin Care (Prevent Wounds)
Neurovascular Checks (Lower extremities)
Monitor for Infx
Pain Management
Ambulation (POD 2-3)

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