Nursing Care for Children with Physical or Developmental Challenges | Summaries Nursing

Maternal & Child Health Nursing

NCM - 109

Macel Nasog

NCM 109(DME)

Chapter 27: Nursing Care of the Child Born With a

Physical or Developmental Challenge

Commonly Affected Systems in Children Born With

Physical or Developmental Challenges

Skeletal system

Gastrointestinal system

Nervous system

Skeletal system

Absent or malformed extremities

Finger and toe conditions

Chest deviations

Torticollis (wry neck)

Craniosynostosis

Physical and Developmental Disorders of the Skeletal

System

Absent or Malformed extremities

Causes: maternal drug Ingestion or Invasion of virus or

amniotic band formation in the utero

Interventions:

Prosthesis

Therapy

Help in forming body Image

Finger and hand deformities

Polydactyly: presence of 1 or more additional

fingers or toes

Syndactyly: 2 or more fingers or toes are fused

Interventions:

Encourage to express feelings

Chest deviations

Pectus excavatum: "funnel chest"-indentation of the

lower portion of the sternum

Risk for decrease lung volume

Heart is displace to the left

Pectus carinatum: sternum is displaced anteriorly

(increases A-P dm)

Torticollis (Wry neck)

Prevention: passive stretching exercises and therapy

Encourage child to look in the direction of the

affected muscle.

Surgery

Use of neck immobilizer

Achondroplasia

Talipes disorders

Developmental dysplasia of the hip

ACHONDROPLASIA

Failure of bone growth inherited as a dominant trait,

causing disorder in cartilage production in utero.

Assessment:

Head unusually large, prominent forehead, flattened nose

bridge

May develop kyphosis and lordosis

Interventions

Use of growth hormone as prescribed

Guidance and counseling

Compare extremity length to newborn's body.

CLUB FOOT (TALIPES EQUINOVARUS)

A complex deformity of the ankle and foot that includes

forefoot adduction, midfoot supination, bindfoot varus

and ankle equinus; (unilateral/bilateral); foot twisted

inward or outward

Goal of tx: achieve painless plantigrade (able to walk on

the sole of the foot with the heel on the ground) and

stable foot

Assessment:

a. Talipes varus: inversion or bending inward

b. Talipes valgus: eversion or bending outward

c. Talipes equinus: plantar flexion in which the lower

toes are lower than the heel

d. Talipes calcaneus: dorsiflexion in which the toes are

higher than the heel

Interventions:

1. Tx begins as soon as after birth as possible

2. Manipulation are performed weekly and casting (for

about 8-12 weeks); a splint is applied if successful

3. Surgery (if normal alignment is (-) 6-12 weeks of age

(older child)

4. Casts:

Monitor for pain and neurovascular status of toes

Change diapers frequently

5. Denise-browne splints

Perform passive foot exercises

6. Assess by straightening newborn's feet to the midline.

Denis-Browne-horizontal abduction bar with footplates

DEVELOPMENTAL DYSPLASIA OF THE HIP

Disorders r/t abnormal development of the hip that

may develop during fetal life, infancy or childhood

Head of femur is seated improperly in the

acetabulum or hip socket of the pelvis

Assessment:

1. Uneven gluteal folds and thigh creases (deeper on

affected side)

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NCM - 109 Macel Nasog Chapter 27: Nursing Care of the Child Born With a Physical or Developmental Challenge Commonly Affected Systems in Children Born With Physical or Developmental Challenges  Skeletal^ system  Gastrointestinal^ system  Nervous^ system Skeletal system  (^) Absent or malformed extremities  (^) Finger and toe conditions  (^) Chest deviations  (^) Torticollis (wry neck)  (^) Craniosynostosis Physical and Developmental Disorders of the Skeletal System Absent or Malformed extremities  Causes :^ maternal^ drug^ Ingestion^ or^ Invasion^ of^ virus^ or amniotic band formation in the utero  Interventions:  Prosthesis  Therapy  Help^ in^ forming^ body^ Image Finger and hand deformities  Polydactyly :^ presence^ of^1 or^ more^ additional fingers or toes  Syndactyly :^2 or^ more^ fingers^ or^ toes^ are^ fused  Interventions:  Encourage^ to^ express^ feelings Chest deviations  Pectus excavatum : "funnel chest"-indentation of the lower portion of the sternum  Risk for decrease lung volume  Heart is displace to the left  Pectus carinatum : sternum is displaced anteriorly (increases A-P dm) Torticollis (Wry neck)  Prevention : passive stretching exercises and therapy Encourage child to look in the direction of the affected muscle.  Surgery  Use^ of^ neck^ immobilizer  Achondroplasia  Talipes disorders  Developmental^ dysplasia^ of^ the^ hip ACHONDROPLASIA  Failure^ of^ bone^ growth^ inherited^ as^ a^ dominant^ trait, causing disorder in cartilage production in utero. Assessment :  Head^ unusually^ large,^ prominent^ forehead,^ flattened^ nose bridge  May^ develop^ kyphosis^ and^ lordosis Interventions  Use^ of^ growth^ hormone^ as^ prescribed  Guidance^ and^ counseling  Compare^ extremity^ length^ to^ newborn's^ body.

CLUB FOOT (TALIPES EQUINOVARUS)

 A^ complex^ deformity^ of^ the^ ankle^ and^ foot^ that^ includes forefoot adduction, midfoot supination, bindfoot varus and ankle equinus; (unilateral/bilateral); foot twisted inward or outward  Goal^ of^ tx:^ achieve^ painless^ plantigrade^ (able^ to^ walk^ on the sole of the foot with the heel on the ground) and stable foot Assessment: a. Talipes varus : inversion or bending inward b. Talipes valgus: eversion or bending outward c. Talipes equinus: plantar flexion in which the lower toes are lower than the heel d. Talipes calcaneus : dorsiflexion in which the toes are higher than the heel Interventions:

1. Tx begins as soon as after birth as possible

Manipulation are performed weekly and casting (for about 8-12 weeks); a splint is applied if successful
Surgery (if normal alignment is (-) 6-12 weeks of age (older child)
Casts:  Monitor^ for^ pain^ and^ neurovascular^ status^ of^ toes  Change^ diapers^ frequently
Denise-browne splints  Perform^ passive^ foot^ exercises
Assess by straightening newborn's feet to the midline.  Denis-Browne- horizontal abduction bar with footplates DEVELOPMENTAL DYSPLASIA OF THE HIP  (^) Disorders r/t abnormal development of the hip that may develop during fetal life, infancy or childhood  Head of femur is seated improperly in the acetabulum or hip socket of the pelvis Assessment:
Uneven gluteal folds and thigh creases (deeper on affected side)

NCM - 109 Macel Nasog

Limited abduction of hip with pain,
Ortolani's sign (Infants < 24 months)
Shortened limb on the affected side (older Infant/child)
Delays in walking; limp, lordosis and waddling gait (older child)
Neonate: Laxity of ligaments around the hip
Positive Barlow test: femoral head can be displaced from the acetabulum on manipulation and pressure, and then the femoral head repositions correctly when the pressure is released  (^) Infant on back; leg flexed  (^) Click sound heard when affected hip is moved to abduction  (^) Older infant and child :  (^) The head of the femur can be felt to move up and down in the buttock when the extended thigh is pushed toward the child's head and then pulled distally  T-burg sign : child stands on 1 foot and then the other foot, holding onto a support and bearing weight on the affected hip; the pelvis tilts downward on the normal side instead of upward, as it wouldwith normal stability  (^) Greater trochanter is prominent  (^) Marked lordosis or waddling gait Predisposition: a. Intrauterine position (breech) b. Gender (female) c. Hormonal imbalance (estrogen) d. Cultural and environmental influences Nursing diagnosis:  Impaired physical mobility  Body Image Disturbance  Risk for injury Interventions:
birth-6 months: splinting of the hips "Pavlik harness maintain flexion and abduction and external rotation(Continuous 3 months)
6-18 months: gradual reduction by traction followed by closed reduction or open reduction (if necessary) under general anesthesia Bryant's traction and casting TREATMENT WITH TRACTION  Bryant's traction used for treating fractures of femur inc o children less than 2 years old or lighter than 20 to 30 lbs o Weight and pulleys extend the limb, the legs are suspended vertically o Weight of child supplies the counteraction. Interventions:
Parents must make sure to hold and sit the infant in chair
Neurovascular assessment is done (cast)
Firm-plastic-covered pillows are required
Overhead trapeze and bar
Well-ventilated rooms
Fracture pan should be available at the bedside for toileting
HOB elevated
Bradford frame (if not toilet trained)
Change in position
Itchiness (gauze extends through the opened area before casting) Considerations:  (^) Discuss modification in bathing, dressing and diapering  (^) Sponge bath is recommended  (^) Put undershirt under chest straps and knee sock under foot Check skin areas 2-3X a day  (^) Gentle massage under straps  (^) Avoid use of lotion and powders  (^) Place diapers under straps  Child^ is^ place^ in^ hip^ spica^ cast^ for^ 2-4^ months^ until^ hip^ is stable; and then a flexion-abduction brace is applied for approximately 3 months  Older^ child:^ Operative^ reduction^ and^ reconstruction Gastrointestinal system  Ankyloglossia  Cleft^ lip^ and/or^ palate  Pierre^ Robin^ sequence^ (syndrome)  Esophageal^ atresia^ and^ tracheoesophageal^ fistula ANKYLOGLOSSIA (TOUNGE-TIE)  A^ congenital^ anomaly^ which^ is^ a^ restriction^ of^ the^ tongue due to an abnormal tight frenulum Types:  Type 1 & 2: most common "classic" and "anterior ties"  Type 3 & 4 : "posterior ties" Assessment:  Uses Hazelbaker Assessment tool based on tongue's appearance and function (Class 1-Class IV)  Decreased tongue mobility may cause problems in feeding, speech, orthodontic problems, mandibular abnormalities and difficulty with oral cleanliness  Infant may tend to slip off the breast and cannot maintain a long latch without falling asleep Interventions:  Frenatomy:  Assess feeding difficulty  Provide lactation support, guidance and feeding assistance by lactation consultants CLEFT LIP AND CLEFT PALATE  Cleft lip and/or palate: visual inspection of palate, especially if lip is involved

NCM - 109 Macel Nasog  Abdominal^ distention Interventions:  Goal: prevent pneumonia  Position infant upright, 60-degree angle  Gastrostomy (helps in keeping stomach empty of secretions and prevent reflux)  IVF and parenteral nutrition  Administer IV medications (to restrict the ability of the stomach to produce acid) and antibiotics  Anastomosis repair  (^) Assess for presence of coplous mucus and "blowing bubbles."  (^) In passing a soft catheter into stomach, radiography may show a colled catheter in a blind pouch. Abdominal wall defects  Umbilical hernia  Omphalocele  Gastroschisis UMBILICAL HERNIA  Protrusion^ of^ a^ portion^ of^ the^ intestine^ through^ umbilical ring, muscle and fascia around the umbilical cord  Predisposing^ factors:  Black^ children  Low-birth-weight  Girls Assessment:  It^ is^ 1-2^ cm^ (0.5-1^ in)^ in^ diameter;^ large^ when^ infant cry or strain  Fascial^ ring^ <2cm,^ dosure^ occurs^ spontaneously; if >2cm surgical repair (to prevent herniation and intestinal obstruction or bowel strangulation (1-2 y/o)  Care^ of^ the^ dressing:^ remains^ in^ place^ until^ sutures^ are well healed; sponge bath  Keep^ diapers^ folded^ well^ below^ the^ dressing^ (to prevent contamination of suture line OMPHALOCELE  (^) Protrusion of the abdominal wall at the point of the junction of the umbilical cord and abdomen due to failure of the abdominal contents to return in the usual way  Associated with other congenital disorders (e.g. cardiac, neurologic, GUT, skeletal and chromosomal abnormalities) GASTROCHISIS  "Stomach deft" or "fissure  Similar omphalocele except the abdominal wall disorder is a distance from the umbilicus and abdominal organs are not contained by a membrane Assessment: o Ultrasound o Elevated matemal serum a-fetoprotein test (15thweek); amniocentesis determines AFP  Associated with maternal obesity Interventions: o Document general appearance of the defect TPN o Prosthetic patch repair o Surgery (monitor respiratory distress ) Abdominal wall defects-(cant.)  Intestinal obstructions  Meconlum plug syndrome  (^) Meconlum lleus  Diaphragmatic hernia  Imperforate anus INTESTINAL OBSTRUCTION  Atresia or stenosis of the fetal bowel  Vovulus (twisting pattern)  Thicker-than-usual meconium formation that blocks the lumen (meconium ileus or meconium plug) Assessment:  Hydramnios (during pregnancy of mother)  No meconium or may pass one stool  Distended and tender abdomen (hard forceful indignant cry); increased bowel sounds  Vomit (sour-smelling)  Increased RR Interventions:  NGT^ insertion^ and^ which^ is^ attached^ to^ low^ suction^ or left open to the air  IV^ therapy  Laparoscopy  Colostomy^ care  Short bowel syndrome (impact of nutrient absorption) MECONIUM PLUG SYNDROME  Extremely hard portion of meconium causing blockage on the intestinal lumen, which leads to bowel obstruction Assessment:  No^ meconium^ passage  Hardened^ stool  Air-filled^ loops^ of^ bowel^ up^ to^ the^ point^ of^ obstruction (X-ray and sonogram)  Gentle^ rectal^ examination Interventions:  Record^ and^ report^ findings^ on^ child^ (e.g.^ defecation)  Assess^ family^ of^ newborn^ who^ has^ a^ meconium^ plug^ for other diseases (cystic fibrosis, Hirschsprung) MECONIUM ILEUS  Obstruction of the intestinal lumen by hardened meconium  Occurs almost exclusively among infants with cystic fibrosis Assessment:  (^) No meconium passage  (^) Abdominal distention  (^) Vomiting of bile-stained fluid Intervention:  The^ bowel^ must^ be^ incised^ and^ removal^ of^ meconium (laparotomy)  Follow^ up^ check^ up

NCM - 109 Macel Nasog DIAPHRAGMATIC HERNIA  Weakness in musculature which allows a portion of the abdominal organs to protrude to the chest wall  Difficulty establishing effective respiration  Scaphoid (sunken) abdomen due to displacement of abdominal contents into the chest  Breath sounds are usually absent on the affected side of the chest cavity  Cyanotic  Intercostal and subcostal retractions  Abdomen is sunken in appearance IMPERFORATE ANUS  Is a stricture or the absence of the anus Assessment:  No stool  Abdominal distention Intervention:  Surgery Nervous system  Hydrocephalus  Neural tube disorders o Anencephaly and microcephaly o Spina bifida occulta o Meningomyelocele o Encephalocele  Arnold-Chiari malformation HYDROCEPHALUS  Characterized by an Increase of cerebrospinal fluid (CSF) within the ventricles of the brain, which causes pressure changes in the brain and an increase in head size.  Measure head circumference at birth for comparison at discharge.  Assess for brow bulging and prominent scalp veins  Assess fontanelles for width and tension.  Transillumination of skull  Congenital:  Acquired: obstruction  Tumor a. Communicating : CSF is not obstructed in the ventricles but is inadequately reabsorbed in the subarachnoid space b. Noncommunicating : obstruction of CSF flow from the ventricles of the brain to the subarachnoid space Assessment a. Enlarged head b. Bulge fontanelles c. Scalp is shiny and veins are dilated (frontal d. Chiari malformation e. Sunsetting eyes f. Irritability g. Vomiting h. Anorexia i. Convulsions j. High-pitched shrill cry Older child:  Headache  Cognitively^ slowing  Personality^ changes  Spasticity  Neurologic^ signs Laboratory data:  CT^ scan  MRI  echoencephalography Diagnosis :  Transillumination:^ to^ visualize^ the^ fluid Nursing dx : Risk for injury NURSING INTERVENTIONS

Teach the family about the management required for the disorder a. Treatment is surgical by direct removal of an obstruction and insertion of shunt to provide primary drainage of the CSF to an extracranial compartment, usually peritoneum (ventriculoperitoneal shunt)
Major complications:  Infection  Malfunction
Other complications include  subdural hematoma caused by a too rapid  reduction of CSF,  peritonitis,  abdominal abscess,  perforation of organs,  fistulas,  hernias and ileus.
Provide preoperative nursing care a. Change position frequently b. Firmly support the head and neck when holding the child. c. Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry. d. Provide skin care for the head to prevent breakdown. e. Give SFF as tolerated until a pre NPO status is precribed to decrease the risk of vomiting.) f. Encourage parental-newborn bonding. g. Reposition head frequently and use an egg crate mattress under the head (to prevent pressure sores) g. Prepare the child and the family for dx procedures and surgery
Provide Postoperative nursing care (nursing Interventions are the same as those for increased ICP) a. Assess for signs of increased ICP and check the following: head circumference (daily), anterior fontanelle for size and fullness and behavior.  (if^ increased^ ICP^ elevate^ HOB^ 15-30^ degrees^ to enhance gravity flow through the shunt) b. Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain. (anticonvulsants if prescribed) c. Monitor v/s and neurologic signs

NCM - 109 Macel Nasog

Hip and joint deformities 6. Hydrocephalus Nursing care
Prevent infection or injury on the sac
Correct positioning
Good skin care
Adequate nutrition
Accurate observations and charting
Health teaching on parents
Medical supervision 8. Habilitation (the patient is learning and not relearning) INTERVENTIONS
Evaluate the sac and measure the lesion  Protect^ the^ sac;^ cover^ with^ sterile,^ molst^ (normal saline), nonadherent dressing (to maintain the moisture of the sac and contents)  change^ dressing^ every^ 2-4^ hours
Observe for deformities and movement of extremities
Measure head circumference
Assess for fontanels
Place In PRONE position (minimize tension on the sac and the risk of trauma; (head turned to 1 side for feeding)
Change the dressing covering the sac whenever It becomes soiled (prevent risk of Infection  diapering^ may^ be^ C/I^ until^ defect^ has^ been repaired
Use aseptic technique
Perform neurologic assessment (post op): o Increased ICP Complications : o meningitis o pneumonia o UTI Urinary incontinence: o Crede's method (infants) o self-catheterization (older children)
Feeding
Considerations:  Latex^ allergy Foods to avoid a. Banana b. Avocado c. Kiwi
Teach parents and eventually the child for long-term home care  positioning,^ feeding,^ skin^ care^ and^ ROM  perform^ clean^ intermittent^ catheterization^ technique  administer^ propantheline^ (Pro-Banthine)^ as prescribed (improve continence  implement^ bowel^ program^ (high-fiber,^ increased fluids, suppositories as needed)

Nursing Care for Children with Physical or Developmental Challenges, Summaries of Nursing

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CLUB FOOT (TALIPES EQUINOVARUS)