The Child with Musculoskeletal or Articular Dysfunction

The Child with Musculoskeletal or Articular Dysfunction Chapter 31 Mosby items and derived items © 2005, 2001 by Mosby, Inc. The Immobilized Child • Immobilization was once thought to be restorative for patients with illness and injury • We know now that immobilization has serious consequences – Physical – Social – Psychological Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobilization • Muscular system – Decreased muscle strength and endurance – Atrophy – Loss of joint mobility • Skeletal system – Bone demineralization – Negative calcium balance Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobilization (cont’d) • Metabolism – Decreased metabolic rate – Negative nitrogen balance – Hypercalcemia – Decreased production of stress hormones Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobility (cont’d) • Cardiovascular system – Decreased efficiency of orthostatic neurovascular reflexes – Diminished vasopressor mechanism – Altered distribution of blood volume – Venous stasis – Dependent edema Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobility (cont’d) • Respiratory system – Decreased need for oxygen – Diminished vital capacity – Poor abdominal tone and distention – Mechanical or biochemical secretion retention – Loss of respiratory muscle strength Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobility (cont’d) • GI system – Distention caused by poor abdominal muscle tone – Difficulty feeding in prone position – Gravitation effect on feces – Anorexia Mosby items and derived items © 2005, 2001 by Mosby, Inc. Physiologic Effects of Immobility (cont’d) • 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Effect on Families • Extended periods of immobilization – Logistical management of sick child – Need for family support and home care assistance • Coping skills Mosby items and derived items © 2005, 2001 by Mosby, Inc. Traumatic Injury • Soft tissue injury: injuries to muscles, ligaments, and tendons – Sports injuries – Mishaps during play Mosby items and derived items © 2005, 2001 by Mosby, Inc. Contusions • Damage to soft tissue, subcutaneous tissue and muscle • Escape of blood into tissues— ecchymosis—black and blue discoloration • Swelling, pain, disability • Crush injuries Mosby items and derived items © 2005, 2001 by Mosby, Inc. Dislocations • Occur when force of stress on ligament is sufficient to displace normal position of opposing bone ends or bone ends to socket • Pain increases with active or passive movement of affected extremity • More common in Down syndrome • Hip dislocation: potential loss of blood supply to head of femur Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Strains • A microscopic tear to musculotendinous unit • Similar to sprain • Swollen, painful to touch • Generally incurred over time Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of Soft Tissue Injuries • RICE and ICES • Rest the injured part • Ice immediately (max 30 min at a time) • Wet elastic bandage for compression • Elevation of the extremity • Immobilization and support (casts or splints as appropriate to injury) Mosby items and derived items © 2005, 2001 by Mosby, Inc. Fractures • Common injury in children • Methods of treatment are different in pediatrics than in older adult population • Rare in infants, except with MVC • Clavicle most frequently broken bone in childhood, especially in those under 10 years • School age: bike, sports injuries Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Types of Fractures • Compound or open: fractured bone protrudes through the skin • Complicated: bone fragments have damaged other organs or tissues • Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue • Greenstick: compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture Mosby items and derived items © 2005, 2001 by Mosby, Inc. Clinical Manifestations of Fracture • Generalized swelling • Pain or tenderness • Diminished functional use • May have bruising, severe muscular rigidity, crepitus Mosby items and derived items © 2005, 2001 by Mosby, Inc. Bone Healing and Remodeling • Typically rapid healing in children • Neonatal period—2-3 weeks • Early childhood—4 weeks • Later childhood—6-8 weeks • Adolescence—8-12 weeks Mosby items and derived items © 2005, 2001 by Mosby, Inc. Fractures • Diagnostic evaluation: x-ray is most useful diagnostic tool • Therapeutic management goals • Nursing considerations Mosby items and derived items © 2005, 2001 by Mosby, Inc. Assessment of Fractures: The 5 Ps • Pain and point of tenderness • Pulse–distal to the fracture site • Pallor • Paresthesia–sensation distal to the fracture site • Paralysis–movement distal to the fracture site Mosby items and derived items © 2005, 2001 by Mosby, Inc. The Child in a Cast • Cast application techniques • Nursing considerations • Cast care at home • Cast removal • Skin care Mosby items and derived items © 2005, 2001 by Mosby, Inc. The Child in Traction • Traction: extended pulling force may be used – To provide rest for an extremity – To help prevent or improve contracture deformity – To correct deformity – To treat dislocation – To allow position and alignment – To provide immobilization – To reduce muscle spasms (rare in children) Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 patient’s contact with the bed Mosby items and derived items © 2005, 2001 by Mosby, Inc. Types of Traction • Manual traction: applied to body part by the hand placed distally to fracture site • Skin traction: pulling mechanisms are attached to skin with adhesive material or elastic bandage • Skeletal traction: Applied directly to skeletal structure by pin, wire, or tongs inserted into or through diameter of bone distal to fracture Mosby items and derived items © 2005, 2001 by Mosby, Inc. Cervical Traction • Crutchfield or Barton tongs • Inserted through burr holes in skull with weights attached to the hyperextended head • As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord is no longer pinched between vertebrae • Halo traction can be applied in some cases Mosby items and derived items © 2005, 2001 by Mosby, Inc. Nursing Considerations • Assessing patient in traction • Skin care issues • Pain management/comfort Mosby items and derived items © 2005, 2001 by Mosby, Inc. Distraction • Process of separating opposing bone to encourage regeneration of new bone in created space • Can be used when limbs are unequal in length and new bone is needed to elongate shorter limb Mosby items and derived items © 2005, 2001 by Mosby, Inc. Amputation • Surgical amputation • Surgical repair of severed limb • Prosthetics • Pain management/―phantom pain Mosby items and derived items © 2005, 2001 by Mosby, Inc. Congenital Defects • Developmental dysplasia of the hip (DDH) • Formerly called ―congenital hip dysplasia‖ or ―congenital dislocation of the hip‖ • ―DDH‖ reflects variety of hip abnormalities – Shallow acetabulum – Subluxation – Dislocations Mosby items and derived items © 2005, 2001 by Mosby, Inc. Three Degrees of DDH • Acetabular dysplasia (preluxation) – Mildest form; osseous hypoplasia of acetabular roof – Femoral head remains in the acetabulum • Subluxation: incomplete dislocation of hip • Dislocation: femoral head loses contact with acetabulum and is displaced posteriorly and superiorly; ligaments elongated and taut Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of DDH • Importance of early intervention • Newborn to age 6 months: pavlik harness for abduction of hip • Age 6-18 months: dislocation unrecognized until child begins to stand and walk; use traction and cast immobilization (spica) • Older child: operative reduction, tenotomy, osteotomy; very difficult after 4 yrs Mosby items and derived items © 2005, 2001 by Mosby, Inc. Clinical Manifestations of DDH • Infant – Shortened limb on affected side – Restricted abduction of hip on affected side – Unequal gluteal folds when infant prone – Positive Ortolani test – Positive Barlow test Mosby items and derived items © 2005, 2001 by Mosby, Inc. DDH in Older Infant and Child • Affected leg shorter than the other • Telescoping or piston mobility of joint • Trendelenberg sign • Greater trochanter is prominent and appears above line from anterior superior iliac spine to tuberosity of ischium • Marked lordosis if bilateral dislocations • Waddling gait if bilateral dislocations Mosby items and derived items © 2005, 2001 by Mosby, Inc. Congenital Clubfoot • Talipes varus: inversion or bending inward • Talipes valgus: eversion or bending out • Talipes equinus: plantar flexion with toes lower than the heel • Talipes calcaneus: dorsiflexion with toes higher than the heel Mosby items and derived items © 2005, 2001 by Mosby, Inc. Classifications • Mild or postural – May correct spontaneously or require passive exercise or serial casting • Tetralogic – Associated with other congenital anomalies – Usually require surgical correction with high incidence of recurrence • Idiopathic – Bony abnormality almost always requiring surgical intervention Mosby items and derived items © 2005, 2001 by Mosby, Inc. Congenital Clubfoot • Diagnostic evaluation • Therapeutic management • Nursing considerations Mosby items and derived items © 2005, 2001 by Mosby, Inc. Metatarsus Adductus • AKA metatarsus varus • Most common congenital foot deformity • Often result from abnormal position in uterus, usually evident at birth • Angulation at tarsometarsal joint • ―Pigeon toed‖ gait • Treatment: PT, orthotics Mosby items and derived items © 2005, 2001 by Mosby, Inc. Skeletal Limb Deficiency • AKA reduction malformations • Wide range of severity • Most are primary defects of development • May have prenatal destruction of limb from constriction of amniotic band Mosby items and derived items © 2005, 2001 by Mosby, Inc. Types of Limb Deformities • Amelia: absence of entire extremity • Mecromelia: partial absence of extremity • Phocomelia: deficiency of long bones with relatively good development of hands and feet attached at or near shoulder or hip (―seal limbs‖) Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Osteogenesis Imperfecta (OI) • A group of heterogeneous inherited disorders of connective tissue • Characterized by excessive fragility and bone defects • Defective periosteal bone formation and reduced cortical thickness of bones • Hyperextensibility of ligaments Mosby items and derived items © 2005, 2001 by Mosby, Inc. Classification of OI—Type I • Type I-A: mild bone fragility, blue sclera, normal teeth, presenile deafness • Type I-B: same as A except with abnormal dentition • Type I-C: same as B but no bone fragility • Two thirds of all cases are Type I Mosby items and derived items © 2005, 2001 by Mosby, Inc. Classification of OI—Type II • Lethal; stillborn or die in early infancy • Severe bone fragility with multiple fractures at birth • Autosomal-recessive inheritance Mosby items and derived items © 2005, 2001 by Mosby, Inc. Classification of OI—Type III • Severe bone fragility leads to severe progressive deformities • Normal sclera, marked growth failure • Most are autosomal-recessive, but some are autosomal-dominant inheritance Mosby items and derived items © 2005, 2001 by Mosby, Inc. Classification of OI—Type IV • Type IV-A: mild to moderate bone fragility, normal sclera, short stature, variable deformity, autosomal-dominant • Type IV-B: same as A except abnormal dentition (dentinogenesis imperfecta) • Approximately 6% of OI cases are Type IV-B Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of OI • Primarily supportive care • Drugs of limited benefit • May rule out OI if multiple fractures occur • Nursing considerations: – Caution with handling to prevent fractures – Family education – Occupational planning and genetic counseling Mosby items and derived items © 2005, 2001 by Mosby, Inc. Legg-Calve-Perthes Disease • Self-limited, idiopathic, occurs in juveniles ages 3-12, more common in males age 48 • Avascular necrosis of femoral head • 10 to 15% of cases have bilateral hip involvement • Most have delayed bone age Mosby items and derived items © 2005, 2001 by Mosby, Inc. Legg-Calve-Perthes Disease • Pathophysiology: cause is unknown but involves disturbed circulation to the femoral head with ischemic aseptic necrosis • After resolving may have normal femoral head or may have severe alteration Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Legg-Calve-Perthes Disease (cont’d) • Prognosis – Self-limited disease – Outcome has wide variations due to multiple factors • Nursing considerations – Identification of affected children and refer – Teaching care and management – Compliance issues with child/family Mosby items and derived items © 2005, 2001 by Mosby, Inc. Kyphosis • 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Lordosis • Accentuation of the cervical or lumbar curvature beyond physiologic limits • May be idiopathic or secondary complication of trauma • May occur with flexion contractures of hip, congenital dislocated hip • In obese children, abdominal fat alters center of gravity causing lordosis Mosby items and derived items © 2005, 2001 by Mosby, Inc. Scoliosis • 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Scoliosis (cont’d) • Multiple potential causes, most cases idiopathic • Generally becomes noticeable after preadolescent growth spurt • May have complaints of ―ill fitting clothes‖ • School screening controversial Mosby items and derived items © 2005, 2001 by Mosby, Inc. Diagnostic Evaluation • Standing radiographs to determine degree of curvature • Asymmetry of shoulder height, scapular or flank shape, or hip height • Often have primary curve and compensatory curve to align head with gluteal cleft Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management • Team approach to treatment • Bracing • Exercise • Surgical intervention for severe curvature (instrumentation and fusion) – Harrington rods – L-rods Mosby items and derived items © 2005, 2001 by Mosby, Inc. Nursing Considerations • Concerns of body image • Concerns of prolonged treatment of condition • Preoperative care • Postoperative care • Family issues Mosby items and derived items © 2005, 2001 by Mosby, Inc. Osteomyelitis • Inflammation and infection of bony tissue • May be caused by exogenous or hematogenous sources Mosby items and derived items © 2005, 2001 by Mosby, Inc. Exogenous Osteomyelitis • Infectious agent invades bone following penetrating wound, open fracture, contamination in surgery, or secondary extension from abscess or burn Mosby items and derived items © 2005, 2001 by Mosby, Inc. Hematogenous Osteomyelitis • Preexisting infection spreads to bone • Source may be furuncles, skin infections, URI, abscessed teeth, pyelonephritis • Any organism can cause osteomyelitis • Infective emboli travel to arteries in bone metaphysis, causing abscess formation and bone destruction Mosby items and derived items © 2005, 2001 by Mosby, Inc. Osteomyelitis • Signs/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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of Osteomyelitis • May have sub-acute presentation with walled off abscess rather than spreading infection • Prompt, vigorous IV antibiotics for extended period (3-4 weeks or up to several months) • Monitor hematologic, renal, hepatic responses to treatment Mosby items and derived items © 2005, 2001 by Mosby, Inc. Nursing Considerations • Complete bedrest and immobility of limb • Pain management concerns • Long-term IV access (for antibiotic administration) • Nutritional considerations • Long-term hospitalization/therapy • Psychosocial needs Mosby items and derived items © 2005, 2001 by Mosby, Inc. Septic Arthritis • AKA suppurative, pyogenic, and purulent arthritis • May result from extension of soft tissue infection • May involve any joint, but most common in hip, knee, shoulder • Usually involves only one joint Mosby items and derived items © 2005, 2001 by Mosby, Inc. Signs and Symptoms of Septic Arthritis • Characteristic appearance • Joint is warm, tender, painful, swollen • Frequently follows traumatic injury • Fever, leukocytosis, increased sedimentation rate • Neisseria gonorrheae is frequent cause of septic arthritis in sexually active teens • Other pathogens Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management and Nursing Considerations • Diagnosis made from blood culture, joint fluid aspirate and X-rays • Treatment goals – Prevent destruction of joint cartilage – Decompress the joint to maintain circulation to epiphysis – Eradicate the infection – Prevent secondary bone infection or hematogenous spread Mosby items and derived items © 2005, 2001 by Mosby, Inc. Tuberculosis • Hematogenous dissemination of pulmonary TB may result in tubercular infection of bones and joints • Common sites: fingers and toes (tubercular dactylitis), spinal erosion (Pott disease) Mosby items and derived items © 2005, 2001 by Mosby, Inc. TB Clinical Manifestations • May be difficult to assess • Pain over affected area, with motion, posture change, limp, and/or localized swelling • Diagnosis should be considered in child with exposure to TB and positive PPD Mosby items and derived items © 2005, 2001 by Mosby, Inc. TB Management • Surgical debridement • Oral antituberculin therapy for 1 year • Prognosis: excellent with treatment • Carefully monitor disease contacts (family and others) Mosby items and derived items © 2005, 2001 by Mosby, Inc. Bone Tumors • Osteosarcoma and Ewing sarcoma account for 85% of all primary malignant bone tumors in children • Occur more commonly in males, with highest incidence during accelerated growth rate of adolescence Mosby items and derived items © 2005, 2001 by Mosby, Inc. Diagnosis of Bone Tumors • Rule out trauma or infection first • Definitive diagnosis based on radiologic studies (CT scans, bone scans) and bone biopsy • MRI to evaluate neurovascular and soft tissue extension • Labs: elevated alkaline phosphatase with some bone tumors Mosby items and derived items © 2005, 2001 by Mosby, Inc. Osteogenic Sarcoma • Most frequent malignant bone tumor type in children • Peak incidence age 10-25 yrs • Most primary tumor sites are in metaphysis of long bones, especially legs • >50% occur in distal femur • Other sites: humerus, tibia, pelvis, jaw Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management • Traditional approach: radical surgical resection or amputation of affected area • Limb-salvage procedures: resection of bone with prosthetic replacement of affected area • Chemotherapy accompanying surgical treatment Mosby items and derived items © 2005, 2001 by Mosby, Inc. Nursing Considerations • Preoperative preparation is crucial • Support during adjustment to concept of amputation, surgical resection • Body image concerns—issues of adolescents • Pain management – Phantom limb pain Mosby items and derived items © 2005, 2001 by Mosby, Inc. Ewing Sarcoma • Second most common malignant bone tumor in children and adolescents, rare in age >30 yrs • Arises in marrow especially in – Femur, tibia, ulna, humerus – Vertebrae, pelvis, scapula, ribs, and skull Mosby items and derived items © 2005, 2001 by Mosby, Inc. Treatment of Ewing Sarcoma • Radiation most common first approach • Chemotherapy as adjunct to radiation • Surgical resection in some cases— usually able to preserve affected limb • Prognosis best if no metastasis at time of diagnosis; distal lesions have best potential for cure Mosby items and derived items © 2005, 2001 by Mosby, Inc. Nursing Considerations • Assisting family in dealing with diagnosis of malignancy • Managing complications of radiation and chemotherapy • Nutritional concerns throughout treatment regimen Mosby items and derived items © 2005, 2001 by Mosby, Inc. Rhabdomyosarcoma • Malignant neoplasm originating from undifferentiated mesenchymal cells in muscle, tendon, bursa, and fascia or in fibrous, connective, lymphatic, or vascular tissue • Name reflects tissue of origin – Myosarcoma (myo—muscle) – Rhabdomyosarcoma (rhabdo— striated muscle) Mosby items and derived items © 2005, 2001 by Mosby, Inc. Potential Sites of Rhabdomyosarcoma • Orbit • Nasopharynx • Paranasal sinuses • Middle ear • Retroperitoneal area • Perineum Mosby items and derived items © 2005, 2001 by Mosby, Inc. Diagnostic Evaluation of Tumor • Signs/symptoms depend on site of tumor and compression of adjacent tissues • Tumor in orbit—symptomatic early in course of disease leads to rapid diagnosis and improved prognosis • Tumor in retroperitoneal area—minimal symptoms until tumor large and invasive • Many symptoms vague and common to childhood maladies (e.g., earache) Mosby items and derived items © 2005, 2001 by Mosby, Inc. Tumor Treatment and Prognosis • Highly malignant and frequent metastasis • Complete removal of tumor if possible • Radiation therapy for most tumors • Chemotherapy to shrink tumor may precede radiation therapy • Long-term chemotherapy (1-2 yrs) • Prognosis Mosby items and derived items © 2005, 2001 by Mosby, Inc. Juvenile Rheumatoid Arthritis (JRA) • AKA juvenile chronic arthritis • AKA idiopathic arthritis of childhood • Possible causes • Peak ages: age 1-3 yrs and 8-10 yrs • Often undiagnosed Mosby items and derived items © 2005, 2001 by Mosby, Inc. JRA (cont’d) • 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) Mosby items and derived items © 2005, 2001 by Mosby, Inc. JRA (cont’d) • 90% of 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. American College of Rheumatology Diagnostic Criteria • Age of onset <16 yrs • One or more affected joints • Duration of arthritis >6 weeks • Exclusion of other forms of arthritis Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of JRA • 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc. JRA—Pharmacology • NSAIDs • SAARDs • Corticosteroids • Cytotoxic agents • Immunologic modulators Mosby items and derived items © 2005, 2001 by Mosby, Inc. Management of JRA • Therapy individualized to child • PT, OT • Nutrition, exercise • Splinting devices • Pain management • Prognosis • Nursing considerations Mosby items and derived items © 2005, 2001 by Mosby, Inc. Systemic Lupus Erythematosus (SLE) • Chronic, multisystem, autoimmune disease of connective tissues and blood vessels • Characterized by inflammation • Symptoms variable and unpredictable • Symptoms mild to life threatening Mosby items and derived items © 2005, 2001 by Mosby, Inc. Incidence of SLE • More common in females age 10-19 yrs • More common in African-American, Asian, and Hispanic children • Familiar tendency • Cause unknown • Possible triggers: hormonal imbalance, immune disorders, environmental exposure to drugs, infection, stress, chemical agents Mosby items and derived items © 2005, 2001 by Mosby, Inc. Clinical Manifestations of SLE • Cutaneous lesions, lymphadenopathy • Nausea, vomiting, diarrhea, and pain • Generalized weakness, arthritis, joint pain and stiffness without deformity • Forgetfulness, seizures, paralysis • Pleurisy, pericarditis • Proteinuria and renal failure Mosby items and derived items © 2005, 2001 by Mosby, Inc. SLE—Criteria for Diagnosis (must have four of the following) • Renal disorder • Neurologic disorders • Hematologic disorders • Butterfly rash • Discoid rash • Photosensitivity • Oral ulcers • Arthritis • Serositis • Immunologic disorders • ANA Mosby items and derived items © 2005, 2001 by Mosby, Inc. Therapeutic Management of SLE • Goals of treatment • Supportive care • Pharmacology • Nursing considerations – Minimize exacerbations – Therapy compliance – Body image concerns Mosby items and derived items © 2005, 2001 by Mosby, Inc.