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Hip dysplasia in children [...] nursing care and considerations of the child with congenital or developmental hip dysplasia. Hip dysplasia occurs actually quite commonly in infants and children all over the world. There are some special considerations nurses should use when caring for these patients, including recognizing the early symptoms of hip dysplasia in infants and children, and fully understanding the treatment necessary to help the family cope with the disease. Treating and diagnosing children is often much more difficult than diagnosing and treating older patients who can communicate more effectively, so the nurse must be patient, cognizant, and highly aware of the disease, its indicators, and its treatment.
Hip dysplasia in infants and children used to be known by two terms, developmental dysplasia of the hip (DDH), or congenital dislocation of the hip (CDH). However, today, most professionals refer to the condition as DDH. Hip dysplasia occurs when the head of the femur (thigh bone) does not fit correctly into the pelvis, creating a hip joint that does not match. The condition can be quite mild to extremely severe. Sometimes the femur is just slightly out of adjustment, and sometimes it can be extremely out of adjustment, not meet at all, or be severely dislocated. The condition can occur at birth, or can develop as the baby grows and develops. Sometimes it occurs in both hips, and sometimes only one. Sometimes the condition shows up at the time of birth, and other times it does not show up until the baby begins trying to walk. For some reason that has not been discovered, the condition seems to occur more in girls than boys ("Developmental," 2004). In addition, it occurs more in first-born children. The condition occurs in about four out of every 1,000 births, and for some reason is more prevalent in Lapps and Native Americans ("Hip," 2004).
An exact cause is also not known, but many healthcare professionals believe there are several different items that can contribute to the condition, including: certain body hormones cause the baby or child's hip joint to be very loose. Genetic links which mean that DDH is passed down in the family. The baby is in breech position in the uterus before it is born, and swaddling clothes that keep a baby's hips straight all the time ("Developmental," 2004). Others firmly believe the condition only begins in the womb (D'Alessandro and Huth, 2002). Sometimes the condition is evident at birth, but often the signs do not show up until the baby is older. Often, well-baby check-ups are the first indication that the condition is present. Some of the signs of the condition are: extra folds or wrinkles on the thigh under the child's buttocks. The child may not be able to move the effected hip as well as the other one. Laying flat on the back, one of the child's legs may look shorter than the other one. The child may seem to have a funny "waddling" walk or may sway toward the affected side. Caregivers may hear or feel "pops" and "clicks" in the baby's hip with special movement tests ("Developmental," 2004). The doctor may order an MRI, ultrasound, CT scan, or x-rays for further diagnosis. Recently, it has been discovered that ultrasound seems to give a more accurate diagnosis of the condition than other types of scans ("Hip," 2004). Some children may have to have surgery or traction to straighten the limb, or they may have to wear a splint known as a Pavlik Harness that helps to hold the hips in the correct position. Sometimes, older children have to wear a spica, or lower-body cast. All of these decisions for treatment are based on the severity of the problem and the age of the child.
Treatment of the problem should begin as soon as it is discovered, and the ultimate goal of treatment is to align the bones correctly. If the problem is not treated early and effectively, the child may continue to have problems with the hip throughout their lives, and the condition can often lead to debilitating arthritis. Studies have also shown that surprisingly, some children born with DDH will simply outgrow the condition, and never need treatment (Berant, 1999).
There are many important considerations for nurses to remember when caring for these young patients. First, many of the infants are so young they cannot talk, so they cannot let caregivers know what hurts. Patience is probably one of the key factors in treating and caring for these young patients, because they do not understand what is happening, or the treatment, which can often be painful when placed in a splint, brace, or cast. The most common form of treatment in early diagnosis is the Pavlik Harness, which children may have to wear for six weeks, and then another six weeks on-and-off to correct the alignment of the hips. The harness creates several treatment and care difficulties, as do casts and splints. Clothing, car seats and high chairs, and especially diapering and bathing must be adjusted when children are treated with these items. Nursing professionals can help parents with these difficulties by understanding the importance of leaving the Pavlik Harness in place during bathing, dressing, and diapering. They should also be able to assist the parents with these items if necessary, to illustrate the proper way to protect the child and the harness. For example, nurses might recommend loose-fitting clothing that fits over the harness or cast, and different methods of diapering that will protect the baby while keeping the cast or harness as clean as possible. In addition, nurses will want to show parents how to remove and replace the harness in case this is necessary. In some cases, the physician may allow the harness to be removed for bathing, etc., and in other cases, they may not. Nurses should be familiar with the operation and fitting of the harness, and the difficulties associated with it for infants and small children. The physician's nurse can also help in diagnosing the disease by understanding the indicators, and initially examining the patient. They can also ask family members pertinent questions regarding the child and their problems with walking, etc.
If the child is going to have surgery to correct the problem, there are many responsibilities for the RN or RN first assistant (RNFA). First, the RNFA completes a preoperative patient evaluation and reinforce the surgeon's instructions. Then they discuss how the family and patient will deal with home health needs after surgery, and provides them with educational materials they will need. In addition, the RNFA discusses how the physical therapy (PT) and occupational therapy (OT) departments will work with the patient on postoperative ambulation and provide tools for the family to help with activities of daily living during recovery. (The RNFA can also discuss personal experience with these activities and tools.) Finally, the RNFA indicates when the patient should arrive at the hospital for surgery and discusses medications and NPO status (Gillett, 2002). In this, the RNFA aids the physician in passing on vital information to the patient and family, and helps overcome some of the family's worry and distress about the surgery.
On the day of surgery, a preoperative holding area nurse will evaluate the patient as a prerequisite to surgery. These signs include: "vital signs, skin integrity and condition, color, warmth, and sensation of both lower extremities, and presence and quality of pedal pulses bilaterally. The nurse then puts thigh-high antiembolism stockings on the patient" (Gillett, 2002). If the patient is old enough, the nurse then discusses the surgery, asks necessary questions, such as tooth condition, body piercing, etc., and pain management after surgery with the patient. If not, the nurse discusses these items with the patient's family. From this point, the patient is taken to the OR; where a circulating nurse takes over care of the patient, and helps the scrub nurse gather the proper instruments, supplies, and equipment necessary for the surgery. The circulating nurse meets the patient, and verifies the patient's identity verbally and with the I.D. bracelet, and identifies the correct hip for surgery. They also discuss the length of the surgery with the family, and how the OR team will communicate with the family (if necessary) during the surgery (Gillett, 2002). The circulating nurse also assists throughout the surgical procedure, along with the RNFA and other OR personnel.
After surgery, the patient is transported to the Pediatric Acute Care Unit (PACU), where the PACU nurse takes over care. This nurse evaluates and monitors the patient for post-operative problems, including "dressing, vital signs, oxygen saturation, urine output, pain, headaches, nausea and vomiting, and changes from the patient's preoperative baseline color, warmth, and sensation of both lower extremities and presence/quality of bilateral pedal pulses" (Gillette, 2002). The PACU nurse also regulates any IV lines, and maintains pain management for the patient. The RNFA also again becomes involved with post-operative treatment including a neurovascular examination of both legs for complications or problems, further…[continue]
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