NCLEX-RN: Pediatric Nursing

Pediatric Nursing: MUSCULOSKELETAL SYSTEM

Focus topic: Pediatric Nursing

The musculoskeletal system comprises the bones, joints, and muscles. In order to effectively assess and treat disorders associated with this system, it is necessary to consider the effects of the blood vessels, skin, nerves, and tendons.

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History.

  • Pertinent perinatal and birth history.
  •  Family history of musculoskeletal disorders.
  •  Previous injuries, fractures, surgeries, or other musculoskeletal problems.
  •  Any pain, swelling, or current problems.

B. Inspection.

  •  Observe gait (or crawling) for limping, toe walking, equal movement, and balance.
  •  Inspect spine and curvature of spine. Have child bend forward at waist and observe level of scapulae, ribs, and hips.
  •  Assess shape of back; toddlers normally have lumbar lordosis, older children may have kyphosis from chronic slouching.
  •  Observe strength and size of muscles.
  •  Evaluate length and shape of extremities.
  •  Observe gluteal skin folds for symmetry.

C. Palpation.

  •  Assess strength of upper extremities by having child squeeze examiner’s fingers.
  •  Palpate hips of neonate by performing Barlow and Ortolani maneuvers to check for hip dysplasia.
  •  Palpate joints for swelling or pain, evaluate ROM.

Pediatric Nursing: System Implementation

Focus topic: Pediatric Nursing

A. Identify abnormality of musculoskeletal structure.

  •  Evaluate newborn for congenital abnormality of the musculoskeletal system.
  •  Check for adequate range of motion and strength in all extremities.
  •  Check for normal hip joints in newborn.
  •  Check for abnormal spinal curvature (usually most noticeable in the school-age child.)

B. Prevent abnormal movement.

  •  Limit movement if developing abnormal patterns.
  •  Establish program of teaching ambulation with a physical therapist.

C. Prevent limitation of movement.

  •  Position body parts in proper alignment.
  •  Complete appropriate active and passive range of motion.

D. Control pain.

  •  Schedule painful procedures around analgesic schedule.
  • Implement measures to reduce pain (e.g., massage, heat and/or cold compresses, relaxation techniques).

E. Promote adequate circulation.

  •  Remove any restrictive garments or bandages.
  •  Check circulation of extremities at frequent intervals.
    a. Capillary filling.
    b. Temperature.
    c. Color.
    d. Peripheral pulses.
    e. Edema.

F. Promote alignment through splinting, casting, or traction.

  •  Check the vascular status of the extremity.
  •  Check the neurological status of the extremity.
    a. Level of sensation, any numbness, paresthesias (tingling).
    b. Movement of extremities and each digit, with or without pain.
  •  Observe traction for intactness in both skeletal and skin traction.

G. Promote healing through proper casting and cast care.

  • Check the vascular status of the extremity.
  • Examine the cast for signs of bleeding. If bleeding is present, draw a circle around the site, indicating time and date.
  •  Examine the cast for any pressure areas.
  •  Pull stockinette over cast edges and secure with tape (prevents cast crumbs from falling inside cast).
  •  Keep the cast clean and dry.
  •  If appropriate, keep the level of the cast above the heart to prevent edema formation.

Pediatric Nursing: Congenital Defects

Focus topic: Pediatric Nursing

Pediatric Nursing: Developmental Dysplasia of the Hip

Focus topic: Pediatric Nursing

Definition: Abnormalities of the hip present at birth, usually accompanied by abnormalities of the acetabulum, subluxation, or dislocation. Occurs in 1 or 2 per 1000 live births, and six times more often in females.

Assessment
A. Check for unequal major gluteal folds in infants, or varying heights of bent knees as viewed distally with infant supine.

B. Assess for presence of a hip “clunk” on abduction as femur slips over acetabulum using the Barlow and Ortolani maneuvers.
C. The hip will have asymmetric abduction or limited abduction when the child is placed supine with the knees and hips flexed.
D. Assess for femur that may appear shortened, or limp in older child.

  •  Abnormal tilting of the pelvis on the unaffected side when bearing weight on the affected side (Trendelenburg sign).
  •  Waddling gait or abnormal lordosis of spine if bilateral dislocation.

E. Assess degree of dysplasia.

  •  Preluxation (acetabular dysplasia): mildest form, femoral head remains in acetabulum but delayed acetabular development occurs.
  • Subluxation: most common form. Femoral head remains in contact with acetabulum, but is partially displaced.
  •  Dislocation: Femoral head loses acetabulum contact.

Implementation
A. Referral and complete evaluation by orthopedic specialist. An ultrasound of the infant’s hip is used because ossification is not complete until 1 year of age.
B. Teach parents importance of application of Pavlik harness, and maintaining alignment. It is used for infants less than 5–6 months of age for a duration of about 3–5 months so that the hip is in a continually abducted position so that the femoral head can remain in contact with the acetabulum.
C. Protect skin under the splint.
D. Bring environment to child: Surround with ageappropriate toys, support development.
E. Correction of DDH in older children may require operative reduction; osteotomy usually required and tenotomy of contracted muscles. A short course of traction may be used prior to application of the spica (hip) cast.

  •  Cast care teaching essential: diapering, keeping cast clean, checking skin frequently.
  •  Feeding more challenging if casted head must be elevated may require modified chair.
  •  Assist in discharge planning/teaching; focusing on daily activities; bathing, play, car seat adaptations, mobility (wagon, stroller, or scooter).

Pediatric Nursing: Congenital Clubfoot

Focus topic: Pediatric Nursing

Definition: Congenital deformity in which the foot is twisted out of its normal position. The deformity is described according to the position of the foot and ankle.The most common type is talipes equinovarus (95%), in which the foot is pointed downward and inward. Other forms include talipes varus (foot bends inward), talipes valgus (foot bends outward), talipes equinus (plantar flexion with toes lower than heel), or talipes calcaneus (dorsiflexion with toes higher than heel).

Assessment
A. Assess whether foot deformity is accompanied by other problems such as neurological defects or spina bifida.
B. Assess general health status of infant in preparation for treatment.
C. Determine aspects of treatment: occurs in three stages and includes exercises, manipulation, casting, and splinting.

Implementation
A. Treatment plan consists of correction, maintenance, and follow-up.

  •  Correction usually starts with manipulation followed by serial casting (shortly after birth). Casts are changed at regular intervals, as needed due to rapid growth of infant.
  •  Another method is the French physiotherapy method in which daily sequential stretching, strengthening, and mobilization of the foot is followed by taping and splinting to allow for gradual correction of the deformity by experienced physical therapists.
  •  More severe forms may require surgery.

B. Assist in passive exercises (manipulation) of the foot following a demonstration by physician or physical therapist.
C. Instruct parents in cast and/or splint care.
D. Provide emotional support and encourage bonding and infant development.

Pediatric Nursing: Osteogenesis Imperfecta

Focus topic: Pediatric Nursing

Definition: A congenital defect (most commonly autosomal dominant, but may also occur as autosomal recessive inheritance) resulting in severely brittle and fragile bones. Affected individuals appear to have abnormal precollagen preventing the formation of collagen; classified into four grades of severity. Tendency to fracture may not occur until later in childhood, but may occur at early ages, beginning with a fractured clavicle from the birth process.

Assessment
A. Refer for genetic counseling.
B. Assess skin—often is thin, easily injured, excessive diaphoresis.

C. Assess for blue sclera, discolored teeth, and conductive hearing loss.
D. Radiographs show thin bone shafts; possibly multiple old, healed fractures (must rule out child abuse).
E. Assess ROM, activity, limitations in activities of daily living (ADLs), level of comfort.

Implementation
A. Careful handling of infant to prevent fractures, especially when diapering.
B. Teaching and support in use of casts, braces, or splints utilized.
C. Assist with physical therapy plan.
D. Surgery may be necessary to correct deformities.
E. Support growth and development of infant and child.
F. Teaching principles.

  •  Emphasize safety and prevention of fractures.
  •  Reinforce medical therapeutic plan and prognosis.
  •  Refer to appropriate community agencies and support groups.
  •  Teach other healthcare professionals about defect. Families may be wrongfully accused of non-accidental trauma.

Pediatric Nursing: Muscular Dystrophy

Focus topic: Pediatric Nursing

Definition: Gradual degeneration of muscle fibers with progressive weakness of symmetric groups of the skeletal muscles. There are more than 30 different kinds of muscular genetic diseases, which vary in their pattern of inheritance and age at onset (most are identified in early childhood).

Characteristics
A. Duchenne’s muscular dystrophy is the most common type and the most severe.
B. Genetic pattern is an X-linked recessive; 30–50% have no family history.
C. Usually this disease appears at 3–5 years of age; rare in infancy or at birth; ambulation usually impossible after about 12 years.
D. Death usually occurs from pneumonia or cardiac failure; some live into their 20s or 30s.

Assessment
A. Assess for delay in motor development: clumsiness, walking on toes, waddling gait.
B. Assess for abnormal fatigue when walking or running.
C. Check for presence of Gower’s maneuver: climbing up on legs from supine position, marked lordosis when upright.
D. Assess for progressive muscle weakness: axial and proximal before distal, in symmetric muscle groups.

E. Check for elevated serum creatine kinase (CK).
F. Electromyography may be used for evaluation. DNA testing can determine the type of gene mutation.

Implementation
A. Provide support so that child can maintain independence as long as possible.

  •  Assist parents to develop physical therapy program.
  •  Support use of wheelchair when necessary to maintain mobility.

B. Counsel parents to prevent respiratory infection.

  •  Teach deep-breathing exercises.
  •  Maintain adequate diet to promote healthy status.

C. Counsel parents to monitor child’s weight to promote mobility and health.
D. Assist parents to obtain emotional support to deal with child more adequately at home.

  •  Identify community resources that will support family.
  •  Refer for genetic counseling.
  •  Counsel family to deal with chronic illness and with eventual death of the child.

Pediatric Nursing: Acquired Defects

Focus topic: Pediatric Nursing

Pediatric Nursing: Legg–Calvé–Perthes Disease

Focus topic: Pediatric Nursing

Definition: A self-limiting disease in which aseptic necrosis of the femoral head produces hip deformity and dysfunction.

Characteristics
A. Usually affects children 2–12 years of age and males 4–8 years of age; usually unilateral and self limited. This disorder usually progresses through five stages over a 1–2 year period.
B. Stages.

  • Stage I: The femoral capital epiphysis shows effects of ischemia. Synovitis produces stiffness and pain. Necrosis begins; x-rays show reduction in size and increased density of the femoral head the avascular stage.
  •  Stage II: Once necrosis occurs, the bone weakens and dies, causing collapse of the femoral head necrotic stage.
  •  Stage III: Avascular bone is reabsorbed and healing occurs as new bone is formed the fragmentation stage.
  •  Stage IV: The femoral head and neck begin to re-form the reossification stage.
  •  Stage V: final healing the reconstitution stage.

Assessment
A. Assess for pain in hip or knee most evident on rising or at end of the day.
B. Assess for limp or joint dysfunction on the affected side may be intermittent.
C. Assess for stiffness and tenderness over hip capsule.

Implementation
A. Goal of treatment is to keep the head of the femur contained in the acetabulum.

  • Initial therapy is rest to reduce inflammation and restore motion.
    a. Active range of motion exercises.
    b. Anti-inflammatory drugs such as Advil or Motrin.
    c. Weight-bearing as long as the acetabulum remains in femoral head (and is protected).
  • Containment accomplished by several measures.
    a. Non–weight-bearing devices such as abduction brace, leg cast, or leather harness sling that prevents weight bearing on affected limb.
    b. Weight-bearing appliances such as abduction– ambulation brace or cast.
  •  Conservative treatment may be continued for 2–4 years; surgical correction allows the child to resume normal activities in 3–4 months.
  •  Disease is self-limiting, but early treatment is essential to avoid permanent damage.

B. Most care is outpatient, so nursing emphasis is on teaching.

  •  Teach family use of corrective device selected for therapy.
  •  Stress importance of compliance for resolution of disease.
  •  Provide support for inactivity forced upon child.
  • Support normal growth and development and school progress.

Pediatric Nursing: Slipped Femoral Capital Epiphysis

Focus topic: Pediatric Nursing

Definition: The spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior direction. Most often occurs around puberty in obese children (slightly more often in boys).

Assessment
A. Obtain growth history and correct height and weight, recent injury/trauma.
B. X-rays demonstrate widening of growth plate; slipping produces deformity of femoral head and stretching of blood vessels.
C. Assess gait for limping.
D. Evaluate pain (may be hip or knee pain) and ROM of hip.
E. The leg is often externally rotated.

Implementation
A. Usually requires internal fixation with pins.
B. Routine postoperative cast care and pain management.
C. Support family, reinforce diagnosis with child and parents.
D. Teach activity limitations and traction/crutch walking (non–weight-bearing for 4–6 weeks).
E. Discharge planning/teaching; emphasize ADLs and support growth and development.

Pediatric Nursing: Scoliosis

Focus topic: Pediatric Nursing

Definition: Scoliosis is a lateral curvature of the spine and may be “C-shaped” or “S-shaped.” In addition to the lateral curvature, there is an actual rotation of the vertebral bodies in the spine, therefore, considered to be a three-dimensional deformity. There are three types of scoliosis: congenital or infantile, juvenile (ages 4–9), and adolescent idiopathic scoliosis (AIS) the most common type (80% of all cases).

Characteristics
A. Age of onset the younger the child, the greater the chances for deformity.

  •  Deformity increases during growth periods.
  •  Usually not noticed until adolescence.
  •  Affects more girls than boys.

B. Curves less than 25 degrees require observation for progression regardless of skeletal maturity.
C. Curves of 25-degree angle and still skeletally immature are treated with a back brace worn 22–23 hours/day until 18–24 months post menarche for girls, and until late adolescence for boys past the time of peak growth velocity.
D. Curves more than 40 degrees or those causing respiratory compromise warrant surgical intervention. The primary goal is to reduce the size of the curve using spinal fusion or an internal fixation system. The goal is provide a well-balanced spine that centers the client’s head, shoulders, and trunk over the pelvis.
E. Pattern of curve—when the primary curve is thoracic, there is a greater likelihood that deformity will occur.
F. Can be detected in 2–3% of children aged 10–16 years; 60–80% are girls. One shoulder seems higher than the other or clothes do not hang straight, usually detected during routine physical exam.
G. Scoliosis and its treatment often interfere with an adolescent’s self-image and self-esteem. Counseling or psychotherapy may be needed.

H. Types of curvature.

  •  Kyphosis: flexion deformity usually at thoracic spine.
  •  Lordosis: fixed extension deformity usually occurring to compensate for other abnormalities.
  • Scoliosis: lateral curvature of the spine.
    a. Nonstructural: Caused by changes outside the spine; treated with exercises.
    b. Structural: The spine itself has rotated; treated by bracing, exercise, or surgery.

Assessment
A. Assess fatigue in the lumbar region after prolonged sitting or standing. Muscular backaches in areas of strain (e.g., in the lumbosacral angle) or dyspnea may be reported.
B. Question client about ability to breathe and when client usually has difficulty breathing.
C. Adam’s forward bend screening exam expose back and check for deviations. Have client bend forward at waist.

  •  Check level of scapulae.
  •  Assess difference in shoulder height, elbow level, and height of iliac crests.
  •  Look for in-folding of one flank and flattening of another.

D. Assess range of motion of the spine.
E. Observe for deviations of the hips, rib cage, shoulders, and iliac crest.
F. Assess for mild pain and/or discomfort.

Implementation
A. Instruct on use of braces.

  • Teach adolescent to wear the brace correctly and remove it only to bathe or as prescribed by the physician.
  •  Explain necessity for good skin care where brace touches.
  •  Assist adolescent to understand the need for the brace, and help the client deal with the altered body image.

B. Provide care when child undergoes surgery.

Surgery
A. Primary goal is prevention of curve progression through spinal fusion and partial curve correction.
B. Procedure:

  • Posterior spinal fusion (PSF) with instrumentation and bone grafting is the most common. Contemporary implants are segmental and consist of a variety of hooks, screws, and wires that can be used to attach contoured rods to the spine at multiple vertebrae, or “segments.” This provides:
    a. Greater control over positioning and rotation of the spine.
    b. Increased stability of segmental instrumentation.
    c. Early mobilization with ambulation the day after surgery without external support such as a body cast or brace.
Pediatric nursing

 

  •  Anterior instrumentation and fusion may be performed for thoracolumbar and lumbar scoliosis.
    a. Convex side of the spine is exposed by a thoracotomy and/or retroperitoneal approach.
    b. Curve is corrected by shortening the convex side of the deformity.
    c. Advantages of the anterior approach include:
    i. Less blood loss.
    ii. Lower risk of neurologic injury.
    iii. No disturbance of the paraspinal muscles.
    d. Disadvantages include:
    i. Increased complexity.
    ii. Decreased pulmonary function if the thoracic cavity is entered and/or the diaphragm is opened.
  •  Video-assisted thoracoscopic surgery (VATS) for anterior instrumentation of the thoracic spine using instrumentation inserted through several small incisions thoracoscopically. Its use seems to be decreasing.
    a. Advantages of video-assisted thoracoscopic surgery over posterior spinal fusion with thoracic pedicle screws include:
    i. Reduced blood loss.
    ii. Fewer total levels fused.
    iii. Preservation of nearly one caudad fusion level.

b. Disadvantages include:
i. Increased operative times.
ii. Slightly less improvement in pulmonary function.

C. Complications of surgery include:

  •  Blood loss.
    a. Because of the risk of blood loss, many hospitals provide clients the option of autologous blood donation before surgery.
    b. Intra-operative blood salvage (“cell saver”).
  •  Infection.
  •  Implant failure.
  •  Neurologic injury.
  •  Pseudoarthrosis (failure of fusion).
  •  Lung injury.

Preoperative Nursing Interventions
A. Evaluate child’s level of understanding regarding condition and development progression.
B. Check preoperative lab work to ensure all values are within normal limits.
C. Assist child with pulmonary function tests.

  • Teach child to use incentive spirometer, cough, and deep-breathe.
  • Explain the importance of doing this postoperatively.

D. Evaluate child’s and parents’ understanding of surgical procedure.

  •  Explain to their level of understanding.
  •  Discuss postoperative course with child and parents to help them know what to expect.
  •  Answer questions they may have.
  •  Have parents review and sign written consent.

E. Visit the ICU, when appropriate, with family and child to familiarize them with the surroundings.

Postoperative Nursing Interventions
A. Check vital signs every 15 minutes until stable, then every hour.
B. Watch for signs and symptoms of hypovolemia, tachycardia, BP. (Blood loss in the operating room can be considerable.)
C. Assess respiratory function: breath stacking (BS), RR, chest excursion, color, grunting, flaring, retractions.

  • Continual assessment of respiration function with vital signs is essential; pneumothorax or punctured lung is a risk after surgery.
  •  Start incentive spirometer after child has been awake for 1 hour. Encourage to cough and deep breathe between use of incentive spirometer.

D. Check ABGs.
E. Monitor hydration status.

  •  Maintain strict I&O.
  •  Monitor urine output hourly. Urine output must be adequate (at least 1 mL/kg/hr). Assess for clinical signs of hypovolemia.

F. Check CMS (circulation–color, movement, sensation) of lower extremities and feet q1h × 8 hrs, q2h × 24 hrs, then q4h.
G. Turn after 1 or 2 hours by logrolling only. Maintain alignment of spine.
H. Medicate child prior to turning or doing procedures (per orders).

  •  It is important to keep child comfortable and administer narcotics in appropriate doses  preferably by  continuous IV infusion.
  •  Observe vital sign changes as indicative of pain.

I. Maintain NPO until child has positive bowel sounds, is passing flatus, or has had a stool.
J. Start diet with ice chips only. (Paralytic ileus is a common side effect.)
K. Check skin and dressing hourly to assess for skin breakdown and bleeding.
L. Instruct child to flex feet to improve circulation and maintain muscle tone.
M. Rehabilitation postoperatively is dependent on procedure and child’s ability to progress with movement and ambulation. Thoracoscopic procedures:

  •  After the wound is stable and child recovered from anesthesia, child may sit at the side of the bed.
  • Progresses to ambulation. No postoperative immobilization is required.

N. Discharge planning and teaching specific to surgical intervention performed; support of family and growth and development.

Pediatric Nursing: Inflammatory Diseases

Focus topic: Pediatric Nursing

Pediatric Nursing: Osteomyelitis

Focus topic: Pediatric Nursing

Definition: Infection usually of the long bones that involves cortex or marrow cavity. It is considered chronic if it lasts longer than 1 month. It is caused most frequently by Staphylococcus aureus, including community-acquired methicillin-resistant S. aureus (MRSA). In younger children, Streptococcus pyogenes, Haemophilus influenzae, and group B streptococci may cause osteomyelitis. Pseudomonas from the soil causes osteomyelitis from trauma and Salmonella causes osteomyelitis in sickle cell disease.

Characteristics
A. Occurs most frequently in children under the age of 6.

B. It is twice as common in boys.
C. The infection can result from exogenous causes (direct bacterial invasion from the outside) or hematogenous spread from a preexisting infection.

Assessment
A. Assess for abrupt onset or trauma to affected bone.
B. Assess for recent infection or injury anywhere else in child’s body.
C. Evaluate for fever, malaise, and pain.
D. Assess for localized tenderness in the bone at the metaphysis.
E. Evaluate for swelling and redness over affected bone.
F. Observe for fever, irritability, GI symptoms (vomiting or diarrhea).
G. Elevated WBCs, elevated ESR, CRP, positive blood culture.
H. Area of osteomyelitis may be noted on radiography, ultrasound, radionuclide bone scans, MRI, and/or CT scans.

Implementation
A. Control infection.

  • Supervision of high-dose parenteral antibacterial therapy effective against the specific organism.
  •  Long-term antibiotic therapy requires a peripherally inserted central catheter (PICC line).
  •  Monitor renal and hepatic function with long term therapy.

B. Control pain.

  •  Immobilization of affected limb; casting may be necessary.
  •  Analgesics as needed.

C. Surgical drainage of area may be necessary.
D. Monitor hydration and nutrition.

  • Child should be encouraged to drink fluids (supplement with IVs when necessary).
  •  Encourage high-calorie foods and supplements; offer frequent snacks.

E. Prepare for discharge support family and child’s growth and development.

Pediatric Nursing: Juvenile Idiopathic Arthritis

Focus topic: Pediatric Nursing

Definition: This is a systemic autoimmune disorder with multiple manifestations, arthritis (swelling of a joint) being the most characteristic. Etiology is unknown. Generally, onset is seen between 2 and 4 years of age, more commonly in girls. One of the most common chronic illnesses in children and leading cause of childhood disability.

Assessment
A. Assess for inflammation of joints—swelling of one or more joints lasting more than 6 weeks suggests juvenile idiopathic arthritis (JIA).

B. Assess for edema and congestion of synovial tissues. (As the disease progresses, synovial material fills the joint, causing narrowing, fibrous ankylosis, and bony fusion.)
C. Assess for premature closure or accelerated epiphyseal growth.
D. Assess joint involvement.

  • Arthritis may start slowly with gradual development of joint stiffness, swelling, and loss of motion.
  •  Most frequently affects knees, ankles, feet, wrists, and fingers although any joint may be involved.
  •  Affected joints are swollen, warm, painful, and stiff.
  •  Young children appear irritable and anxious, guarding their joints.
  • Weakness and atrophy of muscles appear around affected joints.
  •  Chronically affected joints may become deformed, dislocated, or fused.

E. Lab studies.

  •  CBC with differential with elevated WBCs during exacerbations.
  •  ESR and CRP elevation.
  •  Antinuclear antibodies may indicate a risk for uveitis (not always present).
  •  Rheumatoid factor may or may not be present; other markers inconsistent.

F. Assess systemic involvement, which frequently occurs.

  • Irritability, anorexia, and malaise.
  • Fever.
  • Intermittent macular rash.
  • Generalized lymphadenopathy.
  •  Anemia
  • Uveitis (inflammation of the anterior chamber of the eye).

Implementation
A. Supervise medication administration major goal is to relieve pain, while maintaining function.

  •  Primary drugs are nonsteroidal anti-inflammatory drugs (NSAIDs), which may include Aleve (naproxen), Advil, Clinoril (sulindac), and Celebrex (celecoxib).
  •  Observe for gastric irritation, blood in stool, easy bruising.
  •  Disease-modifying antirheumatic drug (DMARD) such as Trexall (methotrexate).
    a. May be given to clients not responding to NSAIDs
    b. Monitor CBC and liver function tests.
    c. Avoid use of alcohol.
    d. Use birth control to avoid birth defects while on Trexall.
  •  Immunologic modulators (biologics) to alter the immune response, including Enbrel (etanercept), and others such as Humira (adalimumab), Remicade (infliximab), and Kineret (anakinra).
    a. Weekly or biweekly subcutaneous injections.
    b. Cause immunosuppression (avoid live virus vaccines).
    c. Seek care if suspected infection.
  • Local injections of corticosteroids to the joints.

B. Maintain joint function.

  •  Exercise joints.
  •  Provide night splints, provide heat, and encourage proper positioning at rest.
  •  Educate parents in how child should perform exercises and impress upon them the child’s need for physical  therapy and splints.

C. Prevent eye damage encourage parents to report any signs of eye problems in the child immediately to the physician.
D. Counsel family. Encourage compliance with the treatment plan.

  • Explain physiology and unpredictable nature of the disease to the parents and the child.
  • Provide emotional support to the parents for dealing with a chronically ill child or adolescent.
  •  Refer to appropriate support groups.
  •  Encourage independence in the child and in ADLs.
  • Encourage mastery of developmental tasks appropriate to the age group of the child; encourage participation in school and school activities.
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