Alterations in Musculoskeletal Function ■ 801

■ Understanding and involvementincrease motivation andcompliance while reducing fear.

■ Preoperative teaching andfamiliarity with hospital proceduresreduces the stress related to surgeryand postoperative complications.

■ Evaluation of the child’s respiratorycondition anticipates and avoidscomplications. Analgesics such asmorphine may increase orpotentiate respiratory compromise.

■ Oxygen increases peripheraloxygen saturation to 95%–100%.

■ Spirometry increases lungexpansion and aeration of thealveoli.

■ Good hydration promotes loosesecretions and helps preventinfection.

■ Repositioning ensures inflation ofthe lung fields.

NOC Suggested Outcome:Knowledge: Extent of understandingconveyed about scoliosis treatment.

The child and family accuratelyverbalize knowledge about the diseaseand its treatment. The child andfamily ask appropriate questionsabout postoperative care.

NOC Suggested Outcome:Respiratory Status: Ventilation:Movement of air in and out of thelungs.

The child has no respiratorycomplications.

NOC Suggested Outcome: RiskControl: Actions to eliminate orreduce modifiable health risks.

NIC Priority Intervention: Teaching,Disease Process and Preoperative:Assisting the patient to understandinformation and mentally prepare forsurgery and postoperative recovery.

■ Teach the child and family aboutthe course of the disease, its signsand symptoms, and treatment.Provide appropriate handouts.Encourage the child and parents toask questions.

■ Begin preoperative teaching at thetime of admission. Orient the childto hospital and postoperativeprocedures. Before surgery, havethe child demonstrate log-rolling,range-of-motion exercises, and theuse of an incentive spirometer.Discuss pain management.

NIC Priority Intervention: AirwayManagement and RespiratoryMonitoring: Facilitation of patencyof air passages and analysis of patientdata.

■ Monitor respiratory status,especially after the administrationof analgesics. Apply pulse oximeter.

■ Administer oxygen if ordered.

■ Have the child use an incentivespirometer.

■ Monitor intake and output.

■ Reposition the child at least every 2hours.

NIC Priority Intervention: InjuryPrevention: Instituting specialprecautions with patient at risk.

(continued)

NURSING CARE PLANThe Chi ld Undergoing Surgery for Scol iosis

GOAL INTERVENTION RATIONALE EXPECTED OUTCOME

1. Knowledge Deficit (Child and Parents) related to lack of information about surgery

The child and parents will verbalize understanding of the disease, its treatment, and the surgical procedure.

2. Ineffective Breathing Pattern related to hypoventilation syndrome

The child will show no signs of respiratory compromise.

3. Risk for Injury related to neurovascular deficit secondary to instrumentation

802 ■ C H A P T E R 2 1

■ When the spinal column ismanipulated during surgery, alteredneurovascular status, thrombusformation, and paralysis arepossible complications.Postoperative risks include loss ofbowel or bladder control, weaknessor paralysis, and impaired vision orsensation.

■ Antiembolism stockings preventblood clots and promote venousreturn. Thrombus formation is apostoperative risk.

■ Swelling may indicate a tightdressing and tissue damage. Apositive Homans’ sign and painmay indicate thrombus formation.

■ Abnormalities may indicate a fluidshift problem.

■ Activity promotes mobility andreduces risk of thrombus formation.

■ Adequate pain management allowsfor faster healing and a morecooperative patient. Patientcontrolled analgesics may beeffective.

■ Medicating around-the-clock helpsto maintain comfort. Monitoringensures patient safety.

■ Alternative treatments alsointerrupt the pain stimulus andprovide relief. Nonpharmacologicmethods can be an effectiveadjunct to pain management.

■ Proper documentation guides theselection of the most effectivemeans of pain control.

■ Realistic expectations decreaseanxiety and give the child a senseof control.

The child exhibits only temporaryalteration (pale skin, faint pulse, andedema occur but then resolve withinthe initial postoperative phase). Thechild returns to the preoperativebaseline state by discharge.

NOC Suggested Outcome: PainLevel: Amount of reported ordemonstrated pain.

The child experiences pain relief earlyin the postoperative period.

■ Monitor the child’s color,circulation, capillary refill, warmth,sensation, and motion in allextremities. Perform neurovascularchecks every 2 hours for the first 24hours and then every 4 hours forthe next 48 hours. Record presenceof pedal and distal tibial pulsesevery hour for 48 hours. Reportchanges and abnormal findingsimmediately.

■ Have the child wear antiembolismstockings until ambulatory. Thestockings may be removed for 1 hour 2-3 times daily.

■ Check for any pain, swelling, or apositive Homans’ sign in the legs.Record any evidence of edema.

■ Monitor input and output.

■ Encourage and assist the child withrange-of-motion exercises, bothpassive and active.

NIC Priority Intervention: PainManagement: Alleviation of pain ora reduction of pain to a level ofcomfort acceptable to the patient.

■ Assess the level of pain and initiatepain management strategies assoon as possible. Use patient-controlled analgesia if ordered.

■ Administer pain medication around-the-clock to help ensure pain relief,especially during the first 48 hours.Monitor epidural blocks and patient-controlled analgesia or othermethods used for pain control.

■ Use nonpharmacologic painmanagement techniques, such asimagery, relaxation, touch, music,application of heat and cold, andreduced environmental stimulationto supplement medications (seeChapter 9).

■ Document pain assessment,interventions, and the child’sreactions.

■ Reassure the child that somediscomfort is expected and that avariety of measures can be tried toreduce discomfort.

NURSING CARE PLANThe Chi ld Undergoing Surgery for Scol iosis (continued)

GOAL INTERVENTION RATIONALE EXPECTED OUTCOME

3. Risk for Injury related to neurovascular deficit secondary to instrumentation (continued)

The child’s neurovascular system will remain intact as evidenced by circulation, sensation, and motor checks. The child will feel no numbness or tingling.

4. Pain related to spinal fusion with instrumentation

The child will verbalize an adequate level of comfort or show absence of pain behavior within 1 hour of a specific nursing intervention.

Alterations in Musculoskeletal Function ■ 803

■ Proper positioning preventstwisting or turning the spine.

■ Exercises help maintain strength,circulation, and muscle tone. If thespine is stable and the physicianhas ordered no external support,the child may progress to fullambulation as tolerated. If thespine is not stable, great care mustbe taken until external supportivedevices are used.

■ Involvement in activitiesdemonstrates that a “normal” life isrealistic.

■ Peers are an effective means ofsupport.

■ Providing education decreasesanxiety and increases compliancewith treatment plan.Demonstration reinforces thelearning process.

■ Follow-up visits help the nurse andphysician evaluate the effectivenessof the treatment plan and patientcompliance.

NOC Suggested Outcome:Ambulation: Ability to walk fromplace to place.

The child is as mobile as appropriatefor condition with 3–5 days aftersurgery.

NOC Suggested Outcome: BodyImage: Positive perception of ownappearance and body.

The child has a positive self-image andis involved in community activities orsupport groups.

NOC Suggested Outcome:Knowledge: Extent of understandingconveyed about postoperativetreatment and follow-up care.

The child and family demonstratehome care and implementation ofdischarge teaching.

NIC Priority Intervention: Positioningand Ambulation: Moving thepatient to provide comfort andpromote healing, assist with walking.

■ Reposition the child every 2 hoursusing the log-roll technique.Support the back, feet, and kneeswith pillows.

■ Have the child do passive andactive range-of-motion exercisesevery 2 hours for 48 hours andthen every 4 hours while awake.Have the child dangle his or herlegs at bedside by the second tofourth postoperative day. Beginambulation by the third to fifthpostoperative day. Note anycomplaints of dizziness, pallor, etc.Proceed slowly.

NIC Priority Intervention: BodyImage Enhancement: Improvingconscious and unconsciousperceptions toward the body.

■ Encourage independence in dailyactivities within allowable limits.Use positive reinforcements.Encourage the child to participatein community activities, if possible.Involve the child in scoliosissupport groups.

■ Provide contact with a peerresource person who hasundergone treatment for scoliosis.

NIC Priority Intervention: Teaching:Prescribed Treatment: Preparingfamily to understand and performprescribed treatment.

■ Teach cast or brace care asappropriate (see pp. 786 and 788).Provide oral and written instructionsand a list of activity limitations (seeFamilies Want to Know:Postoperative Activities after SpinalSurgery). Have the child and familydemonstrate adequate knowledge.

■ Arrange for follow-up appointmentsas ordered by the physician.Encourage the child and family tonotify the nurse or physician if theyhave any questions or concerns.

NURSING CARE PLANThe Chi ld Undergoing Surgery for Scol iosis (continued)

GOAL INTERVENTION RATIONALE EXPECTED OUTCOME

5. Impaired Physical Mobility related to movement restrictions and pain

The child will maintain proper body alignment and progress with activity as ordered by the physician. If no anteroposterior shell bracing is required the child will have active mobility by the third to fifth postoperative day.

6. Risk for Body Image Disturbance related to treatment

The child will verbalize feelings about body image and self-esteem in relation to the disease and its treatment. The child will be informed about available support services and use them as needed.

7. Risk for Knowledge Deficit (Child and Parent) related to lack of information about home care

The child and family will verbalize reduced anxiety about home care. The child will demonstrate knowledge of self-care and permitted activities.