Alterations in Musculoskeletal Function
The Child Undergoing Surgery
NURSING CARE PLAN
GOAL
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
■ 801
for Scoliosis
INTERVENTION
NIC Priority Intervention: Teaching,
Disease Process and Preoperative:
Assisting the patient to understand
information and mentally prepare for
surgery and postoperative recovery.
■ Teach the child and family about
the course of the disease, its signs
and symptoms, and treatment.
Provide appropriate handouts.
Encourage the child and parents to
ask questions.
■ Begin preoperative teaching at the
time of admission. Orient the child
to hospital and postoperative
procedures. Before surgery, have
the child demonstrate log-rolling,
range-of-motion exercises, and the
use of an incentive spirometer.
Discuss pain management.
NIC Priority Intervention: Airway
Management and Respiratory
Monitoring: Facilitation of patency
of air passages and analysis of patient
data.
■ Monitor respiratory status,
especially after the administration
of analgesics. Apply pulse oximeter.
■ Administer oxygen if ordered.
■ Have the child use an incentive
spirometer.
■ Monitor intake and output.
■ Reposition the child at least every 2
hours.
NIC Priority Intervention: Injury
Prevention: Instituting special
precautions with patient at risk.
RATIONALE EXPECTED OUTCOME
NOC Suggested Outcome:
Knowledge: Extent of understanding
conveyed about scoliosis treatment.
■ Understanding and involvement The child and family accurately
increase motivation and verbalize knowledge about the disease
compliance while reducing fear. and its treatment. The child and
family ask appropriate questions
about postoperative care.
■ Preoperative teaching and
familiarity with hospital procedures
reduces the stress related to surgery
and postoperative complications.
NOC Suggested Outcome:
Respiratory Status: Ventilation:
Movement of air in and out of the
lungs.
■ Evaluation of the child’s respiratory The child has no respiratory
condition anticipates and avoids complications.
complications. Analgesics such as
morphine may increase or
potentiate respiratory compromise.
■ Oxygen increases peripheral
oxygen saturation to 95%–100%.
■ Spirometry increases lung
expansion and aeration of the
alveoli.
■ Good hydration promotes loose
secretions and helps prevent
infection.
■ Repositioning ensures inflation of
the lung fields.
NOC Suggested Outcome: Risk
Control: Actions to eliminate or
reduce modifiable health risks.
(continued)
802 ■ CHAPTER 21
NURSING CARE PLAN
GOAL
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.
The Child Undergoing Surgery
for Scoliosis (continued)
INTERVENTION
■ Monitor the child’s color,
circulation, capillary refill, warmth,
sensation, and motion in all
extremities. Perform neurovascular
checks every 2 hours for the first 24
hours and then every 4 hours for
the next 48 hours. Record presence
of pedal and distal tibial pulses
every hour for 48 hours. Report
changes and abnormal findings
immediately.
■ Have the child wear antiembolism
stockings until ambulatory. The
stockings may be removed for
1 hour 2-3 times daily.
■ Check for any pain, swelling, or a
positive Homans’ sign in the legs.
Record any evidence of edema.
■ Monitor input and output.
■ Encourage and assist the child with
range-of-motion exercises, both
passive and active.
NIC Priority Intervention: Pain
Management: Alleviation of pain or
a reduction of pain to a level of
comfort acceptable to the patient.
■ Assess the level of pain and initiate
pain management strategies as
soon 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 other
methods used for pain control.
■ Use nonpharmacologic pain
management techniques, such as
imagery, relaxation, touch, music,
application of heat and cold, and
reduced environmental stimulation
to supplement medications (see
Chapter 9).
■ Document pain assessment,
interventions, and the child’s
reactions.
■ Reassure the child that some
discomfort is expected and that a
variety of measures can be tried to
reduce discomfort.
RATIONALE EXPECTED OUTCOME
■ When the spinal column is The child exhibits only temporary
manipulated during surgery, altered alteration (pale skin, faint pulse, and
neurovascular status, thrombus edema occur but then resolve within
formation, and paralysis are the initial postoperative phase). The
possible complications. child returns to the preoperative
Postoperative risks include loss of baseline state by discharge.
bowel or bladder control, weakness
or paralysis, and impaired vision or
sensation.
■ Antiembolism stockings prevent
blood clots and promote venous
return. Thrombus formation is a
postoperative risk.
■ Swelling may indicate a tight
dressing and tissue damage. A
positive Homans’ sign and pain
may indicate thrombus formation.
■ Abnormalities may indicate a fluid
shift problem.
■ Activity promotes mobility and
reduces risk of thrombus formation.
NOC Suggested Outcome: Pain
Level: Amount of reported or
demonstrated pain.
■ Adequate pain management allows The child experiences pain relief early
for faster healing and a more in the postoperative period.
cooperative patient. Patient
controlled analgesics may be
effective.
■ Medicating around-the-clock helps
to maintain comfort. Monitoring
ensures patient safety.
■ Alternative treatments also
interrupt the pain stimulus and
provide relief. Nonpharmacologic
methods can be an effective
adjunct to pain management.
■ Proper documentation guides the
selection of the most effective
means of pain control.
■ Realistic expectations decrease
anxiety and give the child a sense
of control.

NURSING CARE PLAN
GOAL
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.
The Child Undergoing Surgery
for Scoliosis (continued)
INTERVENTION
NIC Priority Intervention: Positioning
and Ambulation: Moving the
patient to provide comfort and
promote healing, assist with walking.
■ Reposition the child every 2 hours
using the log-roll technique.
Support the back, feet, and knees
with pillows.
■ Have the child do passive and
active range-of-motion exercises
every 2 hours for 48 hours and
then every 4 hours while awake.
Have the child dangle his or her
legs at bedside by the second to
fourth postoperative day. Begin
ambulation by the third to fifth
postoperative day. Note any
complaints of dizziness, pallor, etc.
Proceed slowly.
NIC Priority Intervention: Body
Image Enhancement: Improving
conscious and unconscious
perceptions toward the body.
■ Encourage independence in daily
activities within allowable limits.
Use positive reinforcements.
Encourage the child to participate
in community activities, if possible.
Involve the child in scoliosis
support groups.
■ Provide contact with a peer
resource person who has
undergone treatment for scoliosis.
NIC Priority Intervention: Teaching:
Prescribed Treatment: Preparing
family to understand and perform
prescribed treatment.
■ Teach cast or brace care as
appropriate (see pp. 786 and 788).
Provide oral and written instructions
and a list of activity limitations (see
Families Want to Know:
Postoperative Activities after Spinal
Surgery). Have the child and family
demonstrate adequate knowledge.
■ Arrange for follow-up appointments
as ordered by the physician.
Encourage the child and family to
notify the nurse or physician if they
have any questions or concerns.
Alterations in Musculoskeletal Function ■ 803
RATIONALE EXPECTED OUTCOME
NOC Suggested Outcome:
Ambulation: Ability to walk from
place to place.
■ Proper positioning prevents The child is as mobile as appropriate
twisting or turning the spine. for condition with 3–5 days after
surgery.
■ Exercises help maintain strength,
circulation, and muscle tone. If the
spine is stable and the physician
has ordered no external support,
the child may progress to full
ambulation as tolerated. If the
spine is not stable, great care must
be taken until external supportive
devices are used.
NOC Suggested Outcome: Body
Image: Positive perception of own
appearance and body.
■ Involvement in activities The child has a positive self-image and
demonstrates that a “normal” life is is involved in community activities or
realistic. support groups.
■ Peers are an effective means of
support.
NOC Suggested Outcome:
Knowledge: Extent of understanding
conveyed about postoperative
treatment and follow-up care.
■ Providing education decreases The child and family demonstrate
anxiety and increases compliance home care and implementation of
with treatment plan. discharge teaching.
Demonstration reinforces the
learning process.
■ Follow-up visits help the nurse and
physician evaluate the effectiveness
of the treatment plan and patient
compliance.