Case Study - School Nurse Scoliosis Screening

Student begins ambulation on her third post-operative day. What factor must the nurse consider unique to ambulation post scoliosis surgery? (Select all that apply. One, some, or all options may be correct.) Select all that apply A distorted sense of balance. Potential bleeding at the surgical site. Respiratory distress due to shifts in thoracic organs post-operatively. Paresthesias in the lower extremities when first standing. Potential orthostatic hypotension.

A distorted sense of balance. Correction of the spinal curve results in a 2 inch increase in height. The adolescent is not accustomed to this and experiences fear and balance issues when first ambulating. Potential bleeding at the surgical site. Standing does not increase the risk of bleeding. Respiratory distress due to shifts in thoracic organs post-operatively. Respiratory distress is not induced by standing. Paresthesias in the lower extremities when first standing. Standing does not cause paresthesias. Potential orthostatic hypotension. The client has been supine for 3 days and she has experienced blood loss during surgery.

Physiologic Integrity: Physical Assessment Student is resting in the side-lying position after her first log roll. What nursing assessment is most critical when completing this procedure? Vital signs. Pain status. Assess neurovascular status. Wound assessment. Submit Previous Section

Assess neurovascular status. Neurovascular should be assessed before and after log rolling. Any neurovascular compromise must be treated immediately to prevent paralysis.

Safe and Effective Care: ManagementSonja undergoes surgery for insertion of L-rods with bone grafting from the left iliac crest. She is given 0.4 mg of morphine sulfate intrathecally in the operating room, and a local anesthetic at the graft site. A peripheral IV is connected to a PCA pump. There is an order to begin long-term oral opioids as soon as she is able to take fluids by mouth. Student complains of pain at the insertion site. She rates her pain as 6/10. What is the nurse's first responsibility? Since she is verbalizing, assess her ability to swallow oral medication. Assess respiratory status. Determine the time of the intrathecal dose of morphine and assess if a PCA dose is indicated. Since the appropriate pain treatment is administered, assess the surgical sites for bleeding or signs of infection.

Assess respiratory status. There is a risk of respiratory depression with morphine, especially when administered by the intrathecal route.

What critical observations to detect curvature are included in the screening process? (Select all that apply. One, some, or all options may be correct.) Asymmetry of shoulder and hip height. Unequal thigh skin folds and trendelenberg gait. Rib humps. Tibial torsion and eversion of the feet. Inability to perform the Adams forward bend test. Prominent scapula.

Asymmetry of shoulder and hip height. This asymmetry is characteristic of scoliosis. Unequal thigh skin folds and trendelenberg gait. These findings are associated with developmental dysplasia of the hip. Rib humps. A rib hump signifies presence of a rotational deformity, in addition to the lateral curve. Tibial torsion and eversion of the feet. Tibial torsion is an inward twisting of the tibia causing a pigeon- toed walk in toddlers; eversion is associated with club foot. Inability to perform the Adams forward bend test. Presence of a spinal curve does not prevent the child from performing this maneuver. Bending forward facilitates observation of any rotational deformity. Prominent scapula. This is a characteristic of scoliosis.

Scoliometric findings for the female student are: 8º thoracic curve and 4° lumbar curve. What is the correct nursing intervention the school nurse must complete? Document the finding and recommend a rescreen at age 12 years. Refer for spinal x-rays. Send for a consultation for bracing. Document these as normal values.

Document the finding and recommend a rescreen at age 12 years. The 10-year-old has not completed growing. Curves are most pronounced at the end of the adolescent growth spurt. Curves 10° and greater are referred for confirmation via x-ray.

Student's parents are concerned about surgical blood loss and risks of blood transfusions. How should the nurse address the parents' concerns about blood transfusions? Explain that the surgeon determines the need for transfusion based on experience. Discuss the safety of donor blood since careful screening is done. Educate the parents about options such as autologous blood transfusions. Explain that preoperative administration of iron will reduce the need for blood transfusion. Submit Previous Section

Educate the parents about options such as autologous blood transfusions. The client can donate her own blood prior to surgery. Other options include intraoperative blood salvage, hemodilution, or erythropoietin administration.

Safe and Effective Care: ManagementStudent continues to have body image concerns. She visits the school nurse and asks if there are any exercises she could do to improve the curvature of her spine. How should the nurse respond? A rigorous program of stretching is as effective as bracing. Bracing plus exercise decreases curve progression. Exercises can help maintain musculature of the trunk during bracing. The type of stretching exercises needed often result in injury.

Exercises can help maintain musculature of the trunk during bracing. Stretching exercises can increase mobility of the spine and breathing exercises cause temporary improvement in rotational deformities.

The school nurse repeats the scoliosis screening when the student turns 12 years old. Her curve has progressed some, but not to a significant degree (9° thoracic and 5° lumbar). She does not appear to have grown as rapidly as her peers. Which question is most relevant for the school nurse to ask student, when assessing the effect of growth on potential future curve progression? How tall are your parents? What percentile are you on the growth curve? Are you on any medication? Have you started your period?

Have you started your period? Spinal curves progress most rapidly during the period of rapid growth. Girls grow rapidly until the time of their first menses. Growth then continues, but slows over the next 18 to 24 months.

Despite wearing the orthotic brace for 2 years, student's curve progresses to 40° and she experiences low back pain. She is scheduled for surgical correction with insertion of L-Rods (Luque-rods) and grafting. The HCP prescribes preoperative laboratory blood tests. Which orders would the nurse consider a priority for this client? Hemoglobin and hematocrit. White blood cell count. Serum chemistries. BUN and creatinine.

Hemoglobin and hematocrit. Due to gender and age, the client is at risk of iron deficiency anemia. Scoliosis surgery results in significant blood loss making her highly susceptible to anemia.

What is the most appropriate response for the nurse to tell student? You will need to find activities other than sports for the next 2 years. I will show you ways to decorate the brace similar to current fashions. If you do not wear the brace, you will need to have surgery. You will benefit even if you wear the brace for 10 hours a day.

I will show you ways to decorate the brace similar to current fashions. Teens wish to fit in with peers and making the brace a fashion statement will increase adherence.

Student's pain is treated and the nurse determines that this is a good time to reposition her in bed. The nurse reviews the preoperative teaching about log rolling, then the nurse recruits 2 staff members to assist. The nurse provides instructions to the team members for the log rolling procedure. What instructions must the nurse provide to assure safe turning? Demonstrate to the client how to gently grab the side rail to assist with turning. Instruct the third assistant to support the client's head and neck. Instruct the second assistant to stand on the opposite side of the bed and push as the nurse pulls. Place a pillow between the client's legs. Ask the first assistant to stand at the client's shoulder with the second assistant at the client's hips, reach over and pull the draw sheet in one smooth motion.

Place a pillow between the client's legs. Ask the first assistant to stand at the client's shoulder with the second assistant at the client's hips, reach over and pull the draw sheet in one smooth motion. Spinal alignment is maintained at all times, pillows are placed behind the client to maintain a 30° to 45° angle in the side lying position.

Six days after surgery, student complains of abdominal pain and nausea. She initially vomits small amounts but progresses to vomiting copious amounts. Her pain is worse in the supine position. Which physician order should the nurse anticipate? NPO status and administration of antiemetics. Increase in pain medication dosage. Placement of a nasogastric tube and begin parenteral feeding. Prepare client for diagnostic radiology procedures.

Placement of a nasogastric tube and begin parenteral feeding. This complication is superior mesenteric artery syndrome, or compression of the duodenum by the aorta and superior mesenteric artery. The obstruction is treated by gastric decompression. Parenteral nutrition is needed to rest the gut.

Safe and Effective Care: Management of CareStudent is promoted to high school and the school nurse notes in her electronic medical record (EMR) that there appears to be concern in reference to possible scoliosis. The nurse at the high school rescreens her. Additionally, student tells the nurse that she has not begun menstruating. At age 15 years of age, student has a noticeable shoulder height discrepancy. The school nurse rescreens 15-year-old student. The findings include a noticeable rib hump, as well as waist and hip asymmetries, and a thoracic curve of 32°. What is the most appropriate nursing intervention? Continue to observe until the measurement is 50°. Discuss concerns about poor posture. Refer for x-rays and bracing. Refer for surgery.

Refer for x-rays and bracing. X-rays are confirmatory and curves less than 40° respond to bracing.

Student responds to treatment for the superior mesenteric artery syndrome. She continues to ambulate, she participates in physical therapy, and she tolerates oral feeding. She is being prepared for discharge. Student is eager to resume her physical activities including participation in sports. She also wishes to know of risks the spinal instrumentation might cause for pregnancy in the future. How should the nurse counsel the student? Avoid pregnancy. Fully participate in all sports in 3 months. Resume regular activities of daily living, including school in 3 to 4 weeks. Develop hobbies other than sports.

Resume regular activities of daily living, including school in 3 to 4 weeks. It is recommended that regular activities may resume in 3 to 4 weeks.

The nurse informs the student nurses to observe for which signs that would rule out disease processes that can cause scoliosis? Nucal pain and rigidity. Crepitis upon bending. Sacral dimpling or hairy patches. Swelling at any point along the spine.

Sacral dimpling or hairy patches. These findings along with abnormal reflexes, vascular changes in the skin, or bladder and bowel incontinence may indicate spinal abnormalities.

The school nurse prepares informational letters for parents and consent forms for the screening. A mother informs the school nurse that she does not want her daughter to be screened at school. What is the appropriate response from the school nurse? The American Academy of Pediatrics favors school screening. School screening is voluntary. She may have screening done at the pediatrician's office. School policy requires screening for all students who participate in team sports. State law mandates school screening.

School screening is voluntary. She may have screening done at the pediatrician's office. This statement is supportive of the parent's preference and gives guidance for appropriate follow up.

The nurse reviews the pathophysiology of scoliosis with the student nurses. What concepts should the school nurse include? (Select all that apply. One, some, or all options may be correct.) Scoliosis is a simple deformity that involves a lateral curvature of the spine. Most adolescents with scoliosis have a neuromuscular defect. Scoliosis can be classified according to age of onset. Intraspinal abnormalities can cause scoliosis. Most causes of adolescent scoliosis are idiopathic. Untreated mild scoliosis leads to cardiopulmonary disease.

Scoliosis is a simple deformity that involves a lateral curvature of the spine. Scoliosis is a complex curvature that involves rotational deformities and kyphosis in addition to lateral curvatures. Most adolescents with scoliosis have a neuromuscular defect. Scoliosis can occur with a neuromuscular condition but most adolescent cases are not associated with these conditions. Scoliosis can be classified according to age of onset. Scoliosis occurring: in the first 3 years of life is termed infantile; between 4-10 years is termed juvenile, and at age 10 or later is termed adolescent scoliosis. Intraspinal abnormalities can cause scoliosis. Spinal abnormalities such as tethered cord, syringomyelia, or diastematomyelia can cause scoliosis. Most causes of adolescent scoliosis are idiopathic. For most cases of scoliosis occurring after age 10 years, no cause can be detected, although there is growing evidence of a genetic relationship. Untreated mild scoliosis leads to cardiopulmonary disease. Severe, untreated curves can cause alterations in pulmonary functions, however, persons with moderate curves do not necessarily need surgical correction.

Safe and Effective Care: PathophysiologyStudent's family questions why she is required to have pulmonary function studies prior to surgery. The nurse clarifies the purpose of pulmonary function tests. Which of the following statements is correct? Scoliosis can cause obstructive lung disease. Scoliosis restricts movement of the ribs. Scoliosis increases lung compliance. Scoliosis results in air trapping.

Scoliosis restricts movement of the ribs. Mechanical function of respiratory muscles is also affected.

Safe and Effective Care: ManagementThe nurse recognizes that student is in a hypermetabolic state in the postoperative period. Despite understanding the need for increasing caloric intake, student does not wish to eat due to pain and opioid use. The nurse's goal to maximize nutrition is to provide nutritious, calorie-dense but low-volume meals. Which of the following meals would best meet this goal? Supplement meals with 8 ounces of a liquid/nutrient-dense dietary supplement 3 times a day. Request an order for total parenteral nutrition (TPN). A hamburger, spinach, french fries and milk. Explain to the client that if she cannot eat, a nasogastric tube will be placed.

Supplement meals with 8 ounces of a liquid/nutrient-dense dietary supplement 3 times a day. An 8 ounce serving could contains 220 calories, 9 grams of protein and 26 essential vitamins and minerals depending on what supplement is used. Examples of supplements include Ensure®, Boost®, Carnation Breakfast Essentials®.

The school nurse will screen the 6th grade girls. The nursing students question why screening is limited to this population. What is the school nurse's explanation as to the purpose of scoliosis screening in this population? Avoid privacy issues that concern parents of younger children. Target high prevalence age groups. Avoid screening boys because they are not at risk for scoliosis. Maximize privacy by separating boys and girls.

Target high prevalence age groups. Adolescent idiopathic scoliosis is the most common form of scoliosis and is most frequently found in girls following the adolescent growth spurt.

The nurse notes a spinal distortion in a 10-year-old female student and uses a scoliometer to measure the degree of curvature. What is the correct method of assessment with the scoliometer? The student lies prone on the exam table, and the scoliometer is placed on the highest part of the curve. The student bends over with arms dangling, and the scoliometer is placed on the thoracic curve, then on the lumbar curve. The student is placed in the Adams position, and the school nurse slides the scoliometer along the length of the spine and records the greatest angle. The student lies prone on the exam table and the readings are recorded at the cervical, thoracic, lumber and sacral spine.

The student bends over with arms dangling, and the scoliometer is placed on the thoracic curve, then on the lumbar curve. It is recommended that measurements be repeated twice with the child returning to a standing position between measurements.

Safe and Effective Care: CommunicationThe nurse plans a preoperative teaching session with student and her parents. Surgery will be via a posterior approach. What topics must the nurse include in the teaching with student and her parents? (Select all that apply. One, some, or all options may be correct.) Select all that apply The use of incentive spirometry. Operation of a PCA pump. Management of chest tubes. Care of the central venous line. Presence of a Foley catheter and frequent neurovascular monitoring. The need for log rolling when turning postoperative.

The use of incentive spirometry. Coughing and deep breathing and incentive spirometry as used to prevent respiratory complications post operatively. Operation of a PCA pump. Orthopedic surgery is painful. It is critical to teach the client about pain management strategies. Management of chest tubes. Chest tubes are used when surgery entails an anterior approach. The client will have a posterior approach. Care of the central venous line. Peripheral intravenous lines will be in place. Presence of a Foley catheter and frequent neurovascular monitoring. A Foley catheter will be in place in the initial postoperative period. Frequent nursing assessments of neurovascular status are necessary given the risk for injury to nerves. The need for log rolling when turning postoperative. This is the appropriate way to turn which is necessary to prevent trauma to the grafted bone.

Safe and Effective Care: CommunicationStudent's mother asks the school nurse about the recommended procedures that will be done to evaluate the spine. The school nurse provides education to the student and her mother about the diagnostic procedures for scoliosis. Which response provides accurate information? An MRI will validate X-ray findings. The client will be instructed to stand as straight as possible while the x-ray is taken. X-rays are not needed after bracing. X-rays will be taken in several positions including a side view.

X-rays will be taken in several positions including a side view. The client will be asked to bend to either side to assess spinal flexibility and traction will be placed on extremities to stretch the spine. Lateral views assess presence of kyphosis.