1. Describe scoliosis including the different types.

Types of idiopathic scoliosis are categorized by both age at which the curve is detected and by the type and location of the curve.

When grouped by age, scoliosis usually is categorized into three age groups:

Infantile scoliosis: from birth to 3 years oldJuvenile scoliosis: from 3 to 9 years oldAdolescent scoliosis: from 10 to 18 years old

Scoliosis curves are often described based on the direction and location of the curve. Physicians have several detailed systems to classify specific curves, but here are some common terms used to describe scoliosis:

Terms that describe the direction of the curve:

Dextroscoliosis describes a spinal curve to the right ("dextro" = right). Usually occurring in the thoracic spine, this is the most common type of curve. It can occur on its own (forming a "C" shape) or with another curve bending the opposite way in the lower spine (forming an "S").Article continues belowLevoscoliosis describes a spinal curve to the left ("levo" = left). While common in the lumbar spine, the rare occurrence of levoscoliosis in the thoracic spine indicates a higher probability that the scoliosis may be secondary to a spinal cord tumor. A physician will order an MRI for a thorough diagnosis.Terms that describes the location of the curve:

Thoracic scoliosis is curvature in the middle (thoracic) part of the spine. This is the most common location for spinal curvature.Lumbar scoliosis is curvature in the lower (lumbar) portion of the spine.Thoracolumbar scoliosis is curvature that includes vertebrae in both the lower thoracic portion and the upper lumbar portion of the spine.

2. Discuss the incidence and etiology of idiopathic scoliosis.

Idiopathic scoliosis (unknown cause) - in about 80% of cases the cause is unknown. Neuromuscular conditions - these are conditions that affect the nerves and muscles. About 20% of scoliosis cases are caused by neuromuscular conditions, such as cerebral palsy or muscular dystrophy. It is not caused by activity such as exercise, sports, or carrying heavy object; nor does it come from sleeping position, posture, or minor differences in leg length.

3. How might her diagnosis impact on her growth and development?Spinal curvatures may become worse or emerge during growth spurts but with proper treatment there is no long term impact on growth.

4. Describe the treatment.Scoliosis treatment decisions are primarily based on two factors: The skeletal maturity of the patient and the degree of spinal curvature. A small degree of curvature in a patient nearing skeletal maturity is not likely to need treatment; Conversely, a younger patient with a bigger curve is likely to have a curve will continue to advance and will need treatment. There are three main scoliosis treatment options for adolescents:

-Observation-Back braces-Scoliosis surgeryNo exercises for scoliosis have proved to reduce or prevent curvature. However, exercise is highly recommended for both scoliosis and non-scoliosis patients alike to keep back muscles strong and flexible.

5. Discuss the teaching required for Kimberlli and her parents.Because of her age and her curvature, Kimberlli will most likely need a brace. Bracing does not straighten the curve that is already present. Instead, the goal of a back brace is to stop the progression of the spinal curve as the child continues to grow. The child will continue to wear the brace until he or she reaches skeletal maturity. Once the individual stops growing, there is little likelihood of progression of a curve. Working under the direction of an orthopedic surgeon, an orthotist will fit a custom brace to the individual. The braces usually are made of molded plastic and fit tightly around the body and are worn under the clothes every day. Some are worn overnight; some are worn 23 hours a day. Although braces for scoliosis are more comfortable than ever before, they still have a low compliance rate for various reasons: children and adolescents feel different from their peers when they have to wear them, and some genuinely cause discomfort and perhaps difficulty breathing. Support for children wearing back braces is key to their effectiveness. Studies clearly show that the more closely patients follow their prescribed bracing regimen, the less the scoliosis curve progresses.

6. After Kimberli’s scoliosis does not respond to conservative treatment, she is scheduled for a posterior spinal fusion. What are the priorities of care?

Obtain consent and prepare the patient for surgery. The patient should be kept NPO starting midnight before the procedure. Measurements of the curvature should be reassessed before surgery.

7. What is a Harrington rod and how is it used?The device itself was a stainless steel distraction rod fitted with hooks at both ends and a ratchet and was implanted through an extensive posterior spinal approach, the hooks being secured onto the vertebral laminae.

8. Following her surgery, what are the post operative priorities?

Use log rolling to reposition the child every 2 hours to inhibit development of pressure sores and to adequately inflate lungs. Monitor vital signs following surgery. Apply antiembolism stockings while the patient is on bed rest. Remove the antiembolism stocking for 1 hour three times a day. Assess the patient’s pain level. Assess for Homan sign for signs of an embolism Measure the circumference of the calf frequently if the calf is swollen to determine if there are changes to the swelling. Assess for ischemia: Pain, pallor, pulselessness, paresthesia, paralysis. Support the back, feet, and knees with pillows when the patient lies on the side. Perform range-of-motion exercises to maintain muscle tone. Avoid twisting or turning the spine when moving the patient.

9. Pulse oximetry reveals that Kimberli’s pulse ox is 89% She is receiving 2 L of oxygen per nasal cannula. What should the nurse do?

Check to see if the pulse ox is on correctly and check to see if the oxygen is attached and flowing. If yes, consider calling an RRT. Increase the oxygen level, place the patient in high fowlers, get a set of vitals and contact the physician.

10. Discuss the importance of pain management and what agents you anticipate will be prescribed.

Pain management is important to promote wound healing. The patient may have been given prescriptions for several different pain medications. Common medications include Percocet (oxycodone/ acetaminophen) for severe pain; Lortab (hydrocodone/ acetaminophen) for moderate to severe pain; and Darvocet (propoxyphene/ acetaminophen) for mild to moderate pain. Sometimes patients will be sent home on a short course of long acting narcotics (Oxycontin) to help will pain control for 10-14 days.

11. Discuss nursing interventions to prevent complications of the surgery.Apply antiembolism stockings, assess the 5 p’s q 30 mins for the first two hours. Assess pain levels and treat pain. Monitor vital signs and watch for s/s of bleeding.

12. You are preparing to help Kimberli out of bed what interventions are necessary?Make sure to avoid twisting or turning the spine when moving the patient. Log roll out of bed. Support the back, feet, and knees.

13. Kimberli has not had a bowel movement what factors may have precipitated the condition and which nursing interventions are appropriate?

Pain medications and not moving are the largest factors that can contribute to constipation. Administer Colace, promote fluid intake, promote increased fiber, and exercises in bed and walking as tolerated can help relieve the constipation.