Texas Scottish Rite Hospital for Children's Scoliosis Spinal Fusion Home Care Program
BARBARA SHORT, RN
The Scoliosis Spinal Fusion Home Care Program was developed to assist the nursing staff in educating parents and patients about the care needed at home after spinal fusion. This instructional program provides a comprehensive approach in teaching activities of daily living; pain control and management; school activities and participation; wound and skin care; problems, warning signs, and what to do for them; and special suggestions for parents to help the child regain activity.
The purpose of the program is to encourage patients to remain active after having a spinal fusion. Parents should become confident in their role of understanding their child's needs, and should know what measures they can implement to help the child to prevent complications. The goals are threefold: 1) to enable the child to regain the presurgical activity level by becoming familiar with ways to achieve this, 2) to help the child and parent demonstrate knowledge of the care needed at home and to recognize problems and what to do for them if they arise, and 3) to provide the means by which the parent win be comfortable with caring for the child at home and will learn measures to deal with the child to promote optimal recuperation.
Teaching guidelines involve both parent and child. The patient should increase confidence in self-care by increasing mobility and thereby decreasing stiffness and pain. The parent should allow the child to do as much as possible independently to regain the previous activity level. Both should understand pain, including its causes and controls. The patient should be as active as possible, especially in daily living tasks to increase mobility and decrease stiffness and pain. The parent should be supportive as the child regains strength and ability to conduct self-care; plain Tylenol may be needed for pain control.
Family members should distinguish permissible from contraindicated activities. During the first six weeks after surgery, the child should minimize activity, riding in a car and walking, but not running. Between six weeks and six months, the patient may begin light sports and bicycle riding, but should avoid diving, contact sports, such as football, gymnastics, trampoline, horseback riding, and water amusement parks. After the sixth month, the child may return to all activities, except contact sports. Most children return to school a week after hospital discharge. These guidelines are for those who do not have a brace or cast after surgery. Appliances limit the child's activity, and specific questions regarding appropriate activities should be discussed with the surgeon.
Wound care is an important component of the program. The incision line should be kept clean and dry for a week after the child returns home. The patient should not have tub baths or showers for the first week. Bandages are to be left in place until the child resumes bathing; they will peel off gradually after getting wet. A week after going home, the child may begin baths and showers if the incision line looks healed, without redness or drainage, and if the child is not wearing a brace or cast. If the child has a thin paper dressing on the incision line, it should be left in place until the patient begins bathing.
Most children who have a plastic jacket will wear it 23 hours daily for approximately six months after surgery. The hour out of the jacket is for sponge bathing. The jacket is never to be removed unless the child is lying down; the child should remain recumbent, without sitting or standing, until the jacket is replaced. It is removed by unfastening the straps and rolling the child onto the side to remove the back part. While the jacket is off, the inside should be cleaned with mild soap and water and dried with a towel to keep the orthosis smelling fresh as the child will perspire under the plastic.
Skin should be checked for reddened areas. Massaging red areas with rubbing alcohol toughens the skin and helps to prevent breakdown. Lotion, creams, powders and oils should not be applied to skin under the jacket as these substances soften the skin and may cause it to deteriorate. Parents should notify the hospital of any blisters, broken skin, or persistent red areas.
The jacket should be reapplied over a clean, dry undershirt with all wrinkles smoothed. Wrinkles can cause red pressure areas. Parents should mark the top, bottom, back and front of the jacket to avoid confusion when putting it on the child. It has a top and bottom and will not fit correctly if applied upside down. The orthosis is donned by having the child roll onto it. It is fastened tightly to the marks placed on the straps initially in order to keep it from rubbing when the child moves.
Some children who go home in plastic jackets are allowed to shower without the jacket. It is removed by someone other than the child while the patient stands straight in the shower. Because no bending or twisting is permitted while the jacket is off, the child may need help removing, showering, and reapplying a clean undershirt and orthosis.
For children with a cast, care should be taken to keep the cast dry. Parents should inspect the skin around the edges of the cast for red areas or breakdown. Rubbing alcohol may be applied to red areas to toughen the skin, but no other materials should be used on the skin around or under the cast. Nothing should be poked under the cast if the skin itches, as the object may break the skin and cause sores to form beneath the cast. A hair dryer on cool setting may be blown under the cast to relieve itching. The hospital should be notified if the child complains of sore spots under the cast, or if drainage or a foul odor is present, or if the child develops a fever for no apparent reason.
Both parent and child should be able to recognize problems and deal effectively with them. The patient must report any pain or tenderness from the incision line or any numbness or tingling in the limbs. The parent should advise the surgeon of the child's complaints, as well as any drainage, odor or redness from the incision line, or sudden fever.
Parents should praise the child liberally, especially when the young patient is learning to deal with pain during daily tasks. The parent should encourage the child to participate actively in self-care. This fosters confidence in the child's own ability by allowing performance of activities which could be done previously. The parent promotes a positive attitude toward recuperation from spinal fusion surgery.
Printed patient care instructions and patient teaching records contribute to the success of the program.
Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219
Note: At the time this article was originally published, Texas Scottish Rite Hospital for Children was known as Texas Scottish Rite Hospital for Crippled Children. This article has been modified from the originally published version to reflect the hospital's new name.