The nurse working on an acute pediatric unit is caring for an 8-year-old child who is profoundly mentally retarded with significant developmental delays and cerebral palsy that limits the child to a wheelchair
The child was admitted for a significant scoliosis, and has had surgery to fuse the spine, with insertion of rods on both sides of the spinal column. In addition to preventing infection and pain management, the nurse's priority of care is: 1. Careful movement and repositioning of the client.
2. Supporting family coping measures.
3. Providing respite care for the primary caregiver.
4. Encouraging ambulation as soon as possible.
1
Rationale: Because of the rod placement, this child must be moved and repositioned carefully to avoid strain on the rods. Insufficient information is available about the family's coping mechanism to know if it is healthy or dysfunctional. Admission to the hospital is respite care for the family. This child is unable to ambulate, and is wheelchair-bound.
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