Health Promotion and Maintenance
34. A child with status post–Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first?
. Call the surgeon immediately.
. Assess patency of the urinary catheter.
. Administer pain medication as ordered.
. Complete a neurological assessment.
Test-Taking Tip
When deciding between the option to phone the physician or perform additional assessments, think about what the nurse might find with the assessment that has the potential to resolve the problem or provide the physician with additional, necessary information. In this case, the nurse should suspect bladder distention, investigate urinary catheter functioning, and fix any malfunction as a way to resolve the problem without first contacting the physician.
Content Area: Child Health, Musculoskeletal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
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Answer 1 is incorrect because the nurse should first assess the likely causes of the symptoms before calling the surgeon. Answer 2 is correct because the child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord surgery. Since bladder distention can lead to this problem, the nurse should first assess the urinary catheter for obstruction or malfunction. Answer 3 is incorrect because the headache is a symptom of the high blood pressure caused by the autonomic dysreflexia, and administering pain medication will not resolve the headache. Answer 4 is incorrect because, although a neurological assessment is an important priority of care, the nurse should first investigate the potential cause of the symptoms.