Post-Operative Scoliosis Nursing Diagnosis Pathway : A Case Study

Abstract

A nursing diagnosis pathway is a structured clinical framework that guides nurses in translating patient assessments into evidence-based diagnoses. This case study aims to develop a post-operative scoliosis nursing diagnosis pathway, an area lacking in current literature. The study was conducted at RSO Soeharso, a referral and teaching hospital managing a high volume of scoliosis surgeries. Using an exploratory qualitative case study design and document analysis method, the research focused on a 17-year-old female patient diagnosed with Adolescent Idiopathic Scoliosis (AIS) Lenke 3, who underwent posterior spinal fusion (PSF) from thoracic 4 to lumbar 4 and was admitted to the ICU post-operatively. Subjective, objective, and supporting clinical data were collected and analyzed using the Indonesian Nursing Diagnosis Classification (SDKI). The resulting diagnoses included three actual conditions: Acute Pain (D.0077), Impaired Physical Mobility (D.0054), and Ineffective Peripheral Perfusion (D.0009), as well as two risk diagnoses: Risk of Fluid Imbalance (D.0023) and Risk of Infection (D.0142). This study contributes a practical diagnostic pathway model for nursing care in post-surgical scoliosis patients, supporting structured and evidence-based clinical decision-making.