NURSING PROCESS:THE PATIENT UNDERGOING A CERVICAL DISCECTOMY
The patient is asked about past injuries to the neck (whiplash) be-cause unresolved trauma may cause persistent discomfort, pain and tenderness, and symptoms of arthritis in the injured joint of the cervical spine. Assessment includes determining the onset, location, and radiation of pain, paresthesias, limited movement, and diminished function of the neck, shoulders, and upper ex-tremities. It is important to determine whether the symptoms are bilateral because with large herniations, bilateral symptoms may be due to cord compression. The area around the cervical spine is palpated to assess muscle tone and tenderness. Range of motion in the neck and shoulders is evaluated.
The patient is asked about any health concerns that may in-fluence the postoperative course. The nurse determines the pa-tient’s need for information about the surgical procedure and reinforces what the physician has explained. Strategies for pain management are discussed with the patient.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Acute pain related to the surgical procedure
· Impaired physical mobility related to the postoperative sur-gical regimen
· Deficient knowledge about the postoperative course and home care management
Other nursing diagnoses may include preoperative anxiety, postoperative constipation, urinary retention related to surgical procedure and dehydration, self-care deficits related to neck or-thosis, and sleep pattern disturbance related to disruption in lifestyle.
Based on all the assessment data, the potential complications may include the following:
· Hematoma at the surgical site, resulting in cord compres-sion and neurologic deficit
· Recurrent or persistent pain after surgery
The goals for the patient may include relief of pain, improved mobility, increased knowledge and self-care ability, and preven-tion of complications.
The patient may be kept flat in bed for 12 to 24 hours. If the pa-tient has had a bone fusion with bone removed from the iliac crest, considerable pain may be experienced. Interventions consist of monitoring the donor site for hematoma formation, adminis-tering the prescribed postoperative analgesic agent, positioning for comfort, and reassuring the patient that the pain can be relieved. If the patient experiences a sudden reappearance or increase of pain, extrusion of the graft may have occurred, requiring reoperation and surgical repositioning of the graft. This should be promptly reported to the surgeon.
The patient may experience a sore throat, hoarseness, and dys-phagia due to temporary edema. These symptoms are relieved by throat lozenges, voice rest, and humidification. A puréed diet may be given if the patient has dysphagia.
Postoperatively, a cervical collar (neck orthosis) is usually worn, which contributes to limited neck motion and altered mobility. Patients are instructed to turn the body instead of the neck when looking from side to side. The neck should be kept in a neutral(midline) position. Patients are assisted during position changes, making sure that head, shoulders, and thorax are kept aligned. When assisting a patient to a sitting position, the nurse supports the patient’s neck and shoulders. Patients should wear shoes when ambulating to increase stability.
The patient is evaluated for bleeding and hematoma formation by assessing for excessive pressure in the neck or severe pain in the incision area. The dressing is inspected for serosanguineous drainage, which suggests a dural leak. In this event, meningitis is a threat. A complaint of headache requires careful evaluation. Neurologic checks are made for swallowing deficits and upper and lower extremity weakness because cord compression may produce rapid or delayed onset of paralysis. The patient who has had an anterior cervical discectomy is also assessed for a sudden return of radicular (spinal nerve root) pain, which may indicate instability of the spine.
Throughout the postoperative course, the patient is moni-tored frequently to detect any signs of respiratory difficulty be-cause retractors during surgery may injure the recurrent laryngeal nerve, resulting in hoarseness and the inability to cough effec-tively and clear pulmonary secretions. In addition, the blood pres-sure and pulse are monitored to evaluate cardiovascular status.
Bleeding at the surgical site and subsequent hematoma for-mation may occur. Severe localized pain not relieved by analgesic agents should be reported to the surgeon. A change in neurologic status (motor or sensory function) should be reported promptly because it suggests hematoma formation that may necessitate surgery to prevent irreversible motor and sensory deficits.
The patient’s hospital stay is likely to be short; therefore, the patient and family should understand the care that is important for a smooth recovery. A cervical collar is usually worn for about 6 weeks. The patient is instructed in use and care of the cervical collar. Patients are instructed to alternate tasks in which the body does not move (eg, reading) with tasks that require greater body movement.
The patient is instructed about strategies for pain manage-ment and about signs and symptoms that may indicate compli-cations that should be reported to the physician. The nurse assesses the patient’s understanding of these management strategies, lim-itations, and recommendations. Additionally, the nurse assists the patient in identifying strategies to cope with activities of daily living (ie, self-care and childcare) and minimize risks to the sur-gical site (Chart 65-6).
A discharge teaching plan is developed collaboratively by members of the health care team to decrease the risk for recurrent disk herniation. Topics include those previously discussed as well as proper body mechanics, maintenance of optimal weight, proper exercise techniques, and modifications in activity.
Patients are instructed to see their physician at prescribed inter-vals to document the disappearance of old symptoms and for as-sessment of range of motion of the neck. Recurrent or persistent pain may occur despite removal of the offending disk or disk fragments.
Patients who undergo discectomy usually have con-sented to surgery after prolonged pain; they have often undergone repeated courses of ineffective conservative management and pre-vious surgeries to relieve the pain. Therefore, the recurrence or persistence of symptoms postoperatively, including pain and sen-sory deficits, is often discouraging for the patient and family. The patient who experiences recurrence of symptoms requires emo-tional support and understanding. Additionally, the patient is assisted in modifying activities and in considering options for subsequent treatment.
The patient with degenerative disk disease tends to focus on obvious needs, issues, and deficits. The nurse needs to remind pa-tients and family members of the need for participating in health promotion and health screening practices.
Expected patient outcomes may include:
1) Reports decreasing frequency and severity of pain
2) Demonstrates improved mobility
a) Demonstrates progressive participation in self-care activities
b) Identifies prescribed activity limitations and restrictions
c) Demonstrates proper body mechanics
3)Is knowledgeable about postoperative course, medications, and home care management.
a) Lists the signs and symptoms to be reported post-operatively
b) Identifies dose, action, and potential side effects of medications
c) Identifies appropriate home care management activities and any restrictions
4)Absence of complications
a) Reports no increase in incision pain or sensory symptoms
b) Demonstrates normal findings on neurologic assessment
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