Anterior Cervical Diskectomy/fusion CarePlan

[regglynn]

This is a long post...hang in there...

My clinical day was today and I had a patinet 1 day post op from anterior cervical diskectomy and fusion. Now I have to write a care plan.

I starting writing down some good interventions last night (we go in the day before for our assignment) and brought my interventions to clinical to get input from my instructor. I decided to use: Risk for Peripheral Neurovascular Dysfunction R/T surgical manipulation of C-spine and post op edema.

She approved it...and also approved my interventions.

#1 Assess for a patent airway. Since the pt. could have edema from the surgery, I felt a patent ariway is important first because of post op inflammtion and edema. But as for my rationale, I can't figure out how to word it. I am going to talk about the AP of repiratory and how it flows through the trachea and about what adequate repsirations should be such as rate, rythem, and depth. But how else can I assess for a patent airway. She wantes me to stick with respiration and the airway for this intervention.

My other interventions are: assess vitals, assess 5 P's, assess LOC, assess swallowing, maintain neck alignmet, provide cervical collar and instruct pt. to where for 6 weeks post op, pain meds, monitor ESR rate, assess moblilty, and of course the usual post op interventions such as turn cough deep breathe.

Our school is big on in depth rationales .But I am stuck with the patient airway...about how to word it...and the direction to go in.....So that's my dilema...just how to word how to check for a patent airway. Can anyone give me an idea or stear me in the right direction......

Thanks

[Daytonite, BSN, RN]

let's see if i can give you some guidance here. excuse me if this doesn't seem well organized.

risk for ineffective breathing pattern r/t edema from incision. this deals with the airway being patent and where the physical ability to breath is providing enough air for the patient. you want to concern yourself with the patient's physical process of breathing for this nursing diagnosis and any blockage to that process. so think about how you assess just plain old breathing. how would the patient be breathing that would lead you to suspect that the patient might have something stuck in their throat (in this case it would be edema constriction the airway)? stridor, perhaps? you are definitely going to assess for things like shortness of breath and what makes it get better or worse and any anxiety. when patient is sob is he to receive oxygen and does it help? is there any orthopnea, nasal flaring or pursed lip breathing? assess type of respirations: abdominal or use of accessory muscles? any intercostals retractions? inspect for symmetry in the movement of the chest with respirations. normally, inspirations should be half as long as expirations. any confusion? does patient get obtunded? any odd or irregular type of respirations? any tachypnea or bradypnea. with tachypnea. . .is pain the cause? observe for cyanosis of the buccal membranes. specifically look for any spread of edema into the surrounding oral tissues (tongue and mouth) that you can see so i would have the patient open their mouth so you can examine the tongue specifically. assess breath sounds. just as one last point, check for distended neck veins (symptom of pneumothorax)

the symptoms of airway obstruction which can be due to just about anything (an aspirated foreign body, mucous plug or the patient's tongue) are as follows, so assess for these signs and symptoms:

• a distressed look of panic on the patient's face
  
• inability to speak
  
• wheezing, stridor, noisy respirations
  
• rhonchi auscultated in the large airways
  
• nasal flaring and/or use of accessory breathing muscles
  
• decreased or totally absent breath sounds
  
• excessive secretions of mucus or blood around the mouth
  
• cardiac dysrhythmias
  
• cyanosis
  
• hypoxemia

some other interventions i can think of are to monitor oxygen sats. demonstrate for the patient how he should breathe and coach him through. semi-fowler's position. give oxygen as needed. provide for frequent rest periods if patient becomes sob with activity.

if you are only restricted to the use of only one nursing diagnosis then you'll go with the one above. however, for a postop patient you have a whole handful of other nursing diagnoses you can add on.

• acute pain
  
• activity intolerance
  
• deficit knowledge
  
• risk for infection
  
• risk for ineffective tissue perfusion (which is another way to go beside ineffective breathing pattern)
  
• risk for constipation

also, specifically for a patient who has had a diskectomy and fusion you should also consider impaired physical mobility or impaired bed mobility.

[regglynn]

Thanks again for the help.

I was making this so hard. I didn't even think about the nasal flaring, stridor, or SOB. Why was I stressing out trying to make this so hard....I thought there was some fancy way I could write about but in reality it's the simple things like breath sounds, rate, evidence of cyanosis, and the first thing I should see...nasal flaring.

You helped me again.

You always have the greatest tips and suggestions. You steered me in the right direction. And your diagnosis are so much easier to write about than the one I was going to use.

Have a good night!!!!!!!!!!!!!!!!!

[Daytonite, BSN, RN]

Well, the difference might be that I'm not under the gun of having to produce a care plan for a grade. Also, I've been in practice a few years and seen what a patient who has an airway obstruction has happen to them. I also have a mountain of books in front of me. One of them, Expert 10-Minute Physical Examinations which was published by Mosby in 1997, actually had the list of what to assess for with an airway obstruction since I left a few out myself! I'm also looking at a NANDA handbook that defines each nursing diagnosis. I made a lot of typos because my cats were sashaying all around me as it was time for them to be fed and for one to get her insulin injection. Multi-tasking, thy name is nursing. Best of luck with your care plan.