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Nursing Care of the Postoperative Spine Patient Care

Nursing Care of the Postoperative Spine Patient Care. Michael D Smith MD Twin Cities Orthopedics October 2012. Objectives. Discuss indications for surgery Present perioperative complications to watch for Review practical surgeon concerns regarding nursing assessment

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Nursing Care of the Postoperative Spine Patient Care

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  1. Nursing Care of the Postoperative Spine Patient Care Michael D Smith MD Twin Cities Orthopedics October 2012

  2. Objectives • Discuss indications for surgery • Present perioperative complications to watch for • Review practical surgeon concerns regarding nursing assessment * biased toward cervical spine procedures *

  3. Indications for Spinal SurgeryThe Big Three • Neurologic compression • Instability • Deformity

  4. Pain -Indication for Surgery? • Pain- unmanageable and associated with compression, deformity, or instability • Degenerative findings- common and incidental

  5. Disc HerniationGrade 1-4 based on morphology and extension beyond PLL

  6. Neurological Indications • Pain, numbness, weakness, tingling from cord or root compression

  7. Instability • Spine unable to tolerate daily loads without excessive motion • Degenerative, acquired, post-traumatic, neoplastic, congenital

  8. Traumatic Instability

  9. Degenerative Instability

  10. Cervical Deformity

  11. Perioperative Complications • General medical- cardiac (MI), respiratory, urologic pulmonary (UTI) • Specific- device related (posterior > anterior) • Surgical- hematoma, vascular or visceral injury, infection Clin Orthop Relat Res. 2011 March; 469(3): 649–657

  12. Risk Factors for Complications • Pulmonary circulation 9.52 • Renal disease 5.55 • Metastatic Cancer 4.21 • Electrolyte abnl 3.97 • CHF 3.46 • Etoh abuse 1.16

  13. Demographics for Mortality • Male • Posterior vs. anterior • Rural vs. Urban • Older vs. younger • A-American vs. Caucasian

  14. Risk Factors for MortalityUnproven* • DM, simple • DM, complicated • Obesity • PVOD

  15. Common Cervical Spine Procedures • Anterior discectomy/fusion -ACDF • Anterior corpectomy/fusion -ACCF • Anterior discectomy/replacement -ACD • Posterior decompression –foraminotomy/laminaplasty - • Posterior fusion -PSF

  16. Surgical Technique-Anterior Decompression/Fusion

  17. Operative Approach • Transverse incision -cosmetic • Left sided preferred (recurrent laryngeal nerve at less risk) • Careful anatomic exposure

  18. Incision Localization

  19. Exposure Superficial Dissection

  20. Exposure Deep Dissection

  21. Completed Exposure

  22. Fusion Bone Graft Insertion

  23. Typical ACDF Fixation

  24. Cervical Corpectomy • Anterior approach • Extensive exposure • Longer OR times • More complicated stenosis • Increased complication rate, airway, dysphagia

  25. Cervical Corpectomy

  26. Cervical Disc Replacement

  27. Posterior Procedures • Positioning • Padding of neurovascular points • Peruse facial-cervical area

  28. Posterior Procedure Positioning

  29. Posterior Procedures • Adhere to demonstrated ROM to avoid impingement cord/root

  30. Indications and Need for Nursing Care • Varied patient population • Varying neurologic presentation • Broad age range and support structures • Outpatient to lengthy hospitalizations

  31. Phases of Nursing Care • Preoperative  • Education, counseling, support

  32. Phases of Nursing Care • Perioperative  • Routines, time outs, counts, cross pollination

  33. Phase of Nursing Care • Postoperative  • Dependent on nursing input and remote assessment • Typical defines patient perception f care

  34. Complications • Anything that is touched, moved, looked at, exposed, intubated, extubated, cooled, or heated can be injured.

  35. Postoperative Edema

  36. Nursing Concerns • Tracheal obstruction- expanding hematoma, lymphatic congestion, vocal cord paralysis • Stridor- an impending arrest

  37. Nursing Concerns • Esophageal – retraction, local change in motility, laceration • Indigo carmine for leak assessment • Difficulty –> barium swallow, steroids, feeding tube

  38. Esophageal Perforation

  39. Esophageal Perforation

  40. Displaced Bone Graft

  41. Nursing Concerns • Neurological assessment- compare pre to post op status • Pain management – separate topic

  42. Mental Health Issues • Anxiety • Depression • Somatization • Unrealistic expectations

  43. Anxiety Disorders • 18% of general population (40M) • Pervasive and variable in expression Kessler RC Arch Gen Psychiatry, 2005 Jun;62(6):617-27.

  44. Anxiety Disorders • OCD • PTSD • Social phobias • Specific phobias • GAD

  45. Depression • 10% of general population • Variable expression • Surgeons do poor job in pre-op recognition • May coexist with anxiety syndromes

  46. Depression The 3 Rs • Reduced threshold for need for surgery • Reduced threshold for reporting pain after surgery • Reduced support systems and preop physical prowess

  47. Substance Abuse240M in Risk Group • Chemical 5% 12M • Alcohol 10% 24M • Tobacco 19% 46M • Associated mental health issue (i.e., anxiety+Etoh) 54% www.hhs.gov/od/about/fact_sheets/substanceab use.html

  48. Coping Skill Set PointReadjusted

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