Intervertebral Disc Disease
Leakage of CSF Signs and Symptoms
Complaints of severe headache Clear or slightly yellow drainage present on the dressing
Nursing Interventions (Paralytic Ilues)
Determine whether patient is passing gas Auscultate bowel sounds in all quadrants Palpate abdomen Administer stool softeners (docusate) if needed
A patient is experiencing signs of painful constipation related to an ileus after spinal surgery. Which medication should the nurse anticipate administering to this patient?
Docusate Docusate is a stool softener that will assist in resolving the constipation caused by the paralytic ileus. Opioid use often results in constipation.
Bladder impairment Signs and Symptoms
Incontinence Difficulty with bladder or bowel elimination Nursing Interventions Report to provider immediately Encourage use of bedside commode Catheterization may be needed. Men can dangle legs off bed or stand during urination.
The nurse would most likely expect to see vertebral discs break down in which region of the spine?
Lumbar The lumbar area is the most common area for vertebral disc breakdown because it is the most used area of the spine.
Complementary alternative medicine
Massage therapy Chiropractic Acupuncture
Paralytic ileus Signs and Symptom
Nausea Vomiting Abdominal distention Constipation
Disc replacement
Patients are commonly hospitalized for one to three days after the procedure. Patients are encouraged to stand and walk by the first day after surgery. Because bone healing is not required after artificial disc replacement, the typical patient is encouraged to move through the mid-section. Patients should perform basic exercises, including walking and stretching, during the first several weeks after surgery. Patients are to avoid any activities that cause hyperextension of the back. Most patients can expect reduction of lower back pain and disability in weeks to months after surgery. Studies show that disc replacement reduces but does not completely eliminate pain.
When preparing to care for a patient with intervertebral disc disease, what should the nurse plan to tell the patient to do in order to maintain proper body mechanics?
Sit upright while seated at a desk Sitting upright will promote and maintain proper alignment of the spine.
Those at greatest risk for DDD these changes are:
Smokers Obese individuals Individuals with previous back injury Individuals who do substantial physical work (e.g., heavy lifting)
The nurse is providing orientation to a new graduate who is caring for a patient with a herniated disc. The graduate asks, "What is a disc herniation?" Which is the appropriate response by the nurse?
The nucleus pulposus has bulged out through an opening in the annulus fibrosus." Rationale When the jellylike center of the vertebra bulges out through the tough outer layer of the vertebra, the disc is herniated.
A nursing student is making a clinical presentation regarding the anatomy of the spine, and the instructor asks the student about the annulus fibrosus. Which response by the student indicates an understanding of the topic?
"It is the tough outside capsule of the disc." The tough outer coating that protects the soft inner portion of the disc is the annulus fibrosus.
A patient being prepared for a laminectomy tells the nurse, "I only took six days off from work to recover. Will that be enough time?" Which response by the nurse is appropriate?
"It may take a few weeks to fully recover from the surgery. Six days may not be enough time." Depending on the amount of lifting, walking, and sitting the patient's job involves, the patient may be able to return to work within a few weeks.
A nurse is caring for a patient with complaints of lower back pain and decreased range of motion, unrelieved by nonoperative measures. The nurse suspects that the patient may have intervertebral disc disease. Which health care provider's order would the nurse anticipate?
Prepare the patient for an x-ray. An x-ray provides an image of the spinal column, which can confirm or rule out the presence of suspected disc disease.
Nursing Interventions for SCF drainage
Report to provider immediately Test drainage with a dipstick for the presence of glucose (to confirm presence of CSF) Note color, amount, and characteristics
Nursing Interventions for Neurologic Impairment
Report to surgeon immediately Assess movement and sensation every two to four hours Perform neurovascular assessment of extremity
Conservative therapy includes:
Restricted activity (with limited total bed rest) Ice and heat application Physical therapy Medications
A patient tells the nurse that she has tried several conservative approaches for intervertebral disc disease and even had "one quick surgery." After learning that the patient's spine is unstable, which procedure does the nurse most likely anticipate for the patient?
Spinal fusion If the patient's spine is unstable, a spinal fusion is likely to be performed. In a spinal fusion, adjacent vertebrae are fused together using a bone graft. Metal rods may also be put in place to provide more stability and decrease vertebral motion.
A patient diagnosed with intervertebral disc disease has elected to receive nonoperative therapy. The patient reports to the nurse that after four months of activity restriction and physical therapy, the symptoms are resolved. Which action should the nurse implement next?
Teach the patient about proper body mechanics and how to perform back-strengthening exercises. Rationale: When pain subsides, the patient should begin back-strengthening exercises twice a day and continue doing them for life. The nurse should also explain the importance of good body mechanics.
The nurse is reviewing the medical history of a patient with degenerative disc disease (DDD). Which reported history finding is a risk factor for DDD?
Tobacco smoking Smoking can cause degenerative changes of the intervertebral discs, leading to DDD.
Bleeding Signs and Symptoms
Blood-soaked bandages Hematoma formation Nursing Interventions If bone graft was used, assess donor site for excessive bleeding. Conduct frequent neurovascular assessments of affected site
Disc herniation commonly occurs at:
C5-6 C6-7 L4-5 L5-S1
IPD
Can be done on an outpatient basis Minimal blood loss and risk of infection Takes 15 to 45 minutes to perform Implant can become dislodged or moved out of place. The bones may settle around the implant, which is a very common risk for individuals with osteoporosis. Spinous process can fracture when the surgeon inserts the IPD spacer. Patients may need additional surgery to relieve pain. Activities—vigorous exercise, bending backward, heavy lifting, climbing stairs—should be limited for several weeks after surgery. Comfortable, gentle movement, such as light walking, is encouraged. Patients may need physical therapy.
The medical-surgical charge nurse receives a patient in the postanesthetic care unit after successful completion of spinal fusion. The patient is still sedated and is assigned to a staff nurse. The unit charge nurse intervenes when the staff nurse prepares to give which prescription to the patient?
Diazepam, 2.5 mg, by mouth The sedated patient should not be given an oral medication. The presence of a gag reflex and the ability to tolerate oral fluids must be assessed first.
The nurse is providing health education to a patient who is scheduled for disc replacement. Which information should the nurse include in the teaching plan about the procedure?
Disc replacement will reduce, but not eliminate, pain. Disc replacement will likely make the pain more manageable, but it is not a permanent or long-term solution.
The nurse is caring for a patient with a herniated disc at L4-5 and symptoms of radiculopathy. The nurse would expect the patient to experience pain in which location?
Dorsum of foot Pain with a herniation at L4-5 is experienced in the area from the back to the buttocks to the top (dorsum) of the foot and the big toe.
Pathophysiology
Drying and shrinking of the jellylike center (nucleus pulposus) of the disc can cause DDD. When this occurs, the space between the vertebrae becomes thinner and narrowed, placing pressure on the outer capsule of the disc (annulus fibrosus). This can result in tiny tears or cracks in the annulus. DDD can occur anywhere in the spine, but it is most common in the cervical and lumbar regions. These changes can lead to osteoarthritis, herniated discs, or spinal stenosis.
The nurse is caring for a patient who has undergone cervical spine surgery. Which findings should prompt the nurse to implement immediate life-saving measures?
Dyspnea Dyspnea is a sign of respiratory distress and can be life threatening to the patient. Nasal flaring Nasal flaring is a sign of respiratory distress and can be life threatening to the patient.
A patient who had a lumbar spinal fusion six weeks ago is experiencing pain when he sleeps. Which action is appropriate for the nurse to take?
Encourage the patient to sleep on a firm mattress Rationale: A firm mattress can support spinal healing and promote comfort for the patient during sleep. A soft mattress, on the other hand, can cause pain in patients recovering from spinal fusion.
The nurse is caring for a patient after cervical spine surgery. Which actions should the nurse take while managing the care of this patient?
Monitor the patient for signs of respiratory distress. Keep the patient's neck immobilized with a cervical collar.
Neurologic impairment Signs and Symptoms
New onset of muscle weakness or paresthesia Movement or sensation reduced compared with preoperative status
Medications
Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) Muscle relaxants (e.g., cyclobenzaprine) Anticonvulsants (e.g., gabapentin) Antidepressants (e.g., duloxetine) Epidural corticosteroid injections
Radiofrequency discal nucleoplasty
Normally an outpatient procedure The patient will need to have a ride home. The patient will need to wear an abdominal binder that will support the back and limit motion for at least the first two weeks. Activities must be limited after the procedure to allow the disc sidewall to heal and the center of the disc to close and form a scar. A mild flare-up of back pain may occur for a few days after the procedure. Patients should be advised to use ice packs initially. Almost all patients experience a return to at least their usual level of pain within a week.
The nurse is assessing the dressing of patient after completion of lumbar spine surgery and notes yellow-tinged drainage. After further examination, the nurse documents that the patient has a headache with a rating of seven on a pain scale of one to 10. Which action is most appropriate action for the nurse to take next?
Notify the health care provider immediately The health care provider should be alerted immediately because these are signs of cerebrospinal fluid leakage, which can be life threatening.
A nurse is caring for an older adult patient and suspects the patient may have a herniated disc. Which signs/symptoms are indicative of a herniated disc?
Pain Radiculopathy is a symptom of a herniated disc; this includes pain caused by the distressed disc. Numbness Radiculopathy is a symptom of a herniated disc and includes numbness. Leg weakness Radiculopathy is a symptom of a herniated disc and includes leg weakness secondary to nerve impingement.
Laminectomy
Patients may go home on the same day the surgery is performed, although some may need a short hospital stay. The health care provider may recommend physical therapy. Activities that involve lifting, bending, and stooping should be limited for several months after the procedure. Depending on the amount of lifting, walking, and sitting involved in a patient's job, he or she may be able to return to work within a few weeks.
Discectomy
Patients should be encouraged to get out of bed and walk as soon as the numbness wears off. Patients should slowly resume exercise and other activities. Patients should walk as often as comfortably possible for the first several weeks. Walking helps lower the risk of excessive scar tissue formation. Many patients can resume work and daily activities soon after surgery. Physical therapy and home exercises may be recommended. If a patient works in an office, he or she may return to work in two to four weeks. If a patient's job requires physical labor (such as lifting or operating machinery that vibrates), he or she may be able to go back to work 4 to 8 weeks after surgery.
After cervical surgery
When the patient is supine, place pillows under the thighs. When the patient is in a side-lying position, place pillows between the legs. Reassure the patient who is fearful of turning or movement. Proper technique should always be used. Call for assistance when turning a patient to avoid any undue pain or strain for the patient and nurse. Neck may be immobilized with a cervical collar Monitor for signs of respiratory distress: Dyspnea, Retractions, Nasal flaring Monitor for signs of worsening neurologic condition of the upper extremities. Respiratory distress and worsening neurologic condition of the upper extremities may indicate spinal cord edema.
