COLLABORATIVE DIAGNOSIS: Potential complications

  1. respiratory distress related to:
    1. trauma to the phrenic nerve during surgery and/or compression of the phrenic nerve following surgery associated with inflammation or accumulation of blood in the surgical area (can occur with a cervical laminectomy because the phrenic nerve arises at the C3 - 5 level)
    2. tracheal compression associated with inflammation or accumulation of blood in the surgical area following a cervical laminectomy (particularly if the anterior approach was used)
    3. closure of the glottis associated with paralysis of the vocal cords (can occur as a result of injury to the bilateral recurrent laryngeal nerves during an anterior cervical laminectomy);
  2. cerebrospinal fluid leak related to inadvertent damage to and/or incomplete closure of the dura (care is taken during surgery to keep the dura intact; however, it is sometimes necessary to incise dura that extends along the involved nerve);
  3. laryngeal nerve damage related to surgical trauma or pressure on the nerve(s) associated with inflammation or accumulation of blood in the surgical area (can occur with an anterior cervical laminectomy);
  4. paralytic ileus related to:
    1. impaired innervation of the intestinal tract following a lumbar laminectomy associated with stimulation of sympathetic nerves and/or loss of parasympathetic nerve function in the operative area
    2. the depressant effect of anesthesia and some medications (e.g. centrally acting muscle relaxants, narcotic [opioid] analgesics, some antiemetics).
Desired Outcome
The client will not experience respiratory distress as evidenced by:
  1. unlabored respirations at 12-20/minute
  2. absence of stridor and sternocleidomastoid muscle retraction
  3. usual mental status
  4. oximetry results within normal range
  5. blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Following a cervical laminectomy, assess for and immediately report:
    1. increased swelling of the neck or bulging of the wound
    2. statements of difficulty swallowing or choking sensation
    3. signs and symptoms of respiratory distress (e.g. rapid and/or labored respirations, stridor, sternocleidomastoid muscle retraction, restlessness, agitation)
    4. abnormal blood gases
    5. significant decrease in oximetry results.
  2. Have tracheostomy and suction equipment readily available following cervical laminectomy.
  3. Implement measures to prevent respiratory distress following a cervical laminectomy:
    1. perform actions to reduce inflammation and/or prevent bleeding and subsequent hematoma formation in the surgical area:
      1. implement measures to reduce strain on the surgical area (e.g. keep neck in proper alignment, ensure that cervical collar is applied correctly, instruct and assist client to support neck when moving)
      2. elevate head of bed 30-45° unless contraindicated
      3. apply ice pack to incisional area as ordered
      4. administer corticosteroids (e.g. dexamethasone) if ordered
    2. maintain wound suction and patency of wound drain to prevent the accumulation of blood in the surgical area.
  4. If signs and symptoms of respiratory distress occur:
    1. place client in a high Fowler's position unless contraindicated
    2. loosen neck dressing or cervical collar if it appears tight
    3. administer oxygen as ordered
    4. assist with intubation or emergency tracheostomy if performed
    5. prepare client for surgical evacuation of hematoma or repair of the bleeding vessel(s) if planned.
Desired Outcome
The client will have resolution of cerebrospinal fluid leak if it occurs as evidenced by:
  1. absence of cerebrospinal fluid drainage from lower back or neck incision
  2. no reports of headache.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of a cerebrospinal fluid leak:
    1. presence of glucose in wound drainage as shown by positive results on a glucose reagent strip; be aware that any drainage containing blood will also test positive for glucose
    2. a clear, pink, or yellowish ring ("halo") around bloody or serosanguineous drainage on lower back or neck dressing, sheet, or pillowcase
    3. reports of headache.
  2. Implement measures to reduce strain on the surgical area (see Postoperative Diagnosis 2, action b.1) in order to promote healing of the dura and subsequent resolution of cerebrospinal fluid leak.
  3. If signs and symptoms of cerebrospinal fluid leak occur:
    1. maintain activity restrictions as ordered to reduce stress on the dural tear
    2. change dressing as soon as it becomes damp; maintain meticulous sterile technique when changing dressing
    3. administer antimicrobials if ordered
    4. assess for and report signs and symptoms of meningitis (e.g. fever; chills; new, increasing, or persistent headache; nuchal rigidity; photophobia; positive Kernig's and Brudzinski's signs)
    5. prepare client for surgical repair of the torn dura if planned (usually the torn dura heals spontaneously within a few days).
Desired Outcome
The client will experience resolution of laryngeal nerve damage if it occurs as evidenced by:
  1. improved voice tone and quality
  2. gradual resolution of hoarseness
  3. absence of respiratory distress.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for the following indications of laryngeal nerve damage:
    1. voice changes (e.g. hoarseness; weak, whispery voice; inability to speak)
    2. respiratory distress (see action A in respiratory distress complication).
  2. Implement measures to reduce pressure on the laryngeal nerves (see actions C.1 and 2 in respiratory distress complication).
  3. If signs and symptoms of laryngeal nerve damage occur:
    1. encourage client to avoid unnecessary talking in order to rest the vocal cords
    2. implement measures to facilitate communication (e.g. provide pad and pencil, flash cards, or magic slate; ask questions that require a short answer or nod of head)
    3. reinforce physician's explanation regarding the permanence of voice changes (voice tone and quality usually return to normal as inflammation subsides)
    4. notify physician immediately if signs and symptoms of respiratory distress occur, client is unable to speak, or hoarseness or voice changes worsen.
Desired Outcome
The client will not develop a paralytic ileus (see Standardized Postoperative Care Plan, Diagnosis 20, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 20, for measures related to assessment and management of a paralytic ileus.