Nursing diagnosis ineffective tissue perfusion related to diminished or interrupted blood flow—edema of operative site, hematoma formation, hypovolemia
Possibly evidenced by
Paresthesia or numbness
Decreased range of motion (ROM) or muscle strength
Desired Outcomes/Evaluation Criteria—Client Will
Report or demonstrate normal sensations and movement as appropriate.
Nursing intervention with rationale:
1. Check neurological signs periodically and compare with baseline. Assess movement and sensation of hands and arms (cervical) and lower extremities and feet (lumbar).
Rationale: Although some degree of sensory impairment is usually present, changes in neurological assessments may reflect development or resolution of spinal cord edema or tissue inflammation due to damage to motor nerve roots from surgical manipulation. Assessment findings may also indicate tissue hemorrhage that causes spinal cord compression. Spinal cord compression requires prompt medical evaluation and intervention.
2. Keep client flat on back for several hours, per protocal.
Rationale: Pressure to operative site reduces risk of hematoma.
3. Monitor vital signs. Note skin color, warmth, and capillary refill.
Rationale: Hypotension, especially postural, with corresponding changes in pulse rate may reflect hypovolemia from blood loss, restriction of oral intake, and nausea and vomiting.
4. Monitor intake and output (I&O) and wound drains, such as Jackson-Pratt or Hemovac, if used.
Rationale: Fluid balance indicates circulatory status and replacement needs. Excessive or prolonged blood loss requires evaluation and ongoing assessments to continually determine and provide prompt and appropriate intervention.
5. Visually check and gently palpate operative site for swelling. Inspect dressing for excess drainage. Test drainage for glucose if cerebrospinal fluid (CSF) leakage is suspected
Rationale: Changes in contour of operative site suggest hematoma or edema formation. Inspection may reveal frank bleeding or dura leak of CSF, thus requiring prompt intervention. CSF will test positive for glucose.
6. Assess extremities—particularly lower extremities—for redness, swelling, and pain.
Rationale: Redness, swelling, and pain in the extremities suggest complications associated with immobility including deep vein thrombosis (DVT).
7. Administer intravenous (IV) fluids or blood, as indicated.
Rationale: Fluid replacement depends on the degree of hypovolemia and duration of oozing, bleeding, or leakage of CSF.
8. Monitor blood counts—hemoglobin (Hgb), hematocrit (Hct), and red blood cells (RBCs).
Rationale: These laboratory tests help establish fluid status and the need for fluid and blood product replacement. They also indicate effectiveness of fluid resuscitation interventions.
9. Apply and maintain schedule for wearing anti-embolic hose or sequential compression devices.
Rationale: Anti-embolic hose, sequential compression devices, and related products reduce the risk for venous stasis in lower extremities.