NIFA RN First Assistant Program Case Study

NIFA RN First Assistant Program Case Study

Name of Procedure:

Application of skull fixation and right cervical foraminotomy C7 – T1, C6 – C7, and C5 – C6

SECTION II (Continuation)

Planning & Implementation: List actions and interventions to achieve the optimal outcomes (may also include delegated tasks). Include:

• Priorities:

The patient was examined to determine whether he had blood clotting or bleeding issues.

The patient had to stop taking aspirin to prevent unwanted bleeding during and after surgery. The patient was also assessed on any other blood-thinning medications. The patient was also noted as hypertensive and checked whether he had any allergies.

• Communication with team members:

The neurosurgeon communicated with the nurse to ensure that all precautionary measures mentioned above had been checked before the onset of the operation.

• Patient education and frequently asked questions (patient and family information):
  • Discuss options for addressing the problem:

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Besides the operation, other options could be used to manage the condition. Pain medications such as standard and non-standard opioid analgesics, anticonvulsants, and membrane-stabilizing agents could be used to manage the disease. Nerve sheath injection, where a local anesthetic is injected through the neck’s skin using CT scan guidance, is the other option for addressing the problem. Physical therapies such as physiotherapy, hydrotherapy, massage, and osteopathy could also be used to manage the condition. Finally, activity modification and other surgical procedures such as anterior cervical decompression and fusion (ACDF) and cervical laminectomy could be used to address the problem.

• Preoperative preparation:

Since the procedure is performed in the back of the neck, the patient was required to lie face down on the operating table. General anesthesia was then administered to the patient to help him feel nothing during the procedure.

• Pre-hospital admission information:

The patient did not have any bleeding or blood clotting issues at the time of admission to the hospital. However, aspirin was one of the recently taken drugs in the patient’s medical history. The patient also presented with hypertension. The patient did not report any allergies or health problems besides hypertension.

• Course and length of surgery:

The typical duration of the operation is 1 – 2 hours.

• Hospital stay:

The recommended period for the patient to stay in the hospital is 1 – 2 nights.

• Anesthesia (include the type of anesthesia, preop preparation, and preop medication):

General anesthesia was administered to the patient, with the patient lying face down to ensure that he did not feel pain during the surgery.

• Incision site:

A skin incision of approximately 3 – 5cm was made at the back of the patient’s neck. The incision was in the midline and vertical.

• Body image changes:

The patient felt pain after surgery, especially at the incision site. He was given pain medications to relieve the pain.

• Wound care:

Avoiding possible blood clot in the wound was one of the precautionary measures in the surgical operation. The wound was closed with sutures at the end of the surgery. The GP then checked the wound four days after the procedure, with the patient being advised to keep the wound dry for three weeks after the surgery. A Zinc tablet, to be taken once every day, commencing one month following the surgery, was prescribed to the patient to help in healing the wound.

• Bathing:

The patient was instructed to shower with the dressing intact since the wound had to be dry for three weeks after surgery. The wound would be dried, followed by the application of a new dressing if it was moistened during bathing.

• Pain management:

Pain medications were administered to ease pain after the surgery.

• Medications to take and avoid taking:

The patient was instructed to avoid taking medications such as aspirin, warfarin, and other herbal supplements that could thin the blood. The patient was required to take opioids to manage short-term acute pain, nonsteroidal anti-inflammatory drugs to prevent nerve-root inflammation, and muscle relaxants to reduce muscle spasms.

• Tubes/drains; care and removal:

After the tubes are removed and all surrounding areas checked to ensure that no disc fragments or compressive spurs are remaining, sterile water containing antibiotics was used to wash the wound area. The doctor then used two strong sutures to close the deep subcutaneous layer and fascial layer.

• Equipment/aids to mobility:

The patient was advised to avoid activities that would result in excessive bending or twisting of the neck. Though he was instructed on the proper technique of getting out of bed, in bed, and walking independently, he was not allowed to use mobility aids as he could bend or twist his neck accidentally.

• Diet/nutrition:

The patient was instructed to eat a healthy and well-balanced diet, coupled with plenty of rest to speed up the recovery.

• Anti-embolic stockings/SCD:

The patient was instructed to continue using anti embolic stocking 2-3 weeks after surgery to prevent unanticipated injury to the wound due to excessive twisting and bending of the neck.

• Driving:

With the need to avoid activities that require excessive twisting and bending of the neck, the patient was instructed not to drive until three weeks after the surgery.

• Activity restrictions:

The patient was instructed against engaging in activities that involve extreme or rapid rotating or twisting of the neck. The patient was also barred from lifting any objects that are heavier than 2kgs. He was only restricted to light housework and barred from activities such as mowing, vacuuming, carrying cloth baskets, and changing clothes on the line. The patient was also barred from exercising and driving until the collar was removed, and the surgeon approved the decision.

• Follow-up in the office:

The GP checked the wound four days after surgery. In the visit, the GP applied a new dressing to the wound. The patient was instructed to report any redness, persistent oozing, or discharge from the wound to the GP. The staples were then removed ten days after surgery.

• Return to work:

Considering the desire of the patient to return to work, the doctor instructed the patient to wait until the neck collar is removed, and he is deemed fit by the doctor to return to work.

• Sex:

The patient was instructed to avoid sex until the collar is removed and the doctor allows him to engage in strenuous activities that need twisting or bending of the neck.

• Smoking:

The patient was instructed to avoid smoking as smoking would impair wound fusion and healing process.

• Worrisome-but-normal considerations:

The worrisome-but-normal considerations that the doctor required the patient to monitor include increasing leg or arm pain, numbness or weakness, problems with balance or walking, worsening neck pain, fever, and leakage of fluids from the wound. The patient was also instructed to report shortness of breath or chest pains, increasing temperature, suspected wound infection, and any other concerns.

• Potential complications; patient responsibilities to avoid them:

While most surgeries are safe and complications rare, the patient should look out for concerns such as worsening pain, infection, blood clot in the wound, and other concerns. Having identified any fears, the patient should report them to the GP immediately.

• Long-term effects of the surgery:

A significant pain reduction and reduction of prior symptoms is the long-term effect of the operation. The patient would observe improved arm pain, headaches, neck pain, weakness, and probable improvement of numbness and needles or pins.

• Organizations to assist with recovery:

While there are organizations that could help with recovery by ensuring that the patient adheres to the recovery conditions, the patient was allowed to recover at home, having cited enough support from the wife and family members.

• Preop orders:

The preoperative orders conducted on the patient before surgery are blood tests, metabolic tests, urinary tests, medications, cardiovascular tests, pulmonary tests, blood loss, smoking test, and consent form.

Evaluation: List your goal (outcome statements) for the patient. Use outcome statements to determine whether preoperative outcomes were met or are pending. The nursing process is an ongoing event. Evaluation not only involves analyzing the success of the goals and interventions but examining the needs for adjustments and changes. Evaluation leads back to assessment, and the whole process begins again.

The outcome statements for the patient were:

• To obtain a significant benefit from the surgery in the long term
• To achieve a substantial reduction in arm pain, head pain, and neck pain.
• To improve the patient’s strength by reducing weakness.
• To reduce the presentation of numbness or pins.

SECTION III: INTRAOPERATIVE

(Begins when the patient is transferred to the OR room bed and ends when they are admitted to the PACU)

Assessment:

• Points to consider:
  • Positioning:

The patient lay face down on the operating table. The patient’s shoulders were taped down to give traction to the skin and assist in visualizing the cervical levels.

• Anesthesia and level of consciousness:

A general anesthetic was used before the procedure to avert the risk of a significant catastrophe. The doctor waited until the patient was unconscious before commencing the process.

• Skin condition:

No visible skin lesions.

• Interruption in skin integrity:

The integrity of the patient’s skin showed no issues since the patient was well-groomed with proper nutrition.

Planning & Implementation:

• Monitoring of physiologic alterations:

The patient was attentive and denied any suicidal or depressive thoughts.

• Level of consciousness, anxiety level, coping ability:

The patient was conscious and alert. He was not anxious and was ready and willing to undergo the procedure.

• Patient comfort considerations:

Before the surgery, the patient was dressed in comfortable, loose-fitting attire. The patient was placed in a prone position with the head resting on a soft, facial pillow comfortably.

• Safety considerations (staff and patient):

The doctor ensured that the patient was not susceptible to the typical risks of cervical foraminotomy, such as bleeding and blood clotting, by ensuring that the patient did not take aspirin or any other blood-thinning drugs on the day of the surgery.

• Anesthesia; type, medications, monitoring, and considerations:

A general anesthetic was administered to the patient to induce unconsciousness. The operation did not commence until the patient was confirmed to be entirely unconscious.

• Preoperative medication and pain control:

The general anesthetic administered before the operation and pain medications administered after the surgery to relieve pain were the medications used during the procedure.

• Gas exchange:

The patient was positioned in a manner that would allow him to breathe effortlessly during the procedure.

• Positioning equipment, instruments, supplies, and considerations:

A Jackson table with six posts, a soft facial pillow, the operating table, tape, and tubular dilators were the essential positioning equipment and supplies available in the operating room. The patient’s shoulders were taped down to give traction and help the doctor to visualize the lower cervical levels.

• Existing tubes and drains:

The working tube (14mm in diameter) that overlay the lamina-facet junction was secured to a sterile arm that was attached to the table. The operative tube was then placed over the C5-C6 disk space. A breathing tube was also inserted to assist the patient to breathe.

• ESU dispersive pad (Bovie):

The pad was used in the surgery in cutting and coagulating by ensuring efficient homeostasis.

• Catheterization if applicable:

Foley catheterization was not required for the operation.

• Skin preparation:

The skin was cleaned using antiseptic solution before the general anesthetic was injected to induce anesthesia.

• Draping:

Before draping the incision site, the doctor waited for three minutes for the antiseptic solution to evaporate before wiping the skin with a cotton swipe and wrapping the site. A clear, plastic adhesive drape was used to prevent flammable vapors from collecting beneath the draping.

• Incision:

The skin incision was made next to the spinous process over the operative level on the side of the abnormality.

• Thermal regulation:

The temperature in the operating room was regulated to avoid extreme temperatures that would make the patient’s body to become either too hot or too cold.

• Fluid support and electrolyte balance:

The patient’s water and sodium levels were maintained continuously due to the increase in ADH activity during surgery.

• Aseptic practices within the periop setting (specific to this case):

Aseptic technique was followed during the surgical procedure when inserting the tubes, handling surgery equipment, and incision to prevent the potential spread of pathogens that could cause infection.

• Hemodynamic, metabolic, respiratory and cardiac complications, their manifestations and treatment:

No complications were recorded arising from the anesthetic procedure, positioning of the patient, and dura exposure.

THE PROCEDURE: Step-by-step. Include any specific RNFA potential or actual scope of practice issues and considerations.

• Include:
  • Positioning: equipment, table changes, techniques, and purpose:

A Jackson table with six posts, a soft facial pillow, the operating table, tape, and tubular dilators were the critical positioning equipment and supplies available in the operating room. The patient’s shoulders were taped down to give traction and help the doctor to visualize the lower cervical levels.

• Induction support:

The patient was required to stay in the facility for two nights. During this period, he was given pain medications and encouraged to move around a few hours after surgery to help the blood to continue circulating normally and prevent blood clotting in the legs.

• Skin prep:

The skin was cleaned using antiseptic solution before the general anesthetic was injected to induce anesthesia.

• Draping:

Before draping the incision site, the doctor waited for three minutes for the antiseptic solution to evaporate before wiping the skin with a cotton swipe and wrapping the site. A clear, plastic adhesive drape was used to prevent flammable vapors from collecting beneath the draping.

• Special equipment & supplies. (ex. Dermatome, Woods lamp, etc.):

A Jackson table with six posts, a soft facial pillow, the operating table, tape, and tubular dilators were the critical positioning equipment and supplies available in the operating room. The patient’s shoulders were taped down to give traction and help the doctor to visualize the lower cervical levels.

• Procedure: Use appropriate anatomical nomenclature and medical terminology. Avoid non-approved or unfamiliar abbreviations.
  • Incisional approach:

The skin incision was made adjacent to the spinous process on the side of the affected area on the operative level.

• Anatomical landmarks:

In order to avoid complications, the neurosurgeon was on the constant lookout for cervical nerve roots, lateral mass, and intervertebral disc.

• Structures requiring special attention to preserve and protect:

The cervical nerve roots, lateral mass, and intervertebral disc were the structures that needed special care to protect and preserve during the surgery.

• Tensile strength of tissues:

Throughout the procedure, ligamentous and muscle attachments to the spine were preserved by the neurosurgeon to reduce postoperative pain spasm, thus improving stability.

• Surgical technique and sequence of the procedure:

The specific surgical processes were positioning the patient, performing the incision, using tubular dilators to create the operation portal, performing the surgical operation, wound closure, and postoperative care.

• Tissue handling:

The neurosurgeon performed the incision while taking care not to damage tissues adjacent to the wound area.

• Dissection techniques:

After making the small incision on the side of the affected area, the neurosurgeon pushed away the back muscles around the spine to expose the intervertebral foramen. The surgeon then removed the blockage inside the foramen, thus relieving pressure on the nerves. All the tools were then removed, and the patient’s muscles put back in place.

• Providing exposure:

The surgeon pushed away the back muscles around the spine to expose the intervertebral foramen.

• Wound closure/suturing: (research each material used, description, action, indications, contraindications, warnings, precautions, adverse reactions HINT: look at the inserts in each suture box)
  • What (suture used):

Large monofilament sutures were used to straighten the skin folds.

• Why is it used for the type of tissue?

These sutures are able to put traction on the skin, thus opening up intertriginous folds.

• Technique:

The doctor straightened the skin folds over the posterior cervical region by taping the shoulders gently, before using large sutures to put traction on the skin and open up intertriginous folds since the individual was hypertensive.

• Hemostasis: specify the type, why it is used, and how it is used:
  • Chemical:

The patient’s water and sodium levels were maintained continuously due to the increase in ADH activity during surgery.

• Mechanical:

The patient was closely monitored to check balance a few hours after the surgery. This was necessary to ensure that there was no blood clotting in the legs.

• Thermal:

The temperature in the operating room was regulated to avoid extreme temperatures that would make the patient’s body to become either too hot or too cold.

• Drains and/or tubes: type, rationale, location, and insertion technique:

After the tubes are removed and all surrounding areas checked to ensure that no disc fragments or compressive spurs are remaining, sterile water containing antibiotics was used to wash the wound area. The doctor then used two strong sutures to close the deep subcutaneous layer and fascial layer.

• Intraoperative pharmaceuticals: include specifics and how they are administered (exclude anesthesia medications):

General anesthesia was administered to the patient, with the patient lying face down to ensure that he did not feel pain during the surgery. The patient was then given pain medications to such as standard and non-standard opioid analgesics, anticonvulsants, and membrane-stabilizing agents to manage the condition.

• Laboratory/pathology: specify location, technique, and reason for obtaining and what information could be gained:

The patient required an X-ray of the neck, as well as an MRI and a CT scan before the operation. This was needed to determine the specific disc or discs that were responsible for the symptoms. The patient also went through blood tests, metabolic tests, urinary tests, medications, cardiovascular tests, pulmonary tests, blood loss, and smoking test to ensure that the medicines used and the surgical procedure itself would not endanger his life.

• Dressings and why a particular type is used:

Before the surgery, the patient was dressed in comfortable, loose-fitting attire. The patient was also required to continually put on a neck cover to shield his neck against unintentional bending or twisting that could negatively affect the healing process.

• Extubation, transfer gurney or bed, then to PACU (assistant duties, precautions):

The patient was carefully transferred to PACU from the operation room to ensure no disturbances to the wound.

Evaluation: This hypothetical case study should indicate the optimal outcome statement(s) that you would hope your patient achieves based on the plan of care you have created.

The surgical procedure was successful as the patient did not exhibit any other issues that required urgent medical attention.

SECTION IV: POSTOPERATIVE

(Begins with admission to the PACU and ends with a resolution of surgical sequela)

Assessment:

• Postop diagnosis:

The patient was examined for any notable pain. The patient reported feeling pain and was given pain medications to relieve the pain. The patient was then required to move around a few hours after surgery. The doctor observed the patient’s movement to check for normal blood circulation and probable formation of blood clots in the legs.

• Postop orders:

The patient was instructed to avoid twisting and bending of the neck within the first two weeks following the procedure. The patient was instructed to begin twisting or bending the neck 2-3 weeks after the procedure.

• Physical assessment: Immediate postoperative points to consider:
  • Airway:

No blockage of the airway after the procedure.

• Vital signs and level of consciousness:

Vital signs: BP: 142/84, O₂: 99%, Pulse: 72, Temp: 98.4. The patient was conscious.

• Body temp: 98.4
• Length of procedure: The procedure lasted 1 hour 30 minutes
• Positioning:

The patient lay face down on the operating table. The patient’s shoulders were taped down to give traction to the skin and assist in visualizing the cervical levels.

• Skin condition, pressure points:

No visible lesions or pressure points.

• Pain assessment: if pain control is inadequate, what steps to take:

The patient reported pain after the procedure. The pain was successfully managed by pain medication administered to the patient.

• Wound care:

Avoiding possible blood clot in the wound was one of the precautionary measures in the surgical operation. The wound was closed with sutures at the end of the surgery. The GP then checked the wound four days after the procedure, with the patient being advised to keep the wound dry for three weeks after the surgery. A Zinc tablet, to be taken once every day, commencing one month following the surgery, was prescribed to the patient to help in healing the wound.

• Monitor existing lines, drains, and tubes:

No significant observation was made.

Planning & Implementation: List nursing actions and interventions to achieve optimal identified outcomes (may also include delegated tasks).

• Collaborate with team members and patient support systems:

The patient and his wife were required to collaborate with the GP to report any worrisome concerns and adhere to the instructions to speed up the healing process.

• Transfer to the patient care unit:

There was no need to transfer the patient to a patient care unit as he passed the postoperative tests required for discharge.

• Progress notes:

The patient did not show any movement difficulties or blood clotting in the legs. Moreover, the patient did not show any worrisome signs that required emergency attention, such as surgery.

• Orders:

The patient was instructed to continue using pain medications and avoid activities that required excessing twisting or bending of the neck, such as carrying loads of more than 2kgs or hanging clothes.

• RNFA actions:

The nurse was required to follow-up on the patient and ensure that he was on the right course to recovery. The nurse monitored signs such as leakages from the wound, bleeding, and intense pain that could necessitate emergency care.

• Discharge planning:

After passing the postoperative tests, the RNFA started the discharge procedure by teaching the patient and his wife on the appropriate home care that would speed up the recovery.

• Follow-up in office:

The GP checked the wound four days after surgery. In the visit, the GP applied a new dressing to the wound. The patient was instructed to report any redness, persistent oozing, or discharge from the wound to the GP. The staples were then removed ten days after surgery.

• Extended postoperative considerations:

The nurse examined vital areas of concern such as bleeding, intense pain, blood circulation, and blood clotting in the legs after the surgery.

• Complications and how they are manifested:

While most surgeries are safe and complications rare, the patient was instructed to look out for concerns such as worsening pain, infection, blood clot in the wound, and other concerns. Having identified any fears, the patient should report them to the GP immediately.

• Wound healing: (research normal sequence in wound healing, phases, principles, and influencing risk factors):

The healing of the patient’s wound underwent the four overlapping phases of hemostasis, defensive or inflammatory phase, proliferative phase, and maturation phase, thereby eliciting no concerns for urgent medical attention.

• Follow-up care, teaching, home care:

The patient was required to check for notable concerns such as intense pain and leakages from the wound. If these concerns arose, he was instructed to report to the GP for immediate medical attention. The patient was also told to avoid strenuous activities that involved bending or twisting of the neck within 2-3 weeks after the surgery.

• Special postoperative needs:

There were no notable special postoperative needs, unless if the patient had significant concerns such as leaking from the wound.

• Long-term goals:
• To obtain a significant benefit from the surgery in the long term
• To achieve a substantial reduction in arm pain, head pain, and neck pain.
• To improve the patient’s strength by reducing weakness.
• To reduce the presentation of numbness or pins
• Ethical & professional issues, professional accountability:

The patient was required to sign a consent form before the surgery. However, this was easy for the patient since he was neither depressed nor anxious about his condition while being admitted into the facility.

Evaluation: Use outcome statements to determine whether preoperative outcomes were met or are pending.

The postoperative outcomes were met after the surgery. The doctor successfully relieved compression on the root of the nerve by removing the part of the vertebral bone to increase the space where the nerve exits the spinal column. The patient also reported a reduction in arm pain, head pain, neck pain, numbness, and weakness after the surgery.

References:

Bydon, M., Mathios, D., Macki, M., De La Garza-Ramos, R., Sciubba, D. M., Witham, T. F., … & Bydon, A. (2014). Long-term patient outcomes after posterior cervical foraminotomy: an analysis of 151 cases. Journal of Neurosurgery: Spine, 21(5), 727-731.

Ghany, W. A. A., & Toubar, A. F. (2014). Posterior Cervical Foraminotomy for recurrent radiculopathy after anterior cervical discectomy and fusion. Egyptian Journal of Neurology, Psychiatry and Neurosurgery, 223-228.

Song, Z., Zhang, Z., Hao, J., Shen, J., Zhou, N., Xu, S., … & Hu, Z. (2016). Microsurgery or open cervical foraminotomy for cervical radiculopathy? A systematic review. International orthopedics, 40(6), 1335-1343.

Terai, H., Suzuki, A., Toyoda, H., Yasuda, H., Kaneda, K., Katsutani, H., & Nakamura, H. (2014). Tandem keyhole foraminotomy in the treatment of cervical radiculopathy: a retrospective review of 35 cases. Journal of orthopaedic surgery and research, 9(1), 38