NR 324 Week 6 Spinal Fusion Perioperative Write-Up Example

Perioperative Write-Up: A 64-Year-Old Retired Librarian Through Lumbar Spinal Fusion, From the Evening Before to the End of the First Day After

Student Name

College of Nursing, Chamberlain University

NR 324: Adult Health I

Instructor Name

Month Day, Year

Perioperative Write-Up: A 64-Year-Old Retired Librarian Through Lumbar Spinal Fusion, From the Evening Before to the End of the First Day After

The Patient

Mrs. E. is a 64-year-old retired librarian with lumbar spinal stenosis and a slipped vertebra at L4 to L5 that causes leg pain after walking about a block. She is scheduled for a decompression and fusion at L4 to L5 at 0730 tomorrow. She takes lisinopril for blood pressure, naproxen for her back, and sertraline; she has no other surgical history. She weighs 71 kilograms and lives with her husband in a ranch-style house. This write-up follows her in three windows of time. Most of it concerns the hours before and after surgery, where nursing does most of its work; the operating room passage is kept to the nursing role. The sequence follows the Enhanced Recovery After Surgery Society's consensus for lumbar fusion, which covers preoperative education, prevention of hypothermia, multimodal pain control and early mobilization (Debono et al., 2021).

Window 1: The Evening Before, 1800 to 2200

1800, medication check: confirmed with Mrs. E. and her pill bottles that she stopped naproxen 7 days ago, as instructed by the surgeon's office, because anti-inflammatory drugs increase bleeding and may affect bone healing. Lisinopril: the anesthesia plan says to hold it tomorrow morning, and she was told not to take it. Sertraline: continue with a sip of water.

1815, baseline neurological check, both legs: strength 5 of 5 in hip flexion, knee extension, ankle dorsiflexion and great toe extension on both sides; sensation to light touch intact along both shins and feet; numbness along the outer left calf, which she says has been there for a year. Recorded as her baseline so postoperative checks have something to be compared with.

1830, teaching while she is alert and pain-free: the log roll, done with the nurse, turning shoulders and hips together; getting out of bed by rolling to the side and pushing up with her arms while lowering her legs; the plan to sit on the edge of the bed tomorrow evening and walk the morning after, with physical therapy. She practiced the log roll twice on the bed and got out of bed once by the method. She was asked to say back when she would call the nurse: new numbness or weakness in either leg, a wet dressing, or trouble passing urine.

1900, pain plan explained: a patient-controlled analgesia pump for the first night, scheduled acetaminophen, and a muscle relaxant as needed; she was told that the goal is to be able to move and walk, not to have zero pain.

2000, carbohydrate drink and fasting: clear fluids allowed until 2 hours before surgery, per the unit's enhanced recovery order; solid food stopped at midnight.

2100, skin: shower with the antiseptic wash provided; nails short, no polish.

Window 2: The Operating Room, 0730 to 1100

Positioning: prone on a padded spinal frame, face in a foam headrest with eyes and nose free of pressure, arms forward on arm boards with shoulders below 90 degrees, knees and ankles padded, breasts and genitals checked for pressure; positioning rechecked after every table adjustment.

Warmth: forced-air warming blanket from induction, warmed intravenous fluids, temperature monitored throughout; a Cochrane review found that active warming reduced shivering and, in low-quality evidence, surgical site infection (Madrid et al., 2016).

Counts and record: sponge, needle and instrument counts at the start, before closure and at skin closure, all correct; implant log completed.

Handoff to recovery: surgeon's note of a drain, estimated blood loss 350 milliliters, and no neurological monitoring changes during the case.

Window 3: The Hours Afterward, Day of Surgery and Postoperative Day 1

Every hour for 4 hours, then every 4 hours: leg checks against last night's baseline, strength in the four muscle groups on both sides, sensation along both shins and feet; any new weakness or numbness, or a change from the old outer-calf numbness, reported to the surgeon immediately.

Every 4 hours: dressing checked for drainage; drain output recorded; a sudden large drain output or clear fluid on the dressing reported.

Every 2 hours while in bed: log roll with two staff, alternating her back and sides, pillow between the knees, heels floated.

Every 4 hours: pain on the 0 to 10 scale at rest and with the log roll; sedation level before any extra opioid dose; breathing rate counted for a full minute.

Every 1 hour while awake: deep breathing and coughing with a pillow braced against the chest, and use of the incentive spirometer, ten breaths. A review by Eltorai et al. (2018) found no clear evidence that the spirometer alone prevents postoperative lung complications, so the emphasis is on getting her upright and walking, with the spirometer as a prompt to breathe deeply rather than the main intervention.

First 6 to 8 hours: urine output; a bladder scan if she has not voided within 6 hours of catheter removal, because opioids and lying flat can cause retention.

Day of surgery, 1800: sat on the edge of the bed with physical therapy, using the log-roll method taught the evening before, for 10 minutes; blood pressure checked lying and sitting.

Postoperative day 1, 0900: walked 30 meters with a walker and physical therapist; pain 5 of 10 walking; no dizziness. Patient-controlled analgesia stopped at 1000 and switched to oral medicines.

Postoperative day 1, 1400: walked 60 meters; voided twice without difficulty; leg strength and sensation unchanged from baseline; drain output 60 milliliters over 8 hours.

Reflection

The evening before surgery turned out to be the most important window for nursing. Every postoperative leg check depended on the baseline recorded at 1815, including the old numbness in her outer left calf, which could otherwise have been mistaken for a new injury. The log-roll and getting-out-of-bed practice done the night before meant that on the evening of surgery, when she was sore and drowsy, she remembered the method and needed only prompting. I also learned to be careful with the incentive spirometer, which I had been taught as the core of pulmonary care after surgery, and to put walking first. Finally, the operating room section was the hardest to keep short. I found myself wanting to describe the fusion itself, the screws and the bone graft, which I had read about with interest, but none of it changes what a nurse does before or after, and the rubric rewards the nursing hours.

References

Debono, B., Wainwright, T. W., Wang, M. Y., Sigmundsson, F. G., Yang, M. M., Smid-Nanninga, H., Bonnal, A., Le Huec, J.-C., Fawcett, W. J., Ljungqvist, O., Lonjon, G., & de Boer, H. D. (2021). Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS) Society recommendations. The Spine Journal, 21(5), 729-752. https://doi.org/10.1016/j.spinee.2021.01.001

Eltorai, A. E. M., Szabo, A. L., Antoci, V., Jr., Ventetuolo, C. E., Elias, J. A., Daniels, A. H., & Hess, D. R. (2018). Clinical effectiveness of incentive spirometry for the prevention of postoperative pulmonary complications. Respiratory Care, 63(3), 347-352. https://doi.org/10.4187/respcare.05679

Madrid, E., Urrútia, G., Roqué i Figuls, M., Pardo-Hernandez, H., Campos, J. M., Paniagua, P., Maestre, L., & Alonso-Coello, P. (2016). Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database of Systematic Reviews, (4), Article CD009016. https://doi.org/10.1002/14651858.CD009016.pub2