RN Nursing · Pathophysiology · Practice question
Patient's Data. Complete the following sentence by choosing from the lists of options. Based on the client assessment, the nurse suspects the client is most likely experiencing ____ of ____, which is a complication of the client's surgical procedure.
Nurse’s Notes
6/16
0730
Client presents to clinic with reports of lower back pain. Client has been experiencing this pain for the past 8 months. Conservative management measures recommended but have been unsuccessful in relieving the client's pain. Pain interferes with the client's activities of daily living. Client also reports recent burning pain that radiates down both legs. CT today reveals L4 herniated disk compressing the spinal nerve. Provider recommends open discectomy procedure. RN to schedule surgical procedure with hospital.
6/20
0600
Client admitted to preoperative unit for open discectomy. Peripheral IV started in left hand. Consents obtained. Client prepped for surgery.
0930
Client transferred to post-anesthesia recovery unit following surgical procedure. Client vital signs stable on 2 L oxygen via nasal cannula. Client sleepy but arouses to name. Client maintained flat in bed.
1130
Client transferred to surgical unit for continued postoperative management. Client on room air. Client has experienced some pain as client has become more alert. Morphine sulfate 4 mg IVP administered 1 hour ago. RN assumes care and assesses client. Neuro assessment completed and as expected. Dressing to back dry and intact with minimal drainage shadowing. Client has not voided since urinary catheter removed after surgery. Client may sit up in bed and may stand and ambulate later this evening as tolerated. Client has taken some sips of water and ice chips. May advance diet as tolerated. Client without complaints of nausea.
1300
Client in bed with head of bed elevated at 45 degrees. Client reporting pain to back rated 6/10. Client also reporting a headache "that just came on suddenly" rated 5/10. Client attempted to void in urinal; 75 mL of clear yellow urine passed, but client reports feeling a mild urge to void still. Client consumed clear liquids at lunch and asked, "Can I have something more solid for dinner?" Dressing to back dry and intact with a larger amount of drainage shadowing and halo noted to outer edge of dressing.
Answer & explanation
Correct:
Following an open discectomy, the client at 1300 reports a sudden-onset headache rated 5/10, back pain rated 6/10, and has a dressing with a noticeably larger drainage shadow with a halo noted at the outer edge. A halo sign on a wound dressing after spinal surgery is a classic indicator of cerebrospinal fluid (CSF) leakage. The halo effect occurs because CSF, which is less viscous and lighter in color than blood, migrates to the outer ring of a mixed drainage spot, forming a distinctive halo pattern around blood or serosanguineous drainage. A sudden positional headache after spinal surgery is also characteristic of CSF leakage, as reduced CSF volume causes traction on pain-sensitive intracranial structures when the client is upright. Therefore, the nurse suspects leakage of cerebrospinal fluid. Hemorrhage of blood would present with bright red saturating drainage and hemodynamic instability. Accumulation of clotted blood would not explain the halo sign or sudden headache. Obstruction of the urethra is unrelated to these findings. The urine output, while low, is not the central concern of this clinical presentation. The combination of the halo sign on the dressing, the sudden-onset headache following spinal surgery, and the surgical site context all point specifically to CSF leakage as the most likely complication.
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