Ineffective Tissue Perfusion — Laminectomy Nursing Care Plan (NCP)

NURSING DIAGNOSIS: Tissue Perfusion, ineffective (specify)

May be related to

• Diminished/interrupted blood flow (e.g., edema of operative site, hematoma formation)
• Hypovolemia

Possibly evidenced by

• Paresthesia; numbness
• Decreased ROM, muscle strength

Desired Outcomes

Neurological Status (NOC)

• Report/demonstrate normal sensations and movement as appropriate.

Ineffective Tissue Perfusion — Laminectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Check neurological signs periodically and compare with baseline. Assess movement/sensation of lower extremities and feet (lumbar) and hands/arms (cervical).	Although some degree of sensory impairment is usually present, deterioration/changes may reflect development/resolution of spinal cord edema and/or inflammation of the tissues secondary to damage to motor nerve roots from surgical manipulation; or tissue hemorrhage compressing the spinal cord, requiring prompt medical evaluation intervention.
Keep patient flat on back for several hours.	Pressure to operative site reduces risk of hematoma.
Monitor vital signs. Note color, warmth, capillary refill.	Hypotension (especially postural) with corresponding changes in pulse rate may reflect hypovolemia from blood loss, restriction of oral intake, nausea/vomiting.
Monitor I&O and Hemovac drainage (if used).	Provides information about circulatory status and replacement needs. Excessive/prolonged blood loss requires further evaluation to determine appropriate intervention.
Palpate operative site for swelling. Inspect dressing for excess drainage and test for glucose if indicated.	Change in contour of operative site suggests hematoma/edema formation. Inspection may reveal frank bleeding or dura leak of CSF (will test glucose-positive), requiring prompt intervention.
Administer IV fluids/blood as indicated.	Fluid replacement depends on the degree of hypovolemia and duration of oozing/bleeding/CSF leaking.
Monitor blood counts, e.g., hemoglobin (Hb), hematocrit (Hct), and red blood cells (RBCs).	Aids in establishing replacement needs, and monitors effectiveness of therapy.