2.1. Participants
A total of 85 participants were included in the study, and they underwent CC7 surgery in Huashan Hospital from June 2015 to June 2018. The inclusion and exclusion criteria were similar to those in our previous study [4] .
2.2. The Huashan nursing program
The Huashan program was illustrated in Figure 1, and the detials were elaborated as following [8, 9].
A. Preoperative nursing
Psychiatric Nursing: All patients were educated in a routine manner after admission to hospital, mainly on CC7-realted principles, possible complications and reasonable postoperative expectations. In addition, the hospital anxiety and depression scale (HADS) was used to assess the psychological states of the patients, and special attention was given to the patients with a score ≥ 8 [10]. We encouraged communication among patients to eliminate negative emotions and build patients' confidence in treatment, and multimedia materials were also used to share information on CC7.
Clinical Path in Health Education: We outlined the entire track a patient is expected to follow throughout the course of the treatment. Both orderliness and timeliness were stressed, and education was scheduled in phases [11]. The path will lead to a better understanding and the cooperation of patients and promote efficient and orderly operations for nursing work.
Surgical Risk Assessment: The assessment is essential, as most stroke survivors are characterized by an advanced age and many basic diseases [5]. Special effort should be made to prevent pulmonary embolism, pulmonary infection and stroke recurrence. Details regarding the preoperative examinations were listed in Table 1. The patient's medical history and physical signs are of great significance, and examinations should be performed appropriately to minimize risk.
Preoperative Preparation: Routine preparation includes stopping taking antiplatelet and anticoagulant drugs 5 days before surgery; water and food fasting for 6 hours before surgery; removing the denture; training for cough and sputum excretion; and preparing the skin of both armpits, the jaw and the uninjured limb (for the preparation of a sural nerve graft).
B. The routine postoperative nursing
The patients took a supine position after surgery. Two negative pressure drainage tubes were used, and the color, quality and quantity of drainage fluid were monitored. Generally, the drainage tubes were removed when the color of the drainage fluid turned faint yellow and the volume collected over 24 hours was less than 20-30 ml. When the volume increased suddenly or the color turned bright red, we checked for active bleeding and reported it in a timely manner. In contrast, when the volume decreased suddenly, an obstruction could have occurred, and we needed to identify and resolve the problem. Meanwhile, sandbags were placed over the bilateral clavicle for 48 hours to reduce bleeding and the incidence of hematoma. The patient's state, particularly regarding complaints of chest tightness, difficulty breathing and neck swelling, was closely monitored.
ECG monitoring and oxygen inhalation were performed for 4-6 hours after surgery. Blood pressure management is essential for the prevention of cerebrovascular accidents. We instructed the patients with hypertension to continue antihypertensive therapy as usual. A low ambient temperature, anxiety, pain and sleep disturbances can increase blood pressure, and the impact of these factors should be minimized as much as possible (details provided in the next section). Esophageal edema may occur due to the stimulation or pulling of the esophagus during the operation; thus, postoperative dietary guidance is required to protect the esophagus. A liquid diet was allowed 6 hours after surgery, and a semiliquid diet was provided on postoperative day 2. From postoperative day 3 onward, the patients consumed a soft diet, and after 1 month, the patients consumed a general diet. For the prevention of lung infection, early out-of-bed activity was encouraged, and the range and intensity of activity was gradually increased. For the prevention of lower extremity deep venous thrombosis, air pressure treatment can be utilized.
C. The position and immobilization
To reduce the magnitude of traction on the transferred C7 nerve, a neck collar and bandage were used to reduce the movement of the head and the paralyzed arm, respectively, for 4 weeks after surgery [12]. The shoulder on the paralyzed side was kept in an adducted position, and we helped the patients hold a towel with the paralyzed hand to relieve spasticity.
D. Targeted nursing for adverse events
As shown in Table 2, adverse events occurred in 10 patients after surgery. Targeted nursing for the above adverse events played essential roles in recovery, and the details are as follows (also seen in Figure 2).
Neck Hematoma. Attention should be paid to the self-reported symptoms of patients and the quality and quantity of the drainage liquid. When the amount of drainage liquid increased and the color turned dark, we needed to remove the neck collar, watch the color of the neck, observe whether the neck widened, and palpate the neck to assess muscle tension. Neck hematoma is usually caused by poor drainage and the use of anticoagulant drugs. For obstructed drainage, the tubes were repositioned. For the patients with a medical history of anticoagulant drugs, pressure dressings were effective, and drainage tubes were not removed unless the situation improved.
Hoarseness. Injuries of the recurrent laryngeal nerve can lead to hoarseness, which is generally caused by excessive traction during surgery or neck hematoma compression [13]. Attention should be paid to monitor whether there is a change in voice or coughing when drinking, especially in patients with neck hematoma. For patients suffering from nerve traction, hoarseness spontaneously resolves within approximately one week, and we should increase doctor-patient communication and relieve the anxiety of patients during the nursing process. Regarding patients with neck hematoma, treatments of the primary disease should be stressed, and the details are listed above. For nerve traction, hoarseness spontaneously resolves, but attention should be paid to patient comfort and communication with nurses so that the patients consistently maintain a positive mood.
Severe Pain. Pain and numbness of the arm were the most common adverse events after surgery [4]. In severe cases, sleep disorders, anxiety and depression, and fluctuations in blood pressure and blood glucose levels can occur, which ultimately negatively impact recovery. The face rating scale (FRS) was utilized to assess the severity of pain [14]. For patients with a score less than 5, the preferred treatment was physical therapy. For the patients with a score between 5 and 7, imagery therapy was added, and the patients were asked to relax their minds and imagine good things, which attenuated sympathetic activation to relieve pain. For the patients with an score higher than 7, sleep disorders can occur, and drug therapy is often necessary. Painkillers (i.e., gabapentin and pregabalin) and sleeping pills were used as needed.
Dyspnea. Phrenic nerve injury can lead to dyspnea [15], which is usually caused by excessive traction or accidental injury when the scalenus is cut anteriorly. We closely monitored the patients’ self-reported symptoms, respiratory frequency and oxygen saturation. When dyspnea occurred, a high concentration of oxygen was used, and emergent blood gas analysis and chest CT scans were performed to determine the severity. Afterwards, patients were asked to enhance thoracic breathing. The exercise was performed three times on the first day for ten minutes each time. Then, the duration and intensity of breathing exercise improved gradually. To prevent lung infection, the head of the bed was raised to 30°, the patient was assisted in turning over, the back of the patient was patted, and atomization inhalation was performed [16, 17].