Splenectomy NCLEX Review

A splenectomy is a procedure in which the spleen is removed either partially or completely, with partial procedures being more common in children. Most of the time, the procedure is performed laparoscopically, but it may also be performed in what is called an “open” abdominal procedure which involves a larger incision and more extensive recovery.

There are a few different reasons why someone would have a splenectomy:

• The spleen is the organ most at risk for injury in blunt abdominal traumas. Approximately 25% of splenectomies are due to traumatic splenic rupture which puts the patient at very high risk for extensive internal bleeding. 
• About 25% of splenectomies are due to hypersplenism, which is an overactive spleen that causes excessive cell destruction. Patients with hypersplenism will typically have an enlarged spleen (splenomegaly) and are at high risk for significant hemolysis or thrombocytopenia. Hypersplenism can be a consequence of many conditions such as liver disease, viral infections, cancer, tuberculosis, sickle cell disease, thalassemia, polycythemia vera, splenic vein thrombosis, Felty’s syndrome, and as a result of certain abdominal surgeries.
• A rare reason for splenectomy is “wandering spleen.” In this condition the ligaments that anchor the spleen are ineffective, putting the spleen at risk for torsion, ischemia and infarct.
• Occasionally a splenectomy may be conducted when there is no known cause for splenomegaly. In these cases, the spleen is removed in order to determine the patient’s underlying condition. Diagnostic splenectomies typically show the patient has lymphoma or leukemia.

Spleen Overview

The highly-vascularized spleen is the largest lymphoid organ in the body. It sits in the LUQ of the abdomen and is approximately the size of a fist or about 12 cm in length. An enlarged spleen is greater than 20 cm in length and weighs more than 1000 g.

The spleen filters blood and plays a key role in immunity, which is why patients without a spleen are at high risk for infection:

• Filters blood at a rate of approximately 150 ml/min
• Filters out old or damaged red blood cells
• Removes bacteria and pathogens from the bloodstream
• Produces antibodies 
• Produces mature B-lymphocytes for humoral immunity 
• Detects antigens and initiates immune responses to antigens in blood
• Produces macrophages that can detect and remove bacteria in blood

Now that you have a general understanding of the spleen, let’s dive into the nursing care using the Straight A Nursing LATTE method.

L: How will the patient LOOK?

Prior to surgery the patient may have a distended abdomen due to an enlarged spleen when splenomegaly is present. In cases of splenic rupture due to trauma, the patient may show signs such as pain and tenderness in the LUQ, left shoulder pain (referred pain) and lightheadedness or confusion. 

After surgery, the patient will essentially look the same as any post-abdominal surgery patient, which can include: 

• One or more dressings, depending on whether the procedure was done laparoscopically or with one large incision. 
• The patient may have a JP drain or hemovac drain.
• The patient may have an abdominal binder in place if the procedure was “open.”
• The patient will show signs of surgery-related pain such as restlessness, guarding, grimacing, tachycardia, hypertension, and increased respiratory rate.
• In cases of trauma, the patient may have multiple other injuries and is often in the intensive care unit.
• The patient will have SCDs post-operatively and may be using a PCA to help control their pain.

Some key signals your patient may be experiencing a complication after splenectomy include: 

Internal bleeding – Increased pain, abdominal distention, abdominal rigidity, ecchymosis, tachycardia, hemodynamic compromise, decreased LOC.

Splenic or portal vein thrombosis – Vague abdominal pain, decreased appetite, malaise, nausea.

Pancreatic injury – Up to 15% of laparoscopic splenectomy procedures involve pancreatic injuries which can lead to pancreatitis. Signs of pancreatitis include severe upper or epigastric abdominal pain that may radiate to the back, nausea, vomiting, abdominal guarding or tenderness, Cullen’s sign, and Turner’s sign.

DVT – Unilateral calf pain, redness, warmth, edema.

Pulmonary embolism – Sudden onset SOB, chest pain, cough, hemoptysis, dropping O2 saturation, restlessness, lightheadedness, cyanotic lips/nails, feeling of impending doom.

Overwhelming post-splenectomy infection (OPSI) – Any infection can become life-threatening in a patient without a spleen. Signs of OPSI, which has a mortality rate of about 50%) are essentially signs of infection that progress to sepsis quickly.

A: How do you ASSESS the patient?

Prior to surgery access the patient’s vaccination status. Once the spleen is removed (or partially removed), they will be at much higher risk for infection. 

 It’s also important to assess the patient’s medication regimen prior to surgery by ensuring all current medications and doses are in the EMR and verified by the patient. Some doses may need to be adjusted and some medications may need to be discontinued, especially those that put the patient at risk for infection. 

After surgery your key assessments will involve monitoring your patient for signs of infection, which can be life-threatening. A patient with OPSI can progress to a life-threatening septic state within 12 to 48 hours. Signs of infection include: 

• Alterations in temperature (elevated or decreased)
• Chills
• Tachycardia (HR > 90 can be  associated with sepsis)
• Tachypnea – an elevated respiratory rate is one of the early warning signs of sepsis and sadly, is often overlooked or explained away as anxiety or pain
• Malaise, muscle aches
• Diarrhea, vomiting
• Abnormal labs such as elevated or decreased WBC or elevated blood glucose in non-diabetic patients
• Purulent drainage at incision site, as well as warmth, edema, erythema, pain

Other key assessments for your post-surgical splenectomy patient include monitoring for signs of VTE and signs of bleeding (remember, the spleen is highly vascularized!)

And, of course, you’ll assess your patient’s pain carefully. Pain can be related to the surgical incision or it could be due to a complication such as internal bleeding, a thrombus, splenosis (when spleen tissue breaks off and implants in another location) or even a missed accessory spleen, which is present in about 10-30% of people.

T: What TESTS are conducted?

Prior to surgery your patient will get a standard workup including CBC with differential and coagulation labs (to assess bleeding risk). Ultrasound and/or CT scan will be conducted to evaluate the organ’s size, abnormalities, surrounding structures and the presence of an accessory spleen.

Common tests postoperatively include:

• Hgb/Hct to monitor for bleeding
• Complete blood count (CBC)
  • Monitor for elevated or depleted WBC, which are signs of infection
  • Elevated leukocytes or platelets are signs of a potential thromboembolic complication
  • Thrombocytopenia (a low platelet count) is an early indicator of OPSI
• Abdominal US or CT scan may be utilized to assess potential complications after surgery
• Cultures are conducted if signs of infection are present
  • Blood cultures – assess for systemic infection
  • Wound cultures – assess for localized infection
  • Urine culture – assess for UTI
  • Sputum culture – assess for pneumonia
  • Catheter tip culture – if a central line infection is suspected, the line is removed and the tip is cultured

T: What TREATMENTS are utilized for a patient undergoing a splenectomy?

Vaccines – Patients with a planned splenectomy will receive all recommended vaccines about 10 to 12 weeks prior to surgery. In some cases this may be shortened to two weeks prior to surgery, which still allows time for passive immunity to develop. If the procedure is emergent, vaccines are typically administered two weeks post-op.

Blood products – Prior to surgery, patients may receive platelets and PRBCs to reduce the risk of bleeding and hemodynamic compromise. Intravenous immune globulin (IVIG) may also be utilized to help increase platelet counts in those with immune thrombocytopenia (ITP). Though not a blood product, a thrombopoietin receptor antagonist may be used instead of IVIG when platelet counts are low due to ITP.

VTE prophylaxis – Patients undergoing splenectomy are at higher risk for venous thromboembolism. Patients will wear SCDs when not ambulatory and may also receive low-molecular weight heparin (LMWH), depending on bleeding risk.

Pain management – Options for pain management after splenectomy include acetaminophen, opioids and blocks (placed by the anesthesiologist). Some patients will utilize patient-controlled analgesia (PCA). NSAIDs are typically avoided in the immediate postoperative period due to heightened risk of bleeding.

Infection prevention – The patient will receive prophylactic antibiotics both before and after surgery. Many patients may take prophylactic antibiotics daily for an extended period of time while others may need to take them for life (depending on infection risk).

General nursing care – Nursing interventions after splenectomy are aimed at preventing infection, increasing mobility and monitoring for complications.

• Exquisite hand hygiene
• Change the dressings on schedule and when soiled, wet, or loose
• Early ambulation and OOB for meals
• Encourage use of the incentive spirometer – if the patient had an “open” procedure, this is especially important as deep breathing is likely to be painful
• Encourage splinting when coughing or changing position
• Manage drains by monitoring output, draining as needed and reapplying compression
• Apply SCDs while patient is in bed
• If the patient is using a PCA, the protocol at many facilities is to provide supplemental oxygen of at least 2L/min via nasal cannula and place the patient on continuous pulse oximetry monitoring

E: How do you EDUCATE the patient after splenectomy?

The main focus after splenectomy is teaching the patient to avoid infection. General infection prevention techniques are to avoid crowds and individuals who are ill, performing proper hand hygiene, staying current on vaccines, and general food safety practices to prevent food-born illness such as salmonella. 

Ensure your patient understands the signs of infection and when to seek medical attention since even a small infection can progress to OPSI and become life-threatening, especially in the first three years after surgery. General things to watch for are fever, chills, a cold that lasts longer than expected, sore throat, cough, malaise, muscle aches, redness/tenderness anywhere in the body (especially wounds), painful urination or cloudy urine, vomiting, and diarrhea.

Teach your patient that they will need to carry high-dose antibiotics with them at all times in case signs of infection develop. This does not preclude their need to seek medical attention, so ensure your patient understands they MUST notify their MD or seek emergent care when signs of infection are present.

Teach your patient that they may be prescribed prophylactic antibiotics for a period of two to three years, possibly even for life. They will need to take this medication on schedule without fail in order to help prevent infection. 

Other key teaching points include:

• The patient should be advised to wear a medical ID bracelet or carry a card that states they are asplenic.
• The patient should discuss travel plans with their physician, especially if planning to visit a country where the risk for malaria or parasitic infection is high. 
• The patient should seek medical attention if scratched or bitten by an animal, even their own pet. 
• Encourage the patient to undergo all age-related cancer screenings since having a splenectomy may increase their risk of cancer. 

If the LATTE format helped you understand this topic, download the free LATTE template and use it to study on your own!

Looking for more lessons on the gastrointestinal system? I’ve got you covered here.

Take this topic on the go by tuning in to episode 272 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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