PRESENTORS: Heriette Tolentino Janvincent Tolentino Cristine Joy Tolento Rochelle Ann Tomale JONATHAN TORIBIO Lovely Tuliao

Hazel Paz Tuliao Arphy Bryan Tuliao

OBJECTIVES
General Objectives: This case study aims to help the patient, student nurses, Clinical Instructors and the community people in effectively providing holistic care for a patient suffering from spinal cord injury. It also aims to aid the patient in coping with life situations and improve his level of functioning. Specific Objectives: 1. Establish rapport and interact with the patient at the patient’s own level of understanding and taking into consideration to his present condition. 2. Perform a thorough assessment in his present condition, and discuss the physical and social changes. 3. Identify the signs and symptoms presented by the patient in relation to the injury process. 4. Implement a comprehensive plan of care for the patient with spinal cord injury. 5. Evaluate the interventions provided in the given span of time for efficiency and effectiveness. 6. Develop skills such as, interpersonal, technical and communication.

INTRODUCTION
Spinal cord injury: Spinal cord injury is damage to the spinal cord as a result of a direct trauma to the spinal cord itself or as a result of indirect damage to the bones and soft tissues and vessels surrounding the spinal cord. SCI results in a decreased or absence of movement, sensation, and body organ function below the level of the injury. The most common sites of injury are the cervical and thoracic areas. SCI is a common cause of permanent disability and death in children and adults. The spine consists of 33 vertebrae, including the following: • • • • • 7 cervical (neck) 12 thoracic (upper back) 5 lumbar (lower back) 5 sacral (sacrum – located within the pelvis) 4 coccygeal (coccyx – located within the pelvis)

Injury to the vertebrae does not always mean the spinal cord has been damaged. Likewise, damage to the spinal cord itself can occur without fractures or dislocations of the vertebrae. Types of SCI SCI can be divided into two main types of injury: • Complete injury -Complete injury means that there is no function below the level of the injury — either sensation and movement — and both sides of the body are equally affected. Complete injuries can occur at any level of the spinal cord. Incomplete injury -Incomplete injury means that there is some function below the level of the injury — movement in one limb more than the other, feeling in parts of the body, or more function on one side of the body than the other. Incomplete injuries can occur at any level of the spinal cord.

Causes Injury may be traumatic or nontraumatic A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or compresses one or more of your vertebrae. It may also result from a gunshot or knife wound that penetrates and cuts your spinal cord. Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around your spinal cord. A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation or infections, or disk degeneration of the spine. Common causes of spinal cord injury The most common causes of spinal cord injuries in the United States are:

• • • • • •

Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 40 percent of new spinal cord injuries each year. Acts of violence. As many as 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Institute of Neurological Disorders and Stroke. Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause about one-quarter of spinal cord injuries. Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 8 percent of spinal cord injuries. Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries. Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Symptoms Symptoms vary depending on the severity and location of the SCI. At first, the patient may experience spinal shock, which causes loss of feeling, muscle movement, and reflexes below the level of injury. Spinal shock usually lasts from several hours to several weeks. As the period of shock subsides, other symptoms appear, depending on the location of the injury. Generally, the higher up the level of the injury to the spinal cord, the more severe the symptoms SCI is classified according to the person’s type of loss of motor and sensory function. The following are the main types of classifications: • Quadriplegia (quad means four) — involves loss of movement and sensation in all four limbs (arms and legs). It usually occurs as a result of injury at T1 or above. Quadriplegia also affects the chest muscles and injuries at C4 or above require a mechanical breathing machine (ventilator). Paraplegia (para means two like parts) — involves loss of movement and sensation in the lower half of the body (right and left legs). It usually occurs as a result of injuries at T1 or below. Triplegia (tri means three) — involves the loss of movement and sensation in one arm and both legs and usually results from incomplete SCI. Quadriparesis and paraparesis refer to partial loss of function.

• • •

The following are the most common symptoms of acute spinal cord injuries. However, each individual may experience symptoms differently. Symptoms may include: • • • • • • • • Muscle weakness or paralysis in the trunk, arms or legs Loss of feeling in the trunk, arms, or legs Muscle spasticity Breathing problems Problems with heart rate and blood pressure Digestive problems Loss of bowel and bladder function Sexual dysfunction

The symptoms of SCI may resemble other medical conditions or problems. Always consult your physician for a diagnosis. Diagnosis The full extent of the SCI may not be completely understood immediately after the injury, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of SCI is made with a physical examination and diagnostic tests. During the examination, the physician obtains a complete medical history and inquires as to how the injury occurred. Trauma to the spinal cord can cause neurological problems and requires further medical follow-up. Diagnostic tests may include: • • X-ray — a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Computed tomography scan (also called a CT or CAT scan) — a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays. Magnetic resonance imaging (MRI) — a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Treatment Specific treatment for an acute spinal cord injury will be determined by your physician based on: • • • • • • Overall health, and medical history Extent of the SCI Type of SCI Your tolerance for specific medications, procedures, or therapies Expectations for the course of the SCI Your opinion or preference

SCI requires emergency medical attention on the scene of the accident or injury. This is accomplished by immobilizing the head and neck areas to prevent the patient from moving. This may be very difficult since the victim and/or bystanders may be very frightened after the traumatic incident. Surgery is sometimes necessary to, stabilize fractured back bones, decompress (or release) the pressure from the injured area, and to manage any other injuries that may have been a result of the accident. Treatment is individualized, depending on the extent of the condition and the presence of other injuries. Treatments may include: • Observation and medical management in the intensive care unit (ICU)

• • • •

Medications, such as corticosteroids (to help decrease the swelling in the spinal cord) Mechanical ventilator, a breathing machine (to help the patient breathe) Foley catheter — a tube that is placed into the bladder that helps to drain the urine into a collection bag. Feeding tube (placed through the nostril to the stomach, or directly through the abdomen into the stomach, to provide extra nutrition and calories)

Recovery from a SCI requires long-term hospitalization and rehabilitation. An interdisciplinary team of physicians, nurses, therapists (physical, occupational, or speech), and other specialists work to medically manage the patient to control pain, to monitor the • • • • • • Heart function Blood pressure Body temperature Nutritional status Bladder and bowel function and Spasticity (attempt to control involuntary muscle shaking)

Life-long considerations for a person with a SCI A traumatic event that results in a SCI is devastating to the person and the family. The healthcare team educates the family after hospitalization and rehabilitation on how to best care for the person at home and outlines specific clinical problems that require immediate medical attention by the patient’s physician. The disabled person requires a focus on maximizing his/her capabilities at home and in the community. Positive reinforcement will encourage him/her to strengthen his/her self-esteem and promote independence. A person with a SCI requires frequent medical evaluations and diagnostic testing following hospitalization and rehabilitation to monitor his/her progress. Prognosis Prognosis for patients with spinal cord injuries varies and depends largely on the degree of damage. The first year following injury is critical, as more patients die of the injuries within that time period than any other. Complications • Bladder control. Your bladder will continue to store urine from your kidneys. However, your brain may no longer be able to control bladder emptying, as the message carrier (the spinal cord) has been injured. The loss of bladder control increases your risk of urinary tract infections. It may also cause kidney infection and kidney or bladder stones. Drinking plenty of clear fluids may help. And during rehabilitation, you'll learn new techniques to empty your bladder. Bowel control. Although your stomach and intestines work much like they did before your injury, your brain may no longer be able to control the muscles that open and close your anus. This may cause fecal incontinence. A

high-fiber diet may help regulate your bowels, and you'll learn techniques to better control your bowels during rehabilitation. Impaired skin sensation. Below the neurological level of your injury, you may have lost part or all skin sensations. Therefore, your skin can't send a message to your brain when it's injured by things such as prolonged pressure, heat or cold. This can make you more susceptible to pressure sores, but changing positions frequently — with help, if needed — can help prevent these sores. And, you'll learn proper skin care during rehabilitation, which can help you avoid these problems. Circulatory control. A spinal cord injury may cause circulatory problems ranging from spinal shock immediately following your spinal cord injury to low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities throughout your lifetime. These circulation changes may increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus. Another problem with circulatory control is a potentially life-threatening rise in blood pressure (autonomic hyperreflexia). Your rehabilitation team will teach you how to prevent autonomic hyperreflexia. Respiratory system. Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are affected. These include the diaphragm and the muscles in your chest wall and abdomen. Your neurological level of injury will determine what kind of breathing problems you may have. If you have cervical and thoracic spinal cord injury you may have an increased risk of pneumonia or other lung problems. Medications and therapy can treat these problems. Muscle tone. Some people with spinal cord injuries may experience one of two types of muscle tone problems: spastic muscles or flaccid muscles. Spasticity can cause uncontrolled tightening or motion in the muscles. Flaccid muscles are soft and limp, lacking muscle tone. Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. However, limited mobility after spinal cord injury may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes. Sexual health. Sexuality, fertility and sexual function may be affected by spinal cord injury. Men may notice changes in erection and ejaculation; women may notice changes in lubrication. Doctors, urologists and fertility specialists who specialize in spinal cord injury can offer options for sexual functioning and fertility. Pain. Some people may experience pain, such as muscle or joint pain from overuse of particular muscle groups. Nerve pain, also known as neuropathic or central pain, can occur after a spinal cord injury, especially in someone with an incomplete injury.

Prevention Following this advice may reduce your risk of a spinal cord injury: • Drive safely. Car crashes are one of the most common causes of spinal cord injuries. Wear a seat belt every time you drive or ride in a car. Make sure that your children wear a seat belt or use an age- and weight-appropriate child safety seat. To protect them from air bag injuries, children under age 12 should always ride in the back seat. Don't drive while intoxicated or under the influence of drugs.

• •

Be safe with firearms. Lock up firearms and ammunition in a safe place to prevent accidental discharge of weapons. Store guns and ammunition separately. Prevent falls. Use a stool or stepladder to reach objects in high places. Add handrails along stairways. Put nonslip mats on tile floors and in the tub or shower. For young children, use safety gates to block stairs and consider installing window guards. Take precautions when playing sports. Always wear recommended safety gear. Check water depth before diving to make sure you don't dive into shallow water. Avoid leading with your head in sports. For example, don't slide headfirst in baseball, and don't tackle using the top of your helmet in football. Use a spotter for new moves in gymnastics.

STATISTICS CVMC (2009)
Month January February March April May June July August September October November December Male 0 0 2 3 3 4 0 0 1 0 1 0 Female 1 1 0 0 1 1 0 1 0 0 0 1

National Spinal Cord Injury Statistical Center (2009) Current estimates are 250,000 - 400,000 individuals living with Spinal Cord Injury or Spinal Dysfunction. • • • • • 82% male, 18% female Highest occurs between ages 16-30 Average age at injury - 33 Median age at injury - 26 Mode (most frequent) age at injury 19

NURSING HISTORY
I. Present History  4 hours prior to hospitalization, pt. Y is driving his tricycle at Baggao, Cagayan to sell rice crops and earn money for his family. When he reached the end of the bridge, his tricycle suddenly stops. He tried to restart the engine but he failed to control it because of his tricycle’s weight. So pt. Y and his tricycle fell down under the bridge with an estimated height of 15 feet. He tried to jump away from his tricycle while they were falling, but unexpectedly his foot got hooked on the kick starter and his back was hit when they reached the ground. Right after the accident, pt. Y felt pain all over his body especially on his back & on his Left pelvic area. Luckily somebody saw him and they removed the tricycle on top of him, then 2 people lifted him up to get into the other tricycle with sitting position inside. They brought him to Baggao Hospital but they referred him to CVMC because of lack of facilities. During their trip, the pt. Y kept on complaining for back pain. They arrived at ER of CVMC at 12:50PM on December 6, 2009 via stretcher. He received anti tetanus vaccines & anti toxins vaccines. Past History  According to pt. Y, he had experienced some common childhood illnesses such as measles, chicken pox and mumps when he was in elementary. He had also experienced sore throat, cough, colds, and fever. He managed it through bed rest and sometimes he takes herbal medicine such as oregano for cough and guava leaves if he has wounds. He also took OTC drugs such as paracetamol for fever, biogesic for headache and neozep for colds. He didn’t receive any immunization. He has no allergy to foods, drugs & animals. The patient has one history of hospitalization when he was in elementary due to malaria. He had never undergone any major/minor operation and he had no history of fracture.

II.

III. Family History  According to patient Y, they had a history of asthma on maternal side & hypertension on both sides. They don’t have any history of Diabetes Mellitus, Cancer & any other diseases which are hereditary. IV. Social History  Pt. Y is the 3rd child in the family and he has 5 siblings. He got married at the age of 26. He is High School graduate. He’s a farmer & sometimes he drives his tricycle. His wife X is an elementary graduate & a housewife but sometimes she is helping his husband on their farm. They have five children, 2 girls & 3 boys. All of his children have their own family. His son and his family lives together with patient Y’s house. Pt. Y is the one who provides all of his family needs. He drinks liquor once a week but he does not smoke. He also mingles with his neighbors and friends after he finishes his work on the farm.

GORDONS 11 FUNCTIONAL PATTERNS
I. Health Perception - Health Management Pattern Before Hospitalization:  Patient Y stated that health for him is very important to support his family financially. He defined a healthy person as free or absence of disease and can do anything he wants without limitations. He also stated that he didn’t have any allergy to food, drugs and animals. According to patient Y, he uses herbal plants such as oregano for cough and guava leaves if he has wounds. He also uses over the counter drugs such as Paracetamol for fever and Neozep for colds. He also takes Biogesic for headache if it can’t be manage by bed rest. He manages his muscle pain through rest. He seldom goes to the hospital for check up. He’s not taking any supplemental vitamins. Patient Y believes in quack doctor. During Hospitalization:  According to patient Y, it is his second hospitalization; his first hospitalization was during his elementary age due to malaria. Patient Y perceives that his health became poorer compare before hospitalization because he can’t accomplish most of his ADL’s required without assistance. Patient Y stated that he is complying well with all therapeutic regimen and management for his condition for faster recovery. He still does not take any supplemental vitamins. II. Nutritional Metabolic Pattern Before Hospitalization:  Patient Y stated that he eats three times a day with a good appetite. His breakfast was sometimes composed of coffee with bread or plain rice or plain rice and egg. He can consume 2 to 3 cups of rice each meal. He was fond to eat any kinds of vegetable and salty foods such as dried fish and bagoong. He seldom eats meat and fish because they lack of money. Sometimes he takes his snack in the afternoon with a cup of coffee and bread, but he never takes his snack in the morning. He had never uses any food supplements and had no allergy to foods. He drinks 8 to 10 glasses of water a day. He sometimes drinks soft drinks and drinks liquor once a week and he doesn’t smoke cigarette. He can chew and swallow foods without any difficulty. The patient weighs 58 kg. And 5’7” (174cm) in height. His BMI is 19.33 During Hospitalization:  According to patient Y his appetite has change. He can’t even consume 1 cup of rice each meal and he is just eating 1 pack of biscuit (sky flakes) and just sips of water or juice. His snack contains 1 biscuit or fruits with a cup of coffee or water because he is worried

about his condition regarding his elimination pattern. He drinks 2 to 3 glasses of water a day and is not taking any food supplements. His IVF was D5LRS regulated at 30gtts/min. III. Elimination Pattern

Before Hospitalization:  According to patient Y, he had no difficulty in urinating and defecating. He described his urine as yellow in color. He voids 4 to 6 times a day, with an estimated amount of 1 glass per voiding which is equivalent to 240 cc. He defecates once a day or once in two days with formed stool but according to him, it sometimes depends on the foods he had eaten. During Hospitalization:  Patient Y has IFC inserted because he can’t void but he has no urge to urinate. His urine output was 150 cc per shift with yellow amber in color. On his ten days of staying at the hospital, patient Y didn’t defecate, even though he is taking dulcolax. This is due to his present condition in which his bowel reflex is paralyzed. After 17 days of not defecating, he had defecated last Christmas Break, Dec. 23 and Dec. 29, 2009 with formed stool. IV. Activity - Exercise Pattern

Before Hospitalization:  Patient Y can perform his ADL’s without assistance. He woke up as early as 5:00 am to prepare their breakfast and after cooking and eating he would proceed to his working place by walking. He considered walking and plowing the field as a form of his exercise. He spent his leisure time listening to radio. Aside from being a farmer he is also a tricycle driver. During Hospitalization:  Patient Y tried to be independent as much as possible. His wife and daughter are assisting him in doing his ADL’s. Patient can eat, drink alone and even combs his hair but he can’t able to move his two feet alone. He spends his day in the hospital resting, talking to his wife, daughter and his visitors. Passive range of motion is his form of exercise. He is placed on complete bed rest and should be repositioned every 2 hours. On our second week of duty, patient Y can move his legs, turn side to side alone without assistance, but he can’t sit. V. Sexuality Reproductive Pattern Before Hospitalization:  According to patient Y, he was circumcised at the age of 9. He experienced his first sexual intercourse when he was 16 y/o. He has an active sexual relationship but as he grows older it gradually decreases. His last sexual intercourse with his wife was on Dec. 5, 2009. Patient Y had never experienced any problem in sexuality and he doesn’t have any sexually transmitted disease. They didn’t use

any contraceptive. He experienced erection every morning especially when he feels the urge to urinate. During Hospitalization:  Patient Y stated that sex is no longer important because his condition is his priority. Besides he is in IFC and stated that he doesn’t experienced a penile erection. VI. Sleep - Rest Pattern Before Hospitalization:  Patient Y stated that he had 6 to 8 hours of uninterrupted sleep at night. He sleeps around 9 pm and wake up at between 4-5 am. He takes 15 minutes nap during daytime every after eating his lunch. His not using any sleeping aids. He is easily awakened by loud noise and when he feels the urge to urinate. During Hospitalization:  According to patient Y he has difficulty in sleeping because of the new environment and due to worries about his condition. He has interrupted sleep at night due to treatment regimen. He sleeps around 9 PM and wakes up before 12 midnight and sleep again around 1AM and wakes up between 5-6 AM. He stated that sometimes the cause of the interruption of his sleep at night is because the room is crowded and have insufficient ventilation. On our second week of duty, according to patient Y he can’t fall asleep easily because he worries about his operation, hospital bills and hot environment. He goes to sleep around 4 AM and wakes up at 6 AM because of routinely activities of the staff and to eat breakfast. After breakfast he goes to sleep again at 9 AM and wakes up when its time to eat lunch. He sleeps again after lunch until late afternoon. VII. Cognitive Perceptual Pattern Before Hospitalization:  Patient Y was able to see object; hear sounds, taste food, smell and sensitive to heat and cold. He doesn’t use any prosthesis such as eye glasses or hearing aid. He can speak and understand ilocano and tagalog. Patient Y has no difficulty with his vision, hearing, and he has the ability to feel, taste and smell. According to him, the best way for him to learn something new is through everyday experience. During Hospitalization:  Patient Y can still able to see object; hear sound, taste food, smell and sensitive to heat and cold. He doesn’t use any prosthesis such as eye glasses or hearing aid. He can still speak and understand Ilocano and Tagalog. Patient Y has no difficulty with his vision, hearing, and the ability to feel, taste and smell. Patient Y is oriented to place, time and person. He can answer and respond to question appropriately. VIII. Self Perception Pattern Before Hospitalization

Patient Y described himself as a real man though he is not handsome because he can provide and give the needs of his family such as food, shelter, clothing and sending his children to school but his children was the one who refuses to go to school. They just chose to get married. He considered his family as a source of his strength and his weakness was to loose one member of his family.

During Hospitalization:  Patient Y described himself as worthless and useless because when he was hospitalized, he know that he can’t walk and use his legs, meaning he can’t provide the needs of his family. He doesn’t consider now himself as a real man because for him, he can’t do his ADL’s alone without assistance. He considered God and his family as source of his strength and his weakness was to be paralyzed all throughout his life. IX. Role Relationship Pattern Before Hospitalization  Patient Y was the bread winner and head of the family. He described his family as lovable, supportive and happy to be with, though they are not rich, they show their concern to each other. Patient Y and his wife are helping in term of making decision. He considered his wife as the most important person in his life because according to him, his wife can’t leave him but his children has the possibility to leave him any time. He also had a good relationship with his neighbors. During Hospitalization:  Patient Y stated that his family was more supportive to him and to his condition. They show their concern to patient Y by accompanying him to the hospital and according to patient Y; he sees it on their faces. Patient Y and his wife were helping in making decision regarding the treatment for his condition. He considered God as the most important in his life because according to him, it is in God’s plan what will going to happen in his life. He is thinking if he can still do what he does before he was hospitalize. X. Coping stress tolerance pattern Before hospitalization:

 According to patient Y, the most stressful situation in his life was

when he was not earning money for his family. And whenever he is in bad mood he diverts his attention through going to his farm and visits his rice crops or he just cut woods to use for cooking or he drinks liquor alone or with his neighbors. He is not fond of sharing his problem to any of his neighbors but instead he shares it to his wife. He doesn’t cry when he have a problem. He is not using any form of prohibited drugs to forget his problem.

During hospitalization:  According to the patient the most stressful time in his life is his present condition thinking that there is a possibility that he can’t use

his legs to walk and it is considered stressful to him. The only way for him to divert his attention is by sleeping and by talking to his wife, daughters and visitors. He doesn’t cry for his problem regarding his present condition but instead he is praying to God for his faster recovery. XI. Value Belief Pattern Before Hospitalization:  Patient Y was baptized as Roman Catholic. He seldom goes to mass because according to him it was not part of his routine, but he believes that God is our savior and creator. Patient Y says that even though he was not going to mass there is a certain time that he prays to God and asks for his guidance and protection. Patient Y also believed in quack doctor. During Hospitalization:  Patient Y stated that his relationship to God got strengthened says that his illness is a test for his faith, because whenever he has no problem he is not praying to God.

Date interviewed started on: December 14, 2009 Ended on: January 4, 2010

ANATOMY AND PHYSIOLOGY

Spinal cord is a bundle of nerves that carries messages between the brain and the rest of the body.  The spinal cord functions in the transmission of ascending impulses to the brain and of descending impulses from the brain to the cord. Spinal Column  Common name applied to the structure of bone or cartilage surrounding and protecting the spinal cord.  Humans are born with 33 separate vertebrae. By adulthood, most have only 24, due to the fusion of the vertebrae in certain parts of the spine during normal development.

The spine consists of 33 vertebrae, including the following: • • • • •  7 cervical (neck) 12 thoracic (upper back) 5 lumbar (lower back) 5 sacral* (sacrum – located within the pelvis) 4 coccygeal* (coccyx – located within the pelvis) By adulthood, the five sacral vertebrae fuse to form one bone, and the four coccygeal vertebrae fuse to form one bone.)

L4 supplies many muscles, either directly or through nerves originating from L4. They are not innervated with L4 as single origin, but partly by L4 and partly by other spinal nerves. The muscles are:  Quadratus lumborum  Is a common source of lower back pain. Because the QL connects the pelvis to the spine and is therefore capable of extending the lower back when contracting bilaterally, the two QLs pick up the slack, as it were, when the lower fibers of the erector spinae are weak or inhibited (as they often are in the case of habitual seated computer use and/or the use of a lower back support in a chair).  Gluteus medius  One of the three gluteal muscles, is a broad, thick, radiating muscle, situated on the outer surface of the pelvis.  With the leg in neutral (straightened), the gluteus medius and gluteus minimus function together to pull the thigh away from midline, or "abduct" the thigh  Gluteus minimus  The gluteus medius and gluteus minimus abduct the thigh, when the limb is extended, and are principally called into action in supporting the body on one limb, in conjunction with the Tensor fasciæ latæ

 

 Tensor fasciae latae is a muscle of the thigh is a tensor of the fascia lata; continuing its action, the oblique direction of its fibers enables it to abduct the thigh and assists with internal rotation and flexion of the hip inward (medial rotation).

Obturator externus muscle

 Obturator externus muscle is a flat, triangular muscle, which
covers the outer surface of the anterior wall of the pelvis.  Inferior gemellus muscle

 Inferior gemellus muscle is a muscle of the human body. The Gemelli

are two small muscular fasciculi, accessories to the tendon of the Obturator internus which is received into a groove between them. The Gemellus inferior arises from the upper part of the tuberosity of the ischium, immediately below the groove for the Obturator internus tendon. It blends with the lower part of the tendon of the Obturator internus, and is inserted with it into the medial surface of the greater trochanter. Rarely absent.

Quadratus femoris  Quadratus femoris is, as its name implies, a flat, quadrilateral skeletal muscle. Located on the posterior side of the hip joint, it is a strong lateral rotator and adductor of the thigh, but also acts to stabilize the femoral head in the Acetabulum.

PATHOPHYSIOLOGY
BOOK BASED AND PATIENT CENTERED Predisposing Factor Etiology Precipitating Factor

 Age (16-35 y/o)  Gender (male)

> vehicular accidents > lifestyle (fond of driving) > falls, sport activities > work (driver) > Disease (bone cancer, osteoporosis, arthritis) Can result to      any of the following: Hyperextension Hyperflexion Rotational movement Compression Lateral flexion

Fracture and dislocation of vertebral disc Excessive force is exerted on spinal cord

If L4 & L5 is affected or damage L4- controls bowel & bladder elimination  Urinary Retention  Loss of bowel reflex  Low back pain L5 – controls lower limb or extremities

can lead to: > Ischemia > Hemorrhage

   

Muscle weakness Absence of withdrawal reflex Absence of Patellar reflex Muscle Paralysis In gray matter Increase in size rapidly Necrosis Scaring Shrinkage of axonal and Myelin sheath Rapid loss of axonal conduction Result to production of free radicals - normally found in the body but quickly controlled by antioxidant enzyme tissue When antioxidant is overwhelmed Free radicals damage tissue in white matter lead to massive edema frequently spreads to involve surrounding segment

Dilation of arterioles in injured area Result capillary bed close Increase blood flow of injured tissue

inflammatory process (lumbar area) Increase capillary permeability lead to loss of protein rich fluid in

at injured site

extravascular tissue

Bleeding

pain

hematoma Decrease extravascular osmotic pressure Fluid shift Edema fever (compensatory mechanism) Increase intravascular osmotic pressure

PHYSICAL ASSESSMENT
General Appearance: The patient is awake, lying on bed conscious and coherent. He looks worried about his present condition , weak, long hair, fair in complexion. He has on going IVF of D5 LRS 1L to run for 8 hours, hooked, intact and infusing well on his left hand. Vital Signs: BP: 110/80 Date Assessed: AREA ASSESSED METHOD USED NORMAL FINDINGS ACTUAL FINDINGS EVALUATION RATIONALE Temp: 36.8 C PR: 82 bpm RR: 20 cpm

SKIN

Inspection

Palpation

-Varies from light to deep brown from ruddy pink to light pink There should be no presence of scar, edema, hematoma -Compare skin temperature must be uniform and within normal range -Skin turgor, skin of extremities returns back to original state when pinched (1-2 seconds)

Skin is deep brown

NORMAL

Presence of scar and hematoma Skin temperature is uniform and within normal range -Skin returns to normal state when pinched after 1 sec.

ABNORMAL

Due to accident and blleding

NORMAL

NORMAL

HAIR

Inspection and Palpation

-Can be black to brown or burgundy depending on race - Evenly distributed covers the whole scalp with no evidences of alopecia - Thick or thin, coarse or smooth

- black

NORMAL

- Evenly distributed covers the whole scalp with no evidences of alopecia - thick and smooth -Normal convex curvature

NORMAL

NAILS

Inspection

-Inspect nail plate shape; convex curvature; angle between nail bed about 160 -Inspect nail bed color and appearance

NORMAL NORMAL

-Pink and dirty

ABNORMAL

Due to poor Hygiene

Blanch Test Palpation HEAD - Skull Inspection and Palpation Inspection and Palpation

-Prompt return (2-3 sec) of pink or usual color Normocephalic no tenderness and upon palpation - lighter in color than complexion - can be moist or oily - no scars noted - free from lice, nits

-Prompt return to normal color within 2 seconds Normocephalic, no tenderness and upon palpation - lighter in color than complexion - oily - no scars noted

NORMAL

NORMAL

-

Scalp

NORMAL NORMAL NORMAL

and dandruff - no lesions - no tenderness nor masses FACE Inspection - face is symmetrical - Palpebral Fissure is equal in both eyes - Bilateral Nasolabial fold is present when smiling. Slight asymmetry in the fold is normal

- free from lice, nits and dandruff - no lesions - no tenderness nor masses - face is symmetrical - equal palpebral fissure - Presence of Bilateral Nasolabial Fold when smiling and is symmetrical

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

EYEBROWS

Inspection

- Symmetrical and in line with each other - Maybe black, brown or blond depending on race. - Evenly distributed

- Symmetrical and in line with each other - black

NORMAL

EYELIDS

Inspection

- Upper eyelids cover the small portion of the iris, cornea and sclera when eyes are open - No PTOSIS present (drooping of upper eyelids) - Meets completely when eyes are closed

- Evenly distributed - Upper eyelids cover the small portion of the iris, cornea and sclera when eyes are open. - No PTOSIS noted (drooping of upper eyelids) - Meets completely when eyes are closed.

NORMAL NORMAL

NORMAL NORMAL

- Symmetrical

- Symmetrical

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

EYELASHES

Inspection

- Color dependent on race - Evenly distributed - Turned outward - Evenly placed and inline with each other - Non protruding - Both conjunctivae are pinkish or red in color - Moist - No ulcers - No foreign objects Sclera is white in color

- black - Evenly distributed - Turned outward - Evenly placed and inline with each other - Non protruding - Both conjunctivae are pinkish in color

EYES

Inspection

Conjunctiva

Inspection

- Moist - No ulcers - No foreign objects white in color

NORMAL NORMAL NORMAL NORMAL

Sclera

Inspection - Pupil equally round, reactive to light and accommodation

Pupil EARS

Inspection Inspection - The ear lobes are bean shaped, parallel, and symmetrical - The upper

- Pupil equally round, reactive to light and accommodation - Ear lobes are bean shaped, parallel, and symmetrical

NORMAL NORMAL

connection of the ear lobe is parallel with the outer can thus of the eye - The ear canal has normally some cerumen upon inspection - No discharges or lesions noted at the ear canal Palpation - The auricles have a firm cartilage on palpation - The pinna reoils when folded -There is no pain or tenderness on palpation of the auricles and mastoid process - Nose in the midline - No discharges - No nasal flaring - Both nares are patent - Nasal septum in the mid line and not perforated - No bone and cartilage deviation noted on palpation - No tenderness noted

- Upper connection of the ear lobe is parallel with the outer canthus of the eye - Some cerumen noted upon inspection - No discharges noted

NORMAL

NORMAL

NORMAL - The auricles have a firm cartilage on palpation - The pinna reoils when folded -There is no pain or tenderness on palpation of the auricles and mastoid process - Nose in the midline - No discharges - No nasal flaring - Both nares are patent - Nasal septum in the mid line and not perforated - No bone and cartilage deviation noted on palpation - No tenderness noted on palpation

NORMAL

NORMAL NORMAL NORMAL

NOSE

Inspection

Palpation

NORMAL

on palpation

NORMAL

MOUTH Lips

Inspection

- With visible margin - Symmetrical in appearance and movement - Pinkish in color - No edema - No bleeding - Pinkish in color - Number of teeth is 32 - White to yellowish in color -Pinkish in color

- With visible margin - Symmetrical in appearance and movement - Pinkish in color - No edema - No bleeding - Pinkish in color - Number of teeth is 32 - Yellowish in color -Pink in color - The neck is straight and at the midline -No visible mass or lumps -Symmetrical -No jugular venous distention -Thorax is elliptical -Moves symmetrically

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

Gums Teeth

Inspection Inspection

Hard Palate Neck

Inspection Inspection and Palpation

-The neck is straight and at the midline -No visible mass or lumps -Symmetrical -No jugular venous distention -The shape of the thorax in normal adult is elliptical -Moves symmetrically on breathing with no

Thorax

Inspection

obvious masses. -No chest retraction must be noted as this may suggest difficulty in breathing -The spine should be straight, with slightly curvature in the thoracic area. - There should be no scoliosis, kyphosis, or lordosis. - Expiration is usually longer than inspiration Palpation -No lumps, masses and areas of tenderness -Normal heart sound and no heart murmurs -Vesicular and broncho vesicular, Bronchial sounds -No adventitious breath sounds -Skin color is uniform, no lesions. -Some clients may have striae or scar. -Normal bowel sounds are high pitched,

-No chest retractions noted -Spine is straight with slight curvature - Presence of kyphosis on vertebral column - Expiration is longer than inspiration -No lumps masses and tenderness - Normal heart sound and no heart murmurs - Vesicular and broncho vesicular, Bronchial sounds -No adventitious breath sounds. - Skin color is uniform, no lesions. -No presence of striae or scars. -Hyperactive bowel sound

NORMAL

NORMAL

Abnormal NORMAL NORMAL

Due to fracture of lumbar vertebrae

Heart

Auscultation

-NORMAL

Lungs

Auscultation

-NORMAL -NORMAL -NORMAL -NORMAL -Abnormal -Due to prolonged use of laxative

Abdomen

Inspection

Auscultation

gurgling noises that occur approximately every 5 - 15 seconds. It is suggested that the number of bowel sounds may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound. Percussion Tympany over the stomach and gas filled bowels; dullness, especially over the liver and spleen or a full bladder. -No nodules or masses upon palpation -No abdominal tenderness -No abdominal rigidity -Both extremities are equal in size, have the same contour with prominences of joints. -No involuntary movements -No edema -Temperature is warm and even

(30 burburigmi)

Tympany over the stomach and gas filled bowels; dullness, especially over the liver and spleen or a full bladder. - No nodules or masses upon palpation -No abdominal tenderness present. -No abdominal rigidity. -Extremities are equal in size, same contour with prominences of joints. -No involuntary movements -No edema -Temperature is warm and even.

- NORMAL

Palpation

-NORMAL -NORMAL -NORMAL -NORMAL -NORMAL -NORMAL -NORMAL

Extremities

Inspection

Palpation

Blanch Test Observation Motor Function

-capillary refill (1 – 2 seconds) -No difficulty on Movement, full ROM,and strong lower extremities

- capillary refill (1 – 2 seconds) -Limited ROM, weak extremities as evidence by need of assistance while moving

-NORMAL -ABNORMAL -Due to L4- L5 spinal cord injury.

0- No Muscle power or total paralysis 1- Contraction visible or palpable 2- Active movement or full ROM without gravity 3- Active movement or Full Rom against gravity 4- Active movement full ROM with moderate resistance 5- Normal motor with active movement with full ROM against resistance RESULT: Left wrist – 5 Right wrist- 5 Left elbow- 5 Right elbow- 5 Left knee- 3 Right knee- 2 Left ankle- 3 Right ankle- 2

Patellar Reflex – stretch reflex, muscle contract is response to stretching force.  RESULT: absence of Patellar Reflex Withdrawal reflex- is to remove a limb or other body part from a painful stimulus  RESULT: absence of withdrawal reflex as evidence by can’t remove his extremities when painful stimulus is applied Achilles Reflex- sitting position to test for plantar flexion  Can’t perform because patient can sit.

LAB RESULTS
Result Hemoglobin Hematocrit RBC count Platelet count WBC count 135 g/dL 0.42 l/l 4.36 x 10¹²/L 3.21 x 10/L 16.0 x 10/L Normal Values 135-180 g/dL 0.42-0.52 l/l 4.7-6.1 x 10¹²/L 150-400 x 10/L 5-10 x 10/L Rationale Normal Normal Decrease due to bleeding Normal Increase due to inflammatory process Normal

Lymphocyte

0.23

.20-.40

BUN creatinine

Result 6.65 123.65

Normal values 3.30-6.70 53.00-115.00

Indication Normal Increase due to end product of muscle metabolism

URINALYSIS Result Yellow Turbid (cloudy) Normal Findings Yellow amber Clear Indication Normal Due to presence of infection because of prolonged use of IFC Normal Normal Due to infection Due to tissue and bone damaged.

Color Transparency

PH Specific gravity Leukocyte Amorphous Phosphate

8.0 1.005 Abundant +++

4.6-8 1.001-1.020 Absent Absent

CT SCAN of the LUMBOSACRAL SPINE Multiple Axial Tomographic sections of the lumbar spine (L1-S1) with sagittal & 3D reconstruction were obtained. No IVF or intrathecal contrast was given. The upper half of the L4 vertebral body is fragmented with signs of ventral & dorsal displacement. A ledge shaped fragment is displaced 1.96 cm ventrally at the level of the L3-L4 intervertebral space with slight torsion of the fracture towards the left. There is displacement of the posterior aspect in to the spinal canal with demonstration & intracanalicular fragments. The bilateral intervertebral facets are distracted. The transverse & spinous process & lamina are intact. These are linear fractures of the L1-L2 right transverse processes & L3 bilateral transverse processes. The broad contours of the L4-L5 disc extend beyond the rim of the vertebral bodies. There is evidence of gas at level of L4-L5 intervertebral disease. (-) for calcification. The superior & inferior articulation facets & lateral recesses are unremarkable. The ligamentum flavum is not thickened. The rest of the intervertabral spaces are maintained. Osteophytes are noted along the margin of vertebral bodies. The pedides, laminae, rest of the transverse & spinous process are intact. The rest of the visualized soft & osseous structures are unremarkable. Scanogram shows wedge shaped deformation of the L4 vertebral body with kyphosis of the vertebral column. Impression: Fracture- disclocation, level of L4 Liner fracture, L1 & L2 right & L3 Bilateral transverse processes. Disc herniation with vacuum phenomena, level of L4-L5 Degenerative osteophytes, lumbar vertebral bodies.

   

RATIONALE OF CT SCAN To determine what specific part of spinal cord is damaged or affected. CHEST X-RAY (PA) Both lungs field are clear and with normal vascular pattern. Heart and great vessels are normal in size and configuration. Other chest structures are unremarkable Impression:  RATIONALE OF CXR: To check the readiness of heart and lungs and note if there any contraindication before performing any procedure no radiographic abnormality within the chest

COURSE IN THE WARD DATE 12-06-09 12:50PM ORDER  PLEASE ADMIT TO Ortho Ward under the service of Dr. Lasam Secure consent for admission & management DAT with aspiration precaution Dx: CBC; RATIONALE  To intervene & give the needed health service As a form for legal purposes. NURSING RESPONSIBILITY  Admitted the patient at the ward as ordered.   Witnessed the signing of consent & checked if the consent was signed

For nutritional supplement

 Inform the
Patient and his SO about his diet and its important.  Informed the patient & his SO about the laboratory exams needs to be done.

 •

• •

BT; CXR PA

Meds: Celecoxib 200mg/ cap BID Insert IFC connect to urine bag refer

To evaluate for possible abnormalities indicating infection or ↓ in platelet count or if there is any deviation. To know the ABO blood type prior to blood transfusion. To visualize chest part & determine if there is any part affected by the accident. Treatment for acute pain

 To facilitate
urine excretion & monitor for urine output To inform the physician about the condition of the patient

Observed the 10 R’s before administering the drug Inserted IFC & maintained aseptic technique.

 Referred to the

physician if there is untoward signs and symptoms

12-07-09

IVF D5LRS 1L to run for 8˚ Give ketorolac 300mg IV for severe pain every 8˚ PRN D5W 500 ml + 2 ampule diclofenac 50 mg to run for 24˚ For CXR APL

Serve as route for IV drug administratio n and promote hydration

Hooked D5LRS 1L regulated properly and check for patency Observe the 10 R’s before administering the drug. Regulated properly the IVF and checked the 10 R’s before administering the drug

 Treatment
for pain 

 Treatment
for acute pain

12-09-09

For CT scan of lumbar vertebra (L1 – S1)

To check the readiness of heart and lungs and note if there any contraindicati on before performing any procedure To determine the extent of injury and determine what specific part is affected

 Informed the
patient about the importance of undergoing CXR and instruct to remove any metallic objects in the body

 Informed the
patient and SO about the diagnostic exam needed to be done. Check for any allergy in iodine or shellfish.  Instructed patient to lie still during the procedure and tell patient that this will last up to 1 hour and remove all metals in the body. Informed the patient and SO about the diagnostic exam needed to be done Check for any allergy in iodine or shellfish Instructed patient to lie still during the procedure and tell patient that this will last up to 1 hour and remove all metals in the

Shows in detail a specific plane of involved bone/injuries .

12-09-09 10:30 am

For ct scan of lumbar vertebra ( L1 – S1 ) with plate 3D reconstruction

To determine the extent of injury and determine what specific part is affected

Shows in detail a specific plane of involved bone/injuries

12-09-09 5:00 pm 6:00 pm

Refer to Dr. Lacambra for co management

To inform the physician about the condition of the patient. To promote blood circulation and prevent bed sore and pneumonia

body. Referred to Dr. Lacambra Turning schedule done and post at the bedside, turn patient using log roll technique Emphasized the importance of egg crate mattress and encourage the patients S.O to provide egg crate mattress. Informed the patient and SO about the diagnostic exam needed to be done Check for any allergy in iodine or shellfish Administered meds as ordered following 10 R’s

Bed sore precaution: Turn patient side to side every 2 hours  Secure egg crate mattress for the use of the patient.

  To prevent bed sores.

Facilitate Lumbar (L1 – S1) CT scan at St. Paul Hospital.

  To determine the extent of injury and determine what specific part is affected

Give 1 Dulcolax (Bisacodyl) suppository now then start 1 tablet at bedtime tomorrow. Refer accordingly

To prevent constipation and to increase peristalsis by acting directly the smooth muscles of the intestines. To inform the physician about the condition of the patient.

Referred monitored condition of patient to the physician.

12-18-09

Medicine Notes  Patient seen and examined History and Physical examination reviewed  Physical Examination Findings: - conscious and coherent - Vital signs: BP: 130/80,   To assessed and to note the improvement of the condition of the patient To note any diseases or disorder that is contraindicat ed to the treatment regimen  Assisted the physician during physical examination Assisted the physician during physical examination Assisted the physician during physical examination

-

-

-

12-19-09 

PR: 78, RR: 19 No cyanosis, no pallor Anicteric sclera, pink palpebral conjunctiva Symmetrical chest expansion clear breath sounds A dynamic precordium pulse at 5th ICS normal Flat abdomen and soft NABS Full and equal pulses No vein engorgement Reinsert IFC

To assess the patient physical condition

 To prevent

infection and UTI; relieve bladder distention according to the next doctor’s order.

Refer to surgery if distended bladder is still unresolved inspite of reinsertion of IFC

For collaborative management about the unresolved bladder distention For the patient to undergo surgery To promote blood circulation and to prevent bed sore and maintain skin integrity To prevent UTI

12-24-09

Still securing funds for implant Continue bedsore precaution Change IFC

For urinalysis

Performed IFC insertion and observed aseptic technique and practice catheter care such as encouraging patient to increase fluid intake; catheter is lower than bladder and ensure that the urine bag doesn’t touch the floor Referred untoward sign and symptoms of bladder distention Informed the patient to secure fund for upcoming surgery Turning schedule done and post at the bedside, turn patient using log roll technique Performed IFC insertion and observed aseptic technique and practice catheter care such as encouraging patient to increase fluid

To check for the characteristic of the urine and check for any abnormal value

intake; catheter is lower than bladder and ensure that the urine bag doesn’t touch the floor Aspirate urine specimen from the Y port of the catheter using aseptic technique and send it immediate to the laboratory

DRUG STUDY
DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING CONSIDERATION  Drug may be hepatotoxic; watch for signs and symptoms of liver toxicity. Drug can be given without regard to meals, but food may decrease GI upset. Tell patient to report history of allergic reactions to sulfonamides, aspirin, or other NSAIDs before starting therapy. Advise patient to immediately report rash, unexplained weight gain, or swelling.

Celecoxib

Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2 (COX-2), to produce anti-inflammatory, analgesic, and antipyretic effects.

For Acute pain and primary dysmenorrhea

Contraindicated in patients hypersensitive to drug, sulfonamides, aspirin, or other NSAIDs. Contraindicated in those with severe hepatic impairment.

 CNS: dizziness, headache, insomnia.  CV: peripheral edema.  EENT: pharyngitis, rhinitis, sinusitis.  GI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea.  Metabolic: hyperchloremia.  Musculoskeletal: back pain.  Respiratory: upper respiratory tract infection.  Skin: rash.  Other: accidental injury.

DRUG NAME Diclofenac potassium Cataflam Diclofenac sodium Fenac‡, Voltaren, VoltarenXR, Voltaren Rapide†, Voltaren SR†

ACTION  Unknown. May inhibit prostaglandin synthesis, to produce antiinflammatory, analgesic, and antipyretic effects.

INDICATION  For Acute pain and primary dysmenorrhea

CONTRAINDICATION  Contraindicated in patients hypersensitive to drug and in those with hepatic porphyria or history of asthma, urticaria, or other allergic reactions after taking aspirin or other NSAIDs. Use cautiously in patients with history of peptic ulcer disease, hepatic dysfunction, cardiac disease, hypertension, fluid retention, or impaired renal function.

ADVERSE REACTION  CNS: anxiety, depression, dizziness, drowsiness, insomnia, irritability, headache, aseptic meningitis. CV: heart failure, hypertension, edema, fluid retention. EENT: tinnitus, laryngeal edema, swelling of the lips and tongue, blurred vision, eye pain, night blindness, epistaxis, reversible hearing loss. GI: abdominal pain or cramps, constipation, diarrhea, indigestion, nausea, abdominal distention, flatulence, taste disorder, peptic ulceration, bleeding, melena, bloody diarrhea, appetite change, colitis. GU: proteinuria, acute renal failure, oliguria, interstitial nephritis, papillary necrosis, nephrotic syndrome, fluid retention. Hepatic: jaundice, hepatitis, hepatotoxicity. Metabolic: hypoglycemia, hyperglycemia. Musculoskeletal: back, leg, or joint pain. Respiratory: asthma. Skin: rash, pruritus, urticaria, eczema, dermatitis, alopecia, photosensitivity reactions, bullous eruption

NURSING CONSIDERATION  Because of their antipyretic and antiinflammatory actions, NSAIDs may mask the signs and symptoms of infection. Tell patient to take drug with milk, meals, or antacids to minimize GI distress. Instruct patient not to crush, break, or chew enteric-coated tablets. Advise patient to avoid consuming alcohol or aspirin during drug therapy. Tell patient to wear sunscreen or protective clothing because drug may cause sensitivity to sunlight.

 

    

DRUG NAME

ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING CONSIDERATION  Correct hypovolemia before giving ketorolac When appropriate, give by deep IM injection. Patient may feel pain at injection site. Put pressure on site for 15-30 seconds after injection to minimize local effects. NSAID’S may mask signs and symptoms of infection because of their antipyretic and antiinflammatory actions

Ketorolac Non steroidal antiinflammatory drugs

Unknown. May exhibit prostaglandin synthesis, to produce antiinflammatory, analgesics and antipyretic

For acute pain

Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation Contraindicated in children younger than age 2 and in patients with history of peptic ulcer disease or GI bleeding Use cautiously in patients who are elderly or have hepatic or renal impairment or cardiac decomsation

 

CNS: drowsiness, sedation, dizziness, headache CV: edema, hypertension, palpitations, arythmias GI: nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation Hematologic: decrease platelet adhesion, prolonged bleeding time Skin: pruritus, rash, diaphoresis Other: pain at injection site

DRUG NAME

ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING CONSIDERATION

Dulcolax (Bisacodyl)

Unknown. Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine, by irritating the muscle or stimulating the colonic intramural plexus. Drug also promotes fluid accumulation in colon and small intestine

To prevent constipation.

Contraindicated in patients hypersensitive to drug or its components and in those with rectal bleeding, gastroenteritis, intestinal obstruction, abdominal pain, nausea, vomiting or other symptoms of appendicitis or acute surgical abdomen

CNS: muscle weakness with excessive use, dizziness, faintness GI: nausea, vomiting, abdominal cramps, diarrhea with high doses, burning sensation in rectum with suppositories, laxative dependence with long term or excessive use, protein-losing enteropathy with excessive use Metabolic: alkalosis, hypokalemia, fluid and electrolyte imbalance Musculoskeletal: tetany

Give drug at times that don’t interfere with scheduled activities or sleep Before giving for constipation, determine whether patient has adequate fluid intake, exercise and diet Tell patient to take drug with a full glass of water or juice. Teach patient about dietary sources of bulk, including bran and other cereals, fresh fruit and vegetables. Advise patient to report adverse affects to prescriber.

NURSING CARE PLAN

Assessment Subjective: “madi nak makatakki” as verbalized by the patient Objective: Hyperactive bowel sounds = 30 bourborygmi sound upon auscultation

Diagnosis Impaired bowel elimination r/t loss of nerve conduction above the level of reflex arc

Planning

Intervention

Rationale  To asses causative/ contributing factors  To help determine level of hydration

Evaluation Goal partially met, the patient verbalized understanding of condition, participated on measures to correct the defects, and defecated last December 23 and 29, 2009.

Within the duration  Assisted with of duty, the patient physical will verbalize examination understanding of (palpation the condition, achieve abdomen) normal elimination pattern or  Determined participate in client’s usual measures to daily fluid intake, correct for defects noted condition of skin and mucous membrane  Ascertained clients previous pattern of elimination Ascertained clients S.O’s perception of problem/ degree of disability Encouraged fluid intake up to 3000 or more m/L per day

 For comparison with current situation  To assess the degree of interference/ disability

 For hydration

Encouraged client to verbalize fears/concern about his condition Administered medication as ordered

 Open expression allows client to deal with feelings and begin problem solving  To help his bowel elimination

Assessment Subjective:  Verbal report of fatigue and weakness. “ Agkakapsot ti bagik” Objective:  Needs assistance in repositioning  Inability to do his ADL’s

Diagnosis Activity intolerance r/t neuromuscular impairment

Planning Within the duration of duty, the patient will demonstrate a decrease in physiologic sign of intolerance

Intervention

Rationale

Evaluation Goal partially met. Within the duration of duty, the patient demonstrated a decrease in physiologic sign of intolerance as evidenced by participation of activities of daily living such as grooming, hygiene and turning independently

 Evaluated clients  To provide actual and perceive comparative limitations/ degree of baseline and provide deficit in light of usual information about status needed education/ intervention regarding quality of life  Noted client’s report  Symptoms may of weakness, fatigue, results of/or pain and difficulty contribute to accomplishing his intolerance of task. activity  Ascertained ability to move about and  To determined degree of assistance current status and necessary use of needs associated equipment with participation in needed desired activities.  Encouraged expression of feelings  To assist the client contributing to his to deal with condition contributing factors and manage activities within individual limits  Assist with activities and provide/ monitor  To protect from clients use of assistive injury devices  Promote comfort

measures and provide relief of pain  To enhanced the ability to participate  Repositioning every 2 in activities hours  To prevent bedsore and to maintain body alignment all  Made repositioning the time. schedule and post at  To prevent bedsore bedside and educated and to promote the patient’s S.O in circulation. proper turning the patient

Assessment Subjective: “Hindi ako makaihi as verbalized by the patient” Lack of awareness of bladder fullness  Absence of urge to void Objective:  Uninhibited bladder contraction  Urine output of 150 ml per shift 

Diagnosis Impaired urinary elimination r/t loss of nerve conduction above the level of the reflex arc

Planning Within the duration of duty, the patient will achieve normal elimination pattern or participate in measures to correct or compensate for defects

Intervention  Palpated for bladder distention and observed for over flow  Encouraged to increase his oral fluid intake up to 3,000 or more mL per day  Kept bladder deflated by use of an IFC  Emphasized importance of keeping area clean and dry  Demonstrated proper positioning of catheter drainage tubing and bag

Rationale  Bladder dysfunction is variable but may include loss of bladder contraction To maintain renal function and to prevent infection and formation of urinary stones To empty the bladder To reduce risk of infection To facilitate drainage and to prevent reflux

Evaluation Goal partially met. Within the duration of duty, the patient achieved normal elimination pattern or participate in measures to correct or compensate for defects as evidenced by urine output of 280 ml per shift but still unaware of bladder fullness.

Assessment SUBJECTIVE: “Hindi ako makagalaw” as verbalized by the patient. OBJECTIVE:  Decreased muscle control/strength  Limited ROM  Inability to purposefully more within the physical environment.

Diagnosis Impaired physical mobility related to neuromascular impairment.

Planning

Intervention

Rationale  Evaluates status of individual situation (motor-sensory impairment may be mixed and/ or not clear) for a specific level of injury, affecting type and choice of intervention.  Enables patient to have sense of control, and reduces fear of being left alone.  Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy.

Evaluation Goal met. Within the duration of duty, the patient maintained position of function and skin integrity as evidenced by absence of foot drops, contractures and decubitus ulcer. Patient manifested signs of increased muscle strength

Within the duration  Continually asses of duty, the motor function by patient will requesting patient maintain position to perform certain of function and actions. skin integrity as evidenced by absence of foot drops, contractures and decubitus ulcer  Provide means to summon help.

 Assist in range of motion exercises on all extremities and joints, using slow, smooth movements.

 Plan activities to provide uninterrupted rest  Prevents fatigue, periods. allowing Encourage opportunity for involvement within maximal efforts or individual participations by

tolerance or patient. ability.  Reposition  Reduces pressure periodically even areas, promotes when sitting in peripheral chair. Teach circulation. patient how to use weight-shifting  Open expression techniques. allows client to deal  Encourage with feelings and verbalization of begin problem feelings. solving.  Inspect the skin daily. Observe for pressure areas, and provide meticulous skin care.  Consult with physical or occupational therapist.  Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation.  Helpful in planning and implementing individualized exercise program and identifying or developing assistive devices to maintain function enhance mobility and independence.

DISCHARGE PLAN

M E T H O D S

- Instructed patient Y to take his medication on time with right dose and to complete the duration of his medicine. - Encouraged him to do his activities of daily living as tolerated without exerting too much effort. -Instructed patient to follow his treatment for his faster recovery. - Advised patient Y to maintain his good hygiene by brushing and bed bathing with the help of his S.O everyday tooth

Instructed patient Y to strictly follow scheduled check-up.

- Encouraged patient Y to eat nutritious fruits rich in Vitamin C, such as calamansi and protein rich foods. - Encouraged patient Y to pray to God for his guidance and protection.

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