CASE STUDY SCENARIO: HERNIATED NUCLEUS PULPOSUS

A 43-year-old male is seen with severe low back pain extending down the leg to the left lateral
calf region. Onset of pain was sudden and insidious of one day’s duration. He is a construction
worker for 20 years, injured his back 8 years ago while pouring a concrete.

For the last 2-4 months, prior to admission, he had low back stiffness with progressive tension
up the spine and increasing severe pain mostly in the left hip region radiating down to the back
of his thigh to the left lateral calf and cannot already go to work regularly. He had 3 consecutive
check up in the nearest RHU and given only mefenamic acid 500mg every 6 hours PRN.

Upon admission in the Emergency Room of POC, May 5, 2021, he claimed that he is unable to
get out of bed without assistance of his wife and requires help to shower and dress, waking in
the night every 2-3 hours with severe buttock and posterior thigh pain and denies any pins,
needles or numbness but his right leg has become heavy.

His initial vital signs were the following: BP-150/90, PR-90/cpm, RR-30/bpm and Temp- 37.8
degree Celsius. Pain made worse with coughing, straining, or laughing, claimed also by the
client and 100 kgs weight is now 85 kgs, height 5’9”.

The patient is living in Lucban, Quezon, a quiet and peaceful place, living together with
her husband who is an X-ray Technician. The couple is well-known in their community and
active to any programs in their barangay,church and other social activities.

As a construction worker, he need to wake up at 4:00 am and her work usually starts at
7 am and ends at 5 pm, requires him to travel daily from their home. Early in the morning, he
used to water his plants in their small garden and spent his off days by gardening.

He drinks alcohol occasionally and can consume 3-5 sticks of cigarette/day. His parents
died of stroke. He had 2 children, married already and 3 brothers, also construction workers, all
married, with no known disease. No record of hospitalization except cough, colds and fever and
relieved after taking over the counter drugs like paracetamol, ambroxol and neozep. Once in a
while, he visit the nearest barangay RHU. He used to eat vegetables from their garden, like also
to buy and eat red meat and fish in their barangay”talipapa”.

Initially, an Ibuprofen and Panadeine forte 1 tab every 6 hours had been prescribed
while in the Emergency Room.

The following day, a lumbar spine CT ordered and reported a L5S1 disc protrusion with
right S1 nerve root compression. Also, an MRI was ordered for confirmation. Sagittal and axial
MRI sections revealed a large right-sided L5-S1 extruded with superior migration up to the level
of the L5 vertebral body. This herniated disc was resulting in severe L5 -S1 spinal stenosis and
compression, the right-sided of nerve roots (radiculopathy) manifesting in pain, numbness and
weakness. All his routine laboratory works were normal.

The client completed a 4-week conservative treatment plan that consisted of spinal
stabilization, pain relief modalities, and soft tissue mobilization. He responded positively to
methods such as electrical muscle stimulation, acupuncture, and myofascial release therapy. A
pelvic girdle traction was also applied. These treatments aided in the process of reversing the
inflammation as a result of the herniated disc. Although he responded positively to the
treatment, the patient continued to experience pain especially when sitting for longer than one
hour. He was prescribed pain medication such as NSAIDs, which were not helpful in relieving
his pain.

The patient was referred to an orthopedic surgeon and ordered micro-discectomy under
general anesthesia. The client undergone a microdiscectomy and went home 1 day after the
procedure. Weakness and numbness resolved after few days. Subsequently, his symptoms
significantly decreased and he was able to return to normal ADL’s without experiencing pain.
The patient was cleared to return to his usual activities and further follow up was suggested but
discouraged to return from his previous job as laborer.
I. INTRODUCTION

Nucleus pulposus herniation is the most common cause of sciatic pain and one of the
most common indications for spine surgery worldwide.This condition presents as a
displacement of the nucleus pulposus beyond the intervertebral disc space. 
A disc herniation occurs when the discs between the bones (or vertebrae) of the spine
degenerate due to repetitive stress, and the soft inner gel leaks out into the spinal
canal, putting pressure and irritating the surrounding nerves, causing pain, weakness,
and numbness in the arms, and legs. Rest, medication, and physical therapy can help
ease any discomfort, but when the pain persists even during minimal movements or
gets in the way of everyday activities, surgery to remove the herniated disc material is
recommended.
Diagnosis is usually by MRI or CT. Treatment of mild cases is with analgesics, activity
modification, and physical therapy. Bed rest is rarely indicated. Patients with
progressive or severe neurologic deficits, intractable pain, conservative treatment
failure, or cauda equina syndrome with associated sphincter dysfunction may require
immediate or later elective surgery.

Globally, the prevalence of HNP is about 1–3% in Finland and Italia. In the US, 1–2% of
the population are afflicted with HNP.3 Aside from that, the incidence of HNP in some
developing countries is about 15–20% of the total population. This disease mainly
attacks adults in the age of 30–50 years old and peaks at 40– 45 years old. HNP in the
thoracic vertebrae is very rare and happens only in 1:1 million patients. In individuals of
age between 25-55 years old. Citation

Locally, based on research, the Philippines Statistics Authority (PSA) identified back
pain as the most common occupational disease among workers in 2011, 2013, and
2015. Those engaged in manual labor are prone to back pain (34.3 percent or 14,185
cases), as are those in administrative positions and the call center industry (25.6
percent or 10, 581 cases).

State also reason for choosing this study

General Objectives:
To gain a deeper knowledge and understanding with regards to the disease and
able to provide optimum and standard quality care to the patient through making of the
nursing interventions and health education regimen.

Specific Objectives:

At the end of this case study, the student will be able to:

Knowledge
 Observe necessary information regarding the patient and his condition
 Formulate and prioritize nursing care plan for patient
 Improve knowledge regarding herniated nucleus pulposus
 Identify the main cause of the disease

Skills
  Carry out independent and dependent intervention being done to the client
appropriately and with care
 Perform comprehensive nursing intervention based in the client priority needs
 Demonstrate critical thinking skills necessary for providing safe and effective
nursing care
Attitudes
 Strengthen cooperation and unity among member of the group by performing
right and proper nursing intervention and responsibilities
 Enhance our confidence in handling a patient with same condition
 Develop a warm environment between the student and the patient for better
working relationship towards improvement of health
Client Centered:
At the end of this case study, the patient will able to
Knowledge
 Identify the importance of the treatment done to the patient
 Observe for the client’s condition
 Understand the proper management of her condition
Skills
 Compliance to continue intervention and health teaching provided by the student
 Cooperate with the management of her condition
 Modify the needs for a healthy lifestyle to improve condition
Attitudes
 Express awareness on the needs and condition of her present status
 Develop the family’s support system and distinguish their respective roles in
improving her health status
 Show involvement in promoting on her general health

II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

Name: Patient X

Age: 43 years old

Address: Lucban, Quezon

Gender: Male

Date of Birth: June 12, 1978

Birth Place: Quezon City

Civil Status: Married

Occupation: Construction worker

Position/Role in the family: Husband and Father

Nationality: Filipino
Chief Complaint: Severe lower back pain

Final Diagnosis: Herniated Nucleus Pulposus

2. Environmental Status

The patient is living in Lucban, Quezon, a quiet and peaceful place, living together with
his wife who is a X-ray Technician. Their house is bungalow-type made up of concrete
and wood which is well ventilated and sturdy enough for them to live. Their house was
very close with their neighbor’s house because houses in their area were built close to
one another. Their mode of transportation is walking, they use jeepneys and tricycles.
The source of their water is the local water system. Garbage and waste are placed on
sacks and collected every Monday, Wednesday, and Friday.

3. Lifestyle Status
Patient X is a construction worker  and he need to wake up at 4:00 am and his work
usually starts at 7 am and ends at 5 pm, requires him to travel daily from their home.
Early in the morning, he used to water his plants in their small garden and spent his off
days by gardening. He drinks alcohol occasionally and can consume 3-5 sticks of
cigarette/day.
4. History of Past Illness
Patient X has a history of injured his back 8 years ago while pouring concrete.
For the last 2-4 months, he had low back stiffness with progressive tension up
the spine and increasing severe pain mostly in the left hip region radiating down
to the back of his thigh to the left lateral calf. According to him, he had no any
prior consultations nor confinement regarding his complaint for he thought that it
was natural due to the nature of his work. In addition, it was noted that he has no
family health history of Herniated Nuclues Pulposus or any back or spine injury.
Meanwhile, he stated that his parents died of stroke. He had 2 children, married
already and 3 brothers, also construction workers, all married, with no known
disease. This is part of the hx of present illness 

5. History of Present Illness

Few hours prior to admission at around 8:45 am on June 23, 2021, patient X was
seen with severe low back pain extending down the leg to the left lateral calf
region. According to him, the onset of pain was sudden and insidious of one
day’s duration, Upon admission in the Emergency Room, he claim that he is
unable to get out of bed without assistance of his wife and requires help to
shower and dress, waking in the night every 2-3 hours with severe buttock and
posterior thigh pain and denies any pins, needles or numbness but his right leg
has become heavy. 
B. GENOGRAM

PATERNAL SIDE MATERNAL SIDE

72 77 83 76

65 72 77 74 71 81 77 75 72 65 60

MALE
HYPERTENSION
FEMALE
54 43 40 37 ALCOHOLIC
DEAD
INJURY
PATIENT X

SMOKER
6. 13 Areas of Assessment

I. Social Status

Patient X is a 43 years old man, Lives in Lucban, Quezon. He lives

with his wife. According to patient X, he loves hang out with their relatives
and friends. Patient X has a good relationship with his family members.

Norms:
The ability to interact successfully with people and within
environment of which each person is a part to develop and maintain
intimacy with significant others and to develop respect and tolerance for
those with different opinions and beliefs which are necessary determinants
for a person’s social state. (Kozier, 2015)

Analysis:
Patient X has a good social relationship with his family and friends.
It was also added that he tends to be active to any programs in
their barangay church and other social activities together with his wife.

II. Mental Status

General Appearance and Behavior
Patient X is well groomed and organized in his appearance. He looks
weak but able to answer all the questions asked to him with all sincerity
and confidence. He can maintain eye contact and alertness during the
interview. He is focused and does not get easily distracted with his
surroundings. His facial expression might shows he is in pain but he was
able to manage it.

Level of Consciousness
Patient X shows awareness and consciousness in his surroundings by
being able to respond and think properly.

Orientation
Patient X can tell the exact date, time, and the place where he was
admitted. He is aware in the reason of her hospitalization.

Speech
Patient X can speak clearly and express himself despite having difficulty in
due to pain as evidenced by frequent grimacing and groaning.

Intellectual Function
Patient X was able to understand all of the questions during the interview
and the purpose of conducting it. He could think properly on his own
without the need of companion to help him.

Norms:
The patient should appear relaxed with the appropriate amount of concern
for the assessment. The patient should exhibit erect posture, smooth gait
and symmetrical body movement. The patient should be clean and well-
groomed and should wear appropriate clothing for age, weather, and
socioeconomic status. Facial expressions should be appropriate to the
content of the conversation and should be symmetrical. The patient should
be able to produce spontaneous, coherent speech. Content of the
message should match the patient educational level. The patient should
be correctly responding to questions and to identify all the objects as
 requested. Denial and poor eye contact is normal response on the first
interaction that may be due to uneasiness on the presence of a stranger
or an attempt to screen or ignore unacceptable realities by refusing to
acknowledge them. The patient should demonstrate a realistic awareness
and understanding of self. The patient should be able to evaluate and act
appropriately in situations requiring judgment. Thought process should be
logical, coherent and goal-oriented. Thought content should be based on
reality. (Health Assessment and Physical Examination, 3rd Edition)

Analysis:
Being responsive and able to answer questions accordingly are the major
determinants, which indicate patient’s mental capabilities are still
functioning well. He has a normal mental status.

III. Emotional Status

While assessing Patient X, he was quite, lacking of ease because of
his condition. But he still handle to cooperate with us and able to answer
our questions.

Norms:
Normally, the patient should have the ability to manage stress and to
express emotion appropriately. It also involves the ability to recognize,
accept and express feelings and to accept one’s limitations.
(Fundamentals of Nursing: Concepts, Process, and Practice, 10th Edition,
2018)
Analysis:
Patient X was able to answer our questions even though he has an illness
to bear. He only subjects to the questions that is being asked to him, other
than that he is quite.

IV. Sensory Perception

Patient X has normal hearing acuity by doing the watch tick test. He
responded that he can hear the tick of the watch. His sense of smell is
normal whereas the patient was asked to smell a spray of alcohol on one
hand and he said that he can smell it well and both nares are noted to be
patent. His sense of taste appeared to be normal as he stated he can
appreciate the flavor of the food that he eats almost every day. For the
sense of sight, the patient said that he cannot read well due to blurred
vision wherein he uses an eye glasses with a prescription of 280 on both
eyes for him to read. Sense of touch is normal since the patient could
easily react to the inflicted pain and certain cold or warm temperature
against his skin.

Norms:
Each of the five senses becomes less efficient as the age
advances. Changes result in loss of visual acuity, less power of adaptation
to darkness and dim light, decreased in accommodation to near and far
objects. The loss of hearing is the ability related to aging effects people
over age 65. Gradual loss of hearing is more common among man than
women, perhaps because men are more frequently in noisy work
environment. Older people have a poorer sense of taste and smell and are
less stimulated by food than young. Loss of skin receptors takes place
 gradually, producing in increased threshold for sensations of pain, touch,
and temperature. (Fundamentals of Nursing 7th edition Barbara Kozier)

Analysis:
Patient X’s sense of hearing and sense of touch are normal even his
sense of smell and taste. However, the patient has difficulty to read due to
blurred vision because of his advancing age.

V. Motor Status
Patient X need assistance when he’s standing up and requires help to
shower and dress due to his severe low back pain mostly in his buttocks
and in the left hip region radiating down to the back of his thigh to the left
lateral calf, also he need assistance for his safety. Also, a pelvic girdle
traction is applied.

ASSESS YOU PATIENT

Norms:
Normal motor stability includes the ability to perform different activities
without causing pain and discomfort. It should be firm and have
coordinated movements. (Estes, 2011)
Analysis:
Patient X needs assistance when he’s standing up and requires help to
shower and dress due to his severe low back pain. Since pelvic girdle
traction was applied, his range of motion is limited and discomfort at
certain degrees whenever he moves occurs.

VI. Body Temperature

Date Assessed Time Temperature

June 23, 2021 8:47 am 37.8 °C
Norms:
Normal
axillary

temperature is within 36.4°C to 37.5°C. (Health assessment and physical

examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
Upon assessing Patient X’s body temperature, the data given above
indicates that he has a low grade fever possibly due to his disease
process wherein he experience severe lower back pain.

VII. Respiratory Status

Date Assessed Time Respiratory rate

June 23, 2021 8:47 am 30 rpm

When Patient X was auscultated in lungs, there are no adventitious

sounds noted. However, it was stated by the patient that he was having
 difficulty on breathing because he feels pain at his lower back as he
inspires.
Norms:
Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of
pattern, normal respirations must be regular and even in rhythm. The
normal depth of respirations is non-exaggerated and effortless. (Health
assessment and physical examination 3 rd edition by Mary Ellen Zator
Estes).
Analysis:
Patient X has abnormal respiratory status. His respiratory rate is above
normal which is 26 rpm. According to the patient, he tends to breathe
shallowly to minimize the pain as he inspires.
VIII. Circulatory Status

Date assessed Time Heart rate Blood

pressure
June 23, 2021 8:48 am 90 bpm 150/90
mmhg

During the assessment of his capillary refill, his nail beds returned to its
original color after 2 seconds.
Norms:
The normal cardiac rate or pulse rate of an adult is 60-100 bpm. The
average blood pressure of a healthy adult is 110 to 120 systole 70 to 80
diastole. The normal capillary refill test is 2-3 seconds and upon capillary
refill test was done and it returns to normal state within 2-3 second.
(Kozier, Fundamentals of Nursing 7th Edition.)

Analysis:
The data given above shows that Patient X’s heart rate is normal however,
the blood pressure was noted to be increased due to his current condition.
Pain could be a great factor why the heart rate of the patient was
increased.

IX. Nutritional Status

As a construction worker, patient X needs to wake up at 4:00 am as
his work usually starts at 7 am and ends at 5 pm, therefore, he always
skips his breakfast and tend to drink coffee only. However, he added that
he eats generously at a carinderia during his lunch time with different
viands, mostly fish and vegetables.
 Nutritional Parameters
Parameter Computation Norms Analysis
1. BMI Weight(kg)/ <16= Patient X’s

Height- 5’9” [height(m)]^2 Malnourished BMI is noted

Weight- 85 85/(1.75)^2= 16- to be under

kg 85/3.0625= 19=Underweight the category

27.76/m^2 20-25=Normal of overweight.

26-30=

Overweight

31-40=Moderate

to severe obesity

>40=Morbidly

obese

(Fundamentals of

Nursing by Kozeir,

et al,.)

Norms:
According to the Health Asian Diet Pyramid, there should be a daily
intake of rice, grains, bread, fruit and vegetables; optional daily for fish,
shellfish, and dairy products; weekly for sweets, eggs and poultry, and
monthly for meat. There should be an increase intake of a wide variety of
fruits and vegetables. Include in the diet foods higher in vitamins C and E,
and omega-3 fatty acid rich foods. Fluid intake is on the average of 8-10
glasses per day (Mohan, 2002).

Analysis:
Patient X’s nutritional status is normal. There is a significant weight loss
reported wherein from 100kg, it decreased on 85 kg. However, is BMI is
still not normal since it still falls under the category of overweight. Skipping
breakfast is noted to be unhealthy since he does weight-bearing activities
for 10 hours and heavy meals in the morning is recommended to match
his energy consumption.

X. ELIMINATION STATUS
Patient X claimed that he usually defecates once a day with semi
solid consistency, brownish in color and normal amount in elimination. He
voids 2-3 times a day, light yellow in color with normal amount. However,
since the pain arises in his lower back, he’s having difficulty on defecating
 and voiding since straining aggravates the pain on his back down to his
buttocks.
Norms:
Normal bowel movement of a person must be 1 to 2 times a day
and voiding in 3 to 4 times a day with an output of 1200 to 1500 ml a day.
A normal stool is brown in color and well formed, urine is clear to yellowish
in color. (Fundamentals of Nursing, kozier, 2007)
Analysis:
elimination and voiding pattern is within normal but then, pain
during urination and defecation is noted to be not normal in relation to his
disease process. Why?
XI. REPRODUCTIVE STATUS
Patient X was circumcised at 11 years old. He didn’t undergo to any
surgery for sterility, and doesn’t have any disease pertaining to his
genitalia. Upon admission, there were no abnormalities noted and there
are no presence of discharges, lesions, and tenderness upon palpation
and other deviations from the genitals and its surrounding area. The pubic
hair is well distributed 

Norms:
Examination of the penis includes the skin, corporal erectile bodies,
and urethral meatus. It should be noted whether the patient is circumcised
or uncircumcised. The ease with which a redundant prepuce is retracted is
assessed. The entire penile skin, including that beneath the prepuce,
should be examined for ulcers, warts, rashes, or other lesions. The size
and position of any skin lesion should be described along with the degree
of tenderness to palpation and fixation to subcutaneous tissue. If penile
skin lesions are found, correlation of palpable deep or superficial inguinal
adenopathy should be made at that time. Examination for urethral
discharge or urethral mucosal lesions near the meatus should also be
carried out by everting the lips of the meatus. (Maxwell White, Clinical
Methods: The history, Physical, and Laboratory Examination. 3 rd edition.)

Analysis:
 Patient X reproductive status is normal.

XII. SLEEP-REST PATTERN

Patient X’s stated that he usually sleeps 7 to 8 hours a day. He

usually sleeps at 8 or 9 pm and wakes at 4:00 am. Early in the morning,
he used to water his plants in their small garden and spent his off days by
gardening. He usually watches television at home during rest hours.
Norms:
Sleep refers to altered consciousness with general slowing of
physiologic process while rest refers to relaxation and calmness, both
mental and physical. A typical sleeper will pass through 7 to 9 hours of
sleep and take a rest using home relaxation activities such as reading,
telling stories and others. (Nursing Fundamentals by Rick Daniels)
Analysis:
 Patient X has a normal and adequate sleep pattern.
XIII. STATE OF SKIN AND APPENDAGES

Patient X’s skin is brown, his hair is thin, fine and black in color. His
palpebral conjunctiva is slightly pink and her sclera is white in color.
Norms:
Obvious changes occur in the integumentary system (skin, hair,
nails) with age. The skin becomes drier and more fragile, the hair loses
color, the finger nails and toe nails become thickened and brittle, and in
man over 60, facial hair increases. These integumentary system changes
accompany progressive losses of subcutaneous fat and muscle tissue,
muscle atrophy, and loss of elastic fibers. (Fundamental of Nursing 7th
Edition by Barbara Kozier)
The palpebral conjunctiva should appear pink and moist. Normally,
the skin is a uniform whitish pink or brown color, depending on the
patient’s race. Normally, the nails have a pink cast in light-skinned
individuals and are brown in dark-skinned individuals. (Health Assessment
and Physical Examination 3rd Edition by Mary Ellen Zator Estes)
Analysis:
Based from the above information, the patient has normal state of
skin appendages, however, limited range of motion among his extremities
—especially on his lower extremities are noted due to immobility
secondary to pain.
7. LAB AND DIAGNOSTIC TEST

Diagnostic/ Date Indication/purpose Result Normal values Analysis and Nursing responsibilities prior to, during, and

laboratory ordered/ interpretation of results after the procedure

procedure date

done
Date >A CT scan of the lumbar spine >L5 S1 >Alignment is >There is a presence of Before:

lumbar ordered: may be performed to assess the Disc normal. No herniated disc at lumbar >Check doctor’s order.

spine CT spine for a herniated disk, tumors protrusion fracture or segment 5 and sacral >Confirm patient identity using 2 identifiers.

Date and other lesions, the extent of with right dislocation. Disc segment 1 (L5-S1) usually >Explain the procedure.

done: injuries, structural anomalies, and S1 nerve space heights are causes S1 nerve > Check for NPO status.

other conditions. root preserved. The impingement. >Notify the laboratory and practitioner about any

> A technologist will ask you to lie compressi sacroiliac joints this type of herniated disc medications being taken that may affect the test

on your back during the test. The on are normal. No can lead to weakness results; these may need to be restricted.

technologist may use pillows or prevertebral soft when standing on the During:

straps to ensure that you stay in tissue swelling. toes. Numbness and pain > Instruct the patient to remain still.

the correct position long enough for can radiate down into the >wear comfortable clothing or a gown during the

a quality image to be obtained. You sole of the foot and the procedure.

may also have to hold your breath outside of the foot. After:
 during brief individual scans. >perform neurological checks and vital signs and

Using a remote from a separate compare with baselines.

room, the CT technologist will > Instruct the patient to resume the usual diet and

move the table into the CT activities unless otherwise ordered.

machine.  >Note and report suspected fracture of injury to

the cervical spine or neck pain.

> Encourage the patient to increase fluid intake (if

a contrast is given)

Diagnostic/ Date Indication/purpose Result Normal values Analysis and Nursing responsibilities prior to, during, and

laboratory ordered/date interpretation of after the procedure

procedure done results

MRI Date ordered: >Magnetic >Sagittal and .>Vertebral height, disc .> This herniated Before:

resonance imaging axial MRI height, alignment and disc was resulting >Check doctor’s order.

Date done: (MRI) uses a large sections bone marrow signal are in severe L5 -S1 >Confirm patient identity using 2 identifiers.

magnet and radio revealed a large within normal limits. The spinal stenosis > Explain to the patient that skeletal MRI

waves to look at right-sided L5- canal and neural exit and compression assesses bone and soft tissue. Tell him who will

organs and S1 extruded foramina are capacious at the right-sided of perform the test and where it will take place.

structures inside with superior all levels. The conus nerve roots >remove all accessories and jewelries.

your body. Health migration up to terminates at the T12/L1 (radiculopathy) > Check for NPO status.

care professionals the level of the level and is normal in manifesting in > If the patient is claustrophobic or if extensive

use MRI scans to L5 vertebral appearance. pain, numbness time is required for scanning, explain to him that

diagnose a variety of body. and weakness. a mild sedative may be administered to reduce

conditions, from torn anxiety. Open scanners have been developed

ligaments to tumors. for use on the patient with extreme

MRIs are very useful claustrophobia or morbid obesity, but tests using

for examining the such machine take longer.

brain and spinal During:

cord. > Instruct the patient to remain still throughout

the procedure.
 > If the test is prolonged with the patient lying

flat, monitor him for orthostatic hypotension.

>wear comfortable clothing or wear a gown

during the procedure.

After:

>perform neurological checks and vital signs

and compare with baselines.

> Instruct the patient to resume the usual diet

and activities unless otherwise ordered.

>Note and report suspected fracture of injury to

the cervical spine or neck pain.

> Encourage the patient to increase fluid intake

(if a contrast is given)

Diagnostic/ Date Indication/purpose Result Normal values Analysis and interpretation Nursing responsibilities prior to, during, and

laboratory ordered/ of results after the procedure

procedure date

done
Date > a blood test used WBC: 7,000 cells WBC: 4,500 to 11,000 cells Before:
CBC ordered: to evaluate your mcL per microliter (cells/mcL) >All results are in normal >Explain test procedure. Explain that slight

(Complete overall health and RBC: 5.2 million RBC: 4.5 million to 5.9 million range. discomfort may be felt when the skin is

Blood Date detect a wide range cells mcL cells/mcL for men; 4.1 million punctured.

Count) done: of disorders. Hemoglobin: 15.2 to 5.1 million cells/mcL for >Encourage to avoid stress if possible because

>A needle is gm/dL women altered physiologic status influences and

inserted into the Hematocrit: 45% Hemoglobin: 14 to 17.5 changes normal hematologic values.

vein, and the blood Platelets: 320,000 grams per deciliter (gm/dL) for During:

is collected in an air- platelets/mcL men; 12.3 to 15.3 gm/dL for > Instruct the patient to remain still.

tight vial or a women .

syringe. During the Hematocrit: 41.5% to 50.4% After:

procedure, the band for men; 35.9% to 44.6% for >Apply manual pressure and dressings over

is removed to women. puncture site.

restore circulation. Platelets: 150,000 to 450,000 >Monitor the puncture site for oozing or

Once the blood has platelets/mcL hematoma formation.

been collected, the

needle is removed,

and the puncture

site is covered to
 stop any bleeding.

Diagnostic/ Date Indication/purpose Result Normal values Analysis and Nursing responsibilities prior to, during, and

laboratory ordered/ interpretation after the procedure

procedure date of results

done
Date >A urinalysis is a Color – light Yellow Color – Yellow (light/pale to Before:

UA ordered: test of your urine. A Clarity/turbidity – Clear dark/deep amber) >All results are >Instruct the patient to void directly into a clean,

(Urinary urinalysis is used to pH – 7 Clarity/turbidity – Clear or cloudy in normal range dry container. Sterile, disposable containers are

Analysis) Date detect and manage Specific gravity – 1.005 pH – 4.5-8.0 recommended. Women should always have a

done: a wide range of Glucose –Negative Specific gravity – 1.005-1.030 clean-catch specimen if a microscopic
disorders, such as Ketones – None Glucose – Negative examination is ordered. Feces, discharges,

urinary tract Nitrites – Negative Ketones – None vaginal secretions and menstrual blood will

infections, kidney Leukocyte esterase- Nitrites – Negative contaminate the urine specimen.

disease and Negative Leukocyte esterase – Negative

diabetes. Bilirubin – Negative Bilirubin – Negative

>A urinalysis test is Protein – Negative Protein- Negative After:

performed by RBCs - Negative RBCs - - Negative >Cover all specimens tightly, label properly and

collecting a urine WBCs – Negative WBCs - Negative send immediately to the laboratory.

sample from the Squamous epithelial cells Squamous epithelial cells – 1-5 >Observe standard precautions when handling

patient in a -2 squamous epithelial squamous epithelial cells/hpf urine specimens.

specimen cup. cells/hpf Casts – 0-5 hyaline casts/lpf

Usually only small Casts – 0 hyaline casts/lpf Crystals – Occasionally

amounts (30-60 mL) Crystals – Occasionally Bacteria and parasites – None

may be required for Bacteria and Parasites – Yeast - None

urinalysis testing. None

The sample can be Yeast - None

either analyzed in

the medical clinic or

sent to a laboratory

to perform the tests.

ANATOMY AND PHYSIOLOGY

VERTEBRAL COLUMN (SPINE)

The vertebral column originally develops as a series of 33

vertebrae, but this number is eventually reduced to 24
vertebrae, plus the sacrum and coccyx. The vertebral
column is subdivided into five regions, with the vertebrae
in each area named for that region and numbered in
descending order. In the neck, there are seven cervical
vertebrae, each designated with the letter “C” followed by
its number. Superiorly, the C1 vertebra articulates (forms a
joint) with the occipital condyles of the skull. Inferiorly, C1
articulates with the C2 vertebra, and so on. Below these
are the 12 thoracic vertebrae, designated T1–T12. The
lower back contains the L1–L5 lumbar vertebrae. The
single sacrum, which is also part of the pelvis, is formed by
the fusion of five sacral vertebrae. Similarly, the coccyx, or
tailbone, results from the fusion of four small coccygeal
vertebrae. However, the sacral and coccygeal fusions do
not start until age 20 and are not completed until middle
age.

The disc between the thoracic vertebrae allows great

flexibility in the thoracic region; thick disc between the
lumbar vertebrae reduce flexibility. Notice that the terms
convex and concave refers to the curvature of the
posterior aspect of vertebral column.

A TYPICAL VERTEBRA, SUPERIOR VIEW.

All vertebrae have a similar structural pattern. The common

features of vertebrae include the following:

 Body or the centrum: disclike, weight-bearing part of

the vertebra facing anteriorly in the vertebral
column.
 Vertebral arch: arch formed from the joining of all
posterior extensions, the laminae and pedicles, from
the vertebral body.
 Vertebral foramen: canal through which the spinal
cord passes.
 Transverse process: two lateral projections from the
vertebral arch.
 Spinous process: single projection arising from the
posterior aspect of vertebral arch.
 Superior articular process and inferior articular
process: paired projections lateral to vertebral
foramen, allowing a vertebra to form joints with
adjacent vertebrae.
REGIONAL CHARACTERISTICS OF VERTEBRAE

CERVICAL VERTEBRAE

The seven cervical vertebrae (identified as C1 to C7) from the neck region of the spine. The first two
vertebrae (atlas and axis) are different because they perform functions not shared by the other cervical
vertebrae. The atlas (c1) has no body. The superior surfaces of its transverse processes contain large
depressions that receive the occipital condyles of the skull. This joint allows you to nod “yes.” The skull
axis (c2) acts as a pivot for the rotation of the atlas above. It has a large upright process, the dens, which
acts as the pivot joint. The joint between C1 and C2 allows you to rotate your head from side to side to
indicate “no.”

the “typical” cervical vertebrae are C3 to C7. They are the smallest, lightest vertebrae. The transverse
process of this contains foramina (openings) through which the vertebral arteries pass on their way to
the brain above.
THORACIC VERTEBRAE

Thoracic vertebrae (T1 to T12) are all typical. They are larger than the cervical and are distinguished by
the fact that they are the only vertebrae to articulate with the ribs. The transverse process of each
thoracic articulate with the knoblike tubercles of the ribs. The spinous process is long and hooks sharply
downward.

LUMBAR VERTEBRAE:

Lumbar vertebrae (L1 to L5) have massive, blocklike bodies that are somewhat kidney bean shaped.
Because of the stress on the vertebral column occurs lumbar region, these are the sturdiest of the
vertebrae.

Sacrum

Superiorly it articulates with L5, and inferiorly it

connects with the coccyx. The sacrum is a shield-
shaped bony structure that is located at the base of
the lumbar vertebrae and that is connected to the
pelvis. The sacrum forms the posterior pelvic wall and
strengthens and stabilizes the pelvis.

Coccyx

Is formed from fusion of three to five tiny, irregular

shaped vertebrae. It is the human “tailbone.” helps
support your weight while you sit. If you lean back
while sitting, such as reclining in a chair, the pressure
on your coccyx increases.
 PATHOPHYSIOLOGY

Modifiable: Disc degeneration: deterioration Non-Modifiable:

and loss of function in the cells of a
 Sedentary Lifestyle (lack of tissue or organ.  Age
physical activities or exercise
 Family history
 Postural Problems (lifting
heavy objects)
 Trauma
 Occupation
 Smoking Decreased in protein contents
(oncotic agents)

Decreased fluid in
the annulus

Development of the radiating

cracks in the annulus weakens
resistance to nucleus herniation.

Erosion of vertebral body by

bulging disk teared annulus

Protrusion or rupture of the

nucleus pulposus.

Pain (Radiculopathy): pain,

Stimulation of new bone growth weakness, numbness and tingling
accompanied by vertebral spasm. Irritated pain fibers

Herniated Intervertebral Disk

Local Tenderness Ligaments thicken.

Increased tension Calcification

Replacement of nucleus

Neutral obstruction

Decrease of blood in the affected area. Numbness occurs.

Compression of spinal nerve Impaired mobility

BOOK BASED: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th Edition Volume 2

Degenerative changes: vascular channels start to fail, and

vascular diffusion of nutrients decrease thus number of viable
chondrocytes in the nucleus pulposus diminishes.

Loss of protein polysaccharides in the disk

Water binding capacity of the

nucleus decreases.

Nucleus becomes more fibrous &

stiffer.

Nucleus is less able to bear &

distribute load, transferring load to
the posterior annulus.
B. PLANNING
Nursing Care Plan #1

ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION

DIAGNOSIS
Subjective: “Hirap ako  Self-care deficit Within 48-72 hours of  Monitor vital signs for baseline After 48-72 hours of
kumilos mag-isa, hindi related to rendering appropriate nursing data rendering appropriate
ko kaya” decreased mobility intervention, the patient will:  Assist with clients needs (e.g., nursing intervention, Goal
as evidenced by - Identify individual personal care plans while met. The patient was able
inability to control areas of weakness minimizing problems) to:
 Objective: lower extremities or needs.  Promote client’s/significant other’s - Identify individual
 Body Weakness - Verbalize (SO) participation in problem areas of
 Pain upon moving knowledge of identification and desired goals weakness/ needs.
 Altered ADL healthcare and decision making. To enhance - Verbalize
 Vital signs are as practices commitment to plan, optimize knowledge of
follows:
- Demonstrate outcomes, and support recovery healthcare
o BP:150/90
techniques and and/or health promotion practices
o HR:90 bpm
o RR:22 bpm lifestyle changes to  Develop plan of care appropriate - Demonstrate
o TEMP:37.8 °C meet self-care to individual situation, scheduling techniques and
needs activities to conform to client’s lifestyle changes
- Perform self-care usual or desired schedule to meet self-care
activities within  Practice short-term goal setting needs
level of own ability and achievement. To help a - Perform self-care
- Identity personal  Provide for communication among activities within
and community those who are involved in caring level of own ability
resources that can for or assisting the client. To - Identity personal
provide assistance enhance coordination and and community
continuity of care. resources that
 Perform client’s needs when he or can provide
 she is unable to meet own needs. assistance
(e.g., bathing, toileting)
 Schedule activities to prevent or
accommodate fatigue and/or
exacerbation
 Assist client in accomplishing
activities of daily living, encourage
client to easily accomplish task. To
enhance client’s capabilities and
promote independence
 Provide privacy to enhance self-
esteem and improve ability to
urinat---0e or defecate.
 Assist with medication regimen as
necessary, encouraging timely use
of medications (e.g., use of pain
relievers)


 Monitor fluid and hydration status

 Perform pain assessment each
time pain occurs to demonstrate
improvement in status or to identify
worsening of underlying
condition/developing
complications.
 Use effective coping strategies
throughout stay in hospital
  Discuss impact of pain on
lifestyle/independence and ways to
maximize level of functioning
 Collaborate in treatment of
underlying condition or disease
processes causing pain and
proactive management of pain
 Provide or promote
nonpharmacological pain
management: Quiet and calm
activities

NURSING CARE PLAN #2

ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION

Subjective: “Hirap ako  Self-care deficit
kumilos mag-isa, hindi
ko kaya”
 Objective:
 Body Weakness
 Pain upon moving
 Altered ADL
 Vital signs are as
follows:
o BP:150/90
DIAGNOSIS
Within 48-72 hours of  Monitor vital signs for baseline After 48-72 hours of
related to rendering appropriate nursing data rendering appropriate
decreased mobility intervention, the patient will:  Assist with clients needs (e.g., nursing intervention, Goal
as evidenced by - Identify individual personal care plans while met. The patient was able
inability to control areas of weakness minimizing problems) to:
lower extremities or needs.  Promote client’s/significant other’s - Identify individual
- Verbalize (SO) participation in problem areas of
knowledge of identification and desired goals weakness/ needs.
healthcare and decision making. To enhance - Verbalize
practices commitment to plan, optimize knowledge of
- Demonstrate outcomes, and support recovery healthcare
techniques and and/or health promotion practices
o HR:90 bpm lifestyle changes to  Develop plan of care appropriate - Demonstrate
o RR:22 bpm meet self-care to individual situation, scheduling techniques and
o TEMP:37.8 °C needs activities to conform to client’s lifestyle changes
- Perform self-care usual or desired schedule to meet self-care
activities within  Practice short-term goal setting needs
level of own ability and achievement. To help a - Perform self-care
- Identity personal  Provide for communication among activities within
and community those who are involved in caring level of own ability
resources that can for or assisting the client. To - Identity personal
provide assistance enhance coordination and and community
continuity of care. resources that
 Perform client’s needs when he or can provide
she is unable to meet own needs. assistance
(e.g., bathing, toileting)
 Schedule activities to prevent or
accommodate fatigue and/or
exacerbation
 Assist client in accomplishing
activities of daily living, encourage
client to easily accomplish task. To
enhance client’s capabilities and
promote independence
 Provide privacy to enhance self-
esteem and improve ability to
urinat---0e or defecate.
 Assist with medication regimen as
necessary, encouraging timely use
of medications (e.g., use of pain
relievers)


 Monitor fluid and hydration status

 Perform pain assessment each
time pain occurs to demonstrate
improvement in status or to identify
worsening of underlying
condition/developing
complications.
 Use effective coping strategies
throughout stay in hospital
 Discuss impact of pain on
lifestyle/independence and ways to
maximize level of functioning
 Collaborate in treatment of
underlying condition or disease
processes causing pain and
proactive management of pain
 Provide or promote
nonpharmacological pain
management: Quiet and calm
activities
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
After 8 hours 1.Present a safe 1.These After 8 hours
od nursing environment: measures od nursing
SUBJECTIVE: Impaired intervention bed rails up, bed promote a safe, intervention
physical the Patient in a down secure the Patient
“nahihirapan mobility will perform position, environment was able to
akong related to physical important items and may perform
gumalaw dahil pain and activity close by. reduce risk for physical
sa sakit”as discomfort, independentl falls. activity
verbalized by muscle y or within 2.Execute independently
the patient spasm as limits of passive or active 2.Exercise or within
evidenced disease and assistive ROM enhances limits of
OBJECTIVE: by reports also Patient exercises to all increased disease and
of pain will extremities. venous return, also Patient
Limited range demonstrate prevents was able to
of motion the use of 3.Promote and stiffness, and demonstrate
adaptive facilitate early maintains the use of
Facial grimace devices to ambulation when muscle strength adaptive
increase possible. Aid and stamina. It devices to
Slowed mobility. with each initial also avoids increase
movement change: dangling contracture mobility
legs, sitting in deformation,
Requires help chair, which can build
from his wife in ambulation. up quickly and
order for him could hinder
to sit eat and 4.Show the use prosthesis
drink of mobility usage.
medication. devices, such as
the following: 3.These
Vital signs trapeze, movements
taken as crutches, or keep the patient
follows: walkers. as functionally
working as
Temp: 37.8°c 5.Help out with possible. Early
PR: 90 transfer methods mobility
RR: 30 by using a fitting increases self-
BP: 150/90 assistance of esteem about
persons or reacquiring
devices when independence
transferring and reduces
patients to bed, the chance that
chair, or debilitation will
CHARTING
06/24/21
Shift: 7-1PM
 Subjective: “Hirap ako kumilos mag-isa, hindi ko kaya”
 Objective:
o Body Weakness
o Pain upon moving
o Altered ADL
o Vital signs are as follows:
 BP:150/90
 HR:90 bpm
 RR:22 bpm
 TEMP:37.8 °C

 Analysis: “Self-Care deficit related to decreased mobility as evidenced by inability

to control lower extremities”

 Planning: Within 48-72 hours of rendering appropriate nursing intervention, the

patient will:
- Identify individual areas of weakness or needs.
- Verbalize knowledge of healthcare practices
- Demonstrate techniques and lifestyle changes to meet self-care needs
- Perform self-care activities within level of own ability
- Identity personal and community resources that can provide assistance

 Intervention:
 Monitor vital signs for baseline data
 Assist with client’s needs (e.g., personal care plans while minimizing problems)
 Promote client’s/significant other’s (SO) participation in problem identification and
desired goals and decision making. To enhance commitment to plan, optimize
outcomes, and support recovery and/or health promotion
 Develop plan of care appropriate to individual situation, scheduling activities to
conform to client’s usual or desired schedule
 Practice short-term goal setting and achievement. To help a
 Provide for communication among those who are involved in caring for or
assisting the client. To enhance coordination and continuity of care.
 Perform client’s needs when he or she is unable to meet own needs.(e.g.,
bathing, toileting)
 Schedule activities to prevent or accommodate fatigue and/or exacerbation
 Assist client in accomplishing activities of daily living, encourage client to easily
accomplish task. To enhance client’s capabilities and promote independence
 Provide privacy to enhance self-esteem and improve ability to urinat---0e or
defecate.
 Assist with medication regimen as necessary, encouraging timely use of
medications (e.g., use of pain relievers)

 Evaluation: After 48-72 hours of rendering appropriate nursing intervention, Goal

met. The patient was able to:

- Identify individual areas of weakness/ needs.

- Verbalize knowledge of healthcare practices
- Demonstrate techniques and lifestyle changes to meet self-care needs
- Perform self-care activities within level of own ability
- Identity personal and community resources that can provide assistance
C. IMPLEMENTATION
Medical Management
Drug Order Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities
Action
Generic Name: It inhibits Treatment of mild Hypersensitivity, active CNS: headache, dizziness, drowsiness, Nursing Priority: Assess for rhinitis,
Ibuprofen prostaglandin to moderate pain, GI bleeding or ulcer intra-ventricular hemorrhage, psychic asthma, and urticaria. Patients who
Brand Name: Advil synthesis. fever. Inflammatory disease; chewable tablets disturbances. asthma, aspirin-induced allergy, and
Route: Oral Therapeutic effect: disorders including contain aspartame should EENT: amblyopia, blurred vision, tinnitus. nasal polyps are at increased risk for
Dosage: 1 tab every decreased pain and rheumatic arthritis, not be used in patients CV: HF, myocardial infarction, stroke, developing hypersensitivity
6 hours inflammation. and osteoarthritis, with phenylketonuria; arrhythmias, edema, hypertension. reactions.
Reduction of fever. dysmenorrhea. coronary artery bypass F and E:hyperkalemia Before:
graft (CABG) surgery; GI: GI bleeding, hepatitis, constipation,  Inform client what the drug is
history of recent MI; dyspepsia, nausea, vomiting. for.
severe HF. GU: cystitis, hematuria, renal failure.  Assess for sign and symptoms of
Hemat: anemia, blood dyscrasias, GI bleeding.
prolonged bleeding time. During:
MISC: allergic reactions.  Assess patient for skin rash
frequently during therapy.
Discontinue ibuprofen at first
sign of rash; may be life-
threatening. Steven-johnson
syndrome or toxic epidermal
necrolysis may develop.
After:
 Advise patient to take ibuprofen
with a full glass of water and to
remain in an upright position for
15-30 mins after administration.
 Instruct the patient to take
medication as directed. Take
missed doses as soon as
remembered but not if almost of
 the time for next dose. Do not
double dose.
 May cause drowsiness, or
dizziness. Advice patient to
avoid driving or other activities
requiring alertness.
 Caution patient that use of
ibuprofen with 3 or more glasses
of alcohol per day may increase
the risk of GI bleeding.
 Advise patient to consult health
care professional if rash, itching,
visual disturbances, tinnitus,
weight gain, edema, epigastric
pain, dyspepsia, black stools,
hematemesis, persistent
headache, or influenza-like
syndrome (chills, fever, muscle
aches, pain) occurs.
Generic Name: Panadeine Forte Panadeine Forte is Panadeine Forte is  Constipation. Nursing Priority: Assess BP, pulse,
Paracetamol and contains used to relieve contraindicated for use in  Nausea. and respiratory rate.
Codeine paracetamol and moderate to severe children: younger than 12  Vomiting. Before:
Brand Name: codeine. pain and fever. years; aged between 12 -  Stomach pain.  Inform client what the drug is
Panadeine Forte Paracetamol and 18 years in whom  Dizziness. for.
Route: Oral codeine work respiratory function might  Drowsiness. During:
Dosage: 1 tab every together to stop the be compromised,  Use caution if patient is
 Skin rashes.
6 hours pain messages from including post receiving MAO inhibitors.
 Sweating.
getting through to tonsillectomy and/or After:
the brain. adenoidectomy for  Instruct the patient to take
Paracetamol also obstructive sleep apnea. medication as directed. Take
acts in the brain to
missed doses as soon as
reduce fever.
remembered but not if almost of
 the time for next dose. Do not
double dose. This may increase
the chance of getting an
unwanted side effect.
 Advise patient not to drive
because it may cause drowsiness
and dizziness.
Generic Name: Mefenamic acid is a Mefenamic acid is Mefenamic acid is  stomach pain Nursing Priority: Assess patients
Mefenamic Acid potent inhibitor of used to relieve mild contraindicated in patients  nausea who develop severe diarrhea and
Brand Name: prostaglandin to moderate pain. It with salicylate  vomiting vomiting for dehydration and
Ponstel synthesis in vitro. works by stopping hypersensitivity or  heartburn electrolyte imbalance
Route: Oral the body's NSAID hypersensitivity  constipation Before:
Dosage: 500mg production of a who have experienced  diarrhea  Inform client what the drug is
every 6 hours substance that asthma, urticaria, or other for.
 rash
causes pain, fever, allergic reactions after  Lab test that obtain periodic
 dizziness
and inflammation. taking aspirin or other complete blood counts, Hct and
NSAIDs.  tinnitus (ringing in your ears)
Hgb, and kidney function test.
During:
 Discontinue drug promptly if
diarrhea, dark stools,
hematemesis, ecchymoses,
epistaxis, or rash occur.
 Notify physician if persistent GI
discomfort, sore throat, fever, or
malaise occur.
After:
 Do not drive or engage in
potentially hazardous activities.
 Monitor blood glucose for loss
of glycemic control if diabetic.
Surgical Management
MEDICAL MANAGEMENT/ DATE PERFORMED/ GENERAL DESCRIPTION INDICATION/PURPOSE CLIENT’S RESPONSE TO
TREATMENT CHANGED/ DISCONTINUED TREATMENT

Microdiscectomy Microdiscectomy, also The goal of a microdiscectomy is The patient undergone a

sometimes called to remove the disc material microdiscectomy and went
microdecompression or placing pressure on the nerves. home 1 day after the procedure.
microdiskectomy, is a The procedure is done under
minimally invasive surgical general anesthesia.
procedure performed on patients
with a herniated lumbar disc.
During this surgery, a surgeon
will remove portions of the
herniated disc to relieve
pressure on the spinal nerve
column.
D. EVALUATION

Discharge Planning

For the patient to completely recover after treatment, the nurses will ensure the
continuity of health and care for them as they leave the hospital premises through
teaching the patient about her condition, medications, self-care strategies and
importance of follow-up care and check-ups.
Medications
Instruct the patient about the medication at the same time of the day as prescribed and
for the length of time prescribed. Explain about all medications, including dosage,
potential side effects, and drug interactions.
Follow Up
The patient instructed to comply on every follow up appointment for the continuity of
treatment and recovery.
Health Teachings
Provide patient and relative written and verbal information regarding the following:
 Instruct the patient to have an adequate amount of sleep, plenty of water and
healthy foods. Advise the patient to reduce the amount of high glycemic foods
(ie. Sugar and refined flour), and add more non- tropical fruits like berries,
grapes, peaches and plums, along with dark leafy greens and root vegetables.
 Instruct the patient to perform passive range of motion exercise and activity to
strengthen the muscles that support the spine and reduce pressure on the spinal
column. Avoid the following factors such as acute hip flexion (bending, crossing
the legs), running, jogging and heavy lifting.
 Instruct the patient to use a pillow that supports the head and keeps the spine in
a neutral position. Good posture and proper body mechanics (bend knees, not
the back on lifting).
 Instruct the patient not to sit for long periods. Change positions frequently
 Advise the patient to perform stress reduction and relaxation techniques to
reduce muscle tension and chronic pain
 Advise the patient that scheduled rest periods are important
 Seek medical advice from health care provider in case of complication

Conclusion
Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in
the surrounding annulus fibrosus. The tear causes pain due to irritation of sensory
nerves in the disk, and when the disk impinges on an adjacent nerve root, a segmental
radiculopathy with paresthesias and weakness in the distribution of the affected root
results. Diagnosis is usually by MRI or CT. Treatment of mild cases is with analgesics,
activity modification, and physical therapy. Bed rest is rarely indicated. Patients with
progressive or severe neurologic deficits, intractable pain, conservative treatment
failure, or cauda equina syndrome with associated sphincter dysfunction may require
immediate or later elective surgery (eg, diskectomy, laminectomy).
Recommendation
Student Nurse
The case study allows student nurses to discover and explore about herniated
nucleus pulposus. It is recommended for student nurses because it serves as a
guidelines and reference on their studies.
Health Care Provider
Health care provider engaged themselves in promoting health and prevention of
disease. This study focuses on prevention and promotion to decrease complications,
mortality among people with herniated nucleus pulposus.

Review of Related Literature

According to Cicco (2020), Nucleus pulposus herniation is the most common
cause of sciatic pain and one of the most common indications for spine surgery
worldwide. This condition presents as a displacement of the nucleus pulposus beyond
the intervertebral disc space. The disc anatomy consists of two main structures,
the nucleus pulposus (NP) and the annulus fibrosus (AF). The nucleus pulposus is
composed of water, type II collagen, chondrocyte-like cells, and proteoglycans. This
unique composite allows the NP to be elastic, flexible under stress forces and to absorb
compression. Nucleus pulposus herniation is a common complaint among young adults;
clinical symptoms such as low back or cervical pain with radicular pain (brachialgia or
sciatica) may raise suspicion of a possible nerve root inflammation/compression and
further referral to a specialist.

The estimated prevalence of disc herniation is approximately 1 to 3%. The

highest observed incidence is between 30 to 50 years, and it is more frequent in men
than in women (ratio 2 to 1). A coordinated effort between the primary care provider,
specialty-trained nurses, spine specialists, physical therapists and chiropractors (who
may be the patient's first point of contact), communicating across professions, and
providing patient and family education is vital to guide proper management in patients
with symptomatic nucleus pulposus herniation.

Bibliography
Book Based
Brunner &Suddarth. (2018). Textbook of Medical-Surgical Nursing, 14th edition, Vol. 1
and 2; Lippincott Williams & Wilkins
Brunner &Suddarth’s. (2016). Textbook in Medical- Surgical Nursing 10th edition Vol.
1&2; Lippincott Williams & Wilkins
Ebnezar, J. (2010). Textbook of Orthopedics 4 th Edition; Jaypee Brothers Medical
Publishers (P) Ltd
Internet Based
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/herniated-
nucleus-pulposus-nursing-management/
https://www.ncbi.nlm.nih.gov/books/NBK542307/