II.

PATIENTS PROFILE
Name of Patient: West
Sex: Male
Age: 33 years old
Birthday: March 2, 1988
Birthplace: Pico, La Trinidad
Religion: Roman Catholic
Civil Status: Single
Educational Attainment: High School Level
Occupation: Electrician
Number of Siblings: 5
Nationality: Filipino
Date of Admission: September 27, 1990
Time of Admission: 8:30 AM
Informant: Father
Blood Pressure: 110/60 mmHg
Temperature: 37.7O C
Pulse Rate: 82 bpm.
Respiration: 21 cpm.
Allergy: No known allergy
Attending Physician: Dr. ABC
Admitting Diagnosis: Acute Spinal Cord Injury Cervical Spine
C5 (incomplete) (Central Cord
Syndrome)

 CHIEF COMPLAINT:

His chief complaint is limitation of movement at

extremities. 5 days prior to admission, pt. was apparently well
when he was repairing electrical wiring on the ceiling and
accidentally fell. Pt hit face first on the floor causing loss of level
 of consciousness and then he vomits, after that he already
experience minimal movement of extremities.

ADMITING DIAGNOSIS:

Acute Spinal Cord Injury Cervical Spine C5 (incomplete)

(Central Cord Syndrome)

 FINAL DIAGNOSIS:

Acute Spinal Cord Injury Cervical Spine C5 (incomplete)

(Central Cord Syndrome)

III. HISTORY OF PRESENT ILLNESS

 Present medical history

Patient was repairing electrical wiring on the ceiling and

accidentally fell. Pt hit face first on the floor causing loss of level
of consciousness and then he vomits, after that he already
experience minimal movement of extremities. His companion
was shouting for help, when responder found them; responder
immediately rushed the patient to Baguio General Hospital and
Medical Center.

 Past health history and family history

According to pt. West, 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 has no allergy to foods, drugs & animals.
He had complete immunization and He had never undergone
any major/minor operation and he never had experience any
accident except this one.

According to patient West, 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.
  Social, Environmental History

Patient is an electrician for almost 10 years. He works

mostly on projects of the company around Baguio City, La
Trinidad and nearby provinces. He likes to drink alcohol and
drinks until he’s drunk, and usually has their drinking session
with friends and brother usually at their house and seldom at
which they choice bar. He does not smoke. He lives with his
parents’ house. The house is far from the main road.
IV. 13 AREAS OF ASSESSMENT
1. Psychosocial and Psychological Status
Patient West is 33 years old, born on March 2, 1998. He lives in
a bungalow house with 3 rooms together with his mother and siblings.
He is a fulltime electrician and can understand Kankana-ey and
Ilokano. Their basic needs such as food, clothing, and shelter are
adequate for their family. Based on Erik Erikson’s Theory of
Psychosocial Development, patient falls under intimacy vs isolation,
ages 20-44 years old. Based from the interview the patient is
experiencing intimacy, as he said “kahit hindi ako ganon makagalaw,
meron padin pamilya ko na handang tumulong sakin”. Looking back
to his lifestyle before which is sedentary and full of vices.

2. Mental and Emotional Status

He is conscious and coherent, oriented to time, date, place and
person. He is able to understand instructions and acts according to
his age. He is responsive to verbal commands, touch, and pain
stimuli. According to Jean Piaget’s Theory of Cognitive Development,
the patient falls under Formal Operational Stage wherein during this
time, people develop the ability to think about abstract concepts and
logically test hypotheses. He is also mentally affected because of
present illness however his wife and children became more loving and
supportive to him.

3. Environmental Status
He is oriented that he is in the hospital. Patient is
knowledgeable about his conditions. There is steady pattern of
activity, light noise and color in his environment and it does not
distract him. The food and water are at the side table and is placed at
the right side of the patient, it is accessible to him.
4. Sensor Status
A. Visual Status. Cloudiness in the right pupil is present,
able to read without reading glasses, pupils are equally round,
reactive to light and accommodation, able to follow penlight with
gaze.
B. Auditory. Ears are parallel, symmetrically proportional
to the size of the head. Patient has no difficulty hearing the
spoken words when the whisper test was conducted.
C. Olfactory Status. His nose has no deviation in terms
of shape and size. Upon palpation, no tenderness, no
inflammation or nodules on the frontal, sphenoid, ethmoid, and
maxillary sinuses were noted. No discharges were seen during
the assessment. He was able to distinguish the different smells
since his admission.
D. Gustatory Status. No lesions seen upon inspection.
Patient was able to identify the different tastes such as oranges
and banana.
E. Tactile Status. He can distinguish light from firm
touch on his body and is able to perceive hot and cold
sensations in proportion to stimulus and there are no aberrant
sensations. With skin turgor of 20 seconds.

5. Motor Status
His movements are limited since he is connected to an IV line.
The patient was able to move without assistance. He can move all his
joints slowly and carefully. No prosthetic device was noted present
with the patient and all his extremities are intact.

6. Thermoregulatory Status
Patient’s body temperature ranges from 97.8° F (36.5°C) to 99.5°F
(37.7°C). The patient’s temperature levels all falls on the normal
range.
DATE TIME TEMPERATURE
OCT 11, 2021 7AM 37 .7°C

10 AM 36°C
 2 PM 37°C
7AM 37.1°C

OCT 12, 2021 10 AM 36.7°C

2 PM 36.4°C
7AM 36.7°C

OCT 13, 2021 10 AM 36.2°C

2 PM 37°C

7. Respiratory Status
Patient’s respiration rate ranges from 17 to 23 breaths per
minute. The patient’s respiratory rate falls on the normal range while
the SPO2 ranges from 94-99%.
DATE TIME RR SPO2
7AM 21 BPM 94%

OCT 11,2021 10 AM 21 BPM 97%

2 PM 23 BPM 98%
7AM 22 99%

21 BPM
OCT 12,2021 10 AM 96%

23 BPM
2 PM 97%
OCT 13,2021 7 AM 20 BPM 95%
 10 AM 22 BPM 97%

2 PM 21 BPM 99%

8. Circulatory Status
Patient’s heart rate ranges from 88 to 96 beats per minute. The
patient’s cardiac rate falls within the normal range. Blood pressure
has a systolic reading of 110-120 mmHg and a diastolic reading of 60-
80 mmHg. The patient’s BP has had high systolic and diastolic
readings. Capillary refill ranges 3-5 seconds.
CAPILLIARY
DATE TIME CR BP
REFILL
7AM 88 BPM 3-5 SECONDS 110/60mmHg

3-5 SECONDS
120/80mmHg
OCT 11,2021 10 AM 91 BPM
3-5 SECONDS
110/70mm/Hg

2 PM 96 BPM
7AM 94 BPM 3-5 SECONDS 120/90mmHg

110/80mmHg
OCT 12,2021 10 AM 93 BPM 3-5 SECONDS

110/60mm/Hg
2 PM 90 BPM 3-5 SECONDS
OCT 13,2021 7AM 87 BPM 3-5 SECONDS 120/70mmHg

120/80mmHg
10 AM 89 BPM 3-5 SECONDS

110/80mmHg
 2 PM 96 BPM 3-5 SECONDS

9. Nutritional Status
The patient’s food is being served in the hospital and he is in
low-carbohydrate diet. The patient’s appetite is good. There is no
change in the appetite for food during the hospitalization and health
deviation. There is no culture or religious dietary restrictions reported
by the patient.
10. Elimination Status
Before hospitalization, the patient usually defecates once a day
and voids 7-10 times a day. During our 3 days’ duty, the patient
didn’t defecate and has a urine output of 1500-2000 ml in a day.

11. Sleep, Rest and Comfort Status

The patient claims that he normally sleeps for 8-9 hours in a
day. But during admission the patient claims that he sleeps less than
normal which is 3-5 hours in a day because he is not comfortable due
to his current condition and because of frequent urination.

12. Fluids and Electrolytes Status

Prior to hospitalization the patient usually drinks 2-3 L a day
coming from water, buko juice, coffee and carbonated beverages and
urinates 7 times a day. But ever since he was admitted, he drinks
800- 1500mL of water. He has an ongoing IVF of PNSS 1L regulated at
16 gtts/min to replace fluid and electrolyte loss. The patient denies
the feeling of thirst. The patient’s capillary refill is 3-5 seconds, with
dry and poor skin turgor that goes back after 20 seconds.

13. Integumentary Status

Skin color is brown and with a good skin turgor. Callus noted
on the hands and feet. No lesions and scratches on skin upon
assessment
V. AREAS OF ASSESSMENT/ REVIEW OF SYSTEM

 ANATOMY AND PHYSIOLOGY (AS BACKGROUND

KNOWLEDGE)

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) > accidents

 Gender (male) > falls, sport activities > work (ELECTRICIAN)
> 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

 can lead to:
> Ischemia
 > Hemorrhage
C5 – controls extremities
 Muscle weakness
 Absence of withdrawal reflex
 Absence of Biceps reflex
 Muscle Paralysis
In gray matter in white matter

Increase in size rapidly lead to massive edema

Necrosis frequently spreads to involve

surrounding segment
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

Dilation of arterioles in injured area inflammatory process (lumbar area)

Result capillary bed close Increase capillary permeability

Increase blood flow of injured tissue lead to loss of protein rich fluid in
at injured site extravascular tissue
Bleeding pain hematoma

Decrease extravascular Increase intravascular

osmotic pressure osmotic pressure

Fluid shift

Edema

fever (compensatory mechanism)

BRIEF DISCUSSION OF THE PROPOSED OPERATION
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.

Spinal Motion Segment

This motion segment typically includes the following structures:

> L5 and S1 vertebrae. The L5 and S1 vertebrae have different features:

> L5 consists of a vertebral body in front and an arch in the back that has 3
bony protrusions: a prominent spinous process in the middle and two
transverse processes on the sides. These protrusions serve as attachment
points for ligaments.
> S1, also called the sacral base, is the upper and wider end of the
triangular-shaped sacrum. S1 consists of a body on the top with wing-
shaped bones on either side, called the alae. At the back, the S1 vertebra
contains a long bony prominence called the median ridge. There are bony
openings (foramina) on the right and left sides of this ridge.
> L5 and S1 are joined by the lumbosacral facet joints lined with articular
cartilage.
> L5-S1 intervertebral disc. A disc made of a gel-like material (nucleus
pulposus) surrounded by a thick fibrous ring (annulus fibrosus) is situated
between the vertebral bodies of L5 and S1.

> L5 spinal nerve. The L5 spinal nerve roots exit the spinal cord through
small bony openings (intervertebral foramina) on the left and right sides of
the spinal canal. These nerve roots join with other nerves to form bigger
nerves that extend down the spine and travel down each leg.
> The L5 dermatome is an area of skin that receives sensations through
the L5 spinal nerve and includes parts of the knee, leg, and foot.2
> The L5 myotome is a group of muscles controlled by the L5 spinal nerve
and includes specific muscles in the pelvis and legs, which are responsible
for leg and foot movements.2
> The L5-S1 motion segment provides a bony enclosure for the cauda
equina (nerves that continue down from the spinal cord) and other delicate
structures.

The C5-C6 spinal motion segment includes the following structures:

> C5 and C6 vertebrae. These vertebrae are each composed of a vertebral

body, a vertebral arch, and 2 transverse processes. Together they form
paired, synovial facet joints with gliding movements. Articulating cartilages
are present on the joint surfaces to provide smooth movements and
prevent friction between the facet joint surfaces of C5 and C6 vertebrae at
the back. The vertebrae are held together with ligaments that attach one
vertebra to the other at various attachment points.

> C5-C6 intervertebral disc. A disc made of a gel-like material (nucleus

pulposus) surrounded by a thick fibrous ring (annulus fibrosus) is situated
between the vertebral bodies of C5 and C6. This disc provides cushioning
and shock-absorbing functions to protect the vertebrae from grinding
against each other during neck movements, while also allowing movement
in all directions.

> C6 spinal nerve. In between C5-C6, the C6 spinal nerve exits the spinal
cord through a small bony opening on the left and right sides of the spinal
canal called the intervertebral foramen. This C6 nerve has a sensory root
and a motor root.
> The C6 dermatome is an area of skin that receives sensations through
the C6 nerve. This dermatome includes the skin over the ‘thumb’ side of
the forearm and the thumb.
> The C6 myotome is a group of muscles controlled by the C6 nerve.
These muscles include the wrist extensor muscles, which allow the wrist to
bend backward; and the biceps and supinator muscles of the upper arm,
which serve to bend the elbow and rotate the forearm.
VI. LABORATORY FINDINGS

LABORATORY NORMAL ABNORMAL INTERPRETATION

TEST VALUES FINDINGS

Hemoglobin 12.6 g/dL 135 g/dL Low hemoglobin the substance color
is red. It allows to transport oxygen
throughout the body. Low level of
hemoglobin May lead to anemia,
causes symptoms of fatigue and
troubled breathing

Hematocrit 0.42 l/l A lower than normal level of

-men 41%- hematocrit may indicate an
50%. insufficient supply of healthy red
blood cells (Anemia). The client may
-women experience symptoms such as
36%-44%. fatigue, weakness, or low energy.

RBC  count -men – 4.7 4.36 x When the RBC is insufficient or

to 6.1 10¹²/L below the normal range, Our body
(cells/mcL will be deprived of oxygen because
) Red blood cells are know to transport
adequate oxygen to the cells. A client
-women – may experience weakness, fatigue
4.2 to 5.4 and low level of energy.
cells/mcL.

Platelet count 150,000 to 3.21 x 10/L The person is in normal range. But if
450,000 a person not enough platelets in
platelets blood the body cant’t form clots low
per platelet called thrombocytopenia ,
microliter the condition range from mild to
severe , depending it’s underlying
cause ,for some patients bleeding, if
not treated can be fatal

WBC count 4.5 to 11.0 16.0 x 10/L Low WBC count can be serious
× 10/L because ,it increases the risk
developing a potentially life
threatening infection,Serk prompt
medical care if the patient have low
wbc count and have signs of infection
such as fever , swollen lymph nodes
sore throat or skin lesions
Lymphocyte 1,000 and 0.23 Decrease lymphocytes counts makes
4,800 in 1 it hard to the body to fight infection,
microliter if low the patient may get infection
(µL) caused by viruses fungi parasites or
bacteria . Treatment for an infection
will depends on its severity of
desease

 DIAGNOSTIC PROCEDURE:

1. Physical Examination- a assessment used to test sensory

functions, muscle movement and strength, and reflexes
 Sensory messages include the feelings of hot, cold, touch, pain,
pressure and body position.
 Motor messages are sent to the muscles in your arms, hands,
fingers, legs, toes, chest and other parts of your body. These
messages tell the muscles how and when to move.

2. X-rays- Non-invasive and painless test that can reveal vertebral

(spinal column) problems, tumors, fractures or degenerative
changes in the spine.
Chest x-ray is contraindicated to patients who are pregnant or
suspected of being pregnant unless the potential benefits of a
procedure using radiation outweigh the risk of maternal and fetal
damage.

 NURSING RESPONSIBILITY:
o BEFORE X-RAY:

a. Remove all metallic objects. Items such as jewelry, pins,

buttons etc can hinder the visualization of the chest.
b. No preparation is required. Fasting or medication restriction
is not needed unless directed by the health care provider.
c. Ensure the patient is not pregnant or suspected to be
pregnant. X-rays are usually not recommended for pregnant
women unless the benefit outweighs the risk of damage to the
mother and fetus.
 d. Assess the patient’s ability to hold his or her breath. Holding
one’s breath after inhaling enables the lungs and heart to be
seen more clearly in the x-ray.
e. Provide appropriate clothing. Patients are instructed to
remove clothing from the waist up and put on an X-ray gown to
wear during the procedure.
f. Instruct patient to cooperate during the procedure. The
patient is asked to remain still because any movement will
affect the clarity of the image.

o AFTER X-RAY:

a. No special care. Note that no special care is required

following the procedure
b. Provide comfort. If the test is facilitated at the bedside,
reposition the patient properly.

3. CT scan. A CT scan can provide a clearer image of abnormalities

seen on X-ray. This scan uses computers to form a series of cross-
sectional images that can define bone, disk and other problems.
Computed tomography (CT) is contraindicated in:
a. Pregnant patient (absolute contraindication)
b. Patients with a known allergy to iodine
c. Patients with claustrophobia
d. Patients with renal impairment unless the benefits
outweigh the risks
e. Patients with hyperthyroidism or toxic goiter (induce
thyrotoxic crisis)
f. Patients with complications after a previous administration
of a contrast
g. Patients with severe obesity (usually more than 300
pounds)

 NURSING RESPONSIBILITY:
o BEFORE CT-SCAN:
 a. Informed Consent. Obtain an informed consent properly
signed.
b. Look for allergies. Assess for any history of allergies to
iodinated dye or shellfish if contrast media is to be used.
c. Get health history. Ask the patient about any recent illnesses
or other medical conditions and current medications being
taken. The specific type of CT scan determines the need for an
oral or I.V. contrast medium
d. Check for NPO status. Instruct the patient to not to eat or
drink for a period amount of time especially if a contrast
material will be used.
e. Get dressed up. Instruct the patient to wear comfortable,
loose-fitting clothing during the exam.
f. Provide information about the contrast medium. Tell the
patient that a mild transient pain from the needle puncture and
a flushed sensation from an I.V. contrast medium will be
experienced.
g. Instruct the patient to remain still. During the examination,
tell the patient to remain still and to immediately report
symptoms of itching, difficulty breathing or swallowing, nausea,
vomiting, dizziness, and headache.
h. Inform about the duration of the procedure. Inform the
patient that the procedure takes from five (5) minutes to one (1)
hour depending on the type of CT scan and his ability to relax
and remain still.

o AFTER CT-SCAN:

a. Diet as usual. Instruct the patient to resume the usual

diet and activities unless otherwise ordered.
b. Encourage the patient to increase fluid intake (if a
contrast is given). This is so to promote excretion of the dye

4. MRI. MRI uses a strong magnetic field and radio waves to

produce computer-generated images. This test is helpful for
 looking at the spinal cord and identifying herniated disks, blood
clots or other masses that might compress the spinal cord.
CONTRAINDICATION FOR MRI:
a. Metallic implants.
b. Claustrophobia.
c. Pacemakers, although new protocols allow imaging in
selected cases.
d. MR-incompatible prosthetic heart valves.
e. Contrast allergy.
f. Body weight (MRI tables have specific weight
limitations)

 NURSING RESPONSIBILITIES:
o BEFORE MRI:

a. Make sure the scanner can accommodate the patient’s weight

and abdominal girth.
b. Explain to the patient that skeletal MRI assesses bone and
soft tissue. Tell him who will perform the test and where it will
take place.
c. Explain that the test takes 30 to 90 minutes.
d. Explain to the patient that although MRI is painless and
involves no exposure to radiation from the scanner, a contrast
medium may be used, depending on the type of tissue being
studied.
e. If the patient is claustrophobic or if extensive time is required
for scanning, explain to him that a mild sedative may be
administered to reduce anxiety. Open scanners have been
developed for use on the patient with extreme claustrophobia or
morbid obesity, but tests using such machine take longer.
f. An anesthesiologist may need to be present to monitor a
heavily sedated patient.
g. Tell the patient that he must lie flat, and describe the test
procedure.
h. Explain to the patient that he’ll hear the scanner clicking,
whirring, and thumping as it moves inside its housing.
i. Reassure the patient that he’ll be able to communicate with
the technician at all times.
j. Instruct the patient to remove all metallic objects, including
jewelry, hairpins, or watches.
k. Stop I.V. infusion pumps, feeding tubes with metal tips,
pulmonary artery catheters, and similar devices before the test.
l. Ask whether the patient has any surgically implanted joints,
pins, clips, valves, pumps, or pacemakers containing metal that
could be attracted to strong MRI magnet. If he does, he won’t be
able to have the test.
m. Note and report all allergies.
n. Make sure that the patient or a responsible family member
has signed an informed consent form, if required.

o AFTER MRI:

a. Provide patient with comfort measures as needed.

b. Tell the patient to resume his normal diet and activities
unless otherwise indicated.
c. Monitor vital signs.
d. Monitor the patient for orthostatic hypotension.
VII. DRUG STUDY
NAME OF DRUG MECHANISM OF INDICATION/ SIDE EFFECTS ADVERSE EFFECTS NURSING
ACTION CONTRAINDICATION: IMPLICATION
GENERIC NAME: ACTIONS USES THERAPEUTIC CNS: Drowsiness, ASSESSMENT &
EFFECTS dizziness, vertigo, Drug Effects
TRAMADOL Centrally acting Management of moderate
fatigue, headache,
HYDROCHLORIDE opiate receptor to moderately severe pain. Effective agent for
somnolence,
agonist that control of moderate
(tra'ma-dol) restlessness, >Assess for level of
inhibits the to moderately
euphoria, confusion, pain relief and
uptake of severe pain.
anxiety, coordination administer prn dose
norepinephrine
CONTRAINDICATIONS disturbance, sleep as needed but not
and serotonin,
disturbances, to exceed the
BRAND NAME: suggesting both Hypersensitivity to seizures. recommended total
opioid and tramadol or other opioid
Ultram, Zydol INTERACTIONS daily dose.
nonopioid analgesics; patients on
mechanisms of MAO inhibitors; patients Drug: CV: Palpitations,
pain relief. May acutely intoxicated with Carbamazepine
CLASSIFICATIONS: vasodilation. >Monitor vital signs
produce opioid- alcohol, hypnotics, significantly
CENTRAL NERVOUS like effects, but and assess for
centrally acting analgesics, decreases tramadol
SYSTEM (CNS) causes less orthostatic
opioids, or psychotropic levels (may need up
AGENT; ANALGESIC; respiratory GI: Nausea, hypotension or
drugs; substance abuse; to twice usual dose).
NARCOTIC (OPIATE) depression than constipation, signs of CNS
patients on obstetric Tramadol may
AGONIST morphine vomiting, depression.
preoperative medication; increase adverse
xerostomia,
abrupt discontinuation; effects of MAO
dyspepsia, diarrhea,
alcohol intoxication; INHIBITORS.
PROTOTYPE: abdominal pain, >Discontinue drug
pregnancy (category C); TRICYCLIC
Morphine sulfate anorexia, flatulence. and notify physician
lactation; children <16 y. ANTIDEPRESSANTS,
FREQUENCY/ if S&S of
Pregnancy cyclobenzaprine,
DOSAGE/ hypersensitivity
PHENOTHIAZINES,
ROUTES Body as a Whole: occur.
SELECTIVE
Sweating,
PAIN SEROTONIN-
anaphylactic
Category: C Adult: PO 50–100 CAUTIOUS USE REUPTAKE reaction (even with
mg q4–6h prn INHIBITORS (SSRIs), first dose),
Debilitated patients; >Assess bowel and
(max: 400 mg/d), MAO INHIBITORS withdrawal
chronic respiratory bladder function;
may start with 25 may enhance syndrome (anxiety,
disorders; respiratory report urinary
mg/d if not well seizure risk with sweating, nausea,
depression; older adults; frequency or
tolerated, and tramadol. May tremors, diarrhea,
liver disease; renal retention.
increase by 25 mg increase CNS piloerection, panic
impairment; myxedema,
q3d up to 200 adverse effects attacks, paresthesia,
hypothyroidism, or
mg/d when used with hallucinations) with
hypoadrenalism; GI >Use seizure
other CNS abrupt
Geriatric: PO 50– disease; acute abdominal precautions for
DEPRESSANTS. discontinuation.
100 mg q4–6h prn conditions; increased ICP patients who have a
(max: 300 mg/d), or head injury, increased history of seizures
may start with 25 intracranial pressure; or who are
Herbal: St. John's Skin: Rash.
mg/d if not well history of seizures; concurrently using
wort may increase
tolerated, and patients >75 y. drugs that lower the
sedation.
increase by 25 mg seizure threshold.
q3d up to 200 Special Senses:
mg/d Visual disturbances.

>Monitor
ambulation and
RENAL Urogenital: Urinary
take appropriate
IMPAIRMENT retention/frequency,
safety precautions.
menopausal
Clcr <30 mL/min: symptoms.
decrease to 50–
100 mg q12h
Patient & Family
Education
HEPATIC
IMPAIRMENT
>Exercise caution
 Cirrhosis decrease with potentially
to 50–100 mg hazardous activities
q12h. until response to
drug is known.

>Understand
potential adverse
effects and report
problems with
bowel and bladder
function, CNS
impairment, and
any other
bothersome
adverse effects to
physician.

>Do not breast feed

while taking this
drug.

NAME OF DRUG MECHANISM OF INDICATION/ SIDE EFFECTS ADVERSE EFFECTS NURSING

ACTION CONTRAINDICATION: IMPLICATION
GENERIC NAME: ACTIONS USES THERAPEUTIC Body as a Whole: ASSESSMENT &
EFFECTS Negligible with Drug Effects
ACETAMINOPHEN, Produces Fever reduction.
recommended dosage;
PARACETAMOL analgesia by Temporary relief of mild It provides temporary
rash.
unknown to moderate pain. analgesia for mild to
(a-seat-a-mee'noe- > Monitor for S&S
mechanism, Generally as substitute moderate pain. In
 fen) perhaps by action for aspirin when the addition, of:
on peripheral latter is not tolerated or is acetaminophen hepatotoxicity,
Acute poisoning:
nervous system. contraindicated. lowers body even with
Anorexia, nausea,
BRAND NAME: Reduces fever by temperature in moderate
vomiting, dizziness,
direct action on individuals with a acetaminophen
Abenol , A'Cenol, lethargy, diaphoresis,
hypothalamus CONTRAINDICATIONS fever. doses, especially
Acephen, Anacin-3, chills, epigastric or
heat-regulating in individuals with
Anuphen, APAP, Hypersensitivity to abdominal pain,
center with poor nutrition or
Atasol , Campain , acetaminophen or diarrhea; onset of
consequent INTERACTIONS who have
Datril Extra Strength, phenacetin; use with hepatotoxicity—
peripheral ingested alcohol
Dolanex, Exdol , alcohol. Drug: Cholestyramine elevation of serum
vasodilation, over prolonged
Halenol, Liquiprin, may decrease transaminases (ALT,
sweating, and periods;
Panadol, Pedric, acetaminophen AST) and bilirubin;
dissipation of poisoning, usually
Robigesic , Rounox , CAUTIOUS USE absorption. With hypoglycemia, hepatic
heat. Unlike from accidental
Tapar, Tempra, chronic coma, acute renal
aspirin, Children <3 y unless ingestion or
Tylenol, Valadol coadministration, failure (rare).
acetaminophen directed by a physician; suicide attempts;
has little effect on BARBITURATES, potential abuse
repeated administration carbamazepine,
platelet to patients with anemia from
CLASSIFICATIONS: aggregation, does phenytoin, and Chronic ingestion: psychological
or hepatic disease; rifampin may increase Neutropenia,
CENTRAL NERVOUS not affect dependence
arthritic or rheumatoid potential for chronic pancytopenia,
SYSTEM AGENT; bleeding time, (withdrawal has
conditions affecting hepatotoxicity. leukopenia,
NONNARCOTIC and generally been associated
children <12 y; Chronic, excessive thrombocytopenic
ANALGESIC, produces no with restless and
alcoholism; malnutrition; ingestion of alcohol purpura, hepatotoxicity
ANTIPYRETIC gastric bleeding. excited
thrombocytopenia. Safety will increase risk of in alcoholics, renal
during pregnancy responses).
hepatotoxicity damage.
(category B) or lactation
is not established.
Category: B FREQUENCY/
DOSAGE/
ROUTES
Patient & Family
 Education

Mild to
Moderate Pain,
> Do not take
Fever
other
Adult: PO 325– medications (e.g.,
650 mg q4–6h cold
(max: 4 g/d) PR preparations)
650 mg q4–6h containing
(max: 4 g/d) acetaminophen
without medical
advice;
Child: PO 10–15 overdosing and
mg/kg q4–6h PR chronic use can
2–5 y, 120 mg cause liver
q4–6h (max: 720 damage and
mg/d); 6–12 y, other toxic
325 mg q4–6h effects.
(max: 2.6 g/d)

>Do not self-

Neonate: PO 10– medicate adults
15 mg/kg q6–8h for pain more
than 10 d (5 d in
children) without
consulting a
physician.

>Do not use this

medication
without medical
direction for:
fever persisting
longer than 3 d,
fever over 39.5° C
(103° F), or
recurrent fever.

>Do not give

children more
than 5 doses in 24
h unless
prescribed by
physician.

>Do not breast

feed while taking
this drug without
consulting
physician.this
drug.
 VIII. NCP
Day 1: October 11, 2021
PROBLEM / EPLANATION NURSING INTERVENTION SCIENTIFIC EVALUATION
NURSING OF THE GOAL (USE RATIONALE
DIAGNOSIS PROBLEM THE SMART)
SUBJECTIVE: Patient with STG: After 8 Continually assess Evaluates status of GOAL MET?
lesions above hours of motor function by individual situation
”he can’t move requesting client to (motor-sensory Goal Met. The
the mid- effective
on his own” as perform certain actions impairment may be patient was
thoracic level nursing care,
verbalized by his (e.g, shrug shoulders, mixed and or not clear) able to
have loss of the patient will
significant other spread fingers, for a specific level of maintain
sympathetic be able
release/squeeze injury, affecting type position of
control of demonstrate
examiner’s hands) and choice of function as
peripheral techniques or
OBJECTIVE: interventions. evidenced by
vasoconstricto behaviours that
absence of
r activity, enable Assess skin daily. Altered circulation, loss contractures,
leading to resumption of Observe for pressure of sensation, and
● VITAL foot drop, and
 SIGNS hypotension. activity areas and provide paralysis potentiate increase
Temp. Contractures meticulous skin care. pressure sore strength of
37°C; can develop formation. unaffected/co
rapidly with mpensatory
RR of 28 Assess for redness, In a high percentage of
cpm immobility parts.
LTG: after 3 swelling/muscle clients with cervical
and muscle
CR of 89 days of nursing tension of calf tissues. cord injury, thrombi
paralysis.
bpm; care and health Record calf and thigh develop because of
(Brunner and teaching, the measurements as altered peripheral
spo2 of Suddarth’s patient will indicated. circulation,
95% Medical immobilization, and
maintain
Surgical position of flaccid paralysis.
● LAB Nursing, p. function as
Perform/assist with Enhances circulation,
RESULTS 1939) evidenced by
full ROM exercises on restores/maintains
Hgb: absence of all extremities and muscle tone and joint
135g/dL contractures, joints, using slow mobility and prevents
foot drop and smooth movements. disuse contractures
Hct: 42% increase Hyperextend hips and muscle atrophy.
RBC: 4.36 strength of periodically.
x 106/L unaffected/com
pensatory body Position arms at 90 Prevents frozen
Platelet: parts. degree at regular shoulder contractures.
3.21 x intervals.
10/L
Maintain ankles at 90 Prevents foot drop and
WBC: 16.0 degree with footboard. external rotation of
x 10/L Place trochanter rolls hips.
along thighs when in
bed.

NURSE’S Observe for sudden Development of

onset of dyspnea, pulmonary emboli may
OBSERVATIONS cyanosis, and other be silent because pain
signs of resp. distress. is altered and DVT is
Minimal not easily recognized.
movement on the
extremities;
decrease in Administer medication May be useful for
range in motion as indicated Baclofen reducing pain
(Lioresal) 10 mg/tab associated with
TID as ordered by the spasticity. Note:
NDX: physician. Baclofen may be
delivered via implanted
Impaired intrathecal pump on a
physical mobility long term basis as
related to appropriate.
neuromuscular
impairment
 Day 2: October 12, 2021
Explanation of Nursing
Assessment Goals & Objective Rationale Evaluation
the problem Intervention
Subjective: Mechanism of STG: Identify and Visceral distention is STG:
autonomic monitor the most common
“nahihirapan After 3 hrs of Fully met: After
dysreflexia in a precipitating risk cause of autonomic
ako nursing 8 hrs of nursing
person with factors. dysreflexia, which is
gumalaw, intervention the intervention the
spinal cord considered an
hindi ko mai patient will be able patient was able
injury (at the emergency.
galaw ng to: to identify
level of T6 or
maayos mga preventive /
above). An
kamay ko” corrective
afferent
Identify measures
stimulus (e.g., Observe for signs Early detection and
preventive/correct
distended and symptoms of immediate intervention
Objective: ive measures.
bladder or fecal syndrome such as is essential to prevent
Result: Fully
+ need impaction) changes in VS, serious consequences
met
assistance in triggers a paroxysmal hypert and complications.
peripheral LTG:
ADL’s; stuffy ension,
nose; sympathetic After 3 days of tachycardia or
response that LTG:
complaints nursing bradycardia;
headache; results in intervention the autonomic After 3 days of
heart rate of widespread patient will be able responses. nursing
54 bpm vasoconstriction to: intervention the
and subsequent patient was able
hypertension. Monitor BP This is a potentially
 Baroreceptors frequently (every fatal complication. to comprehend
in blood vessels 3–5 min) during Continuous monitoring and apply the
Nursing Dx: Able to
detect this acute autonomic and intervention may preventive
comprehend and
Risk for hypertensive dysreflexia and reduce patient’s level of measures
apply the
Autonomic crisis and take action to anxiety. provided.
preventive
Dysreflexia signal the brain eliminate
measures provided
via cranial stimulus.
nerve IX and X. Continue to Result: Fully
Descending monitor BP at met
inhibitory intervals after
signals symptoms
normally subside.
respond to
counteract the Aggressive therapy and
rise in blood Stay with patient removal of stimulus
pressure with during episode. may drop BP rapidly,
slowed heart resulting in a
rate and hypotensive crisis,
vasodilation. especially in those
However, patients who routinely
vasodilation is have low BP.
blocked at the
level of the
spinal cord Encourage bowel
injury. This Administer movements by acting
results in laxative on the intestinal wall.
unregulated medications as They increase the
hypertension, ordered by the muscle contractions
flushed/warm physician. that move along the
skin, and
sweating above stool mass.
the level of the
lesion. Below
Lowers BP to prevent
the level of the Elevate head of
intracranial
lesion, bed to 45-degree
hemorrhage, seizures,
cold/pale angle or place
or even death.
extremities and patient in sitting
piloerection position.
may be seen.

To stimulate bowel
Perform Passive
movement.
Autonomic ROM & log rolling.
dysreflexia (AD)
is a life-
threatening
complication of To prevent bladder
spinal cord Perform insertion
distention.
injury (SCI) at of IFC.
T6 or above
that results in Removing noxious
an uncontrolled Eliminate
stimulus usually
sympathetic causative
terminates episode and
discharge in stimulus as
may prevent more
response to able such
serious autonomic
noxious stimuli. as bladder, bowel,
dysreflexia (in the
It is a symptom skin pressure
presence of sunburn,
complex (including
topical anesthetic
characterized loosening tight leg
should be applied).
by a lethal rise bands or clothing,
in blood removing
abdominal binder
 pressure with or elastic
dangerous stockings);
consequences temperature
extremes.

Inform patient and This lifelong problem

SO of warning can be largely
signals and how to controlled by avoiding
avoid onset of pressure from
syndrome such as overdistension of
sweating, visceral organs or
gooseflesh. pressure on the skin.

Encouraged to To soften stool.

increased fluid
intake at least 1L
a day and eat food
rich in fiber.

Day 3: October 13, 2021

PROBLEM/ EXPLANATION OBJECTIVES INTERVENTION RATIONALE EVALUATION
NURSING OF THE
DIAGNOSIS PROBLEM
Subjective: Activity STO: Dx: Dx: STO: Goal met
“nahihirapan intolerance is a
Within 6 hours  Monitor vital  To help After 6 hours of
ako gumalaw nursing
of effective signs and determine effective nursing
dahil sa sugat diagnosis record patient’s
nursing interventions
ko” as defined by current
interventions the patient was
verbalized by NANDA as a health status
the patient will able to:
the patient state in which and evaluate
be able to:
an individual effectiveness -do minimal
has insufficient -do minimal of nursing ADL’s
Objective: physiological or ADL’s intervention
rendered -participate in
psychological
-slow movement -participate in self-care
energy to
self-care  Assess activities
-needs endure or  To determine
activities ability to do
assistance in complete the capacity
doing ADL’s necessary or ADL’s of patient in
desired daily doing ADL’s
-weakness activities. LTO: Goal met
noted
LTO:
 Assess  To know if After 1 day of
Within 1 day of physical there are any effective nursing
effective nursing mobility changes on interventions
interventions status patient’s the patient was
Nursing condition
the patient will able to:
diagnosis: specifically on
be able to:
physical -maintain
Activity aspect
-maintain activity level
Intolerance as
activity level within
evidenced by
within Tx: capabilities as
severe pain on
capabilities as evidenced by
the right  To minimize
evidenced by normal vital
quadrant of the Tx: fatigue and to
normal vital signs, as well as
abdomen
signs, as well as  Assist evaluate the absence
absence of patient in capabilities in weakness, pain
weakness, pain doing ADL’s doing such and difficulty in
and difficulty in accomplishing
accomplishing  To maximize tasks.
tasks. full strength

 Assist to do
active range
of motion  To conserve
energy
 Promote rest
and comfort
Edx:
Edx:
 To determine
 Encourage other factors
to verbalize that might
feelings and contribute to
concerns patient’s
regarding present
his present condition
condition
 To promote
circulation
 Emphasize
importance
of
ambulation
  To maximize
full strength
 Encourage
active range
of motion
 To achieve
 Emphasize therapeutic
importance effect of
of medication
compliance and for fast
to treatment recovery
and
medication

 Encourage  For energy

adequate conservation
rest periods
IX. FDAR
Day 1
October 11, 2021
F - Impaired physical mobility related to neuromuscular impairment
D - Received lying on bed, awake; with an on-going IVF; conscious; oriented to time and place; with minimal
movement on the extremities; decrease in range in motion; vital signs: Temp. 37°C; RR of 28 bpm, CR of 89
cpm; spo2 of 95% BP of 110/90 mmHg
A - Performed bed side care; monitored vital signs; assessed client’s developmental level, motor skills, ease and
capability of movement and posture; assessed skin daily and observed for pressure areas and provide meticulous
skin care; assessed nutritional status and client’s report of energy level; determined degree of immobility in
relation to 0-4 scale, assisted with treatment of underlying condition causing dysfunction; assisted and have the
client reposition self; provided for safety measures; demonstrated use of standing aids and mobility devices;
discussed discrepancies in movement when client is aware and unaware of observation and methods for dealing
with identified problems;
R - Maintained position of function as evidenced by absence of contractures, foot drop, and increase strength of
unaffected/compensatory parts.

Day 2
October 12, 2021
F - Risk for Autonomic Dysreflexia
D - nahihirapan ako gumalaw, hindi ko mai galaw ng maayos mga kamay ko as verbalized by the patient; with a
latest VS of: BP: 110/60, T: 37.7c, PR: 54 bpm, RR: 21cpm. Patient need assistance in ADL’s; reports presence of
headache; nasal flaring is evident

A – Assessed general health status, Attended and assisted to ADL’s, Identify and monitor precipitating risk
factors; Observe for signs and symptoms of syndrome such as changes in VS, paroxysmal hypertension,
tachycardia or bradycardia, Administer laxative medications as ordered by the physician, Perform Passive ROM
& log rolling, Elevate head of bed to 45-degree angle or place patient in sitting position. Encouraged to increased
fluid intake at least 1L a day and eat food rich in fiber
 R – The patient was able to experience episodes of dysreflexia.

Day 3
October 13, 2021
F - Activity Intolerance as evidenced by severe pain on the right quadrant of the abdomen

D - Slow movement; needs assistance in doing ADL’s; weakness noted

A - Monitored vital signs and record; Assessed ability to do ADL’s; Assessed physical mobility status; Assisted
patient in doing ADL’s; Assisted to do active range of motion; Promoted rest and comfort; Encouraged to verbalize
feelings and concerns regarding his present condition; Emphasized importance of ambulation; Encouraged active
range of motion; Emphasized importance of compliance to treatment and medication; Encouraged adequate rest
periods

R – The patient can do minimal ADL without assistance.

X. JOURNAL READING

I. TITLE: Overview of the Spinal Cord Injury – Quality of Life (SCI-QOL) measurement system

AUTHOR: David S. Tulsky et., a

YEAR OF PUBLICATION: 2020

II. SUMMARY

Traumatic spinal cord injury (TSCI) is one of the most catastrophic injuries in human beings. To describe
epidemiological features of traumatic spinal cord injury (TSCI) and to conduct a comparison with data from 2002. the
research was conducted in China Rehabilitation Research Center (CRRC), Beijing. Five hundred and ninety patients
with TSCI were admitted to the CRRC from 1st January 2011 to 31st December 2019. They collected data on sex, age,
marital status, etiology, occupation, neurological level of injury, and the American Spinal Injury Association
Impairment Scale on admission, time of injury and treatment. Statistically significant differences were observed
between data from 2002 and the present results (P < 0.001). The mean age of patients with TSCI was 46.3 ± 15.5 years,
and the male/female ratio was 4.73:1. The incidence of TSCI increased gradually with age and peaked in the 40–49 age
group. The most common occupation was worker (28.6%), followed by office clerk (16.8%) and retired (15.4%). Fall from
heights (30.8%), followed by traffic accidents (27.6%) and low falls (25.1%), were the leading etiologies of TSCI. A
majority of patients (54.9%) had cervical injuries, 91.9% underwent surgical treatment, and the lowest number of
injuries were recorded during winter (19.6%).
According to the changes in the epidemiological characteristics of TSCI, preventative strategies should be
readjusted. We should pay more attention to the risk of low falls of the elderly. The authors recommend that stricter
regulatory practices and safety measures should be developed alongside infrastructure improvements to reduce, and
perhaps prevent TSCI.
III. NURSING IMPLICATIONS

A. To Nursing Practice

By conducting a comparison data from 2002 to 2019 this research will contribute to improve the nursing
profession/ practice because it will have a updated results and conclusions about the data collected in TSCI. Nurses
and other HCP will do preventive strategies and will pay more attention to the risk of low falls of the elderly.
In this research they also address the top 3 high risk groups; workers, office clerks, and the retired. The main etiologies
of TSCI in workers were falls from heights and being struck by an object at work. The primary etiology for injuries in
office clerk was traffic accidents. It will also help us understand the etiology of TSCI and will be handling our patient
more cautiously with safety measures to reduce and prevent tsci.

B. To Nursing Education

Knowing the high risk of injury the nurses will be able to give health education suited to their specific jobs for
example proper body mechanics.Work activities involving bending, twisting, frequent heavy lifting, awkward static
posture and psychological stress are regarded as causal factors for many back injuries. Preventive measures should be
taken to reduce the risk of lower back pain, such as arranging proper rest periods, educational programmes to teach
the proper use of body mechanics and lifestyle change programmes. (Stephen Wanless, 2017)

We, nursing student are also at risk of TCSI because we are carrying patients in positioning them from lying in
the bed to sitting or transferring from ER to designated wards in this situation we might accidentally hurt ourselves if
we we used improper working posture. So in this research it help us nursing student to know the importance of proper
body mechanics in during our RLE duties at the hospital or even in our houses. Use of the body mechanics principle
can reduce clinical-practice fatigue and increase practice satisfaction. Various training programs that can increase use
of the body mechanics principle among nursing students need to be developed so that they can contribute to the
formation of proper habits for physical activities for the safe nursing of patients.(Se-WonKang 2017)
C. To Nursing Research
They focused on the medical records in the hospital and some details in the data were unavailable and I think it
would be better if they also conducted a survey or research if the workers has a PPE/personal protective equipment or
any preventive measurements while on duty because it might be the cause of TSCI. Workers in a wide range of
industries are required to wear personal protective equipment (PPE) to reduce or prevent exposures to hazardous
chemicals, fire, particulates, or other health risks.

IV. PERSONAL INSIGHTS

I do partially agree about this research, because they addressed that the high-risk of injury are workers, office
clerk and elderly. They also gathered enough data to support the research and used proper design and method but as I
have said they should include if the high risk has preventive measurements while on duty or even at their home