DONE ON: 12/04/2021

I. Client Identification
 Name: Kinzang
 Age: 35 years old, Gender: Female
 Address:
1. Local address: Duktse, Yalang, Trashiyangtse
2. Permanent address: Duktse, Yalang, Trashiyangtse
 Care of Guardian (relationship) with contact number: Dorji Gyeltshen (Husband)
1798676
 Date and Time of admission: 15th March 2021
 Ward and Bed number: Orthopedic ward, B3
 Hospital Registration number: 227810
II. Socio-economic Status

Marital status: Married

 Level of Education: Illiterate

 Occupation: Farmer
 Number of siblings: One (one elder brother)
 No children: Two children (A daughter of four years old and a son of thirteen years old)
 Type of house: Lives in typical traditional two stored Bhutanese house
 Total income:
1. Earns Nu 13,000 monthly however it depends upon the harvest obtained and
cow product sold.
2. Yearly income: Earns about Nu156, 000 to Nu200,000.

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III. Health Assessment
A. History taking:

Chief Complaints:

• Acute pain in the back (location of the trauma) for past 1 month.

• Unable to move the right lower limbs (loss of motor function) for past 26 days.

• Constipation for 15 days.

• Fatigue for 28 days.

• Anxiety for 26 days

History of present illness:

1. Acute pain in the back (location of the trauma) for past 1 month.

Onset: Gradual
Duration: Since the night of the accident
Radiation: Radiated from the hip to the back
Precipitation: Physical exertion of the muscles
Relieving factor: Pain reliving medications such as fentanyl
Quality of pain: Sharp and throbbing.

2. Unable to move the lower limbs for (loss of motor function) for past 26 days.

Onset: Gradual
Duration: After one day of the accident
Precipitation: Unknown
Relieving factor: Unknown

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3. constipation for 15 days:

Onset: Gradual
Duration: past 15 days.
Precipitation: limited water intake and lessened body activity.
Relieving factor: Syrup lactulose, soup and water enema and keeping hydrated.

4. Fatigue for 28 days:

Onset: Gradual
Duration: Five days of admission
Precipitation: pain at the trauma site and poor bodily activity.
Relieving factor: rest.

5. Anxiety for 26 days:

Onset: Gradual
Duration: Two days after the accident
Precipitation: Unknown
Relieving factor: Unknown

 Mrs. Kinzang has been previously healthy without any health problems for the last few
decades. However, on 13th March, while she was collecting leaves for her cows to feed
upon, she had an accidental fall from a tree which was approximately five meters in
height and landed on her buttock.
 She was not instantly taken to the hospital as they had brushed it off thinking she was
safe since she landed on her buttock. On that particular night, Mrs. Kinzang felt a severe
pain in the trauma location and it was accompanied by fever. The next morning, she was
taken to the Trashiyangtse hospital where she was managed with analgesics. Then she
was taken to monger hospital. Then she was immediately referred to Jigme Dorji
Wangchuck National Referral Hospital through air lift. She underwent posterior
instrumentation with pedicel screws.

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History of Past illness

Mrs. Kinzang has no past history of tuberculosis, asthma, hypertension, diabetes, heart problem,
mental, allergies and epilepsy.

Family Health History

No family history of tuberculosis, asthma, hypertension, diabetes, heart problem, genetic

disorder, mental and epilepsy.

Personal History

Religion: Buddhism

Diet: Non-vegetarian, eats thrice a day.

Appetite: Loss of appetite.

Sleeping pattern: Gets about 5 to 6 hours of sleep daily.

Exercises: she worked daily and performed strenuous exercises her farmland before the
accident.

Habits: no ill habits.

Reproductive and Sexual Habits

 Voiding pattern: normal

 Any pain during urination: absent
 Any itching and discharge from genital area: absent

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B. General Examination:

General appearance: Ill looking, anxious and worried.

Cooperation: Cooperative

Mental status: Illiterate, is unable to read and write.

Level of consciousness: Conscious and alert.

Nutrition:

 Height:162.5cm
 Weight: 61kg
 B.M.I: 23.28 kg/m^2

Body built: Normal

Vital signs (Obtained on 12th April 2021):

 Blood pressure: 110/60 mm of HG

 Pulse: 74
 Respiration: 18
 Spo2: 96%
 Temperature: 36.6 C
 Pain: 4/10

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A. Physical (Head to Toe Examination):
 Head:
Hair loss, sores, rashes and non-healing ulcers: Absent
Skull; injury, fungal infection and head ache: Absent
 Face: No swelling
 Eyes:
No Yellow discoloration
No discharge
No blurred vision.

 Ears:
No hearing problems (tinnitus or vertigo)
No history of ear infection
No discharge or pus
No deformities
 Nose:
No deviation of the nostril, bleeding or blockage by clots.
No mucus secretions in both the nostrils.
 Mouth:
Non-foul smelling
Absence of toothache, bleeding gums and swelling.
Sore throat/ difficulties in swelling: Absent
Central cyanosis: Absent
Dehydration: Absent
 Skin and Hair:
No non-healing ulcers or rashes.
No sweating, itching or abnormal body temperature
12 staple scar at the lumber region

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  Neck:
Deformities: Absent
Neck stiffness: Absent
Neck vein (Jugular vein): Not engorged
Carotid pulsation: Regular, normal rate and rhythm and volume.
Thyroid gland: Not enlarged, Lymph nodes: Not enlarged
 Nails and Hands:
Tremor: Absent
Deformities: Absent
Palmar erythema: Absent
Koilonychia: Absent
Leukonychia: Absent
Peripheral cyanosis: Absent
Clubbing: Absent
 Legs:
No scars, sores
Edema: Absent
Distend veins (varicose vein): Absent

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C. Systematic Examination [ Musculo-skeletal system] # Done on April 12, 2021
 Inspection:
No alterations in the shapes of the bones.
No shortening of the bones or the joints.
Swelling and inflammation: Present on the right ankle joint.
Effusion, erythema and deformity: Absent
 Palpation:
Bone tenderness: Absent
Fluctuation and crepitus: Absent
Slight swelling on the right ankle joint.

Special considerations:

 Range of Motion:
Upper limbs: Active
Grade: 5 Active motion against full resistance
Lower limbs: Slightly passive on the right side
Grade: 3 Active motion against gravity
 Strength:
Absence of muscle atrophy
 Neck:
Is able to flex, extend, abduct and adduct normally.
 Upper extremities:
Acromioclavicular joint: Normal
Bicep tendons: Normal
Elbows(epicondylitis): Normal
Phalen’s test: Negative
 Lower extremities; Faber test: Negative
 Knees:
No history of past injuries or scars.

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D. Lab investigation (Findings and Normal range):
Hematology; Complete Blood Count obtained on March 15th 2021

Test Name Result Normal Range Units

Neut/Gran% 61.2 H 40-60 %
Eosinophil % 7.6 H 0-5 %
Eosinophil 0.73 H 0-0.4 10^3/ul
Red Blood Cell 5.34 H 3.76-4.84 10^6/ul
Hematocrit 46.4 H 33-45 %
MCHC 31.3 L 11.3-14.9 g/dl

th
Liver Function Test obtained on March 15 2021

Test Name Result Normal Range Units

Total Bilirubin 1.4 H 35-104 mg/dl
Direct Bilirubin 0.41 H <0.2 mg/dl

Radio-imaging and X-ray:

MRI Scan of the spinal cord anterolateral) view was performed on 15th March 2021 prior to the
surgical procedure so as to confirm the diagnosis and the surgical interventions.

X-Ray was performed on 16th March 20201 after the surgical procedure to ensure that the pedicel
screws were in their place and to look for other sorts of complications.

 Currently she is undergoing physiotherapy daily.

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MRI AND X-RAY REPORT:

POSTERIOR INSTRUMENTATION WITH PEDICLE SCREWS (SITE OF SURGERY):

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 E. Medical diagnosis with Definition:
T12 burst fracture:
 A burst fracture is a descriptive term for an injury to the spine in which the vertebral body
is severely compressed.
 It typically occurs from severe trauma such as motor vehicle accident or fall from a height.
With great deal of force vertically onto the spine, a vertebra maybe crushed. If the
vertebral is crushed in all directions it is called a burst fracture.
 In the burst fracture, it is more liable for the spinal injury to occur since the bony margins
spreads out in all the directions. This can lead to paralysis or partial neurologic injury.
(retro-pulsed fragment)
 In a T12 burst fracture, the T12 vertebra is damaged and fragmented.

F. TREATMENT:
 Medicines:

Drugs Mechanism of Adverse Effects Nursing Responsibilities

Action
Injection Morphine acts on the  Pruritus’ Ensure the ten rights of medications while
Morphine specific opioid  Abdominal pain preparing and administering the medications.
D: 3mg receptors which are  Backache Assess history of hypersensitivity to opioids,
R: IV present in the CNS  Anaphylaxis head injury, acute asthma, COPD or seizure
F: QID and other tissues.  Sweating disorders.
Stimulation of the  Peripheral edema Monitor the vital signs frequently.
opioid receptors  Tachycardia Assess the skin color, textures, orientation
decreases the and reflexes.
 Hypothermia
intracellular calcium Dilute and administer slowly through IV to
 Dependency
thus decreasing the minimize the likelihood of adverse effects.
Potentially fatal:
pain perception. Keep opioid antagonist and facilities in case
Respiratory
of opioid overdose situations.
depression
Instruct the patient to report if she or he
Circulatory failure
experiences severe nausea and vomit.
Hypotension

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Injection Diclofenac Sodium is The adverse effects of Ensure the ten rights of medications
Diclofenac a phenylacetic acid Diclofenac sodium are mild while preparing and administering
Sodium derivative which is a and is usually well tolerated the medications.
(Voveron) prototypical NSAID. drug. Asses for history of renal
D: 75mg It has potent anti- However, at the start of the impairment, impaired hearing,
R: IM inflammatory, treatment the patients may allergies or hepatitis.
F: SOS analgesic and anti- sometimes complain of GI Administer the drug after food if GI
pyretic actions. It discomfort, headache and upset occurs.
reversibly inhibits the bleeding may occur. Arrange for periodic ophthalmologic
enzyme, Rare adverse effects include examination during long term
cyclooxygenase thus activation of peptic ulcers, therapy.
resulting in the hematemesis or melena. Instruct the patient to report sore
reduction of throat, fever, rash, itching, swelling
prostaglandins in the ankles, changes in vison and
precursors synthesis. black tarry stools.
Tablet Gabapentin is  Dizziness Ensure the ten rights of medications
Gabapentin structurally related to  Fatigue while preparing and administering
D: 300mg the neurotransmitter  Drowsiness the medications.
F: HS GABA but is neither  Tremor Asses for history of hypersensitivity
R: Oral GABA agonist or  Dry mouth to gabapentin, lactation or
antagonist. High  Vertigo pregnancy.
affinity gabapentin Instruct the patient to report severe
 Weight gain
correspond to the headache, sleep waling, rash, severe
 Peripheral edema
presence of voltage vomiting, chills fever or difficulty in
 Leukopenia
gated Ca channels breathing.
 Back pain
thus modulates the Asses the pain level and seizure
 Constipation
release of excitatory activity.
 Depression
neurotransmitters. Monitor the patient closely for
 Dyspepsia
changes in behavior and depression.
 Hostility

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Tablet Paracetamol exhibits  Thrombocytopenia Ensure the ten rights of medications
Paracetamol analgesics action by  Leucopenia while preparing and administering
D: I gram peripheral blockage  Pain and burning the medications.
F: TDS of pain impulse sensation at injection Ensure that the patient has no past
R: Oral generation. It site. history of allergy to paracetamol.
produces antipyresis Potentially fatal: Asses the patient pain score,
by inhibiting the Stevens-Johnson syndrome
hypothalamic heat Toxic epidermal necrolysis
regulating center. It Acute renal tubular necrosis
is a weak anti- Hepatoxicity
inflammatory activity
related to inhibition
of prostaglandin
synthesis in CNS.
Syrup Lactulose Lactulose promotes Initial dosing may produce Ensure the ten rights of medications
D: 15ml peristalsis by flatulence and intestinal while preparing and administering
F: BD producing an osmotic cramps. the medications.
R: Oral effect in the colon Excessive dosage can lead Provide with fruit juice, water, milk
with resultant to diarrhea, dehydration, if not contraindicated to increase
distension. nausea, vomiting or palatability.
hypokalemia. Do not provide the medication if the
patient complains of abdominal
pain, nausea and vomiting.
Diarrhea may indicate overdose.

Surgical:

Mrs. Kinzang underwent posterior instrumentation with pedicel screws on 15 th of March, 2021.
A posterior instrumentation involves the placement of screws and rods. This procedure is
performed so as to add stability for any lumbar interbody fusion. It\s benefits includes less
trauma to the muscles, minimal blood loss, fast recovery and fewer complications.

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G. PATHOPHYSIOLOGY and COMPRESSION OF CASE AND THEORY:

Etiology:

 Burst fractures are usually caused by:

 High energy trauma
 High velocity accident
 Motor vehicle accident
 Fall from height
 Sporting accidents
 Axial compression mechanism
 It can also result from osteoporosis, cancer, chemotherapy, infection and long-term steroid
use.

Burst Fracture

Pathogenesis:
The bones of the spine have two main sections. The vertebral arch is a ring-shaped section that
form the roof of the spinal canal and protects the spinal cord. The vertebral body id the
cylindrical shaped portion of the vertebral bone that lies In front and provides the majority of the
structural support. In a burst fracture, the vertebral body usually shatters.
When a healthy spine undergoes a major trauma such as fall from height, high velocity accident
or a spine that has been weakened by conditions such as osteoporosis and tumor and undergoes
minor trauma, the axial loading applied to the intervertebral disc results in increased nuclear
pressure and hoop stress in the annulus. This results in a high axial compression on the vertebral
end plate. Thus, these force leads to the burst fracture of the vertebra.

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 Predisposing Factors:
•Old age
•Osteoporosis (a bone disease that occurs when the body loses too much bone or makes too little bone)
•Osteopenia ( a condition where the bone density is lower than the normal value)
•Taking certain medications such as oral steroids, antidepressants and diabetes medications can
weakened the bones.
•A pre-existing spinal fracture.\
•Unhealthy lifestyle habits such as smoking, excessive alcohol consumption and a sedentary lifestyle.
•Female since more density loss is more common in women (Specially post menstrual woman)

Signs and Symptoms

 Moderate to severe back pain that is worse with movement.
 Numbness, tingling and weakness.
 Loss of bowel or bladder control
 Neurologic deficits

pg. 15 Nursing Case Study 2021 Anand prasad biswakarma

MANAGEMENT:
 Immobilization and stabilization of vertebral column.
 A, B, Cs (airway, breathing, circulation).
 Oxygenation by high-humidity mask.
 Assessment and management of nutrition.
 Pain management.
 Pressure injury prevention.
 Bowel and bladder care and training.
 Mobilization once spine stabilized.
REHABILITATION CARE:
 Physical therapy (ROM, mobility, strength, equipment).
 Pain management
 Spasticity management
 Bowel and bladder training
 Occupational therapy (splints, ADLs training)
 Autonomic dysreflexia prevention
 Pressure injury prevention
 Recreational therapy
 Patient and caregiver teaching
COMPLICATION:
 Urinary system: urinary dysfunction occurs as the ability of bladder muscle and
micturition center in the brain to transmit information is impaired.
 GI system: decreased GI motor activity contributed to gastric distension and distension
and chances of paralytic ileus.
 Integumentary system: risk for skin breakdown over bony prominences in area of
decreased or absent sensation is a major consequence of immobility.

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 H. NURSING CARE PLAN:
Nursing Diagnosis Goal and Nursing Scientific Rational Evaluation
Expected Interventions
Outcome
Acute pain in the Goal:  Assessed the  T12 burst fracture  After few
location of the trauma The patient will intensity, and the posterior hours on
related to movement have reduced location, radiation instrumentation evaluation the
of bone fragments as pain intensity of pain and brings about great patient looked
evidenced by patient preferably 2/10. changes in intensity of pain more relaxed
verbalization and Expected sensation. which usually and
facial mask of pain. Outcome:  Provided shoulder radiates to the lower verbalized
Subjective data: The patient will and back rub, extremities. reduced pain
|Patient said “I feel verbalize the avoiding the Assessing the intensity as
sudden pain from my relief of pain operation site. intensity enables one evidenced by
back and it does not and discomfort.  Encouraged the to get a better pain score
go away despite The patient will use of relaxation understand the pain 2/10.
resting” demonstrate the technique. and its management.  The patient
Objective data: use of  Taught the patient  Relives and reduce was able to
The patient has a pain relaxation and about deep pain by altering the sleep and rest
score of 4/10 and a diversional breathing sensory neurons and completely
facial grimace. activities. exercises. muscle relaxation. for few hours.
 Administered  Enhances coping
pain medications abilities.
as prescribed by
the physician:

pg. 17 Nursing Case Study 2021 Anand prasad biswakarma

 opioids, NSAID  Pain medications
and analgesic. helps reduce the pain
and promotes rest.

Impaired physical Goal:  Maintained bed rest  Provides stability  On evaluation

mobility related to The patient as indicated and thus minimizing the patient
loss of motor will be able to provided support of disturbances and was able to
function of the lower perform some while moving and promotes healing. perform
limbs as evidenced daily physical turning.  Prevents fatigue certain
by patient’s limited activities  Planned activities to allowing physical
range of motion and during the provide opportunities for activity such
decreased muscle period of uninterrupted rest maximal efforts and as getting out
strength. admission and periods and participation by the of the bed
Subjective data: after encouraged patient. with help.
The patient states discharge. involvement within  Enhances circulation,  The patient
“My lower limbs feel Expected individual tolerance restores and also
weak and I am unable Outcome: and ability. maintains muscle underwent
to walk properly|” Patient  Performed and tone and joint. physiotherapy
Objective data: performs assisted with full  Motivates patient and which enabled
The patient is unable physical ROM exercise on helps them perform her increase
to walk properly and activity all the extremities better. her range of
has limited independently. and joints, using  Educates the patient motion.
movements. Patient slow smooth and enables them to  The patient
The patient’s muscle demonstrates movements. understand how also
strength and its the use of  Encouraged patient physiotherapy can demonstrated
activity has been adaptative during the increase the rate of methods of
reduced. techniques the healing process. effective

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 that promotes physiotherapy and ambulation
ambulation. helped her wear the and balanced
The patient  Explained why the between
practices patient must moving and
physiotherapy undergo the resting.
daily. physiotherapy.

Constipation related Goals:  Assessed the  The normal  After the

to change in activity The patient patient’s bowel frequency of administration
level and altered will have function and the defecation ranges of soap and
dietary and fluid normal bowel pattern. differently for water enema
intake as evidenced function.  Encouraged well various individuals. the patient
by distend abdomen Expected balanced diet that  Improves was able to
and decreased Outcome: includes bulk and consistency of tool defecate.
appetite. Re-establish roughage (beans, for transient through  The patient
Subjective data: satisfactory orange) and the bowel. was relived of
The patient said “I bowel increased fluid  Improves appetite the discomfort
have not been able to elimination intake of at least and muscle tone as evidenced
defecate for five pattern. 2000ml in a day enhancing the by patient
days.” Relief of including fruit gastrointestinal verbalization.
Objective data: discomfort juices. motility.  The patent
The patient has: and abdomen  Administered  Stimulates peristalsis was able to
Distended abdomen distension. laxative and and routine bowel eat more.
Decreased output Patient suppositories in the evacuation when  The patient
demonstrates beginning following necessary. demonstrated
identification by soap and water  The laxatives aid in the proper
of measures enema. softening the stools measures of
that will  Encouraged and stimulate rectal preventing
prevent exercises and mucosa. Enema constipation
constipation. activity within stimulate defecation.

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 individual’s ability  Exercises stretches
as tolerated. the abdomen muscle
 Classified the and helps in
current medications defection.
usage that may lead
to constipation.

Anxiety related to Goals:  Assessed the patient’s  Assessment of  On

lack of knowledge, The patient physiological and patient’s evaluation
progression of will have psychological physiological and the patient
condition and new reduced comfort. psychological state was less
environment as anxiety level.  Encouraged the helps in making the anxious and
evidenced by Expected patient to verbalize right choices for the looked less
restlessness and Outcome: her worries and patient’s well-being stressed.
frequent asking of The patient doubts. and helps in  The patient
questions by the will discuss  Listened to the understanding the also
patient. feelings of patient talk. patient better. verbalized
Subjective data: anxiety and  Educated the patient  Verbalization of that she felt
The patient stated “I emotions. about deep breathing anxiety or worried more safe
am worried that I The patient exercises and copping thoughts enables and rested
may not be able to will mechanism. individuals to calm after being
walk and I miss my demonstrate  Stayed with the down and feel freer. explained
children” the use of patient and offered  Deeping breathing about her
Objective data: proper reassurance. exercises reduces condition.
The patient looked relaxation  Used simple words anxiety and
agitated and restless. technique. and messages to promotes relaxation.
explain her condition

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The patient also The patient and the medical  Offering reassurance
asked frequent will be procedures she brings about comfort
questions regarding relaxed. underwent. in patient and helps
her treatment and the  Advised the patient them to cope better.
outcomes. attendant to keep the  Use of simple words
patient well occupied reassures patient and
and stress free. helps them get a
clear picture of the
situation.

Risk for impaired Goals:  Encouraged  Regular exercises  On evaluation

skin integrity related The patient continuation of stimulate circulation, the patient
to immobility. will maintain regular enhancing cellular had no signs
Subjective data: proper skin physiotherapy nutrition and of pressure
The patient said “I integrity. program. oxygenation to ulcers.
can neither walk nor Expected  Avoided injection improve tissue health.  Participated
move my lower limbs outcomes: of medication below  Reduces edema voluntarily in
properly” The patient the level of injury. formation. change
Objective data: will verbalize  Encouraged the  Reduced circulation positions after
The patient has: understanding patient to reposition and sensation increase exercises and
Decreased range of of treatment frequently if risk of delayed two offers.
motion. needs. possible. absorption, local
Limited mobility Participate in  Kept the bedclothes reaction and tissue
preventing dry and free of necrosis.
skin wrinkles and  Reduces and prevents
breakdown. crumbs. skin irritation.
Demonstrate  Assessment helps to
methods that compare the condition

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 would ensure  Assessed the overall of the skin integrity
the prevention condition the skin and keep track of the
of skin frequently. progression.
breakdown.  Assessed for edema.  Assessing for edema
helps in preventing its
development.

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I. HEALTH EDUCATION:
1. Optimal nutritional intake includes the following:
 3 well-balanced meals each day
 2 serving from the milk day
 2 or more serving from the meat group including beef, pork, poultry, eggs, fish
 4 or more serving from vegetables and fruit groups
 4 or more serving from the bread and cereal group
2. Fiber intake should be about 20-30g/day. Increase amount of fiber eaten gradually over
1-2 weeks
3. At least 2-3L of fluid per day unless contraindicated. Drink water or fruit juices (fluid
softens hard stools). Limit caffeinated beverages such as coffee, tea and cola(caffeine
stimulates fluid loss through urination).
4. Avoid foods that produce gas (eg: beans) or GI upset (eg: spicy foods).
5. Follow a regular schedule for bowel elimination. A good time is 30min after the first
meal of the day.
6. If possible, an upright position with feet flat on the floor or on a step stool enhance bowel
evacuation. Staying on the toilet, commode, or bedpan for longer than 20-30 min may
cause skin breakdown. Based on stability, someone may need to stay with the patient.
7. Exercise is important for bowel function. In addition to improving muscle tone, it
increases appetite and GI transit time. Exercise muscles, including stretching, ROM,
position changing and functional movement.
8. Suppositories may be needed to stimulate a bowel movement. Manual stimulation of the
rectum may be helpful in starting defecation. Use stool softeners as needed to regulate
stool consistency. Use oral laxatives only if necessary.

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J. REFERENCE:

Brown, A., & Carmuciano, K. (2003). Introduction to skin management in SCI. Education
handout. Victorian Spinal Cord Service.
Gulanick, M., & Myers, J. L. (2007). Nursing care plans: Nursing diagnosis and intervention
(6th ed.). St. Louis, MO: Mosby.
Hicky, J. (2009). The clinical practice of neurological and neurosurgical Nursing (6th ed).
Wolter Kluwer/Lippincott Williams & Wilkins. Philadelphia.
Hinkle, J. L. (2004). Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed).
Philadelphia: Wolters Kluwer Health/Lippincott Williams & wilkins.
National Spinal Cord Statistical Center. Spinal cord injury facts and figures at a glance. (2014).
Retrieved from https;//www.nscisc.uab.edu/Public/Facts. Journal of Spinal Cord Medicine,
37(3), 355-356.

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