PRESENTORS:

Heriette Tolentino

Janvincent Tolentino

Cristine Joy Tolento

Rochelle Ann Tomale

JONATHAN TORIBIO

Lovely Tuliao

Hazel Paz Tuliao

Arphy Bryan Tuliao

OBJECTIVES
General Objectives:
This case study aims to help the patient, student nurses, Clinical Instructors
and the community people in effectively providing holistic care for a patient suffering
from spinal cord injury. It also aims to aid the patient in coping with life situations
and improve his level of functioning.

Specific Objectives:

1. Establish rapport and interact with the patient at the patient’s own level of
understanding and taking into consideration to his present condition.
2. Perform a thorough assessment in his present condition, and discuss the
physical and social changes.
3. Identify the signs and symptoms presented by the patient in relation to the
injury process.
4. Implement a comprehensive plan of care for the patient with spinal cord
injury.
5. Evaluate the interventions provided in the given span of time for efficiency
and effectiveness.
6. Develop skills such as, interpersonal, technical and communication.
 INTRODUCTION
Spinal cord injury: Spinal cord injury is damage to the spinal cord as a result of a
direct trauma to the spinal cord itself or as a result of indirect damage to the bones
and soft tissues and vessels surrounding the spinal cord. SCI results in a decreased
or absence of movement, sensation, and body organ function below the level of the
injury. The most common sites of injury are the cervical and thoracic areas. SCI is a
common cause of permanent disability and death in children and adults.

The spine consists of 33 vertebrae, including the following:

• 7 cervical (neck)
• 12 thoracic (upper back)
• 5 lumbar (lower back)
• 5 sacral (sacrum – located within the pelvis)
• 4 coccygeal (coccyx – located within the pelvis)

Injury to the vertebrae does not always mean the spinal cord has been damaged.
Likewise, damage to the spinal cord itself can occur without fractures or dislocations
of the vertebrae.

Types of SCI

SCI can be divided into two main types of injury:

• Complete injury
-Complete injury means that there is no function below the level of the injury
— either sensation and movement — and both sides of the body are equally
affected. Complete injuries can occur at any level of the spinal cord.
• Incomplete injury
-Incomplete injury means that there is some function below the level of the
injury — movement in one limb more than the other, feeling in parts of the
body, or more function on one side of the body than the other. Incomplete
injuries can occur at any level of the spinal cord.

Causes

Injury may be traumatic or nontraumatic

A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine
that fractures, dislocates, crushes or compresses one or more of your vertebrae. It
may also result from a gunshot or knife wound that penetrates and cuts your spinal
cord. Additional damage usually occurs over days or weeks because of bleeding,
swelling, inflammation and fluid accumulation in and around your spinal cord.

A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation

or infections, or disk degeneration of the spine.

Common causes of spinal cord injury

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

Symptoms

Symptoms vary depending on the severity and location of the SCI. At first, the
patient may experience spinal shock, which causes loss of feeling, muscle
movement, and reflexes below the level of injury. Spinal shock usually lasts from
several hours to several weeks. As the period of shock subsides, other symptoms
appear, depending on the location of the injury.

Generally, the higher up the level of the injury to the spinal cord, the more severe
the symptoms

SCI is classified according to the person’s type of loss of motor and sensory function.
The following are the main types of classifications:

• Quadriplegia (quad means four) — involves loss of movement and sensation

in all four limbs (arms and legs). It usually occurs as a result of injury at T1
or above. Quadriplegia also affects the chest muscles and injuries at C4 or
above require a mechanical breathing machine (ventilator).
• Paraplegia (para means two like parts) — involves loss of movement and
sensation in the lower half of the body (right and left legs). It usually occurs
as a result of injuries at T1 or below.
• Triplegia (tri means three) — involves the loss of movement and sensation in
one arm and both legs and usually results from incomplete SCI.
• Quadriparesis and paraparesis refer to partial loss of function.

The following are the most common symptoms of acute spinal cord injuries.
However, each individual may experience symptoms differently. Symptoms may
include:

• Muscle weakness or paralysis in the trunk, arms or legs

• Loss of feeling in the trunk, arms, or legs
• Muscle spasticity
• Breathing problems
• Problems with heart rate and blood pressure
• Digestive problems
• Loss of bowel and bladder function
• Sexual dysfunction
The symptoms of SCI may resemble other medical conditions or problems. Always
consult your physician for a diagnosis.

Diagnosis

The full extent of the SCI may not be completely understood immediately after the
injury, but may be revealed with a comprehensive medical evaluation and diagnostic
testing. The diagnosis of SCI is made with a physical examination and diagnostic
tests. During the examination, the physician obtains a complete medical history and
inquires as to how the injury occurred. Trauma to the spinal cord can cause
neurological problems and requires further medical follow-up.

Diagnostic tests may include:

• X-ray — a diagnostic test that uses invisible electromagnetic energy beams

to produce images of internal tissues, bones, and organs onto film.
• Computed tomography scan (also called a CT or CAT scan) — a
diagnostic imaging procedure that uses a combination of x-rays and computer
technology to produce cross-sectional images (often called slices), both
horizontally and vertically, of the body. A CT scan shows detailed images of
any part of the body, including the bones, muscles, fat, and organs. CT scans
are more detailed than general x-rays.
• Magnetic resonance imaging (MRI) — a diagnostic procedure that uses a
combination of large magnets, radiofrequencies, and a computer to produce
detailed images of organs and structures within the body.

Treatment

Specific treatment for an acute spinal cord injury will be determined by your
physician based on:

• Overall health, and medical history

• Extent of the SCI
• Type of SCI
• Your tolerance for specific medications, procedures, or therapies
• Expectations for the course of the SCI
• Your opinion or preference

SCI requires emergency medical attention on the scene of the accident or injury.
This is accomplished by immobilizing the head and neck areas to prevent the patient
from moving. This may be very difficult since the victim and/or bystanders may be
very frightened after the traumatic incident.

Surgery is sometimes necessary to, stabilize fractured back bones, decompress (or
release) the pressure from the injured area, and to manage any other injuries that
may have been a result of the accident. Treatment is individualized, depending on
the extent of the condition and the presence of other injuries.

Treatments may include:

• Observation and medical management in the intensive care unit (ICU)

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

Recovery from a SCI requires long-term hospitalization and rehabilitation. An

interdisciplinary team of physicians, nurses, therapists (physical, occupational, or
speech), and other specialists work to medically manage the patient to control pain,
to monitor the

• Heart function
• Blood pressure
• Body temperature
• Nutritional status
• Bladder and bowel function and
• Spasticity (attempt to control involuntary muscle shaking)

Life-long considerations for a person with a SCI

A traumatic event that results in a SCI is devastating to the person and the family.
The healthcare team educates the family after hospitalization and rehabilitation on
how to best care for the person at home and outlines specific clinical problems that
require immediate medical attention by the patient’s physician.

The disabled person requires a focus on maximizing his/her capabilities at home and
in the community. Positive reinforcement will encourage him/her to strengthen
his/her self-esteem and promote independence.

A person with a SCI requires frequent medical evaluations and diagnostic testing
following hospitalization and rehabilitation to monitor his/her progress.

Prognosis
Prognosis for patients with spinal cord injuries varies and depends largely on the
degree of damage. The first year following injury is critical, as more patients die of
the injuries within that time period than any other.

Complications
• Bladder control. Your bladder will continue to store urine from your kidneys.
However, your brain may no longer be able to control bladder emptying, as
the message carrier (the spinal cord) has been injured. The loss of bladder
control increases your risk of urinary tract infections. It may also cause
kidney infection and kidney or bladder stones. Drinking plenty of clear fluids
may help. And during rehabilitation, you'll learn new techniques to empty
your bladder.
• Bowel control. Although your stomach and intestines work much like they
did before your injury, your brain may no longer be able to control the
muscles that open and close your anus. This may cause fecal incontinence. A
 high-fiber diet may help regulate your bowels, and you'll learn techniques to
better control your bowels during rehabilitation.
• Impaired skin sensation. Below the neurological level of your injury, you
may have lost part or all skin sensations. Therefore, your skin can't send a
message to your brain when it's injured by things such as prolonged pressure,
heat or cold. This can make you more susceptible to pressure sores, but
changing positions frequently — with help, if needed — can help prevent
these sores. And, you'll learn proper skin care during rehabilitation, which can
help you avoid these problems.
• Circulatory control. A spinal cord injury may cause circulatory problems
ranging from spinal shock immediately following your spinal cord injury to low
blood pressure when you rise (orthostatic hypotension) to swelling of your
extremities throughout your lifetime. These circulation changes may increase
your risk of developing blood clots, such as deep vein thrombosis or a
pulmonary embolus. Another problem with circulatory control is a potentially
life-threatening rise in blood pressure (autonomic hyperreflexia). Your
rehabilitation team will teach you how to prevent autonomic hyperreflexia.
• Respiratory system. Your injury may make it more difficult to breathe and
cough if your abdominal and chest muscles are affected. These include the
diaphragm and the muscles in your chest wall and abdomen. Your
neurological level of injury will determine what kind of breathing problems
you may have. If you have cervical and thoracic spinal cord injury you may
have an increased risk of pneumonia or other lung problems. Medications and
therapy can treat these problems.
• Muscle tone. Some people with spinal cord injuries may experience one of
two types of muscle tone problems: spastic muscles or flaccid muscles.
Spasticity can cause uncontrolled tightening or motion in the muscles. Flaccid
muscles are soft and limp, lacking muscle tone.
• Fitness and wellness. Weight loss and muscle atrophy are common soon
after a spinal cord injury. However, limited mobility after spinal cord injury
may lead to a more sedentary lifestyle, placing you at risk of obesity,
cardiovascular disease and diabetes.
• Sexual health. Sexuality, fertility and sexual function may be affected by
spinal cord injury. Men may notice changes in erection and ejaculation;
women may notice changes in lubrication. Doctors, urologists and fertility
specialists who specialize in spinal cord injury can offer options for sexual
functioning and fertility.
• Pain. Some people may experience pain, such as muscle or joint pain from
overuse of particular muscle groups. Nerve pain, also known as neuropathic
or central pain, can occur after a spinal cord injury, especially in someone
with an incomplete injury.

Prevention

Following this advice may reduce your risk of a spinal cord injury:

• Drive safely. Car crashes are one of the most common causes of spinal cord
injuries. Wear a seat belt every time you drive or ride in a car. Make sure that
your children wear a seat belt or use an age- and weight-appropriate child
safety seat. To protect them from air bag injuries, children under age 12
should always ride in the back seat. Don't drive while intoxicated or under the
influence of drugs.
 • Be safe with firearms. Lock up firearms and ammunition in a safe place to
prevent accidental discharge of weapons. Store guns and ammunition
separately.
• Prevent falls. Use a stool or stepladder to reach objects in high places. Add
handrails along stairways. Put nonslip mats on tile floors and in the tub or
shower. For young children, use safety gates to block stairs and consider
installing window guards.
• Take precautions when playing sports. Always wear recommended safety
gear. Check water depth before diving to make sure you don't dive into
shallow water. Avoid leading with your head in sports. For example, don't
slide headfirst in baseball, and don't tackle using the top of your helmet in
football. Use a spotter for new moves in gymnastics.

STATISTICS

CVMC (2009)

Month Male Female

January 0 1
February 0 1
March 2 0
April 3 0
May 3 1
June 4 1
July 0 0
August 0 1
September 1 0
October 0 0
November 1 0
December 0 1

National Spinal Cord Injury Statistical Center (2009)

Current estimates are 250,000 - 400,000 individuals living with Spinal Cord Injury or
Spinal Dysfunction.

• 82% male, 18% female

• Highest occurs between ages 16-30
• Average age at injury - 33
• Median age at injury - 26
• Mode (most frequent) age at injury 19
NURSING HISTORY
I. Present History
 4 hours prior to hospitalization, pt. Y is driving his tricycle at
Baggao, Cagayan to sell rice crops and earn money for his family. When he
reached the end of the bridge, his tricycle suddenly stops. He tried to restart
the engine but he failed to control it because of his tricycle’s weight. So pt. Y
and his tricycle fell down under the bridge with an estimated height of 15
feet. He tried to jump away from his tricycle while they were falling, but
unexpectedly his foot got hooked on the kick starter and his back was hit
when they reached the ground. Right after the accident, pt. Y felt pain all over
his body especially on his back & on his Left pelvic area. Luckily somebody
saw him and they removed the tricycle on top of him, then 2 people lifted him
up to get into the other tricycle with sitting position inside. They brought him
to Baggao Hospital but they referred him to CVMC because of lack of facilities.
During their trip, the pt. Y kept on complaining for back pain. They arrived at
ER of CVMC at 12:50PM on December 6, 2009 via stretcher. He received anti
tetanus vaccines & anti toxins vaccines.

II. Past History

 According to pt. Y, he had experienced some common childhood
illnesses such as measles, chicken pox and mumps when he was in
elementary. He had also experienced sore throat, cough, colds, and fever. He
managed it through bed rest and sometimes he takes herbal medicine such as
oregano for cough and guava leaves if he has wounds. He also took OTC
drugs such as paracetamol for fever, biogesic for headache and neozep for
colds. He didn’t receive any immunization. He has no allergy to foods, drugs &
animals. The patient has one history of hospitalization when he was in
elementary due to malaria. He had never undergone any major/minor
operation and he had no history of fracture.

III. Family History

 According to patient Y, they had a history of asthma on maternal
side & hypertension on both sides. They don’t have any history of Diabetes
Mellitus, Cancer & any other diseases which are hereditary.
IV. Social History
 Pt. Y is the 3rd child in the family and he has 5 siblings. He got
married at the age of 26. He is High School graduate. He’s a farmer &
sometimes he drives his tricycle. His wife X is an elementary graduate & a
housewife but sometimes she is helping his husband on their farm. They have
five children, 2 girls & 3 boys. All of his children have their own family. His
son and his family lives together with patient Y’s house. Pt. Y is the one who
provides all of his family needs. He drinks liquor once a week but he does not
smoke. He also mingles with his neighbors and friends after he finishes his
work on the farm.
GORDONS 11 FUNCTIONAL PATTERNS

I. Health Perception - Health Management Pattern

Before Hospitalization:
 Patient Y stated that health for him is very important to support his
family financially. He defined a healthy person as free or absence of
disease and can do anything he wants without limitations. He also
stated that he didn’t have any allergy to food, drugs and animals.
According to patient Y, he uses herbal plants such as oregano for
cough and guava leaves if he has wounds. He also uses over the
counter drugs such as Paracetamol for fever and Neozep for colds.
He also takes Biogesic for headache if it can’t be manage by bed
rest. He manages his muscle pain through rest. He seldom goes to
the hospital for check up. He’s not taking any supplemental vitamins.
Patient Y believes in quack doctor.

During Hospitalization:
 According to patient Y, it is his second hospitalization; his first
hospitalization was during his elementary age due to malaria. Patient
Y perceives that his health became poorer compare before
hospitalization because he can’t accomplish most of his ADL’s
required without assistance. Patient Y stated that he is complying
well with all therapeutic regimen and management for his condition
for faster recovery. He still does not take any supplemental vitamins.

II. Nutritional Metabolic Pattern

Before Hospitalization:
 Patient Y stated that he eats three times a day with a good appetite.
His breakfast was sometimes composed of coffee with bread or plain
rice or plain rice and egg. He can consume 2 to 3 cups of rice each
meal. He was fond to eat any kinds of vegetable and salty foods such
as dried fish and bagoong. He seldom eats meat and fish because
they lack of money. Sometimes he takes his snack in the afternoon
with a cup of coffee and bread, but he never takes his snack in the
morning. He had never uses any food supplements and had no
allergy to foods. He drinks 8 to 10 glasses of water a day. He
sometimes drinks soft drinks and drinks liquor once a week and he
doesn’t smoke cigarette. He can chew and swallow foods without any
difficulty. The patient weighs 58 kg. And 5’7” (174cm) in height. His
BMI is 19.33

During Hospitalization:
 According to patient Y his appetite has change. He can’t even
consume 1 cup of rice each meal and he is just eating 1 pack of
biscuit (sky flakes) and just sips of water or juice. His snack contains
1 biscuit or fruits with a cup of coffee or water because he is worried
 about his condition regarding his elimination pattern. He drinks 2 to
3 glasses of water a day and is not taking any food supplements. His
IVF was D5LRS regulated at 30gtts/min.

III. Elimination Pattern

Before Hospitalization:
 According to patient Y, he had no difficulty in urinating and
defecating. He described his urine as yellow in color. He voids 4 to 6
times a day, with an estimated amount of 1 glass per voiding which
is equivalent to 240 cc. He defecates once a day or once in two days
with formed stool but according to him, it sometimes depends on the
foods he had eaten.

During Hospitalization:
 Patient Y has IFC inserted because he can’t void but he has no urge
to urinate. His urine output was 150 cc per shift with yellow amber in
color. On his ten days of staying at the hospital, patient Y didn’t
defecate, even though he is taking dulcolax. This is due to his
present condition in which his bowel reflex is paralyzed. After 17
days of not defecating, he had defecated last Christmas Break, Dec.
23 and Dec. 29, 2009 with formed stool.

IV. Activity - Exercise Pattern

Before Hospitalization:
 Patient Y can perform his ADL’s without assistance. He woke up as
early as 5:00 am to prepare their breakfast and after cooking and
eating he would proceed to his working place by walking. He
considered walking and plowing the field as a form of his exercise.
He spent his leisure time listening to radio. Aside from being a
farmer he is also a tricycle driver.

During Hospitalization:
 Patient Y tried to be independent as much as possible. His wife and
daughter are assisting him in doing his ADL’s. Patient can eat, drink
alone and even combs his hair but he can’t able to move his two feet
alone. He spends his day in the hospital resting, talking to his wife,
daughter and his visitors. Passive range of motion is his form of
exercise. He is placed on complete bed rest and should be
repositioned every 2 hours. On our second week of duty, patient Y
can move his legs, turn side to side alone without assistance, but he
can’t sit.

V. Sexuality Reproductive Pattern

Before Hospitalization:
 According to patient Y, he was circumcised at the age of 9. He
experienced his first sexual intercourse when he was 16 y/o. He has
an active sexual relationship but as he grows older it gradually
decreases. His last sexual intercourse with his wife was on Dec. 5,
2009. Patient Y had never experienced any problem in sexuality and
he doesn’t have any sexually transmitted disease. They didn’t use
 any contraceptive. He experienced erection every morning especially
when he feels the urge to urinate.

During Hospitalization:
 Patient Y stated that sex is no longer important because his condition
is his priority. Besides he is in IFC and stated that he doesn’t
experienced a penile erection.

VI. Sleep - Rest Pattern

Before Hospitalization:
 Patient Y stated that he had 6 to 8 hours of uninterrupted sleep at
night. He sleeps around 9 pm and wake up at between 4-5 am. He
takes 15 minutes nap during daytime every after eating his lunch.
His not using any sleeping aids. He is easily awakened by loud noise
and when he feels the urge to urinate.

During Hospitalization:
 According to patient Y he has difficulty in sleeping because of the
new environment and due to worries about his condition. He has
interrupted sleep at night due to treatment regimen. He sleeps
around 9 PM and wakes up before 12 midnight and sleep again
around 1AM and wakes up between 5-6 AM. He stated that
sometimes the cause of the interruption of his sleep at night is
because the room is crowded and have insufficient ventilation. On
our second week of duty, according to patient Y he can’t fall asleep
easily because he worries about his operation, hospital bills and hot
environment. He goes to sleep around 4 AM and wakes up at 6 AM
because of routinely activities of the staff and to eat breakfast. After
breakfast he goes to sleep again at 9 AM and wakes up when its time
to eat lunch. He sleeps again after lunch until late afternoon.

VII. Cognitive Perceptual Pattern

Before Hospitalization:
 Patient Y was able to see object; hear sounds, taste food, smell and
sensitive to heat and cold. He doesn’t use any prosthesis such as eye
glasses or hearing aid. He can speak and understand ilocano and
tagalog. Patient Y has no difficulty with his vision, hearing, and he
has the ability to feel, taste and smell. According to him, the best
way for him to learn something new is through everyday experience.
During Hospitalization:
 Patient Y can still able to see object; hear sound, taste food, smell
and sensitive to heat and cold. He doesn’t use any prosthesis such as
eye glasses or hearing aid. He can still speak and understand Ilocano
and Tagalog. Patient Y has no difficulty with his vision, hearing, and
the ability to feel, taste and smell. Patient Y is oriented to place, time
and person. He can answer and respond to question appropriately.

VIII. Self Perception Pattern

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

During Hospitalization:
 Patient Y described himself as worthless and useless because when
he was hospitalized, he know that he can’t walk and use his legs,
meaning he can’t provide the needs of his family. He doesn’t
consider now himself as a real man because for him, he can’t do his
ADL’s alone without assistance. He considered God and his family as
source of his strength and his weakness was to be paralyzed all
throughout his life.

IX. Role Relationship Pattern

Before Hospitalization
 Patient Y was the bread winner and head of the family. He described
his family as lovable, supportive and happy to be with, though they
are not rich, they show their concern to each other. Patient Y and his
wife are helping in term of making decision. He considered his wife
as the most important person in his life because according to him,
his wife can’t leave him but his children has the possibility to leave
him any time. He also had a good relationship with his neighbors.
During Hospitalization:
 Patient Y stated that his family was more supportive to him and to
his condition. They show their concern to patient Y by accompanying
him to the hospital and according to patient Y; he sees it on their
faces. Patient Y and his wife were helping in making decision
regarding the treatment for his condition. He considered God as the
most important in his life because according to him, it is in God’s
plan what will going to happen in his life. He is thinking if he can still
do what he does before he was hospitalize.

X. Coping stress tolerance pattern

Before hospitalization:

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

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

During hospitalization:

 According to the patient the most stressful time in his life is his
present condition thinking that there is a possibility that he can’t use
 his legs to walk and it is considered stressful to him. The only way
for him to divert his attention is by sleeping and by talking to his
wife, daughters and visitors. He doesn’t cry for his problem regarding
his present condition but instead he is praying to God for his faster
recovery.

XI. Value Belief Pattern

Before Hospitalization:
 Patient Y was baptized as Roman Catholic. He seldom goes to mass
because according to him it was not part of his routine, but he
believes that God is our savior and creator. Patient Y says that even
though he was not going to mass there is a certain time that he
prays to God and asks for his guidance and protection. Patient Y also
believed in quack doctor.

During Hospitalization:
 Patient Y stated that his relationship to God got strengthened says
that his illness is a test for his faith, because whenever he has no
problem he is not praying to God.

Date interviewed started on:

December 14, 2009
Ended on:
January 4, 2010
 ANATOMY AND PHYSIOLOGY

Spinal cord is a bundle of nerves that carries messages between the brain and the
rest of the body.
 The spinal cord functions in the transmission of ascending impulses to the
brain and of descending impulses from the brain to the cord.

Spinal Column
 Common name applied to the structure of bone or cartilage surrounding and
protecting the spinal cord.

 Humans are born with 33 separate vertebrae. By adulthood, most have only
24, due to the fusion of the vertebrae in certain parts of the spine during
normal development.
 The spine consists of 33 vertebrae, including the following:

• 7 cervical (neck)
• 12 thoracic (upper back)
• 5 lumbar (lower back)
• 5 sacral* (sacrum – located within the pelvis)
• 4 coccygeal* (coccyx – located within the pelvis)

 By adulthood, the five sacral vertebrae fuse to form one bone, and the four
coccygeal vertebrae fuse to form one bone.)

L4 supplies many muscles, either directly or through nerves originating from L4.
They are not innervated with L4 as single origin, but partly by L4 and partly by other
spinal nerves. The muscles are:

 Quadratus lumborum
 Is a common source of lower back pain. Because the QL
connects the pelvis to the spine and is therefore capable of
extending the lower back when contracting bilaterally, the two
QLs pick up the slack, as it were, when the lower fibers of the
erector spinae are weak or inhibited (as they often are in the
case of habitual seated computer use and/or the use of a lower
back support in a chair).

 Gluteus medius
 One of the three gluteal muscles, is a broad, thick, radiating
muscle, situated on the outer surface of the pelvis.
 With the leg in neutral (straightened), the gluteus medius and
gluteus minimus function together to pull the thigh away from
midline, or "abduct" the thigh

 Gluteus minimus
 The gluteus medius and gluteus minimus abduct the thigh,
when the limb is extended, and are principally called into action in
supporting the body on one limb, in conjunction with the Tensor
fasciæ latæ

 Tensor fasciae latae

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

 Obturator externus muscle

 Obturator externus muscle is a flat, triangular muscle, which

covers the outer surface of the anterior wall of the pelvis.

 Inferior gemellus muscle

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

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

Predisposing Factor Etiology Precipitating Factor

 Age (16-35 y/o) > vehicular accidents > lifestyle (fond of driving)
 Gender (male) > falls, sport activities > work (driver)
> Disease
(bone cancer, osteoporosis, arthritis)

Can result to any of the following:

 Hyperextension
 Hyperflexion
 Rotational movement
 Compression
 Lateral flexion

Fracture and dislocation of vertebral disc

Excessive force is exerted on spinal cord

If L4 & L5 is affected or damage can lead to:

L4- controls bowel & bladder elimination > Ischemia
 Urinary Retention > Hemorrhage
 Loss of bowel reflex
 Low back pain
L5 – controls lower limb or extremities
  Muscle weakness
 Absence of withdrawal reflex
 Absence of Patellar 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)

 PHYSICAL ASSESSMENT
General Appearance:
The patient is awake, lying on bed conscious and coherent. He looks worried about his present condition ,
weak, long hair, fair in complexion. He has on going IVF of D5 LRS 1L to run for 8 hours, hooked, intact and infusing well on his
left hand.

Vital Signs: BP: 110/80 Temp: 36.8 C PR: 82 bpm RR: 20 cpm

Date Assessed:

AREA METHOD USED NORMAL FINDINGS ACTUAL FINDINGS EVALUATION RATIONALE

ASSESSED

SKIN Inspection -Varies from light to Skin is deep brown NORMAL

deep brown from
ruddy pink to light
pink
There should be no Presence of scar and ABNORMAL Due to accident and
Palpation presence of scar, hematoma blleding
edema, hematoma

-Compare skin Skin temperature is NORMAL

temperature must be uniform and within
uniform and within normal range
normal range
-Skin turgor, skin of
extremities returns -Skin returns to normal NORMAL
back to original state state when pinched
when pinched (1-2 after 1 sec.
seconds)
HAIR Inspection and -Can be black to - black NORMAL
Palpation brown or burgundy
depending on race

- Evenly distributed
covers the whole scalp - Evenly distributed NORMAL
with no evidences of covers the whole scalp
alopecia with no evidences of
alopecia
- Thick or thin, coarse
or smooth - thick and smooth
NORMAL
NAILS Inspection -Inspect nail plate -Normal convex NORMAL
shape; convex curvature
curvature; angle
between nail bed
about 160

-Inspect nail bed color -Pink and dirty ABNORMAL Due to poor Hygiene
and appearance

-Prompt return (2-3

Blanch Test sec) of pink or usual -Prompt return to NORMAL
Palpation color normal color within 2
seconds
HEAD
- Skull Inspection and Normocephalic no Normocephalic, no NORMAL
Palpation tenderness and upon tenderness and upon
palpation palpation

Inspection and - lighter in color than - lighter in color than NORMAL

- Scalp Palpation complexion complexion
- can be moist or oily - oily NORMAL
- no scars noted
- free from lice, nits - no scars noted NORMAL
 and dandruff - free from lice, nits and NORMAL
- no lesions dandruff
- no tenderness nor - no lesions NORMAL
masses - no tenderness nor NORMAL
masses
FACE Inspection - face is symmetrical - face is symmetrical NORMAL
- Palpebral Fissure is - equal palpebral fissure NORMAL
equal in both eyes
- Bilateral Nasolabial - Presence of Bilateral NORMAL
fold is present when Nasolabial Fold when
smiling. Slight smiling and is
asymmetry in the fold symmetrical
is normal

EYEBROWS Inspection - Symmetrical and in - Symmetrical and in NORMAL

line with each other line with each other
- Maybe black, brown - black
or blond depending on
race.

- Evenly distributed
- Evenly distributed NORMAL
EYELIDS Inspection - Upper eyelids cover - Upper eyelids cover NORMAL
the small portion of the small portion of the
the iris, cornea and iris, cornea and sclera
sclera when eyes are when eyes are open.
open

- No PTOSIS present - No PTOSIS noted NORMAL

(drooping of upper (drooping of upper
eyelids) eyelids)
- Meets completely - Meets completely NORMAL
when eyes are closed when eyes are closed.
 - Symmetrical - Symmetrical
NORMAL

EYELASHES Inspection - Color dependent on - black NORMAL

race
- Evenly distributed - Evenly distributed NORMAL
- Turned outward
- Turned outward NORMAL
EYES Inspection - Evenly placed and - Evenly placed and NORMAL
inline with each other inline with each other
- Non protruding - Non protruding NORMAL

- Both conjunctivae - Both conjunctivae are NORMAL

Conjunctiva Inspection are pinkish or red in pinkish in color
color

- Moist
- No ulcers - Moist NORMAL
- No foreign objects - No ulcers NORMAL
- No foreign objects NORMAL
Sclera is white in color

white in color NORMAL

Sclera Inspection
- Pupil equally round,
reactive to light and
accommodation
- Pupil equally round, NORMAL
Pupil Inspection reactive to light and
accommodation
EARS Inspection - The ear lobes are - Ear lobes are bean NORMAL
bean shaped, parallel, shaped, parallel, and
and symmetrical symmetrical
- The upper
 connection of the ear - Upper connection of NORMAL
lobe is parallel with the ear lobe is parallel
the outer can thus of with the outer canthus
the eye of the eye
- The ear canal has - Some cerumen noted
normally some upon inspection NORMAL
cerumen upon
inspection - No discharges noted
- No discharges or
lesions noted at the NORMAL
ear canal - The auricles have a
firm cartilage on
- The auricles have a palpation
Palpation firm cartilage on NORMAL
palpation - The pinna reoils when
- The pinna reoils folded
when folded -There is no pain or
-There is no pain or tenderness on palpation NORMAL
tenderness on of the auricles and
palpation of the mastoid process NORMAL
auricles and mastoid
process
NOSE Inspection - Nose in the midline - Nose in the midline NORMAL
- No discharges - No discharges
- No nasal flaring - No nasal flaring
- Both nares are - Both nares are patent
patent - Nasal septum in the
- Nasal septum in the mid line and not
mid line and not perforated
perforated
- No bone and cartilage
- No bone and deviation noted on
Palpation cartilage deviation palpation NORMAL
noted on palpation - No tenderness noted
- No tenderness noted on palpation
 on palpation NORMAL

MOUTH
Lips Inspection - With visible margin - With visible margin NORMAL
- Symmetrical in - Symmetrical in NORMAL
appearance and appearance and
movement movement
- Pinkish in color - Pinkish in color NORMAL
- No edema - No edema NORMAL

- No bleeding - No bleeding NORMAL

Gums Inspection - Pinkish in color - Pinkish in color NORMAL

- Number of teeth is - Number of teeth is 32 NORMAL

Teeth Inspection 32
- White to yellowish in - Yellowish in color NORMAL
color

-Pinkish in color -Pink in color NORMAL

Hard Palate Inspection
-The neck is straight - The neck is straight NORMAL
Neck Inspection and and at the midline and at the midline
Palpation -No visible mass or -No visible mass or NORMAL
lumps lumps
-Symmetrical -Symmetrical NORMAL
-No jugular venous -No jugular venous NORMAL
distention distention

-The shape of the -Thorax is elliptical NORMAL

thorax in normal adult
Thorax Inspection is elliptical
-Moves symmetrically -Moves symmetrically NORMAL
on breathing with no
 obvious masses.
-No chest retraction -No chest retractions NORMAL
must be noted as this noted
may suggest difficulty
in breathing
-The spine should be -Spine is straight with NORMAL
straight, with slightly slight curvature
curvature in the
thoracic area.
- There should be no - Presence of kyphosis Abnormal Due to fracture of
scoliosis, kyphosis, or on vertebral column lumbar vertebrae
lordosis.
- Expiration is usually - Expiration is longer NORMAL
longer than inspiration than inspiration

Palpation -No lumps, masses -No lumps masses and NORMAL

and areas of tenderness
tenderness

Heart Auscultation -Normal heart sound - Normal heart sound -NORMAL

and no heart murmurs and no heart murmurs

Lungs Auscultation -Vesicular and - Vesicular and broncho -NORMAL

broncho vesicular, vesicular, Bronchial
Bronchial sounds sounds
-No adventitious -No adventitious breath -NORMAL
breath sounds sounds.

Abdomen Inspection -Skin color is uniform, - Skin color is uniform, -NORMAL

no lesions. no lesions.
-Some clients may -No presence of striae -NORMAL
have striae or scar. or scars.
Auscultation -Normal bowel sounds -Hyperactive bowel -Abnormal -Due to prolonged
are high pitched, sound use of laxative
 gurgling noises that (30 burburigmi)
occur approximately
every 5 - 15 seconds.
It is suggested that
the number of bowel
sounds may be as low
as 3 to as high as 20
per minute, or
roughly, one bowel
sound for each breath
sound.

Percussion Tympany over the Tympany over the - NORMAL

stomach and gas filled stomach and gas filled
bowels; dullness, bowels; dullness,
especially over the especially over the liver
liver and spleen or a and spleen or a full
full bladder. bladder.

Palpation -No nodules or masses - No nodules or masses -NORMAL

upon palpation upon palpation
-No abdominal -No abdominal -NORMAL
tenderness tenderness present.
-No abdominal rigidity -No abdominal rigidity. -NORMAL

Extremities Inspection -Both extremities are -Extremities are equal -NORMAL

equal in size, have the in size, same contour
same contour with with prominences of
prominences of joints. joints. -NORMAL
-No involuntary -No involuntary
movements movements
-No edema -No edema -NORMAL

Palpation -Temperature is warm -Temperature is warm -NORMAL

and even and even.
 Blanch Test -capillary refill (1 – 2 - capillary refill (1 – 2 -NORMAL
seconds) seconds)

Observation -No difficulty on -Limited ROM, weak -ABNORMAL -Due to L4- L5 spinal
Motor Function Movement, full extremities as evidence cord injury.
ROM,and strong lower by need of assistance
extremities while moving

0- No Muscle power or total paralysis

1- Contraction visible or palpable
2- Active movement or
full ROM without gravity
3- Active movement or
Full Rom against gravity
4- Active movement
full ROM with moderate
resistance
5- Normal motor with active
movement with full ROM
against resistance

RESULT:
Left wrist – 5 Left knee- 3
Right wrist- 5 Right knee- 2
Left elbow- 5 Left ankle- 3
Right elbow- 5 Right ankle- 2

Patellar Reflex – stretch reflex, muscle contract is response to stretching force.

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

Result Normal Values Rationale

Hemoglobin 135 g/dL 135-180 g/dL Normal

Hematocrit 0.42 l/l 0.42-0.52 l/l Normal

RBC count 4.36 x 10¹²/L 4.7-6.1 x 10¹²/L Decrease due to

bleeding
Platelet count 3.21 x 10/L 150-400 x 10/L Normal

WBC count 16.0 x 10/L 5-10 x 10/L

Increase due to
inflammatory
process
Lymphocyte 0.23 .20-.40 Normal

Result Normal values Indication

BUN 6.65 3.30-6.70 Normal
creatinine 123.65 53.00-115.00 Increase due to
end product of
muscle metabolism

URINALYSIS

Result Normal Findings Indication

Color Yellow Yellow amber Normal
Transparency Turbid (cloudy) Clear Due to presence of
infection because of
prolonged use of
IFC
PH 8.0 4.6-8 Normal
Specific gravity 1.005 1.001-1.020 Normal
Leukocyte Abundant Absent Due to infection
Amorphous +++ Absent Due to tissue and
Phosphate bone damaged.
CT SCAN of the LUMBOSACRAL SPINE

Multiple Axial Tomographic sections of the lumbar spine (L1-S1) with sagittal
& 3D reconstruction were obtained. No IVF or intrathecal contrast was given.
The upper half of the L4 vertebral body is fragmented with signs of ventral &
dorsal displacement. A ledge shaped fragment is displaced 1.96 cm ventrally at the
level of the L3-L4 intervertebral space with slight torsion of the fracture towards the
left. There is displacement of the posterior aspect in to the spinal canal with
demonstration & intracanalicular fragments. The bilateral intervertebral facets are
distracted. The transverse & spinous process & lamina are intact.
These are linear fractures of the L1-L2 right transverse processes & L3
bilateral transverse processes.
The broad contours of the L4-L5 disc extend beyond the rim of the vertebral
bodies.
There is evidence of gas at level of L4-L5 intervertebral disease. (-) for
calcification.
The superior & inferior articulation facets & lateral recesses are unremarkable.
The ligamentum flavum is not thickened.

The rest of the intervertabral spaces are maintained.

Osteophytes are noted along the margin of vertebral bodies.
The pedides, laminae, rest of the transverse & spinous process are intact.
The rest of the visualized soft & osseous structures are unremarkable.
Scanogram shows wedge shaped deformation of the L4 vertebral body with
kyphosis of the vertebral column.

Impression:
 Fracture- disclocation, level of L4
 Liner fracture, L1 & L2 right & L3
Bilateral transverse processes.
 Disc herniation with vacuum phenomena, level of L4-L5
 Degenerative osteophytes, lumbar vertebral bodies.

RATIONALE OF CT SCAN
To determine what specific part of spinal cord is damaged or affected.

CHEST X-RAY (PA)

Both lungs field are clear and with normal vascular pattern. Heart and great
vessels are normal in size and configuration. Other chest structures are
unremarkable

Impression:
 no radiographic abnormality within the chest

RATIONALE OF CXR:

To check the readiness of heart and lungs and note if there any contraindication
before performing any procedure
COURSE IN THE WARD

DATE ORDER RATIONALE NURSING

RESPONSIBILITY
12-06-09  PLEASE ADMIT  To intervene  Admitted the
12:50PM TO Ortho Ward & give the patient at the
under the needed health ward as ordered.
service of Dr. service
Lasam  Witnessed the
 Secure consent  As a form for signing of
for admission & legal consent &
management purposes. checked if the
consent was
signed
 DAT with
aspiration  For nutritional  Inform the
precaution supplement Patient and his
SO about his
 Dx: diet and its
important.
• CBC;
• To evaluate  Informed the
for possible patient & his SO
abnormalities about the
indicating laboratory
infection or ↓ exams needs to
in platelet be done.
• BT; count or if
there is any
deviation.
• CXR PA • To know the
ABO blood
type prior to
blood
transfusion.
 Meds: Celecoxib • To visualize
200mg/ cap chest part &
BID determine if
there is any
 Insert IFC part affected
connect to urine by the  Observed the 10
bag accident. R’s before
 Treatment for administering
acute pain the drug
 refer  Inserted IFC &
maintained
 To facilitate aseptic
urine technique.
excretion &
monitor for  Referred to the
urine output physician if
 To inform the there is
physician untoward signs
about the and symptoms
condition of
the patient
12-07-09  IVF D5LRS 1L  Serve as  Hooked D5LRS
to run for 8˚ route for IV 1L regulated
drug properly and
administration check for
 Give ketorolac and promote patency
300mg IV for hydration
severe pain  Observe the 10
every 8˚ PRN  Treatment for R’s before
 D5W 500 ml + pain administering
2 ampule the drug.
diclofenac 50  Regulated
mg to run for  Treatment for properly the IVF
24˚ acute pain and checked the
10 R’s before
administering
 For CXR APL the drug

 To check the  Informed the

readiness of patient about
heart and the importance
lungs and of undergoing
note if there CXR and instruct
any to remove any
contraindicati metallic objects
on before in the body
performing
any procedure
12-09-09  For CT scan of  To determine  Informed the
lumbar vertebra the extent of patient and SO
(L1 – S1) injury and about the
determine diagnostic exam
what specific needed to be
part is done. Check for
affected any allergy in
iodine or
shellfish.

 Shows in  Instructed
detail a patient to lie still
specific plane during the
of involved procedure and
bone/injuries. tell patient that
this will last up
to 1 hour and
remove all
metals in the
body.
12-09-09  For ct scan of  To determine  Informed the
10:30 am lumbar vertebra the extent of patient and SO
( L1 – S1 ) with injury and about the
plate 3D determine diagnostic exam
reconstruction what specific needed to be
part is done Check for
affected any allergy in
iodine or
shellfish

 Shows in  Instructed
detail a patient to lie still
specific plane during the
of involved procedure and
bone/injuries tell patient that
this will last up
to 1 hour and
remove all
metals in the
body.
12-09-09  Refer to Dr.  To inform the  Referred to Dr.
5:00 pm Lacambra for co physician Lacambra
management about the
 condition of
6:00 pm the patient.  Turning schedule
 Bed sore done and post at
precaution:  To promote the bedside, turn
Turn patient side blood patient using log
to side every 2 circulation roll technique
hours and prevent
bed sore and
pneumonia  Emphasized the
 Secure egg importance of
crate mattress egg crate
for the use of mattress and
the patient.  To prevent encourage the
bed sores. patients S.O to
provide egg
crate mattress.

 Facilitate  Informed the

Lumbar (L1 – patient and SO
S1) CT scan at about the
St. Paul  To determine diagnostic exam
Hospital. the extent of needed to be
injury and done Check for
determine any allergy in
what specific iodine or
part is shellfish
affected
 Give 1 Dulcolax
(Bisacodyl)  Administered
suppository now meds as ordered
then start 1 following 10 R’s
tablet at  To prevent
bedtime constipation
tomorrow. and to
increase  Referred
 Refer peristalsis by monitored
accordingly acting directly condition of
the smooth patient to the
muscles of physician.
the intestines.
 To inform the
physician
about the
condition of
the patient.
12-18-09 Medicine Notes

 Patient seen  To assessed  Assisted the

and examined and to note physician during
the physical
improvement examination
 History and of the
Physical condition of  Assisted the
examination the patient physician during
reviewed physical
 To note any examination
diseases or
 Physical disorder that
Examination is  Assisted the
Findings: contraindicate physician during
- conscious and d to the physical
coherent treatment examination
- Vital signs: BP: regimen
130/80, PR: 78,
RR: 19  To assess the
- No cyanosis, no patient
pallor physical
- Anicteric sclera, condition
pink palpebral
conjunctiva
 - Symmetrical
chest expansion
clear breath
sounds
- A dynamic
precordium
pulse at 5th ICS
normal
- Flat abdomen
and soft NABS
- Full and equal
pulses
- No vein
engorgement
12-19-09  Reinsert IFC  To prevent  Performed IFC
infection and insertion and
UTI; relieve observed aseptic
bladder technique and
distention practice catheter
according to care such as
the next encouraging
doctor’s patient to
order. increase fluid
intake; catheter
is lower than
 Refer to surgery bladder and
if distended ensure that the
bladder is still urine bag
unresolved doesn’t touch
inspite of the floor
reinsertion of  For  Referred
IFC collaborative untoward sign
management and symptoms
about the of bladder
unresolved distention
bladder
distention
12-24-09  Still securing  For the  Informed the
funds for patient to patient to secure
implant undergo fund for
surgery upcoming
 Continue surgery
bedsore  To promote  Turning schedule
precaution blood done and post at
circulation the bedside, turn
and to patient using log
 Change IFC prevent bed roll technique
sore and  Performed IFC
maintain skin insertion and
integrity observed aseptic
 To prevent technique and
UTI practice catheter
care such as
encouraging
patient to
increase fluid
intake; catheter
 For urinalysis is lower than
bladder and
ensure that the
urine bag
doesn’t touch
 To check for the floor
the  Aspirate urine
characteristic specimen from
of the urine the Y port of the
and check for catheter using
any abnormal aseptic
value technique and
send it
immediate to the
laboratory
 DRUG STUDY

DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING

CONSIDERATION

Celecoxib  Thought to inhibit  For Acute pain and  Contraindicated in  CNS: dizziness,  Drug may be
prostaglandin primary patients headache, insomnia. hepatotoxic; watch for
synthesis, impeding dysmenorrhea hypersensitive to  CV: peripheral signs and symptoms
cyclooxygenase-2 drug, sulfonamides, edema. of liver toxicity.
(COX-2), to produce aspirin, or other  EENT: pharyngitis,  Drug can be given
anti-inflammatory, NSAIDs. rhinitis, sinusitis. without regard to
analgesic, and  Contraindicated in  GI: abdominal meals, but food may
antipyretic effects. those with severe pain, diarrhea, decrease GI upset.
hepatic impairment. dyspepsia, flatulence,  Tell patient to report
nausea. history of allergic
 Metabolic: reactions to
hyperchloremia. sulfonamides, aspirin,
 Musculoskeletal: or other NSAIDs
back pain. before starting
 Respiratory: upper therapy.
respiratory tract  Advise patient to
infection. immediately report
 Skin: rash. rash, unexplained
 Other: accidental weight gain, or
injury. swelling.
DRUG NAME
Diclofenac potassium
Cataflam
Diclofenac sodium
Fenac‡, Voltaren, Voltaren-
XR, Voltaren Rapide†,
Voltaren SR†
ACTION INDICATION CONTRAINDICATION
 Unknown. May  For Acute pain and  Contraindicated in
inhibit primary patients hypersensitive
prostaglandin dysmenorrhea to drug and in those
synthesis, to with hepatic porphyria
produce anti- or history of asthma,
inflammatory, urticaria, or other
analgesic, and allergic reactions after
antipyretic effects. taking aspirin or other
NSAIDs.
 Use cautiously in
patients with history of
peptic ulcer disease,
hepatic dysfunction,
cardiac disease,
hypertension, fluid
retention, or impaired
renal function.
ADVERSE REACTION
 CNS: anxiety, depression,
dizziness, drowsiness, insomnia,
irritability, headache, aseptic
meningitis.
 CV: heart failure, hypertension,
edema, fluid retention.
 EENT: tinnitus, laryngeal edema,
swelling of the lips and tongue,
blurred vision, eye pain, night
blindness, epistaxis, reversible
hearing loss.
 GI: abdominal pain or cramps,
constipation, diarrhea,
indigestion, nausea, abdominal
distention, flatulence, taste
disorder, peptic ulceration,
bleeding, melena, bloody
diarrhea, appetite change,
colitis.
 GU: proteinuria, acute renal
failure, oliguria, interstitial
nephritis, papillary necrosis,
nephrotic syndrome, fluid
retention.
 Hepatic: jaundice, hepatitis,
hepatotoxicity.
 Metabolic: hypoglycemia,
hyperglycemia.
 Musculoskeletal: back, leg, or
joint pain.
 Respiratory: asthma.
 Skin: rash, pruritus, urticaria,
eczema, dermatitis, alopecia,
photosensitivity reactions,
bullous eruption
NURSING CONSIDERATION
 Because of their
antipyretic and anti-
inflammatory actions,
NSAIDs may mask the
signs and symptoms
of infection.
 Tell patient to take
drug with milk, meals,
or antacids to
minimize GI distress.
 Instruct patient not to
crush, break, or chew
enteric-coated tablets.
 Advise patient to
avoid consuming
alcohol or aspirin
during drug therapy.
 Tell patient to wear
sunscreen or
protective clothing
because drug may
cause sensitivity to
sunlight.
DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING
CONSIDERATION

Ketorolac  Unknown. May  For acute pain  Contraindicated in  CNS: drowsiness,  Correct hypovolemia
exhibit patients sedation, dizziness, before giving
Non steroidal anti- prostaglandin hypersensitive to drug headache ketorolac
inflammatory drugs synthesis, to and in those with  CV: edema,  When appropriate,
produce anti- active peptic ulcer hypertension, give by deep IM
inflammatory, disease, recent GI palpitations, arythmias injection. Patient
analgesics and bleeding or perforation  GI: nausea, dyspepsia, may feel pain at
antipyretic  Contraindicated in GI pain, diarrhea, injection site. Put
children younger than vomiting, constipation pressure on site for
age 2 and in patients  Hematologic: decrease 15-30 seconds after
with history of peptic platelet adhesion, injection to minimize
ulcer disease or GI prolonged bleeding time local effects.
bleeding  Skin: pruritus, rash,  NSAID’S may mask
 Use cautiously in diaphoresis signs and symptoms
patients who are  Other: pain at injection of infection because
elderly or have site of their antipyretic
hepatic or renal and anti-
impairment or cardiac inflammatory actions
decomsation
DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSE REACTION NURSING CONSIDERATION

Dulcolax (Bisacodyl)  Unknown. To prevent  Contraindicated in  CNS: muscle weakness  Give drug at times that
Stimulant constipation. patients with excessive use, don’t interfere with
laxative that hypersensitive to dizziness, faintness scheduled activities or sleep
increases drug or its  GI: nausea, vomiting,  Before giving for
peristalsis, components and in abdominal cramps, constipation, determine
probably by those with rectal diarrhea with high doses, whether patient has
direct effect on bleeding, burning sensation in adequate fluid intake,
smooth muscle gastroenteritis, rectum with exercise and diet
of the intestine, intestinal suppositories, laxative  Tell patient to take drug
by irritating the obstruction, dependence with long with a full glass of water or
muscle or abdominal pain, term or excessive use, juice.
stimulating the nausea, vomiting or protein-losing  Teach patient about dietary
colonic other symptoms of enteropathy with sources of bulk, including
intramural appendicitis or acute excessive use bran and other cereals,
plexus. Drug also surgical abdomen  Metabolic: alkalosis, fresh fruit and vegetables.
promotes fluid hypokalemia, fluid and  Advise patient to report
accumulation in electrolyte imbalance adverse affects to
colon and small  Musculoskeletal: tetany prescriber.
intestine
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired bowel Within the duration  Assisted with  To asses Goal partially met,
“madi nak maka- elimination r/t loss of duty, the patient physical causative/ the patient
takki” as verbalized of nerve will verbalize examination contributing verbalized
by the patient conduction above understanding of (palpation the factors understanding of
the level of reflex condition, achieve abdomen) condition,
Objective: arc normal elimination participated on
Hyperactive bowel pattern or  Determined  To help measures to
sounds participate in client’s usual determine level of correct the defects,
measures to daily fluid intake, hydration and defecated last
= 30 bourborygmi correct for defects noted condition of December 23 and
sound upon skin and mucous 29, 2009.
auscultation membrane

 Ascertained
clients previous  For comparison
pattern of with current
elimination situation

 Ascertained
clients S.O’s  To assess the
perception of degree of
problem/ degree interference/
of disability disability

 Encouraged
fluid intake up to
3000 or more  For hydration
m/L per day
 Encouraged
client to verbalize
fears/concern
about his  Open
condition expression allows
client to deal with
feelings and begin
 Administered problem solving
medication as
ordered  To help his
bowel elimination
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity Within the  Evaluated clients  To provide Goal partially met.
 Verbal report of intolerance r/t duration of duty, actual and perceive comparative Within the duration
fatigue and neuromuscular the patient will limitations/ degree of baseline and provide of duty, the patient
weakness. impairment demonstrate a deficit in light of usual information about demonstrated a
“ Agkakapsot ti decrease in status needed education/ decrease in
bagik” physiologic sign intervention physiologic sign of
of intolerance regarding quality of intolerance as
Objective: life evidenced by
 Needs participation of
assistance in  Noted client’s report  Symptoms may activities of daily
repositioning of weakness, fatigue, results of/or living such as
 Inability to do pain and difficulty contribute to grooming, hygiene
his ADL’s accomplishing his intolerance of and turning
task. activity independently
 Ascertained ability to
move about and  To determined
degree of assistance current status and
necessary use of needs associated
equipment with participation in
needed desired
 Encouraged activities.
expression of feelings  To assist the client
contributing to his to deal with
condition contributing factors
and manage
activities within
individual limits
 Assist with activities
and provide/ monitor  To protect from
clients use of assistive injury
devices
 Promote comfort
 measures and provide
relief of pain  To enhanced the
ability to participate
 Repositioning every 2 in activities
hours
 To prevent bedsore
and to maintain
body alignment all
 Made repositioning the time.
schedule and post at  To prevent bedsore
bedside and educated and to promote
the patient’s S.O in circulation.
proper turning the
patient
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired urinary Within the  Palpated for  Bladder Goal partially met.
“Hindi ako makaihi elimination r/t loss duration of duty, bladder distention dysfunction is Within the duration of
as verbalized by of nerve the patient will and observed for variable but may duty, the patient
the patient” conduction above achieve normal over flow include loss of achieved normal
the level of the elimination bladder elimination pattern or
 Lack of reflex arc pattern or  Encouraged to contraction participate in
awareness of participate in increase his oral  To maintain renal measures to correct
bladder fullness measures to fluid intake up to function and to or compensate for
 Absence of correct or 3,000 or more mL prevent infection defects as evidenced
urge to void compensate for per day and formation of by urine output of
Objective: defects urinary stones 280 ml per shift but
 Uninhibited  Kept bladder still unaware of
bladder deflated by use of  To empty the bladder fullness.
contraction an IFC bladder
 Urine output of  Emphasized
150 ml per shift importance of  To reduce risk of
keeping area clean infection
and dry
 Demonstrated
proper positioning  To facilitate
of catheter drainage and to
drainage tubing prevent reflux
and bag
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Impaired physical Within the duration  Continually asses  Evaluates status of Goal met. Within the
mobility related to of duty, the motor function by individual situation duration of duty, the
“Hindi ako neuromascular patient will requesting patient (motor-sensory patient maintained
makagalaw” as impairment. maintain position to perform certain impairment may be position of function
verbalized by the of function and actions. mixed and/ or not and skin integrity as
patient. skin integrity as clear) for a specific evidenced by absence
evidenced by level of injury, of foot drops,
OBJECTIVE: absence of foot affecting type and contractures and
drops, choice of decubitus ulcer.
 Decreased muscle contractures and intervention.
control/strength decubitus ulcer Patient manifested
 Limited ROM  Enables patient to signs of increased
 Inability to  Provide means to have sense of muscle strength
purposefully more summon help. control, and
within the physical reduces fear of
environment. being left alone.

 Assist in range of  Enhances

motion exercises circulation, restores
on all extremities or maintains
and joints, using muscle tone and
slow, smooth joint mobility, and
movements. prevent disuse
contractures and
 Plan activities to muscle atrophy.
provide
uninterrupted rest  Prevents fatigue,
periods. allowing
Encourage opportunity for
involvement within maximal efforts or
individual participations by
 tolerance or patient.
ability.
 Reposition  Reduces pressure
periodically even areas, promotes
when sitting in peripheral
chair. Teach circulation.
patient how to use
weight-shifting  Open expression
techniques. allows client to deal
 Encourage with feelings and
verbalization of begin problem
feelings. solving.

 Inspect the skin  Altered circulation,

daily. Observe for loss of sensation,
pressure areas, and paralysis
and provide potentiate pressure
meticulous skin sore formation.
care.
 Helpful in planning
 Consult with and implementing
physical or individualized
occupational exercise program
therapist. and identifying or
developing
assistive devices to
maintain function
enhance mobility
and independence.
DISCHARGE PLAN

M - Instructed patient Y to take his medication on time with right dose and
to complete the duration of his medicine.

E - Encouraged him to do his activities of daily living as tolerated without

exerting too much effort.

T -Instructed patient to follow his treatment for his faster recovery.

H - Advised patient Y to maintain his good hygiene by everyday tooth

brushing and bed bathing with the help of his S.O

O - Instructed patient Y to strictly follow scheduled check-up.

D - Encouraged patient Y to eat nutritious fruits rich in Vitamin C, such as

calamansi and protein rich foods.

S - Encouraged patient Y to pray to God for his guidance and protection.