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Herniated Nucleus Pulposus (HNP) is defined as the protrusion of nucleus pulposus

(central part of intervertebral disc) into spine causing compression of spinal nerve roots. It
occurs when all or part of the spinal disk is forced through a weakened part of the disk which
places pressure on nearby nerves. The compression of the nerve roots as well as the
affectation of the adjacent nerves result in back pain and nerve root irritation.

The disease can also be called as to the following:

? „umbar radiculopathy
? mervical radiculopathy
? Herniated intervertebral disk
? Prolapsed intervertebral disk
? ›lipped disk
? uptured disk
? Herniated Disc

The disease is considered as radiculopathy since it affects spinal nerve roots. A

herniated disk is one cause of radiculopathy. It is specifically called as sciatica.



The intervertebral disc is the largest avascular structure in the body. It arises from
notochordal cells between the cartilaginous endplates, which regress from about 50% of the
disc space at birth to about 5% in the adult, with chondrocytes replacing the notochordal
cells. Intervertebral discs are located in the spinal column between successive vertebral
bodies and are oval in cross section. The height of the discs increases from the peripheral
edges to the center, appearing as a biconvex shape that becomes successively larger by about
11% per segment from cephalad to caudal (ie, from the cervical spine to the lumbosacral
articulation). A longitudinal ligament attaches to the vertebral bodies and to the intervertebral
discs anteriorly and posteriorly; the cartilaginous endplate of each disc attaches to the bony
endplate of the vertebral body.
The disc's annular structure is composed of an outer annulus fibrosus, which is a
constraining ring that is composed primarily of type 1 collagen. This fibrous ring has
alternating layers oriented at 60° from the horizontal to allow isovolumic rotation. That is,
just as a shark swimming and turning in the water does not buckle its skin, the intervertebral
disc has the ability to rotate or bend without a significant change in volume and, thus, does
not affect the hydrostatic pressure of the inner portion of the disc, the nucleus pulposus.
The nucleus pulposus consists predominantly of type II collagen, proteoglycan, and
hyaluronan long chains, which have regions with highly hydrophilic, branching side chains.
These negatively charged regions have a strong avidity for water molecules and hydrate the
nucleus or center of the disc by an osmotic swelling pressure effect. The major proteoglycan
constituent is aggrecan, which is connected by link protein to the long hyaluronan. A fibril
network, including a number of collagen types along with fibronectin, decorin, and lumican,
contains the nucleus pulposus.
The hydraulic effect of the contained, hydrated nucleus within the annulus acts as a
shock absorber to cushion the spinal column from forces that are applied to the
musculoskeletal system. Each vertebra of the spinal column has an anterior centrum or body.
The centra are stacked in a weightbearing column and are supported by the intervertebral
discs. A corresponding posterior bony arch encloses and protects the neural elements, and
each side of the posterior elements has a facet joint or articulation to allow motion.
The functional segmental unit is the combination of an anterior disc and the 2
posterior facet joints, and it provides protection for the neural elements within the acceptable
constraints of clinical stability. The facet joints connect the vertebral bodies on each side of
the lamina, forming the posterior arch. These joints are connected at each level by the
ligamentum flavum, which is yellow because of the high elastin content and allows
significant extensibility and flexibility of the spinal column.
mlinical stability has been defined as the ability of the spine under physiologic load to
limit patterns of displacement so as to avoid damage or irritation to the spinal cord or nerve
roots and to prevent incapacitating deformity or pain caused by structural changes. Any
disruption of the components holding the spine together (ie, ligaments, intervertebral discs,
facets) decreases the clinical stability of the spine. When the spine loses enough of these
components to prevent it from adequately providing the mechanical function of protection,
surgery may be necessary to reestablish stability.


¦? Approximately 80% of HNPs occur in the lumbar region.

¦? Approximately 20% of HNPs occur in the cervical region and 20-33% of these
have concurrent lumbar disc involvement.
¦? The age-incidence curve for lumbar HNP peaks in the second through fourth
decades of life and the incidence is higher in males than females.
¦? The age-incidence curve for cervical HNP peaks in the fifth through sixth decades
of life and the incidence is higher in males than females.
¦? „ess than 1% of the HNPs occur in the thoracic region. The age-incidence curve
for thoracic HNP peaks in the fifth through sixth decades of life and the incidence
is equal for both sexes.
¦? Pathologic lesions (i.e. spondylosis and spinal stenosis) have been noted in 50% of
the cases with lumbar HNP.

?  !"#!

The exact cause of herniated nucleus pulposus is unknown, however, it can be
attributed to the following risk factors:

£?  ! $ ! Direct trauma to the vertebra affecting the intervertebral
%? Demands extra effort in the weight-bearing functions of the vertebra.
&? '!"Disrupts the equal distribution of pressure within
the intervertebral contents.
Î? ()*They engage in activities that strains the back.
+? !"Impairs the perfusion of oxygen in the bones affecting bone
,? „oss of calcium ions affecting bone strength.
-? ü autation in genes coding for proteins involved in the regulation of the
extracellular matrix   

 , such as MMP2 and THB›2, has been
demonstrated to contribute to lumbar disc herniation.

? .
Herniated nucleus pulposus can be traced back from different risk factors. mommonly,
HNP is caused by trauma on the intervetebral discs such as accident or injury, being
overweight and engaging in various activities that demand a lot of effort from the spine.
Accident or injury causes direct trauma on the spine which can also affect or injure the
intervertebral discs. Being overweight, on the other hand, puts on a lot of weight on the spine,
demanding constant exertion of pressure from the spine to carry on the extra weight.
Activities that strain the vertebra is also a very crucial predisposing factors in the
development of HNP since such activities disrupts the equal distribution of pressure on the
intervertebral discs because these activities increase the pressure on the discs. In connection
to the latter, males have higher chances of developing the disease since they engage in such
type of activities more frequently than females. These three factors result in the compression
of the anterior side of the disc. Because of the compression, the contents of the intervertebral
disc, most especially the nucleus pulposus, will be pressed against the already thinned (due to
stretching) annulus pulposus on the posterior part.

It is also highly considered that HNP is caused by general wear and tear such as the
different degenerative changes that occur in aging. These degenerative changes primarily
include loss of calcium from the bones which eventually lead to loss of bone strength. Also,
the effects of smoking is related in this regard since smoking, especially lone-term smoking,
reduces bone strength because of the disruption of oxygen perfusion into the bones given that
the cigarette-smoking can lead to vasoconstriction. The loss of the strength of the bones
compromises the function of the vertebra to protect the different intrevertebral contents, one
of which, the nucleus pulposus. Because of the latter, there will be the asymptomatic
fissuring and fragmentation within the disk which will lead to the compression of one side of
the intervertebral disc and exertion of pressure to the other side. Degeneration of the annulus
pulposus can also be considered which will then disrupts the isovolmic rotation of the
It is also considered that mutation in genes coding for proteins involved in the
regulation of the extracellular matrix or the annulus pulposus, such as MMP2 and THB›2,
has been demonstrated to contribute to lumbar disc herniation. Weak annulus pulposus means
a compromise in the functions of the said structure which then results to a disruption in the
isovolmic rotation of the vertebra.
These factors will eventually lead to the herniation of the disk into the spinal canal or
the neural foramen. ›ince the outer annulus pulposus suffers from the pressure exerted by the
nucleus polpusus, the latter will then gradually prolapsed through the annulus pulposus
leading to its innervation which will then be manifested by mild to severe back pain that
radiates to the pelvis and the legs. The innervations of the annulus pulposus allow disk
fragment to herniate through it which will then lead to a diminished tension on the annulus
that is manifested by weakness on the affected part. The decrease in the tension of the
annulus leads to its rupture allowing the nucleus pulposus to potrude resulting now to spinal
nerve compression that leads to the different manifestations of HNP. ›uch manifestations
include back pain that radiates across the buttock and down the leg, weakness of leg and foot
on the affected side, numbness and tingling of toes, „asegue¶s sign, depressed or absent
Achilles reflex, muscle spasm in the lumbar area, shoulder pain that radiates down the arm to
hand, paresthesia and sensory disturbances.

? ..

a.? „aboratory and Diagnostic Procedures

£?  (c! 

A physical examination and history of pain can indicate the presence of a

herniated disk. Often, the pain is most severe at the lower back and it radiates across
the buttock and spreads down the leg (along the sciatic side).

„eg pain that occurs when you sit down on an exam table and lift your leg
straight up usually suggests a herniated lumbar disk.

%?  ! (

A neurological examination will evaluate muscle reflexes, sensation, and

muscle strength. Often, examination of the spine will reveal a decrease in the spinal
curvature in the affected area.

&? #! !  !

A foraminal compression test of ›purling is done to diagnose cervical

radiculopathy. mervical radiculopathy is considered when increased pain or numbness
is felt if the head is bent forward or towards the sides as the healthcare provider
applies pressure on the top of the head.
Î? !

adiography refers to the use of X-rays to view a non uniformly composed

material such as the human body. By utilizing the physical properties of the ray an
image can be developed displaying clearly, areas of different density and


? !

In cases of disk bulging, plain radiographs reveal indirect findings of disk

degeneration in the form of loss of height of the intervertebral disk, vacuum
phenomenon in the form of gas in the disk, and endplate osteophytes. Moderate
bulges appear as nonfocal protrusion of disk material beyond the borders of the
vertebra; this is typically broad based, circumferential, and symmetric.

In most cases of herniated nucleus pulposus (HNP), plain radiographs of

the lumbosacral spine or cervical spine are not needed. Plain radiographs do not
reveal disk herniation; they are usually used to exclude other conditions (eg,
fracture, cancer, infection). When the clinical condition strongly suggests HNP,
plain radiographs can be avoided.

? .!

Myelographic findings in patients with HNP include extradural deformity

or displacement of the contrast-filled thecal sac. In addition, myelograms may
show elevation, deviation, or amputation of the root sleeve and edema of the
affected nerve.

When used in routine practice, magnetic resonance (M) myelography has

been shown to be of limited value. In one study, it assisted in establishing a
diagnosis in only a small percentage of cases (6%). The technique was of limited
additional value in patients with multilevel pathology, and it was of even less
value in patients with scoliosis, for whom it was used to help establish the most
likely level to account for the pathology.

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X-ray is a test that uses radiation to produce images of the bones and
organs of the body. ›pine X-rays provide detailed images of the bones of the
spine, and can be taken separately for the three main parts of the spine--cervical
(neck), thoracic (mid back) and lumbar (lower back).

›pine X-ay is done to rule out other causes of back or neck pain. However, it
is not possible to diagnose a herniated disk by spinal x-ray alone.
0 ›agittal view of the
cervical spine demonstrating an anterior
cervical disc herniation at m2- m3 level, plus
osteophyte formation with calcification of the
anterior longitudinal ligament. The epiglottis
(e) indicates narrowing of the airway
(between arrows).

+? !!) .ü*

Electromyelography involves testing the electrical activity of muscles. Often,

EMG testing is performed with another test that measures the conducting function of
nerves. This is called a nerve conduction study.

EMG is done to determine the exact nerve root that is involved.

0 A decrease in the electrical activity of the muscles is highly
possible when a patient is suspected of HNP. The presence of spinal nerves in the
affected portion of the spine implies the affectation of the functions of the said nerves,
one of which, motor functions. These spinal nerves innervate the different muscles of
the body, hence, the compression of which leads to decreased release of impulses to
the different muscles.

,? !' '

Nerve conduction velocity test is a test of the speed of electrical signals

through a nerve. The distance between electrodes and the time it takes for electrical
impulses to travel between electrodes are used to determine the speed of the nerve

0 Any peripheral neuropathy can cause abnormal results, as can
damage to the spinal cord and disk herniation (herniated nucleus pulposus) with nerve
root compression.

-?  !

momputed Tomography is a medical imaging method employing tomography

created by computer processing. Digital geometry processing is used to generate a
three-dimensional image of the inside of an object from a large series of two-
dimensional X-ray images taken around a single axis of rotation.

0 mT has proved to be as good as or even better than
myelography alone in the diagnosis of herniated disk. mT scanning with myelography
is superior to either one alone.
a.?     !, images show a focal, smooth, outward
displacement of the disk margin in the spinal canal, in the neural foramen, or
lateral to the neural foramen. mT scans may further demonstrate calcification or,
less commonly, gas in the herniation.

b.?  " !, mT scans show a soft-tissue mass with effacement of the
epidural fat and displacement of the thecal sac. If the fragment is no longer
restrained by the P„„ but is still in contact with the disk margin, an irregular,
lobulated excrescence on the disk margin is seen. A separated disk fragment is
often detected in the epidural fat adjacent to the dural sac or sheath of a nerve
root. The disk margin may appear normal. The attenuation of the nuclear
fragments of a fragmented disk is usually 80-120 HU.

Deformity of the dural sac and nerve sheath, along with the bony changes,
help in the diagnosis:

¦? Axial mT myelogram of a large,

central calcified disk extrusion
present at the T5-6 level.
It causes severe spinal cord compression.

¦? Axial mT myelogram shows a

posterior central disk extrusion
present at the T11-12 level.
It compresses the cord.

¦? ›agittal reformatted mT myelogram

shows a large, calcified, posterior
central disk extrusion causing severe
cord compression at the T5-6 level.
Axial mT myelogram shows posterior,
central disk protrusion present at
T11-12 level. Mild cord compression is noted.

‰? .).*

Magnetic esonance Imaging is a method of imaging the interior of structures

noninvasively. MI is important because it is noninvasive, safe, and yields
information that cannot be obtained with any other techniques. Its most common use
by far is in diagnostic medicine but MI has other applications, particularly in the oil
and food industries.

›pine MI or spine mT will show spinal canal compression by the herniated
0 A positive MI result shows the extruded disc material as a
dark mass, and this is the true value of an MI ± revealing the exact location and
severity of nerve compression produced by a herniated intervertebral disc.

MI exquisitely delineates herniated nucleus pulposus (HNP) and its

relationship with adjacent soft tissues. On MI, HNPs appear as focal, asymmetric
protrusions of disk material beyond the confines of the anulus. HNPs themselves are
usually hypointense. However, because disk herniations are often associated with a
radial anular tear, high signal intensity in the posterior anulus is often seen on sagittal
T2-weighted images. On sagittal MIs, the relationship of HNPs and degenerated
facets to exiting nerve roots within the neural foramina is well delineated. In addition,
free fragments of the disk are easily detected on MI.

¦? Axial T1-weighted image shows

protrusion of a left paracentral disk
with compression of left ›1 root.

¦? Axial T2-weighted image shows

protraction of a left paracentral disk
with compression of left ›1 root.

¦? ecurrent postoperative disk extrusion

at „ -5 after „ -5 diskectomy. Axial
and sagittal T1-weighted images
obtained before and after contrast
enhancement reveal a rim of enhancing,
recurrent left central disk extrusion
with downward migration.

¦? ight „5 radiculopathy. ›agittal T1-

and T2-weighted images show a
large, right central disk extrusion at
„ -5 that markedly compresses the
thecal sac. The extruded disk migrates
cranially, compressing the right „5
nerve root.
¦? ight ›1 radiculopathy. Axial T1- and
T2-weighted images at „5-›1 show a
large, right paracentral disk extrusion
causing marked compression of the thecal
sac. Images show compression, but the
right ›1 root is not visible. The extruded
disk also has mild cranial extension that
compresses the right „5 root.

¦? ›agittal T2-weighted imaging of

lumbosacral spine shows an annular tear
at „ -5 and disk protrusion at the
„5-›1 levels.

¦? ›agittal T1- and T2-weighted images and

axial T1- and T2-weighted images show
degenerative changes at the „1-2 and
„2-3 levels, facet hypertrophy at the
„ -5 level, and disk herniation leading to
extrusion and compressing the left „5 root.

¦? ›agittal T1- and T2-weighted gradient

-echo images obtained at m5-6 show a
moderate to severe central disk
extrusion that causes cord compression
with abnormal signal intensity in the
cord. Gradient-echo images improve
the contrast to distinguish between
the hyperintense disk and the
hypointense osteophytosis.

In cases of disk bulging, early findings on MI include loss of the normal
posterior disk concavity. Moderate bulges appear as nonfocal protrusions of disk
material beyond the borders of the vertebrae; bulges are typically broad based,
circumferential, and symmetric.

A radial tear of the anulus fibrosus is considered a sign of early disk

degeneration. It is accompanied by other signs of disk degeneration, such as a bulging
anulus, loss of disk height, herniation of the nucleus pulposus, and changes in the
adjacent endplates. Although a radial tear of the anulus fibrosus can be detected as an
area of increased signal intensity on T2-weighted and gadolinium-enhanced MIs, the
association between the annular tear on MIs and the symptomatic disks is unclear.

b.? Pharmacologic Management

 ? )! !*

£? !1!) *

These drugs are used for long-term pain control and given to people with a
sudden herniated disk caused by some sort of injury (such as a car accident or lifting a
very heavy object) that is immediately followed by severe pain in the back and leg.

.0 This drug works by blocking the production of prostaglandins,

body chemicals that cause inflammation and contribute to the brain¶s perception of

%? !  "!. May be given if the pain does not respond to anti-
inflammatory drugs. And this are drugs taken to relieve discomfort, distinct from
anesthetics (drugs that deaden feeling) and sedatives (drugs that aid relaxation or

.  0 The precise mechanism of action is unknown although the
narcotics appear to interact with specific receptor sites to interfere with pain impulses.

&? c!)2*It works by suppressing the brain¶s perception of pain.

Î? !( )!* It blocks the production of certain chemicals called
prostaglandins that may trigger pain and inflammation.
+? ! )!* It produces a pain-killing effect by interfering with the
action of chemicals called neurotransmitters that are vital for nerve transmission.
,? () !(*It works as an oxygenase inhibitor.

/? . !(

.0These drugs are used to relieve pain by relaxing muscles that

are abnormally contracted (in spasm). They serve as a neuromuscular blockers and

£? !! ) * It relaxes muscles by blocking the transmission of

impulses along certain nerves in the brain stem and the spinal cord.
%? .( ) "(* The mode of action of this drug has not been clearly
identified, but may be related to its sedative properties. Metaxalone does not
directly relax tense skeletal muscles in man.
&? 3! !! )#(!* It works by affecting nerves that
control muscles, but it does not interfere with muscle function
 ? !

May be given either by pill or directly into the blood through an IV.

.  0 This drug travel in the blood that are attached to protein
carriers. When steroid hormones arrive at their target cells, they dissociate to their
protein carriers and pass through the plasma membrane of the cell. ›ome steroid
hormones bind to specific receptor proteins in the cytoplasm and then move as a
hormone receptor complex into the nucleus. Other steroids travel directly into the
nucleus encountering their receptor proteins.

! $)  "   !   ! "* These
can help control pain for several months. It can also reduce swelling around the disk
and relieve many symptoms.

c.? ›urgical Management

›urgery may be an option for the few patients whose symptoms persist despite
other treatments.

£? "

Diskectomy is a surgical procedure that removes a protruding disk. This

procedure requires general anesthesia (asleep and no pain) and 2-3 day hospital stay.
The patient will be encouraged to walk the first day after surgery to reduce the risk of
blood clots. momplete recovery takes several weeks. If more than one disk needs to be
taken out or if there are other problems in the back besides a herniated disk, more
extensive surgery may be needed. This may require a much longer recovery period.
Diskectomy is done when a herniated disk makes a patient suffer from:

¦? ›evere leg pain or numbness that badly affects activities of daily living
¦? Weakness in muscles of the lower leg or buttocks
¦? An inability to control bowel movements or urination


mhemonucleolysis involves the injection of an enzyme (called chymopapain)

into the herniated disk to dissolve the protruding gelatinous substance. This procedure
may be an alternative to diskectomy in certain situations.

This procedure may be done when the following conditions are met:

¦? History, physical examination, and diagnostic imaging (mT scan, MI)

indicate that the disc is bulging, but the material inside the disc (nucleus)
has not ruptured into the spinal canal.
¦? Pain and nerve damage have not improved after at least weeks of
nonsurgical treatment.
¦? ›ymptoms are severe and disabling.
&? .!"

Microdiskectomy is a procedure removing fragments of nucleated disk

through a very small opening.

›urgery may be considered if tests show that the symptoms are due to a
herniated disc and the doctor thinks surgery may help relieve the symptoms. The
following factors are often considered when deciding to have surgery.

¦? A history of persistent leg pain, weakness, and limitation of daily activities

that has not gotten better with at least weeks of nonsurgical treatment.
¦? esults of a physical examination that show you have weakness, loss of
motion, or abnormal sensation (feeling) that is likely to get better after
¦? Diagnostic testing, such as magnetic resonance imaging (MI), computed
tomography (mT), or myelogram, that indicates your herniated disc would
respond to surgery.


This type of surgery is the most often performed. It is the removal of the part
of the vertebral lamina. The surgery is done to relieve pressure on the nerves.

When the spinal cord or other nerves get irritated, they can cause weakness,
numbness and pain in the arm or leg.


This is a procedure that involves the insertion of a wedge-shaped piece of

bone chips between the vertebrae to stabilize them. The bone is usually taken from
from a client donor site such as the iliac crest.

›pinal fusion may be recommended for persistent pain that does not get better
with other treatments. It may be done in the following cases:

¦? Along with other surgical procedures for spinal stenosis, such as

foraminotomy or laminectomy
¦? After diskectomy in the neck
¦? Injury or fractures to the bones in the spine
¦? Weak or unstable spine caused by infections or tumors
¦? ›pondylolisthesis, a condition in which one vertebrae slips forward on top
of another
¦? Abnormal curvatures, such as those from scoliosis or kyphosis

,? #!

Foraminotomy is the enlargement of the opening between the disk and facet
joint to remove bony overgrowth compressing the nerve. The location and size of the
incision is according to the physicians preference and location and size of the ruptured
disk. The posterior approach is taken for lumbar surgery.

c.? ›upportive Management

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Diet and exercise must be encouraged to the patient since they are crucial and
improving back pain. This is because extra weight being carried by an individual
makes back pain worse.

Exercise, also, may help improve posture. Appropriate exercise can help take
pressure off inflamed nerve structures, while improving overall posture and

%? !

Physical Therapy is important for it works on strengthening the muscles of the

abdomen and lower back to help support the spine. Flexibility of the spine and legs is
taught in order to gradually aid in the resumption of the normal functions of the spine
and the back. This can be achieved by the physical therapists¶ performance of
diathermy (project heat deep into the tissues of the back) or manual therapy especially
if the mobility of the spine is impaired.

&? /"!

Back braces help support the spine by aiding the spine to bear the weight of
the head. However, overuse of these devices can weaken the abdominal and back
muscles leading to a worsening of the problem. This, nevertheless, can be addressed
by using weight belts which are helpful in preventing injuries.

Î? !

Traction is used to decrease pressure on the affected disk and may also address
muscle spasms. However, it does not directly reduce the HNP.

+? '

a.? A lumbar support can be helpful for a herniated disk at this level as a temporary
measure to reduce pain and improve posture.
b.? Bed rest on firm mattress with bed boards.

,? !' 

Health care providers must assure that efficient circulation and must be
vigilant, especially prevent, the development of bed sores especially if hospital
admission was indicated.

-? c  

Educate all patients about body mechanics, and discuss the risk factors for
faulty body mechanics, so that applications can be incorporated into individual work
settings, including appropriate seating (eg, lumbar support).

2?  !.

1.? Administer analgesics and other medications as ordered in order to prevent the
sensation of pain and maintain the comfort of the client.
2.? Use a firm mattress and bed board under the client in order to assure the alignment of
the disks and to avoid exacerbations.
3.? Make certain that traction and/or braces are correctly applied and maintained and that
weights hang freely in order for the traction and the braces to be efficient.
.? Use the fracture bedpan to avoid lifting of hips.
5.? Use frequent and extensive back care to relax muscles and promote circulation
6.? ›upport body alignments at all times in order not to exacerbate the condition.
7.? Use log-rolling methods to turn the client (instruct the client to fold arms across the
chest, bend the knee on the side opposite the direction of the turn, and then roll over)
in order for the client to avoid extra effort in lifting his or her body.
8.? Teach the importance of weight loss, wearing low-heeled shoes, and appropriate body
mechanics in order to avoid extra pressure on the affected disks.
9.? Increase fluid intake and encourage diet rich in nutrient-dense foods such as fruits,
vegetables, whole grains, and legumes to improve and maintain nutritional status as
well as prevent constipation; if necessary use stool softener to prevent straining.
10.?Provide special care for the client undergoing repair or removal of a disc.
a.? Explain that pain may persist postoperatively for some time because of edema
b.? Place the bedside table, phone, and call bell within reach to prevent twisting
c.? Observe the dressing for hemorrhage and leakage of spinal fluid; notify the
physician immediately if either occurs
d.? Observe for inadequate ventilation, especially in clients who have undergone a
cervical laminectomy
e.? Assess the patient for changes in neurologic functioning
11.?Allow the client to be dependent, but foster independence to maintain or uphold the
over-all well-being of the client.
12.?Encourage the patient to perform exercises as prescribed to strengthen abdominal
muscles for back support
13.?Encourage the client to express feelings about altered functioning and self-image as
well as their fears about the present condition and future disability to allay anxiety.