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CHAPTER 2
THEORYTICAL BACKGROUND
2.1 Anatomy Physiology
2.1.1 Anatomy of Central Nervous System
2.1.1.1 Spinal Cord
The spinal cord is continuous with the medulla oblongata above
and constitutes the CNS (central nervous system) below the brain.
It is approximately 45cm length and width 11cm. The spinal
nerve exits from each segment of the spinal cord (31 spinal nerve
pair) and consists of motor or anterior roots (root) and sensory or
posterior root.In detail divided spinal cord into vertebral sections
8 cervicals, 12 thoracics,5 lumbars, 5 sacrals, 1 coccygeal that
correspond to paired nerves. At its lower end, it tapers off into a
conical shape called the conus medullaris, from the end of which
the filum terminale descends to the coccyx, surrounded by nerve
roots called the cauda equine (Muttaqin, 2008).
Picture 2.1 Anatomy of Medulla Spinalis (Smeltzer, 2010)
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2.1.2 Physiology of Spinal Cord System
The physiology of Spinal cord as Ginsberg (2008) explains, are part of
the somatic nervous system; starting from the tip of the dorsal and
ventral nerve from the spinal cord (the portion outside of the spinal
cord). Those nerves leads out the cavity and branches along its
journey to the muscle or sensory receptors to a branch of spinal nerves
is generally accompanied by blood vessels, especially the branches
leading to the muscles of the head (skeletal muscles).
Mechanism of input (entry of sensory information to the spinal cord)
and the output of the process that generates the information the motor
can be described as follows: Soma axon-axon cells from spinal nerves
that bring sensory information to the brain and spinal cord are located
outside the central nervous system (except for the visual system
because the retina is the part of the brain). Axon-axon that carries
sensory information coming to the nerves, this is the afferent nerves.
Soma-soma cells from axon that carries sensory information of the
dorsal root ganglia in the gathering. This neuron is unipolar neurons.
The axon branching stems near the soma cell send information to the
spinal cord and to the sensory organs. All of the axon in dorsal root
pass on the information sensorymotoric.
While according to Albert and Vaccaro (2013), the spinal cord has
two general functions. Briefly, it provides conduction routes to and
from the brain and work as the integrator or reflex center for all spinal
reflexes. Spinal cord tracts provide conduction paths to and from the
brain. Ascending tracts conduct sensory impulses up the cord to the
brain. Descending tracts conduct motor impulses down the cord from
the brain. Bundles of axons compose all tracts.
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2.2 Basic Concepts of Myelopathy
2.2.1 Definition
According to Batticaca (2008), myelopathy refers to the neurological
deficits associated with damage to the spinal cord. In general,
clinically myelopathy divided into several categories based on
whether or not there is significant trauma, and the presence or absence
of pain.
As Muttaqin (2008) explains, that myelopathy include injury to the
medulla spinalis due to trauma direct or indirect resulting in the main
function of the disorders, such as the dysfunction of motor, sensory,
autonomic, and reflex, either complete or incomplete. So, from the
definitions above the writer have a conclusion that the myelopathy
include injury to the medulla spinalis due to trauma direct or indirect
resulting in the main function of the disorders, such as the function of
motor, sensory, autonomic, and reflex, either complete or incomplete,
which is the clinically myelopathy divided into several categories
based on whether or not there is significant trauma, and the presence
or absence of pain.
2.2.2 Classification
2.2.2.1 According to Spinal Cord Injury degree according to the
scale of the ASIAN/IMSOP (American Spinal Cord Injury
Association/International Medical Society of Paraplegia,
Chin, 2016)
Table 2.1 Spinal Cord Injury degree according to the scale of
the ASIA/IMSOP Grade Type Disorder of Medulla Spinalis
A Complete Dysfunctions of motor and sensory up to S4-S5
B Incomplete Sensory function half good but the motor is
interrupted until the sacral segments S4-S5
C Incomplete Motor function below the level of the disturbed
but the main motor muscles still have strength <
3
D Incomplete Motor function below the level of the disturbed,
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the power of the main motor muscles > 3
E Normal No abnormality
2.2.2.2 According to NSCISC (2016) divided into 4 syndrome
depends on the part that occur injury
Table 2.2 NSCISC (2016) 4 syndromes of myelopathy
Clinic
Characteristics
Central cord
syndrome
Anterior
cord
syndrome
Brown-
Sequard
syndrome
Posterior
cord
syndrome
Biomechanics
Accident
Common
hyperextenssion
rare
hiperfleksi
Rare
penetration
Very rare
hyperextensi
on
Motoric
The disorder
varies;
rarely the complete
Often the
complete
paralysis
usually
bilateral;
traktus
disorders
descendent
The
weakness of
the limbs
ipsilateral
lesions;
traktus
disorders
descendent
The disorder
varies,
impaired
traktus
descendent
light
Protopatic
The disorder varies,
not typical
Often
missing total
bilateral;
traktus
disorders
ascendant
Often lost a
total of
contralateral;
traktus
disorders
ascendant
The disorder
varies,
usually mild
Propioseptik
Rarely interrupted
Usually
intact
Missing total
Agenesis;
traktus
disorders
ascendant
Disturbed
Repair
Real, fast, frequent;
the typical
weaknesses of the
hand fingers settle
Worst than
another
Bad
function; but
best
independenc
e
-
2.3 Etiology
2.3.1 According to Muttaqin (2008), the etiology of myelopathy are :
2.3.1.1 Accident (most common cause).
2.3.1.2 Sport.
2.3.1.3 Diving in shallow water.
2.3.1.4 The blast Wounds or cuts have pierced.
2.3.1.5 infectious processes
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2.3.1.6 primary Carcinoma
2.3.1.7 A cause of intradural cyst includes, post traumatic
progressive myelomalacic myelopathy, and benign neoplasm
(meningiomas, arachnoid cyst, epidermoid cyst,).
2.3.2 While as in Smeltzer (2010) views the etiology of myelopathy are ;
2.3.2.1 Spondiliosis cervical by myelopathy, which produces a
narrow channel and led to the injury of the medulla spinalis
and against progressive roots
2.3.2.2 Myelitis inflammatory processes resulting from infection or
non-infection;
2.3.2.3 Osteoporosis caused by compression fractures in the
vertebrae;
2.3.2.4 Siringmielia; tumor infiltration as well as compression;
2.3.2.5 Vascular disease.
2.3.2.6 Disc herniation that is reduction of the diameter of the spinal
canal and spinal cord compression, spinal instability,
congenital stenosi and others
2.3.2.7 In addition problem on the in vertebral disc, so that the
vertebrae can be the collapse, formation of osteophytes on the
nerve channels and reduces the vast canalis spinalis and
improves the surface anchoring the load on the bones and
because it reduces the effective strength.
2.3.2.8 On the spinal ischemia may also play a role in the
development of myelopathy. Blood flow on a less adequate
spinalis causes nerve and spinalis network does not get
enough nutrients, so the ligaments that hold the vertebrae can
be thinned and pressing the nerve channels as well as the
disruption of nerve function.
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2.4 Pathophysiology
Muttaqins (2008) views that the pathophysiology of myelopathy is trauma to
the neck can manifest on the broken the structure of the vertebrae, column
compression of the disc, cervical ligament, rupture and compression medulla
spinalis on each side that can suppress the spinal compression and manifests
on the nervous distribution and appropriate radix segments of the spine
cervical. Trauma to the cervical could cause injury spinal stable and unstable.
Stable injuries are injuries that the vertebral components will not be move by
normal movement so that the spinal cord are not broken and are usually more
low-risk . Unstable injury is an injury that can undergo further shift in where
there is a change of the structure of posterior oseoligamentosa (prediculus,
surface of joints, arcus posterior bone, interspinosa and supraspinosa
ligaments), and anterior column (two-thirds of the anterior portion of the
corpus vertebrae, part of the anteriordiskus invertebralis, and the anterior
longitudinal ligament). On injury hyperextension cervical, hit, on face or
forehead will force the head backwards and nobody supporting occipital to
head it strikes the top of the back. The anterior circulate ligament and the disc
can be damaged or it may damage nerves arcus.On injuries of the vertebral
body bruises flexi became the wedge; this is a stable injuries and vertebral
fracture is a type most frequently found. If the posterior ligament be ripped,
injuries are unstable vertebral bodies and the top although the tilting forward
over the body of the vertebra below it.
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2.5 Pathway
Injury of columna vertebral,
Injury of medulla spinalis
Parasimpatic nerve block Microscopic bleeding Damage of sipatetic line
ascending
Inflamation reaction
Broke of
nerve tissue
medulla
spinalis
Lose of
control on
vasomoto
r tonus
simpatic
nerves to heart
Numbness of respiratory muscle
Anesthetic
reaction
Oedema Spinal
shock Ischemia and hypoxemia
Paralysis
and
paraphlegy
1,Impaired of breathing
pattern Compression
of nerves and
vessels
Pain
respons
heavy
and
acute
Spinal
reflex Hypoventilation Paralitic
of ileus,
impaired
of rectum
function
and
bladder
7. impaired
of physical
mobility 3. Decrease
of tissue
perfusion
Activatio
n simpatic
nerve
system
Breathing failure
4. Pain
Weaknesses
general Response of
uncomfortable
in rest
Blood
vesselscont
riction
7. Impaired
of alvi
elimination
and urine
Death
5. impaired of
sleeppattern Risk of
infark on
miocardiac Dysfunction
of perception
spatial and
lose of
sensory
coma Decrease
level of
awareness Decrease of
cough ability,
less of
physical
9. Deficiency
of self care
Compression
of tissue
regional
15. Knowledge
deficit
Changed of
sensory
perception
Inadequate
nutrition Decubity
2. Risk of
ineffective
airway
13. Ineffective coping
individual
14. Risk of ineffective
managementthera
peutic
6. Imbalance
nutrition
11. Risk of
impaired of
skin
integrity
16. Impaired of psychology
17. Changed of family
process
18. Family anxiety and
client
19. Risk of decrease of
praying / spiritual
9.Risk of
injury
Picture 2.2
Pathophysiology myelopathy with modification (Muttaqin,
2008)
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2.6 Clinical Manifestations
2.6.1 According to National Spinal Cord Injury Statistical Center (2016) and
Batticaca (2012) a partial list of common spinal cord injury
symptoms includes:
2.6.1.1 Varying degrees of paralysis, including
tetraplegia/quadriplegia, paraplegia, and hemiphlegy.
2.6.1.2 Difficulty breathing; the need to be on a respirator
2.6.1.3 Problems with bladder and bowel function
2.6.1.4 Bedsores
2.6.1.5 Loss of perspiration,
2.6.1.6 Triafismus,
2.6.1.7 Bradycardia
2.6.1.8 Hypotension.
2.6.1.9 Chronic pain
2.6.1.10 Headaches
2.6.1.11 Changes in mood or personality
2.6.1.12 Nerve pain
2.6.1.13 Chronic muscle pain
2.6.1.14 Pneumonia (more than half of cervical spinal cord injury
survivors struggle with bouts of pneumonia)
2.7 Early Management and Medical Management Of Myelopathy
2.7.1 As Batticaca (2012) explains that early management for myelopathy is
the patient immediately places the incident is very important, because
improper treatment can lead to damage of the loss of function
neurologic. Victims of motor vehicle accidents or accidents drive,
contact sports trauma, falls, or direct trauma to the head and neck
should be considered experienced the myelopathy until evidence of
trauma is removed.
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2.7.1.1 With respect to the accident, the victim has to be mobilized
on a spinal board (back), with the head and neck in a neutral
position, to prevent trauma to complete.
2.7.1.2 One team member had to manage the patient's head to
prevent the flexi, rotation or extension of the head.
2.7.1.3 Hands are placed on either side of the ear to maintain traction
and a temporary alignment tool immobilization cervical
spinal or board is installed.
2.7.1.4 Of at least four victims raised the people must carefully over
the boards to move home sick. The existence of a twisting
motion may damage the medulla spinalis irreversible that
cause fragments of vertebrae is lost, broken, or cut the
medulla complete.
2.7.2 Acute phase management of myelopathy Batticaca (2012) ;
2.7.2.1 Therapy done to maintain neurological function that still
exist, neurological recovery, maximize action on other
injuries, prevent complications and heal, as well as damage to
the neural further. Reeducation over the subluksasi part on
the joints in one's bones to the coral spiral and decompressing
action immobilizes of the spine to the coral protected spiral.
2.7.2.2 The operation of early neural decompression as an indication,
internal fixation, or debridement opens cuts.
2.7.2.3 Elective internal Fixation is performed on the client by the
instability of the spine, ligaments injury without fracture,
progressive spine deformities, injuries that could not
reabduktion, and fracture non-union.
2.7.2.4 Steroid therapy, nomidipin, or dopamine to fix coral blood
flow spiral as need as weight of patient.
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2.7.2.5 Neurological State every hour, including observation of
sensory function, the motor, and it is important to track the
progressive deficit or ascendant.
2.7.2.6 Maintains a network of adequate perfusion, function
ventilation, and track state of decompensation.
2.7.2.7 The management of neurological deficits without a stable
injury such as angulasi or wedge from the body of the
vertebrae, fracture process of transverse foramen, spinosus,
and more. His actions symptomatic (rest pain reduced to
baring), immobilizes with physiotherapy for the recovery of
muscle strength gradually.
2.7.2.8 Injury neurological deficits accompanied by instability. If
there is a shift, fracture requires reabduction and the position
must be maintained.
2.8 Diagnostic Examination
2.8.1 According to Muttaqin (2008),the support examination of diagnostic
findings are :
2.8.1.1 CT-scan Examination
See the scene cuts or lesion, to evaluating the disturbed
structural on medulla spinalis.
2.8.1.2 MRI
Identify the presence of spinal nerve damage, edema and
compression.
2.8.1.3 X –ray
Determine the location and type of bone injuries (fractures,
dislocations), to alignment, reduction after a traction or
surgery.
2.8.1.4 Myelography
To show the column spinalis (vertebral Canal) if pathologic
factors are not clear or suspected dilution on the medulla
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spinalis arachnoids sub space (usually will not be done after
suffering wounds penetrating).
2.8.1.5 Thoracic x-rays
Exposing their lungs (example: changes to the diaphragm,
atelektasis).
2.8.2 Batticaca (2012) suggests that another support examination are :
2.8.2.1 Pulmonary function examination (tidal volume, vital
capacity)
Measure the volume of maximal inspiration especially in
patients with trauma cervical at the bottom or on torakal
trauma with disorders of the nervous frenikus/intercostals
muscles).
2.8.2.2 Serum chemistry
The presence of value Hyperglycemia or hypoglycemia,
electrolyte imbalances, the possibility of a decrease in Hb and
Hemathocryte.
2.8.3 NSCISC (2016) suggest another support examination, there are :
2.8.3.1 Arterial Blood Gas (ABG) examination: the result useful to
measurement the adequacy of respiration (oxygenation and
ventilation)
2.8.3.2 Count of lactate: to know perfusion status
2.8.3.3 Urinalysis: to detect any associated genitourinary damage.
2.9 Complications
According to Dewit and Kumagai (2013), based on the data assessment,
potential complications that may develop include the following:
2.9.1 Spinal shock and neurogenic shock
The disruption in the nerve transmission pathway between up and low
motor neuron may cause spinal shock. Spinal shock occurs actually
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after injury and end in 48 hours to several weeks. Neurogenic shock
may follow within 24 hours and create by loss vasomotor tone.
2.9.2 Muscle spasm
Actually after an accident to medulla spinalis, the victim will usually
have a flaccid type of paralysis.
2.9.3 Orthostatic Hypotension
Vasoconstriction is damaged after injury to the medulla spinalis, and
dysfunction in the legs made pooling of blood in the lower limb. An
quick change imposition from supine to sitting, or from lower to
higher position may cause giddiness and fainting.
2.9.4 Deep vein thrombosis
The drop of blood pressure combined with loss of muscle movement
slows venous back to the heart.
2.9.5 Infection
Damaged of respiratory muscles, with the signs less of cough and
shallow of patient with a high myelopathy to respiratory infection.
2.9.6 Damaged of skin
Loss of sensation and inability to transfer to another place the patient
at high risk for skin damaged and pressure ulcers.
2.9.7 Renal complication
Urinary decrease from the bladder to the kidney often occurs due to
damaged bladder function. The infection could travel up the ureter to
the kidneys. The long lasting kidney damage may occur from such
infection sooner or later.
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2.10 Prognosis
Patient with myelopathy usually have permanent and often devastating
neurologic deficit and disability. The most important aspect of clinical care
for the myelopathy Patient is preventing complications related to disability.
Chin (2016) reports that the complications of myelopathy patient they have
under than 5% a chance to return to be normal. The complete paralysis
continue up till 72 hours after damage will made the recovery is essentially
nil. In the recent 1900s, the cases of death made by myelopathy rate 1 year
after the accident in patients with full lesion approached 100%.
2.11 Basic Concepts of Nursing Care Myelopathy
Nursing care is a therapeutic process that in valves the cooperative
relationship between the nurse with clients, families, or communities to
achieve optimal health status in providing nursing care by using the methods
which include nursing process: assessment, nursing diagnosis, planning,
implementation and evaluation.
2.11.1 Assessment
2.11.1.1 According to Muttaqin(2008), the basic concept of
nursing care with myelopathy are :
a. The identity of the client.
Include: name, age, gender, status, race, religion,
address, education, medical diagnosis, date ofhospital
admission, and the date of assessment was taken.
b. Main Complaint
Mostly the reason for the client ask for help is because
limb weakness on the half of body, incontinent of
urinate and elimination, pressure pain on muscle, and
deformity in injury location.
c. Health History of Current Disease
There are histories of injury in spinal cord caused by
accident, fall, stab wound, gunshot, and the fall of
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hard objects. Assessments obtained include pain, loss
of sensibility and paralysis. This early symptoms from
spinal shock that will be continuing until a several
weeks, paralyticileuses, urine retention and losses of
reflex.
d. Health History of Previous Disease
Any history of hypertension, history of injury in
spinal cord before, anemia, heart disease, the use of
anti-coagulant drugs, aspirin, vasodilators, drugs
addictive and obesity. Assessment of this history can
support the assessment of current disease and the
basic data to further assessment and to provide further
actions.
e. Health History of Family Disease
There is usually a family history of hypertension,
diabetes mellitus.
2.11.1.2 According to Nanda (2014), physical examination head
to toe
a. General condition
Contents about the general condition of the patient,
history of vital signs, awareness and anthropometry
b. Skin
Content of integument / skin system assessment data,
general skin condition, skin intestines, texture,
moisture, presence of ulcers / wounds, turgor, skin
color and skin lesion
c. Head and neck
Include of data from head area assessment, symmetry,
presence of head abnormalities in general, headache of
varying intensity and restlessness and muscle or facial
tension. Assessment of the neck; the existence of
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widening jugulars, enlargement of the thyroid calendar,
enlargement of lymph nodes, and other disorders.
d. Vision and eyes
Content about the results of eye assessment and vision
system function, general eye condition, conjunctiva
(anemic, inflammation, and trauma)
e. Smelling and nose
The content of the nasal area assessment and the
function of the olfactory system, the general condition
of the nose, the airway or the occlusion of the nasal
passages, blood, secretions, and difficulty breathing.
Test the olfactory acuity by using odor stimulation
f. Hearing and ears
Contents of data on ear assessment and hearing system
function, general state of the ear, interruption of
hearing, use of hearing aids and other disorders
g. Mouth and teeth
The contents of the data of the oral assessment and
upper digestive function, the general state of teeth and
mouth swallowing disorders, the presence of
inflammation of the mouth (oral mucosa, gums,
pharynx), the presence of deformities and other
disorders
h. Chest, breathing, heart, and circulation
Contents of data on chest assessment of chest, is from
inspection, (chest expansion or development, chest
symmetry), palpation (chest symmetry,
tactileprematus), percussion and resonance / sonor (air).
Hypersonic (mostly air), dim (fluid), deafness (presence
of mass), respiratory auscultation, (wheezing, vesicular
and ronchi breathing sounds).
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Signs : History of cardiac disease tomyocardial
infarction (MI), rheumatic and vascular
heart disease, heart failure (HF), bacterial
endocarditic, polycythemia
Symptoms : Arterial hypertension which is common
unless CVA is due to embolism or
vascular malformation. Pulse rate may
vary due to various factors, such as
preexisting heart conditions, medications,
effect of stroke on vasomotor center.
Dysrhythmia, changes of
electrocardiographic (ECG). Bruit in
carotid, femoral, or iliac arteries, or
abdominal aorta may or may not be
present.
i. Abdomen
The contents of inspection results that include the
general state of the abdomen, abdominal hygiene,
convex abdominal shape, concave, flat, breathe
movements, presence of lumps in time and symmetry.
The auscultation the sound of bowel per minute. A
general palpation of the abdomen is data about
abdominal life, skin turgor or astringent
j. Genital and reproduction
The contents of the assessment results of the general
state of the genetic apparatus and the function of the
reproductive system. The aabnormalities in anatomy
and function, complaints and disorders of the
reproductive system.
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k. Extremity upper and lower
The results of upper and lower limb assessment range
of motion, muscle strength, ability to mobilize, pitting
edema, pain, physical limitations, motion, presence on
the feet or hands.
According to Nanda (2014), need physical, physiology,
social, and spiritual
1) Activity / Rest
Signs : Difficulty with activity due to
weakness, loss sensation, or paralysis
(hemyphlegy). Tired easily and
difficulty resting, pain or muscle
twitching.
Symptoms : Altered muscle tone (flaccid or spastic),
generalized weakness, one side
paralysis, and altered level of
consciousness (LOC)
2) Psychosocial
Signs : Feelings of helplessness, hopelessness.
Symptoms : Emotional liability, exaggerated or
inappropriate responses to anger,
sadness, happiness and difficulty
expressing self.
3) Elimination
Symptoms : Change in voiding patterns—
incontinence, anuria, distended
abdomen, and distended bladder. May
have absent or diminished bowel
sounds if neurogenic paralytic ileuses
present.
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4) Nutrition
Signs : History of diabetes, elevated serum
lipids (risk factors), lack of appetite,
nausea or vomiting during acute event
(increased intracranial pressure [ICP]),
dysphagia, loss of sensation in tongue,
cheek, and throat.
Symptoms: Obesity (risk factor), chewing and
swallowing problems.
5) Personal hygiene
Contents about the situation at home and in the
hospital, about bathing, shampooing, brushing, teeth,
general overview of clients when hospitalized and
able to self care
6) Sexuality
Content about sexuality, about complaint sexuality
and disturb sexuality
7) Spiritual
The content is the client's trust in God, the client's
belief about illness and client's activities when
healthy and sick.
8) Psychological Assessment
Psychological assessment of myelopathy includes
several dimensions that allow nurses to obtain a
clear perception of the status of emotional,
cognitive, and client’s behavioral. Assessment of
coping mechanisms was used by client was also
important to assess the client's emotional response to
the disease and changes in the client's role in the
family and society as well as the responses or
24
influence in their daily lives, whether in the family
or in the community.
2.11.2 Cranial nerve assessment
According to Muttaqin (2008), the procedures of cranial nerve
examination are:
2.11.2.1 Cranial nerve I (olfactory): Test ability to identify
familiar aromatic odor, one nark at a time with eyes
closed. Usually on myelopathy patient there is no
damaged and dysfunction.
2.11.2.2 Cranial nerve II (optic): Test vision with Snellen chart
and Rosenbaum near vision chart. Usually normal.
2.11.2.3 Cranial nerve III (oculomotor), cranial nerve IV
(trochlear), cranial nerve VI (abducens) : Test visual aids
by confrontation and extinction of vision. Inspect eyelids
for drooping. Inspect pupil’s size for equality and their
direct and consensual response to light and
accomodation. Test extraocular eye movements. Usually
no damaged.
2.11.2.4 Cranial nerve V (trigeminal): Inspect face for muscle
atrophy and tremors. Palpate jaw muscles for tone and
strength when patient clenches teeth. Test superficial
pain and touch sensation in each branch (test temperature
sensation if there are unexpected findings to pain or
touch).
2.11.2.5 Cranial nerve VII (facial): Inspect symmetry of facial
features with various expressions (example: smile,
frown, puffed, cheeks, and wrinkled forehead). Usually
normal and symmetric face.
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2.11.2.6 Cranial nerve VIII (acoustic): Test sense of hearing with
whisper screening test or by audiometric. Usually in
normal condition.
2.11.2.7 Cranial nerve IX (glossopharyngeal), cranial nerve X
(vagus): Test ability to identify sour and bitter taste.
Tests gag reflex and ability to swallow. Inspect palpate
and uvula for symmetry with speech sounds and gag
reflex.. Evaluate quality of guttural speech sounds
(presence of nasal or hoarse quality to voice). Usually in
good condition, there is no inability in swallowing.
2.11.2.8 Cranial nerve XI (accessory): Test trapezius muscle
strength (shrug shoulders against resistance). Test
sternocleidomastoid muscle strength (turn head to each
side against resistance).usually there are existence try
from patient to do cervical flexion and stiff neck (
rigidities nukal)
2.11.2.9 Cranial nerve XII (hypoglossal): Inspect tongue in mouth
and while protruded for symmetry, tremors, and atrophy.
Inspect tongue movement toward nose and chin. Test
tongue strength with index finger when tongue is pressed
against cheek. Evaluate quality of lingual speech sounds.
Usually tongue function normal, symmetric tongue, there
is no deviation and fasciculation.
2.12 Analysis of Data
The collected data must be analyzed to determine the client's problem. Data
analysis is an intellectual process which includes grouping the data,
identifying gaps and determining the pattern of the data collected and
compares the composition or groups of data with a standard normal values,
interpreting the data and ultimately make conclusions. The results of the
analysis are nursing problem statement.
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2.13 Nursing Diagnosis
2.13.1 According to Mutaqqin (2008), nursing diagnosis is a statement
that describes the health status or actual or potential problems.
Nurses wear the nursing process in identifying and synthesizing
clinical data and determine nursing interventions to reduce,
eliminate or prevent the health problems that exist on the client's
responsibility. The nursing diagnoses that often appears on the
status of clients and interventions that can be given as follows:
2.13.1.1 Ineffective breathing pattern related to respiratory
muscle weakness / diaphragm muscle paralysis
2.13.1.2 Ineffective airway clearance related to accumulation of
secrete, decreasing of cough ability, decreasing of
secondary physical mobility, and change of
consciousness level.
2.13.1.3 Decrease of perfusion tissue periphery related to
decrease cardiac output.
2.13.1.4 Pain related to compression of nerve, neuromuscular
injury.
2.13.1.5 Imbalanced nutrition less than body requirement related
to impaired swallowing.
2.13.1.6 Impaired physical mobility related to
hemisparase/hemyphlegi, neuromuscular impairment on
the extremity.
2.13.1.7 Change of elimination pattern of urinate related to
paralysis of urinate nerve.
2.13.1.8 Impaired of alvi elimination/ constipation related to
impaired of bowel and rectum nerve.
2.13.1.9 Impaired of fulfillment of daily activity related to lower
extremity weaknesses
2.13.1.10 Risk of infection related to decrease of primary defense
system.
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2.13.1.11 Risk for impaired tissue integrity related to bed rest
2.13.1.12 Change of sensory perception related to dysfunction of
perception spatial and loss of sensory.
2.13.1.13 Ineffective coping individual related to disease
prognosis, medication program, and bed rest.
2.13.1.14 Anxiety related to critical situational.
2.13.1.15 Family anxiety related to critical situation to client.
2.13.1.16 Risk of ineffective regiment therapeutic related to
tension of client situation.
2.14 Nursing Intervention
According to North American Nursing Diagnosis Asociation (NANDA,
2014) there are some nursing interventions in accordance with existing
diagnostics disease myelopathy are:
2.14.1 Pain related to compression of nerve, neuromuscular injury, relaxes
muscle spasm secondary.
Goal : In 3 x 24 hours after treatment the pain decrease or lose.
(Pain scale 2-0) with outcome criteria:
a. Subjectively report decrease of pain or lose
b. Can identify activity that could increasing or decreasing of pain
c. Client do not restless
Intervention:
a. Explain and help client with no pharmacologic and non invasive
relieve pain.
Rational: approaches using other relaxation and no
pharmacologic have shown effectiveness in reducing pain.
b. Give pain management, set physiology position.
Rational: physiology position will increase intake of oxygen into
ischemia tissue.
c. Teach relaxation technique (deep breath).
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Rational: increasing intake of oxygen with the result that
secondary pain from brain tissue ischemic.
d. Observation of pain level and response of motoric client 30
minutes after give analgesic to assess the effectiveness.
Rational: the optimal assessment will give a nurse the objective
data to prevent possibility of complication.
e. Collaboration with doctor in give analgesic.
Rational: analgesic will block pain track, with the result pain
will decrease.
2.14.2 Impaired physical mobility related to hemisparase/hemiplagia,
neuromuscular impairment on the extremity.
Goal: In 2x24 hours after treatment, client able to did his/her
activity as he/she can with outcome criteria:
a. Client able to participate in the exercise program, there is no
joint contracture, increasing of muscle strength, client perform
mobilization.
Intervention:
a. Assess for the ability to move and change position
Rationale: There may be differing degrees of involvement on the
affected side.
b. Observe for activities that increase or decrease muscle tone
Rationale: Initially muscles demonstrate hyporeflexia, which
later progress to hyperreflexia.
c. Change the position of the client at least every 2 hours.
Rationale: Position changes optimize circulation to all tissues
and relieve pressure.
d. Monitor the client’s skin integrity for areas of blanching or
redness.
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Rationale: Impaired mobility increases the risk for skin
breakdown.
e. Perform activities in quite environment with little distraction.
Rationale: Impaired cognitive function that occurs with stroke
may decrease the client’s attention span and concentration.
f. Perform active and passive ROM exercises in all extremities
several times daily
Rationale: ROM activities preserve muscle strength and prevent
contractures.
g. Refer to physical and occupational therapist as indicated
Rationale: Useful in determining individual needs, therapeutic
activities and assistive devices.
2.14.3 Impaired sleep pattern related to unfamiliar with environment
Goal: In 1 x 8 hours after treatment, impaired sleep pattern not occur
with outcome criteria:
a. Sleep pattern in normal range 6-8 hours per day.
b. Sleep pattern in normal range.
c. Feel fresh after wake up.
Intervention:
a. Asses the General State of the patient
Rational: Know the consciousness and the condition of the body
under normal circumstances or not.
b. Review the sleep pattern.
Rational: To know the ease in bed.
c. Examine the respiratory function: the sound of the breath, pace,
rhythm.
Rational: To knowing the level of anxiety
d. Examine the factors that lead to sleep disorders (pain, fear,
stress, anxieties, immobility, urinary elimination disorder such
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as frequently, disorders of metabolism, transport, environment,
temperature, the activity of which is not adequate).
Rational: To identify the actual cause of sleep disorders
e. Write down the action ability to reduce anxiety.
Rational: To monitors how far it can be calm and relax.
f. Create a cozy atmosphere, reduce or eliminate the distraction of
environment and sleep disorders.
Rational: To help relaxation while sleeping.
g. Limit of visitors during the period of rest that is optimal (e.g.;
after a meal).
Rational: sleep would be hard to do without relaxation,
h. Ask the client to restrict fluid intake and urination at night
before bed.
Rational:. Nighttime Urination can interfere with sleep.
i. Recommend or provide care in the evening hours (e.g.; personal
hygiene, linen and clothes are clean).
Rational: Comfort in body hygiene related patient myself and
wear.
j. Use tools (e.g.; the warm water to compress muscle relaxation,
reading material, a massage on your back, soft music, etc.
Rational: Ease in getting optimal sleep
k. Give the medication with the collaboration of the doctor.
Rational: Drug fits his schedule
2.14.4 Knowledge deficit related to inadequate information about disease
process a medication
Goal: In 1 x1hours after treatment, client and family show
understand about the disease, with outcome criteria:
a. Client and family said understand about the disease, condition,
prognosis and medication program.
b. Client and family can do the procedure correctly.
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c. Client and family can explain about the nurse explain before.
Intervention:
a. Review the level of knowledge of the client and family about
his illness.
Rational: Knowing how far the experience and knowledge of the
client and family about his illness.
b. Give an explanation on the client about his illness and his
condition now.
Rational: by knowing the illness and his condition now, clients
and their families will feel calm and relieve anxiety.
c. Discuss and give health education about client disease to
client and his family.
Rational: the client to reduce anxiety and increase client
knowledge about his illness.
d. Ask the client and family to repeat back about material that
has been given.
Rational: knowing how much understanding of clients and
families as well as assess the success of the action undertaken.
2.14.5 Ineffective management therapeutic related to therapeutic regimen
disobedience
Goal: In 1x 30 minutes after treatment, Ineffective management
therapeutic problem will be solved with outcome criteria:
a. Develop and follow a therapeutic regiment.
b. Being able to prevent risky behaviors.
c. Notice and take down the signs of change in health status.3. Notice
and take down the signs of change in health status
Intervention:
a. Help patients and families in making decisions about patient
care.
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Rational: Develop relationships with patients, families, and
other health workers in providing care.
b. Explain to the client and family about the disease.
Rational: Education will increase the ability client to take care
of the therapeutic of his disease.
c. Give client or the family education in the importance of self-
care
Rational: Discuss lifestyle changes that may be needed to
prevent the next complication or control the disease process
2.15 Implementation
As the same with other stages in the nursing process, the implementation
phase consists of several activities as follow:
2.15.1 Validation (validation) of nursing plans
2.15.2 Creating / documenting nursing plan
2.15.3 Provide nursing care
2.15.4 Continue for collecting the data
2.16 Evaluation
According to Smeltzer (2010),the result of expectation after the nursing
interventions have be done, are:
2.16.1 Demonstrating adequate cerebral tissue perfusion
2.16.2 Demonstrating joint mobility repair
2.16.3 Demonstrating adequate skin integrity
2.16.4 Regain bladder function
2.16.5 Regain bowel function
2.16.6 Admitted to not experiencing pain and discomfort
2.16.7 Free from complications
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