final_spinal stenosis l4, l5 secondary to spondylolisthesis l4, l5 grade ii with hypertrophized...
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
I. INTRODUCTION
Spondylolisthesis is a condition in which one of the bones of the spine
(vertebrae) slips out of place onto the vertebra below it. If it slips too much, the bone
might press on a nerve, causing pain. Usually, the bones of the lower back are affected.
The word spondylolisthesis comes from the Greek words spondylos, which
means "spine" or "vertebra," and listhesis, which means "to slip or slide."
Spondylolisthesis is the most common cause of back pain in teens. Symptoms of
spondylolisthesis often begin during the teen-age growth spurt. Degenerative
spondylolisthesis occurs most often after age 40.
Types of spondylolisthesis
There are different types of spondylolisthesis. The more common types include.
Congenital spondylolisthesis — Congenital means "present at birth."
Congenital spondylolisthesis is the result of abnormal bone formation. In this
case, the abnormal arrangement of the vertebrae puts them at greater risk for
slipping.
Isthmic spondylolisthesis — this type occurs as the result of spondylolysis, a
condition that leads to small stress fractures (breaks) in the vertebrae. In some
cases, the fractures weaken the bone so much that it slips out of place.
Degenerative spondylolisthesis — this is the most common form of the
disorder. With aging, the discs — the cushions between the vertebral bones —
lose water, becoming less spongy and less able to resist movement by the
vertebrae.
Less common forms of spondylolisthesis include:
Traumatic spondylolisthesis, in which an injury leads to a spinal fracture or
slippage
Pathological spondylolisthesis, which results when the spine is weakened by
disease — such as osteoporosis — an infection, or tumor
Post-surgical spondylolisthesis, which refers to slippage that occurs or
becomes worse after spinal surgery
A radiologist determines the degree of slippage upon reviewing spinal X-rays.
Slippage is graded I through IV:
Grade I — 1 percent to 25 percent slip
Grade II — 26 percent to 50 percent slip
Grade III — 51 percent to 75 percent slip
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Grade IV — 76 percent to 100 percent slip
Generally, Grade I and Grade II slips do not require surgical treatment and are
treated medically. Grade III and Grade IV slips might require surgery if persistent,
painful, slips are present.
http://my.clevelandclinic.org/disorders/back_pain/hic_spondylolisthesis.aspx
This condition might lead to spinal stenosis causes narrowing of the spine. The
narrowing can occur at the center of the spine, in the canals branching off the spine
and/or between the vertebrae, the bones of the spine. The narrowing puts pressure on
your nerves and spinal cord and can cause pain. Spinal stenosis occurs mostly in
people older than 50. Younger people with a spine injury or a narrow spinal canal are
also at risk. Diseases such as arthritis and scoliosis can cause spinal stenosis, too.
(http://www.nlm.nih.gov/medlineplus/spinalstenosis.html)
Spinal stenosis occurs when the space around the spinal cord narrows. This puts
pressure on the spinal cord and the spinal nerve roots, and may cause pain, numbness,
or weakness in the legs.
As we age, the bone in our spines
may harden and become overgrown.
This can lead to a narrowing of the
spinal canal, called stenosis. When
stenosis occurs in the lower back, it is
called lumbar spinal stenosis. It often
results from the normal aging process.
As people age, the soft tissues and
bones in the spine may harden or
become overgrown. These degenerative changes may narrow the space around the
spinal cord and result in spinal stenosis.
Degenerative changes of the spine are seen in up to 95% of people by the age of
50. Spinal stenosis most often occurs in adults over 60 years old. Pressure on the
spinal cord is equally common in men and women, although women are more likely to
have symptoms that require treatment. A small number of people are born with back
problems that develop into lumbar spinal stenosis. This is known as congenital spinal
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
stenosis. It occurs most often in men. People usually first notice symptoms between the
ages of 30 and 50. (http://orthoinfo.aaos.org/topic.cfm?topic=a00329)
On the other hand, hypertrophy of the ligaments in the vertebral canal of the spinal
column can increase their mass enough that they narrow the canal (stenosis)
sometimes to the point that the spinal cord and/or nerve roots running through the canal
are compressed further worsening then the spinal stenosis which may cause the
condition called Radiculopathy. It is usually a result of nerve root compression, which
occurs when something puts pressure on the nerve root. Most of the time the pressure
comes from a herniated disc. Above conditions will then result to myelopathy which is
described as the gradual loss of nerve function caused by disorders of
the spine. Myelopathy can be directly caused by spinal injury resulting in either reduced
sensation or paralysis. Degenerative disease may also cause this condition, with varied
degrees of loss in sensation and movement.
(http://backandneck.about.com/od/conditions/f/radiculopathy.htm;
http://www.wisegeek.com/what-is-myelopathy.htm)
Spinal stenosis complications vary, depending on which nerves are compressed.
One of the most common is incontinence, you may lose the ability to control your
bowels or bladder or it can even reach Cauda equina syndrome is a rare but serious
complication, in which the bundle of nerve roots at the lower end of the spinal cord is
compressed. This can cause numbness and paralysis, and emergency surgery may be
necessary to relieve the pressure.
(http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=complications)
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
II. SCOPE AND LIMITATIONS OF THE STUDY
This case study tackles about Spinal Stenosis L4, L5 secondary to
Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy
with Myelopathy Right Sided and the operation performed to improve the condition
specifically on the case of the patient. It includes essential concepts in relation to the
said condition such as the patient’s profile and health history, nursing assessment and
clinical manifestations, drug study and diagnostic exams done. The anatomy and
physiology is also included as well as the pathophysiology of the above said diagnosis
with its associated factors. The Medical and Nursing Management along with the
discharge plans and other relevant data are also being covered.
The scope of the plan encompasses during the course of duty and date of
operation last August ____, 2011 with the assigned students who have assessed the
client with cumulative interaction postoperatively and established good rapport to the
patient and significant other. Nursing Management covers the above mentioned dates
which encompasses the client’s Recovery Phase. Data gathering about the Laboratory
results covers from August __ 2011 to August __ 2011 and other previous laboratory
results, the date and time of operation is also included and how it was performed.
The areas of concerns are limited to the discussions of Spinal Stenosis L4, L5
secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and
Radiculopathy with Myelopathy Right Sided and the quality of nursing care to the
patient. The quantity and quality of the information are limited to the data gathered from
the client, significant others and his medical records.
OBJECTIVES OF THE STUDY
The study aims to explore the concepts about the condition and the quality of
nursing care being rendered to our client.
Primarily, the primordial reason why we have chosen this as our case study
because it is our first time to encounter such health condition and we want to further
brush up our knowledge conditions associated with the indispensable anatomical
structure of our body. Secondly, in order to learn more about the health condition of the
patient, the study wants to fathom about the predisposing and precipitating factors,
anatomy and physiology and the pathophysiology of the condition experienced by the
client. Basically, the main goal of this study in relation to knowledge is to identify the
nursing interventions after the patient undergone an operation.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
The study aims to critically analyze the qualitative and quantitative data gathered
in order to establish connection between the different manifestations experienced by the
patient with that of the disease process. To be able to improve skills, the students also
endeavors to come up with nursing care plans that will alleviate patient’s condition. The
presentors also intend to compare and contrast the ideal management for Spinal
Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized
Ligamentum and Radiculopathy with Myelopathy Right Sided with that of the actual
management. In addition, the study seeks to disseminate essential information to
everybody for awareness.
Furthermore, by this study, the provider will be able to exercise that attitude of
determination and in order to come up with a successful study.
SIGNIFICANCE OF THE STUDY
The study is significant to the following people: the client, the client’s family, and
nursing students.
The study is significant to the client, because it enlightens the client’s queries and
doubts regarding his condition. Allowing him to understand the situation of his
present state, this would allow him to be more aware of the importance of following the
treatment regimen.
Client’s family must also be aware of the condition of the client. With the study,
the client’s family will be able to participate in the client’s continuous treatment, and they
will be able to realize the importance of the support system in participating in the client’s
care.
The study is also important to the nursing students, since it allows them to
explore the client’s condition, giving them firsthand experience in observing the
manifestations of the disease condition and allowing them to apply theoretical
knowledge regarding nursing managements for the manifested signs and symptoms.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
III. CLIENT’S PROFILE
A. Socio-demographic Date
Patient AL is a 64-year old male, Roman Catholic, married to his 60-year
old wife and is currently residing at #270 Demetrio Velez St. Pinikitan, Cagayan
de Oro City, was admitted last August 17, 2011 due to tingling sensation felt at
gluteal area and numbness to the right leg since the year 2008 and lower
extremity weakness.
B. Vital Signs
Upon assessment, the patient’s vital signs were: BP: 120/80 mmHg,
Temperature: 36.9 degree Celsius, PR: 76 beats per minute, and RR: 20 cycles
per minute and 22 cycles per minute upon exertion. The patient weighs 73.6
kilograms and is 170 centimeters tall.
C. Health Pattern Assessment
Aside from the current condition, patient has also persistent problem in
voiding. Generally, he looks normal, neat, conscious and coherent but irritable,
mildly anxious and unable to ambulate and change positions without careful
assistance from the healthcare provider or significant other. Patient used to
smoke 10 sticks per day but had stopped since the year 1996 as well as alcohol
consumption of 1-2 cups thrice a week. He’s taking a cupful of coffee every
morning. No allergies were reported.
1. Past Medical History
Client AL has never been hospitalized until the date of admission
(August 17, 2011) but only seeks and visits the doctor for follow-up check
up. He was diagnosed at this institution-CUMC to have Spinal Stenosis
L4, L5 secondary to spondylolisthesis L4, L5 Grade II with hypertrophized
ligamentum and radiculopathy with myelopathy right sided. He has family
history of hypertension but doesn’t have any home medication to control
elevated blood pressure. He was also diagnosed to have Benign Prostatic
Hyperplasia (BPH) and was given (Xatral) alfuzosin 10 mg, 1 tab @ Hours
of sleep, 8pm and (Uriflow) Bethanicol, 1 tab TID at the specific time of 8
am, 1 pm, and 6 pm.
2. History of Present Illness
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Fifteen years ago patient had sudden onset of tingling sensation on
his right gluteal area; CT-Scan was made, result showed:
Hypertrophic degenerative osteoarthropathy, lumbar spine
Disc herniation, L4-L5
Mild spondylolisthesis, L4-L5
Compression deformity of L1 due to degenerative changes
Five years ago before the admission, patient noticed urine voiding
changes consulted a urologist, diagnosed to have BPH recalled meds
given, 4 years ago, there is persistence of voiding problem, 3 weeks ago
patient had MRI result herniated slip disc L4-L5, L1-2 x L5-S1.
3. Physical Assessment
Before operation, patient AL was hooked with an IVF infusion of
D5NM 1L @ 10 gtts/min and D5LR @ 20 gtts/min on NPO. After
operation, patient AL was hooked with an IV infusion pump of PLR 1L
regulated @ 30 gtts/min. and PNSS 1L regulated @ 30 gtts/min side drip
infusing well at the right arm. It was terminated before the duty on August
25, 2011.
HEENT:
Head, hair and scalp Normocephalic with fine dry hair and clean scalp.
Eyes: sclera, pupils Sclerae are anicteric, pupils are equal in size and
reaction to light. Periorbital region is not sunken
or edematous. Cornea and lens are not opaque
and conjunctiva is pink.
Ears and tympanic membrane Equal in size with no discharges and has equal
auditory function. Intact tympanic membrane.
Nose No nasal flaring noted. Septum is medial. Mucosa
is pink in color. Gross smell is normal and
symmetrical.
Mouth, lips, tongue, teeth and
oral mucosa
Lips and oral mucosa are pale. No lesions noted
in the mouth. Tongue is midline. With dentures.
Gums are pallor.
Throat and neck Trachea and uvula are midline. Thyroids are non
palpable. Tonsils are not inflamed.
Facial movements Symmetrical.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
4. Cognitive/ Neurological Assessment
5. Nutritional and Metabolic Pattern
At home, Client AL usually eats three times a day with red meat
which sometimes combined with vegetables and rice with good appetite.
He drinks water and other fluids at most 6 glasses a day. He takes Fern-C
and Centrum as his supplement.
Upon hospital stay, he was on soft diet, with fair appetite and still drinks fluid at
most 6 glasses a day.
ACTIVITIES OF DAILY LIVING
Feeding 2 – Assist with person
Bathing 3 – Assist with device and person
DRESSING 2 – Assist with person
Grooming 2 – Assist with person
Meal preparation 4 - Total dependence
Cleaning 4 - Total dependence
Laundry 4 - Total dependence
Toileting 3 – Assist with device and person
Bed mobility 3 - Assist with device and person
Chair/toilet transfer 3 - Assist with device and person
Ambulation 3 - Assist with device and person
R.O.M 2 – Assist with persons
8
Level of consciousness Conscious, coherent and responsive
Orientation Oriented to time, place and person
Emotional state Irritable, and mildly anxious but can answer short
simple questions answerable by “yes” or “no”
Primary language Visayan
Educational attainment AB Graduate
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
6. Elimination Pattern
Patient AL’s defecation is usually not consistent; he used to
defecate once a day and sometimes defecates every other day. His stool
appears soft in consistency, greenish to brown in color and in minimal
amount with no discomforts upon defecating.
He urinates at about 5-6 times a day with amber to yellow colored
urine in minimal amount. He has an enlarged prostate and had difficulty
urinating.
7. Activity-Exercise Pattern
He used to jog and walk around twice a week. His leisure activities
include watching TV, sleeping, bonding with his family and reading news
paper.
CARDIOVASCULAR STATUS
Chest pain, radiation No chest pain or radiation
Point of maximal impulse,
Precordial area
5th intercostal space, midclavicular line
Flat
Heart sounds Distinct and regular, no murmurs noted
Peripheral pulses Regular and symmetrical
Capillary refill time 2 seconds, no clubbing noted
RESPIRATORY STATUS
Breathing pattern Regular
Lung expansion Symmetrical
Vocal/tactile fremitus Symmetrical
Percussion Resonant
Breath sounds Vesicular
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Abdominal configuration Symmetrical, no superficial veins, with no lesions
and scars
Bowel sounds Hypoactive upon auscultation, 4 bowel sounds
per minute
Percussion Tympanic and dullness noted on right upper
quadrant
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Cough None
8. Sleep and Rest Pattern
Client AL usually sleeps about 6-8hours a day with naps during day
time, he sleeps early at night and wakes up early morning. He said this
number of hours is adequate enough for his activities the following day.
He does not have any history of sleep disturbances, by just merely closing
his eyes for a moment can make him easily fall asleep, he prays and
meditates before sleeping to promote a good and sound sleep.
9. Role and Relationship Pattern
Client AL is married to his 60- year old healthy wife and a father to
four healthy children- two females and two male ages 30, 29, 23, and 20
years old. He lives with his family. He has a sound and good relationship
to his family; he is very close to them.
10.Value and Belief Pattern
Client X is a Roman Catholic; He usually goes to church every
Sunday together with his family. He said that he needs God the most
especially that he’s hospitalized. He gets his strength in facing his
condition from his faith that gives him hope. He believes his hospitalization
will not interfere with his religious rites but he finds ways to communicate
with God through prayers as an alternative, he knows that he can go to
church when he will get well because he believes that God will answer his
prayer. He considers his family as his support group and thinks they can
help him the most.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
REVIEW OF SYSTEMS
(ANTERIOR)
11
Pale oral mucosa, gums and lips
Irritable and mildly anxious
Prostate Enlargement
Lower extremity weakness
3/5
Difficulty in urination
Hypoactive, 4 bowel sounds per
minute
Uncoordinated gait
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
POSTERIOR
I N T R O D U C T I O N Page 63
Tingling sensation (right
gluteal area)
Pain scale: 8/10 – L4,L5
Right leg numbness
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
IV. ANATOMY AND PHYSIOLOGY
The spinal cord begins below the medulla and ends just above the small of the
back at the conus medularis. The area within the vertebral column beyond the end of
the spinal cord is called the cauda equina.
Meninges
Dorsal (sensory) and
ventral (motor) horn cells
The spinal cord is protected by the vertebrae and the meninges. The dura mater,
arachnoid mater and pia mater of the spinal cord are continuous with those of the brain.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Cerebrospinal fluid is in the subarachnoid space that lies between the arachnoid and pia
mater and in the central canal, a space in the middle of the gray matter of the cord. It
provides a hydraulic cushion for the spinal cord.
When the cord is viewed in a cross-section, its gray matter is "H" shaped or, as
described by Bhatnagar, 2002, butterfly shaped. It has two ventral and two dorsal horns.
The white matter surrounding the cell bodies of the cord is made up of ascending
and descending fibers. Motor tracts are found on the ventral and lateral aspects of the
cord while sensory tracts run along its dorsal area.
Neuronal types
Motor neurons
These lower motor neurons are located on the ventral aspect of the cord. They
are either alpha or gamma cells.
Alpha cells are the principle lower motor neurons of the spinal cord and form the
main portion of the final common pathway. They conduct rapid motor impulses, with
each alpha cell innervating approximately 200 muscle fibers.
Gamma neurons are also part of the final common pathway according to some
sources but they are only half as numerous as alpha cells. Gamma cells conduct slow
motor impulses. Their major function is to stretch muscle spindles.
Association neurons
Interneurons connect the anterior and posterior horns of the gray matter and are
involved in the reflex arc. They work within the same segment of the spinal cord, with a
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
segment being defined as the horizontal section of the cord that gives rise to one pair of
spinal nerves.
Internuncial Neurons travel between segments, sending projections up to the
brain stem and cerebellum. They project in an ascending, not descending manner.
These association neurons are found throughout the central nervous system.
They are much more numerous than motor neurons; the ratio between the two types of
cells is 30:1.
The main function of the association neurons in the spinal cord is that of
inhibitory control. They also interconnect other cells with one another.
Some sources, including Bhatnager and Andy, (1995), do not distinguish
between interneurons and internuncial neurons. Even if these two types of association
neurons are grouped together, they should definitely be distinguished from the spinal
nerves which are lower motor neurons, forming a final common pathway for information
descending from the brain.
The Spinal Nerves
There are thirty-one pairs of spinal nerves. These nerves are mixed, having both
a sensory and a motor aspect. Their motor fibers begin on the ventral part of the spinal
cord at the anterior horns of the gray matter. The roots of their sensory fibers are
located on the dorsal side of the spinal cord in the posterior root ganglia. When the
motor and sensory fibers exit the spinal column through the intervertebral foramina and
pass through the meninges, they join together to form the spinal nerves.
Spinal nerves receive only contralateral innervation from first order neurons:
Eight pairs of spinal nerves are located in the uppermost, cervical region of the
cord
Twelve pairs are found in the thoracic region.
Five pairs are in the lumbar area.
Five pairs are in the sacral area.
One pair is found in the most inferior, coccygeal region.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
These second order lower motor neurons, the spinal nerves, form part of the final
common pathway for information traveling from the central nervous system to the
periphery. The spinal nerves provide innervation to body areas below the neck while
cranial nerves (also second order neurons) carry impulses only to the head and neck,
except for the vagus. (You will understand shortly that cranial nerves can be sensory,
motor or both).
Reflex arc
Also, the sensory and motor fibers of the spinal nerves form a reflex arc. This
type of reflexive behavior occurs when a message from afferent fibers causes a motor
reaction before going to the brain. For example, if you touch a hot burner on the stove,
sensory information about the temperature of the burner travels along spinal nerves to
your spinal cord and are carried directly to their motor nuclei by interneurons; the motor
command goes out along the axons of the lower motor neuron causing you to move
your hand away from the stove. As messages do not have to travel up to the brain to be
processed, reactions mediated by this reflex arc can occur very rapidly. Of course you
will feel pain shortly thereafter (milliseconds) as the information gets to the parietal lobe
via the thalamus
The Autonomic (self regulating) Nervous System
The autonomic nervous system is involved in the control of the heart, glands and
smooth muscles of the body and plays a major role in regulating unconscious,
vegetative functions. It works together with the endocrine system to control the
secretion of hormones and is itself controlled by the hypothalamus.
Because motor fibers make up the bulk of the autonomic system, some
anatomists consider it to be purely motoric although it does include some afferent axons
that carry information from the viscera.
Although the autonomic nervous system is considered to be one of the three
main divisions of the human nervous system in its own right, parts of both the central
nervous systems and the peripheral nervous systems play a role in its functions.
The autonomic nervous system has two components,
the sympathetic system and the parasympathetic system. These two aspects have
antagonistic functions.
Sympathetic System
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
The sympathetic system prepares the body for fight or flight reactions. Action of
this system results in accelerated heart rate, increased blood pressure and blood flow
away from the periphery and digestive system toward the brain, heart and skeletal
muscles. It also causes adrenaline to be released, temporarily increasing physical
strength.
Parasympathetic System
The parasympathetic system brings the body back to a state of equilibrium. It
slows heart rate and decreases the release of hormones into the blood stream. The
activity of the parasympathetic system causes more localized reactions than does the
sympathetic system as much of its output is to specific organs.
The autonomic nervous system consists of four chains of nuclei or ganglia, two of
which are located on either side of the spinal cord. The outer chains of nuclei form
the parasympatheticdivision of the system while those closest to the spinal cord make
up its sympathetic element.
Rami communicantes
The rami of the autonomic nervous system are the axons of pre-ganglionic and
ganglionic fibers. Most of the axons of pre-ganglionic fibers are myelinated. Their cell
bodies are found in the gray matter of the brain stem and spinal cord. Their axons
synapse with neurons within the two ganglionic chains.
Pre-ganglionic cells of the autonomic nervous system are neurons located in
some of the cranial nerves of the brain stem and in some of the spinal nerves that
project to the ganglionic chains of the autonomic nervous system. The autonomic
nervous system is closely connected with the central and peripheral nervous systems.
Ganglionic cells originate within the ganglia. They project to post-ganglionic
neurons.
Post-ganglionic cells are neurons that are located in the target organs and
muscles of the autonomic nervous system.
It can be said that the motor pathways of the autonomic nervous system are
made up of its pre-ganglionic and ganglionic cells.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
The fibers of the ganglionic chain of the parasympathetic system are not as well-
defined as those of the sympathetic chain. All pre-ganglionic neurons of the sympathetic
system synapse with the sympathetic chain. This is not true of the parasympathetic pre-
ganglionic cells, however. Some of them synapse with the chain, but others go directly
to end organs or muscles.
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LEGEND:
Predisposing Factors
Precipitating Factors
Disease Process
Treatment (either through medication or surgery)
Diagnostic Examination
Surgery effects
Signs and symptoms
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
V. PATHOPHYSIOLOGY
Predisposing Factors:
Age: 64 years old
Gender: Male
Predisposing Factors:
Age: 64 years old
Gender: Male
Precipitating Factors:
Frequent rotational forces
Precipitating Factors:
Frequent rotational forces
dessication between the cushion of vertebral bones
Decrease the spongy feature of the vertebral bones
Increase the number of cells as well as to its size
Decrease androgen secretion and other
male hormones
Formation of fibrous nonunionDegeneration of L4 and
L5 spinal discs
Less resistance to vertebral locomotion
Compression of male urethral meatus
Inability to urinate adequate amount
of urine
Inability to urinate adequate amount
of urine
Administration of alfuzocin (Xatral) 10 mg P.O@ HS
Administration of alfuzocin (Xatral) 10 mg P.O@ HS
Male catheterization done
Male catheterization done
Administration of bethanecol (Uriflow) 1 tab PO T.I.D
Administration of bethanecol (Uriflow) 1 tab PO T.I.D
Partial resistance of pars interarticularis
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Progressive shearing of articular facets
Herniates other important spinal components
posteriorly migrated nucleus pulposus ligaments
hypertrophy
Microfractures of the involved vertebral bones
Slippage of lumbar vertebrae ( L4 and L5)
Annulus fibrosis degeneration occurs
Radial tears take place
Intersegmental instability
Facets incompetence will occur
(+) Stork Test(+) Stork Test
Elongation of pars
Inevitable spinal subluxation
Back pain of 8/10Back pain of 8/10
XRAY (08/17 and 24/11) show Mild
to moderate osteodegenerative changes) and
Disk Disease
XRAY (08/17 and 24/11) show Mild
to moderate osteodegenerative changes) and
Disk Disease
XRAY (08/ 24/11) shows Grade 1
Spondylolithesis
XRAY (08/ 24/11) shows Grade 1
Spondylolithesis
I N T R O D U C T I O N Page 63
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Gradual significant loss of nerve sensation
Compression of indispensable nerve roots
Progressive narrowing of the spineXRAY (08/24/11) shows
Mild compression deformity
XRAY (08/24/11) shows
Mild compression deformity
Uncoordinated gait
Uncoordinated gait
Walker provided
Walker provided
Administration of the following:
Hydrocortisone (Solu-cortef) 100mg every 12 hours
Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D
Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week
Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID
(
Administration of the following:
Hydrocortisone (Solu-cortef) 100mg every 12 hours
Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D
Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week
Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID
(
Tingling sensation on the right gluteal area
Tingling sensation on the right gluteal area
Right leg numbnessRight leg numbness TENS givenTENS givenLaminectomy + Foraminotomy
L4L5 Posterior Instrumentation
Pedicular Screw Fixation L4L5 +
Post-spinal Fusion
Laminectomy + Foraminotomy
L4L5 Posterior Instrumentation
Pedicular Screw Fixation L4L5 +
Post-spinal Fusion
NPO temporarily (preoperatively and
postoperatively
NPO temporarily (preoperatively and
postoperatively
Hypoactive bowel dounds of 4
clicks/minutes
Hypoactive bowel dounds of 4
clicks/minutes
Destruction of primary defenses
Destruction of primary defenses
Administration of the following:
1. ranitidine (Zantac) 150 mg 1 tab PO @ HS
2. esomeprazole (Nexium) 40 mg IVTT OD
Administration of the following:
1. ranitidine (Zantac) 150 mg 1 tab PO @ HS
2. esomeprazole (Nexium) 40 mg IVTT OD
Muscle weakness of both lower
extremities 3/5
Muscle weakness of both lower
extremities 3/5
Referred to Physical
Therapist for Rehabilitation.
Referred to Physical
Therapist for Rehabilitation.
Pain at the incision site
Pain at the incision site
I N T R O D U C T I O N Page 63
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
VI. OPERATION PERFORMED
Esophagogastroduodenoscopy (EGD)
Esophagogastroduodenoscopy, or EGD for short, is a procedure used by your
doctor to gain more information about your esophagus, stomach, and small intestine.
Your doctor can look at the insides of these structures by placing an endoscope (a
small, bendable tube that acts like a video camera) into your throat. If any unusual
growths or foreign bodies are found by your doctor, the endoscope may also be used to
treat them.
Preoperative:
When you are ready, medication may be given through your IV to make you
sleepy and relaxed.
In order to make this examination more comfortable, your healthcare provider
may spray a numbing medication into the back of your throat, or you may gargle with it.
This may taste slightly bitter and will make your mouth and throat numb for
approximately 30 minutes. Then you will be positioned on your left side.
Intraoperative:
The use of a long, soft, bendable tube endoscope is utilized. This instrument acts
as a camera and allows your doctor to view the inside of your digestive system on a
video screen. It can also take pictures and videotape the procedure.
A small plastic mouthpiece or guard will be put into your mouth to protect your
teeth when the tube is slowly placed into your esophagus (or food pipe), and to keep
you from accidentally biting the tube.
In order to help relax the muscles in the back of your throat and help open the
passageway, you will need to take slow, deep breaths. You will then be instructed to put
your chin to your chest and open your mouth. As the doctor begins to push the tube in,
you will be asked to swallow. Swallowing makes the tube go down more easily. You
may experience some gagging or nausea during the tube placement into your
esophagus -- this is normal.
Once the endoscope is inside, your doctor will examine your esophagus,
stomach, and the first part of the small intestine. To better see this area, these
structures may be gently filled with a small quantity of air through the endoscope. While
this air may cause you to feel full, it should not be painful. Your saliva may be suctioned
from your mouth using a small plastic tube similar to the ones used by dentists.
Depending on what is found during the endoscopy, your doctor may perform
several procedures through the endoscope. A photograph, biopsy, or cytology may be
taken. A biopsy involves taking a small sample of tissue, and cytology is a brushing of
I N T R O D U C T I O N Page 63
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
cells. Other procedures that may be performed include stretching narrowed areas of the
esophagus, stomach, or duodenum; removing polyps and swallowed objects; or treating
bleeding vessels and ulcers.
When the examination is finished, the doctor will slowly pull the endoscope out
through your mouth. You'll be asked to clear your throat and spit out any saliva or
phlegm. This procedure usually takes about 20 to 30 minutes.
Postoperative:
After the upper endoscopy (also known as an EDG), you will either be closely
monitored in the recovery room or return to your hospital room. If this was done as an
outpatient procedure, you will remain in the clinic area for about one hour. If a
procedure was done that requires more observation, you may stay in the hospital
overnight.
During this time, you may feel slightly bloated from the air that was placed in your
stomach during the examination. Your throat may also feel numb and slightly sore. You
should expect this to last two to four hours.
You will stay in the recovery room long enough for the drugs that make you
sleepy to wear off and to be sure that you are recovering normally. Remember that your
healthcare provider wants you to recover without any problems, so be sure to report
anything that does not feel normal or "right."
Laminectomy + Foraminotomy L4L5 Posterior Instrumentation Pedicular
Screw Fixation L4L5 + Post-spinal Fusion
For an open laminectomy and foraminotomy procedure, the patient is placed under
general anesthesia. The surgeon makes an incision in the back over the area of the
spine more the spinal compression is located.
The surgeon uses small instruments to scrape away or remove portions of the
lamina in the disc or discs causing the problem. He then shaves or cuts away small
portions of the foramen, or the space where nerve roots branch off from the spinal cord
in the cervical, thoracic or lumbar area to make more room for these nerves. The
surgeon may need to use a surgical microscope to see this area more clearly.
At this time, the surgeon will also determine the overall health and condition of the
vertebra and vertebral discs adjacent to the problem area. In some cases, other
procedures made at this time, such as removal of a herniated or bulging disc, called a
discectomy, or spinal fusion if vertebra has slipped out of position.
For a laparoscopic laminectomy or foraminotomy, a small incision is made over the
affected spine area. A very small camera attached to the end of a long tube is inserted
into the incision, which allows the surgeon to view the operating field on a video monitor
in the surgical suite. Very small surgical instruments are inserted into one or more small
I N T R O D U C T I O N Page 63
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
incisions around the affected disc area and the operation proceeds in much the same
way and open laminectomy procedure is performed.
However, if the surgeon feels you may have a herniated or bulging disc or any spine
instability, the patient may not be considered a good candidate for this approach.
Following the procedure, the surgeon will use stitches or staples to close the incision
area.
In most cases, you will stay in the hospital for 1 to 3 days, depending on your overall
health and wellness, your physical condition and your response to the surgery. A
physical therapist may be offered to help you ambulate and perform daily functions,
depending on the area where the laminectomy occurred.
The Spinal Fusion Operation
Spinal fusion is performed under general anesthesia. During the procedure, the
target vertebrae are exposed. Protective tissue layers next to the bone are removed,
and small chips of bone are placed next to the vertebrae. These bone chips can either
be from the patient's hip or from a bone bank. The chips increase the rate of fusion.
Using bone from the patient's hip (an autograft) is more successful than banked bone
(an allograft), but it increases the stresses of surgery and loss of blood.
Fusion of the lumbar and thoracic vertebrae is done by approaching from the rear,
with the patient lying face down. Cervical fusion is typically performed from the front,
with the patient lying on his or her back.
Many spinal fusion patients also receive spinal instrumentation . During the fusion
operation, a set of rods, wires, or screws will be attached to the spine. This
instrumentation allows the spine to be held in place while the bones fuse. The
alternative is an external brace applied after the operation.
An experimental treatment, called human recombinant bone morphogenetic protein-
2, has shown promise for its ability to accelerate fusion rates without bone chips and
instrumentation. This technique is only available through clinical trials at a few medical
centers.
Spinal fusion surgery takes approximately four hours. The patient is intubated (tube
placed in the trachea), and has an IV line and Foley (urinary) catheter in place. At the
end of the operation, a drain is placed in the incision site to help withdraw fluids over the
next several days. The fusion process is gradual and may not be completed for months
after the operation.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
VII. LABORATORY RESULTS
Hematology Report (August 18, 2011)
TEST RESULTS REFERENCE VALUES INTERPRETATION
WBC 7,700 5,000-10,000 cell/mm3 Within Normal Range
RBC 4.78 4.7-6.1 10^6/uL Within Normal Range
Hgb 14.6 13.7-16.7 g/dL Within Normal Range
Hct 44.0 37.0- 47.0 gm% Within Normal Range
MCV 95.2 80.0-96.0 fL Within Normal Range
MCH 31.0 27.0-31.0 pg Within Normal Range
MCHC 33.5 32.0-36.0% Within Normal Range
Differential Count
Lymphocytes 30.0 18-45% Within Normal Range
Monocytes 2.0 4-8% Below Normal Range
Platelet count 200,000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting factor is good.
I N T R O D U C T I O N Page 63
Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
Hematology Report
(August 22, 2011)
TEST RESULTS REFERENCE VALUES INTERPRETATION
WBC 15,300 5,000-10,000 cell/mm3 An increase in the WBC level indicates that there is an infection.
RBC 4.78 4.7-6.1 10^6/uL Within Normal Range
Hgb 12.7 13.7-16.7 g/Dl Low hemoglobin levels indicate the oxygen carrying capacity of the blood is decreased. Low hemoglobin
levels may also indicate anemia.
Hct 38.0 37.0- 47.0 gm% Within Normal Range
MCH 23.3 27.0-31.0 pg A low MCH number might indicate the presence of anemia. The Mean Corpuscular Hemoglobin indicates
the weight of hemoglobin in each cell.MCHC 24.3 32.0-36.0% Below Normal Range
Differential Count
Segmenters 93.0 45-70% Above Normal Range
Lymphocytes 5.0 18-45% Below Normal Range
Monocytes 2.0 4-8% Below Normal Range
Platelet count 333,000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting factor is good.
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided
X-ray Report
(August 17, 2011)
Examination: Chest AP
No active parenchymal infiltrates.
The heart is not enlarged.
The aortic knob is calcified.
Both costophernic sulci and hemidiaphragm are intact.
Degenerative changes are seen in the visualized osseous structures.
Impression:
Atherosclerotic Aorta
Osteodegenerative changes.
(August 24, 2011)
Examination: Lumbo Sacral Spine APL
No old film available for comparison.
Spurformations are seen in the antero-lateral aspects of the lumbar spine. (Mild to moderate osteodegenerative changes)
Mild anterior wedging of L1 is noted. (Mild compression deformity)
L1-L2 and L5-S1 intervertebral disc spaces are narrowed with intra-disctal gas formation. (Disk Disease)
L4 is slightly displaced anteriorly in relation to L5 with metallic brackets and screws at these levels as well as vertebral foraminal narrowing. (Grade 1 Spondylolithesis)
No lytic or blastic lesion seen.
Mild lumbar straightening noted probably secondary to muscle spasm and or fixators.
Alignment is sustained.
Midline surgical staples seen in site.
Drainage tube in site.
I N T R O D U C T I O N Page 63
CT SCAN OF THE LUMBAR
(September 24, 1996)
Findings:
Multiple axial tomographic sections of the lumbar spine without contrast were obtained.
Plain axial images revealed the ff:
Osteophytic spurs seen along the margins of lumbar spine.
Disc hernation noted at the level of L4-L5, centrally located and with some extension
into the intervertebral foramina.
Ligamentum flavum are hypertrophied, (L2-4)
Compression changes of L1 seen as well mild spondylolisthesis of L4 over L5 by
scanogram.
Rest of findings are unremarkable.
Impression:
Hypertrophic degenerative osteoarthropathy, lumbar spine disc hernation, L4 over 5
Mild spondylolisthesis, L4 over 5
Compression deformity of L1 due to degenerative changes.
ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER
(August 18,2011)
Dimension Measurement Normal
LV (ed) 4.3 (4.5- 5.0)
LV (es) 2.6
IVS (ed) 1.1 (0.8 – 1.1)
IVS (es) 1.6
LVPW (ed) 1.5 (0.8 – 1.1)
LVPW (es) 1.7
Aorta 2.2
LA (AP diameter) 3.6 (3.0 – 3.5)
MPA 1.9
LVET 0.2
EPSS 0.6
LVOT 1.9
RV 2.7 (2.2 – 4.0)
RA 2.7 (3.5 – 4.5)
MV Annalus 2.2
TV Annalus 1.7
LVEDV 77.35
LVES 24.24
SV 53.11
CO 3.6
EF 69 % (55.0 – 77.0)
FS 38% (29.0 - 42.0)
VCF (0.5 - 1.5)
LV Mass
Diastolic Function
Parameter Patient Normal
Decel. Time 265
IVRT 71
SPECTRAL and Color Flow Doppler
Valve Maximum Velocity
Peak Gradient
Orifice Area
Regurgitation
Ratio Jet Area cm
GRADIENT
Aorta 0.91 1.08
3.29 4.66
T 42.42
Mitral 0.42 0.56
0.72 2.58
Tricuspid 0.67 0.80
1.81 2.58
Pulmonic 0.82 2.96
RA Pressure
PAt: 134.6
PRJ:
Notes:
Study done in normal sinus rhythm Normal left ventricular cavity with hypertrophied walls with adequate wall motion
contractility and systolic function Normal left atrium, right atrium, right ventricle, main pulmonary artery and aortic
root dimension. Thickened none coronary cusp and left coronary cusp of the aortic valve but
without restriction of motion Thickened mitral valve leaflet but without restriction of motion Structurally normal tricuspid valve and pulmonic valve No pericardial effusion nor intracardiac thrombus noted
Doppler:
Mosaic color flow display noted across the aortic valve during diastole Reverse mitral valve E/A velocity ratio at prolonged deceleration time Normal pulmonary atrial pressure
Conclusion:
Concentric left ventricular hypertrophy with adequate contractility and systolic function but with Doppler evidence of impaired left ventricular relaxation
Aortic sclerosis with aortic regurgitation +/- Mitral sclerosis Normal pulmonary arterial pressure
Urinalysis
(August 17, 2011)
Test Result Normal Value
Color Light yellow Yellow
Reaction Clear Clear
Transparency 7.0
Specific Gravity 1.005
Sugar Negative Negative
Protein
Pus Cells 0-2 cells/HPF
RBC 0-2 cells/HPF
Epithelial Cells
Bacteria Few
Amorphous phosphate Moderate
Clotting Time and Bleeding Time
(August 18, 2011)
Result Normal Value Interpretation
Clotting Time 4 minutes 00 seconds
2-6 minutes Within Normal Range
Bleeding Time 1 minute 00 seconds
1-3 minutes Within Normal Range
Hematology
(August 19, 2011)
Cardiac NT-proBNP
Result: 156 pg/mL
Normal Value: less than 125 pg/mL
Interpretation: Levels above 125 pg/ml may indicate the presence or development of cardiac dysfunction and are associated with an increased risk of cardiac events.
Fecalysis
(August 18, 2011)
Consistency: Soft
Color: Greenish Brown
RBC: --
Pus Cells: --
NO PARASITES SEEN
VIII. DRUG STUDY
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATON CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:ranitidine
Brand Name:Zantac
Classification:Histamine 2 antagonist
Dosage:150 mg 1 tab
Route:PO
Frequency:HS
Timing: 8pm
Competitively inhibit the actions of histamine at the H2 receptors of the parietal cell of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food
Short term treatment of active duodenal ulcer
Short term treatment of GERD
With allergy to ranitidine
Use cautiously with impaired renal or hepatic function
CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo
CV: tachycardia, bradycardia,
DERMATOLOGIC: rash, alopecia,
GI: constipation, diarrhea, nausea, vomiting, abdominal pain
1. Administer oral drug with meals and HS.2. Decrease doses in renal and liver failure.3. Provide concurrent antacid therapy to relieve pain.4. Arrange for regular follow-up, including blood test, to evaluate effects.
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATON CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:cefuroxime
Brand Name:Zinacef
Classification:Antimicrobila agent
Dosage:1.5 g ----- 500 mg 1 tab
Route:IVTT ---- PO
Frequency:PRN ----- TID
Timing:
8pm-1pm-6pm
A second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usuallu bacterial
Skin and skin structure infections, bone and joint infection
Contraindicated in patient with hypersensitivity to cefuroxime or other cephalosporin
Use cautiously in patient with history to sensitivity to penicillin
CNS: headache, malaise, paresthesia, dizziness
GI:pseudomemebranous colitis, nausea, anorexia, vomiting, diarrhea, glossitis, dyspepsia
GU: genital pruritus
HEMATOLOGIC: hemolytic anemia, decrease in hemoglobin
1. With large doses or prolonged therapy monitor for superinfection, especially in high risk patient 2. Give oral drug with food to decrease GI upset and enhanced absorption3. Have vit. K available in case of hypoprothrombinemia occurs
DRUG ORDER(Generic name, brand name, classification,
dosage, route, frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:bethanecol
Brand Name:Uriflow
Classification:Cholinergic (parasympathomimetic)
Dosage:1 tab
Route:PO
Frequency:T.I.D
Timing:
8pm-1pm-6pm
Binds to cholinergic (muscarinic) receptors, mimic the action of acetylcholine
Acute postoperative nonobstructive (functional) urine retention
Contraindicated with unusual sensitivity to bethanicol, hyperthyroidism, peptic ulcer, latent or active asthma, bradycardia, vasomotor instability, CAD.
CV: Transient heart block, cardiac arrest, arthostatic hypotension
GI: abdominal discomfort, salivation, nausea, vomiting, abdominal cramps, diarrhea
GU: Urinary urgency
RESPIRATORY: Dyspnea
Other: Malaise, headache, sweating, flushing
1. Give on empty stomach, otherwise may cause nausea and vomiting2. Monitor vital signs frequently, especially respirations
3. Never give IM or IV it could cause circulatory collapse, hypotension, severe abdominal cramping, bloody diarrhea, shock or cardiac arrest
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:metoprolol
Brand Name:Neobloc
Classification:Antihypertensive
Dosage:50 mg tab
Route:PO
Frequency:T.I.D
Timing:
8pm-1pm-6pm
A beta1-selective blocking agent that decreases myocardial contractility, heart rate and cardiac output; lower blood pressure and reduce myocardial oxygen consumption. Also depresses renin secretion
Hypertension Contraindicated in patient with hypersensitivity to the drugs or other beta blockers and in patient with bradycardia, and cardiogenic shock
Metoprolol masks common signs of shock and hypoglycemia
CNS: fatigue, lethargy, dizziness,
CV:bradycardia. Hypotension, CHF, peripheral vascular disease
GI: nausea, vomiting, diarrhea
RESPIRATORY: dyspnea, bronchospasm
SKIN: rash
Other: fever and arthralgia
1. Always check the patient apical pulse rate before giving drugs. If it is slower than 60 bpm withhold drug and call the doctor immediately.2. Monitor BP frequently and watch out for hypotension.3. Food may increase absorption of metoprolol. Give consistently with meals
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:ipratropium & salbutamol
Brand Name:Combivent
Classification:Bronchodilators
Dosage:1 neb
Route:Inhalation
Frequency:Every 8 hours
Timing:10am-6pm-2am
Salbutamol:
Relaxes bronchial and uterine smooth muscle by actine on beta2-adrenergic receptors
Ipratropium:
Inhibits vagally mediated reflexes by antagonizing acetylcholine, an anticholinergic
Bronchospasm and viscous sputum
Contraincated in patient with hypesensitivity to drugs or any component of the formulation
Use cautiously in patient with cardiovascular disorders, including any insufficiencies and hypertension; in patient with hyperthyroidism or DM
CNS: tremor, nervousness, insomnia, headache
CV: tachycardia, palpitation, hypertension
EENT: drying and irritation of nose and throat( with inhaled form)
GI: heartburn, nausea, vomiting
RESPIRATORY: bronchospasm
1. Monitor closely the patient for toxicity2. Teach the patient to perform oral inhalation correctly3. Aeresol form may be prescribed for use 15 minutes before exercise. induced bronchospasm4. Do chest tapping after every treatment in not contraindicated.
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:esomeprazole
Brand Name:Nexium
Classification:Proton pump inhibitor
Dosage:40 mg
Route:IVTT
Frequency:OD
Timing:6am
Gastric acid-pump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the first step of acid production
Reduction in occurrence of gastric ulcer
Treatment of duodenal ulcer
Patient with hypersensitivity to drugs
Use cautiously with hepatic dysfunction
CNS: headache, dizziness, vertigo, insomnia, anxiety
DERMATOLOGIC: rash, inflammation, pruritus, alopecia, dry skin
GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth,
1. Ensure that the patient swallow whole capsule; do not crush or chew.2. Provide additional comfort measures to alleviate discomfort from GI effects and headache.3. Establish safety precaution if dizziness or other CNS effects occur
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:hydrocortisone
Brand Name:Solu-cortef
Classification:corticosteroids
Dosage:100 mg
Route:IVTT
Frequency:Every 12h
Timing: 8am-8pm
Decrease inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses the immune response; stimulate bone marrow, and influences protein, fat and carbohydrate metabolism
Severe inflammation Contraindicated in patient allergy to any component of the formulation, and in those with systemic fungal infections. Certain injectable forms contain sulfites which can cause allergy
Use cautiously in patient with GI ulceration or renal disease, and hypertension
CNS: euphoria, insomnia, psychotic behavior, pseudomotorcerebri
CV: CHF, hypertension, edema
EENT: cataract, glaucoma
GI: peptic ulceration, GI irritation increased appetite, pancreatitis
1. Elderly patients may be more susceptible to oesteoporosis. Advise patients receiving long term therapy to consider exercise or physical therapy.2. Gradually reduce drug dosage after long term therapy.
3. Do not give IM injections if patient has thrombocytopenic purpura
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
frequency)
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
Generic Name:metronidazole
Brand Name:Dazomet
Classification:Antimicrobial
Dosage:5oo mg
Route:PO
Frequency:B.I.D for 1 week
Timing:8am-6pm
A direct acting trichomonocide and amebicide that works at both intestinal and extra intestinal site
Bacterial infections caused by anaerobic microorganisms,
Prevention of post operative infection in contaminated or potentially contaminated surgery
This drug has shown to be carcinogenic in mice and possibly in rats. Unnecessary use should be avoided.
Use cautiously in patient with a history of CNS disorder and in patient with retinal or visual field changes.
CNS: vertigo, headache, ataxia, incoordination, confusion, irritability, depression, restless
GI: unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps
GU: dysuria, incontinence, darkening of the urine
1. Tell the patient to avoid alcohol or alcohol-containing medications during therapy or at least 48hrs after therapy is completed.2. Tell the patient that the metallic taste and dark or red-brown urine may occur.
3. Give with meals to minimize GI distress
DRUG ORDER(Generic name,
brand name, classification, dosage, route,
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
frequency)
Generic Name:amoxicillin
Brand Name:Amoxil
Classification:Antibiotic
Dosage:500 mg 1 tab
Route:PO
Frequency:B.I.D
Timing:8am-6pm
Bactericidal: inhibits synthesis of cell wall of sensitive organism, causing cell death
Helicobacter pyloric infection
Contraindicated with allergy to penicillin, cephalosporin, other allergen
Use cautiously with renal disorders
CNS: lethargy, hallucination, seizures
GI: stomatitis, sore mouth
GU: nephritis
HEMATOLOGIC: anemia, thrombocytopenia
HYPERSENSITI-VITY
Rash, fever, wheezing, anaphylaxis
1. Culture infected area prior to treatment2. Give in oral preparation only; amoxicillin is not affected by blood3. Use corticosteroids or antihistamines for skin reaction.
4. Take this drug around the clock
DRUG ORDER
(Generic name, brand name,
classification, dosage, route,
MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG
NURSING RESPONSIBILTIES/
PRECAUTION
frequency)
Generic Name:alfuzocin
Brand Name:Xatral
Classification:Alpha adrenergic blocker
Dosage:10 mg
Route:P.O
Frequency:HS
Timing:8pm
Blocks alpha receptors in the muscle of the prostate gland, which causes the muscle in the prostate to relax. This allow urine to flow freely past the prostate and relieve th urinary symptoms
Relieving the urinary symptoms of enlarged prostate gland
Contraindicated in elderly patient, history of decreased liver function, allergy to alpha blocker, CAD and angina pectoris
CNS: dizziness, headache
CV: orthostatic hypotension, syncope, tachycardia, chest pain
GI: abdominal pain, dyspepsia, constipation
GU: impotence, bronchitis, URI
1. Taken after meal, the tablet should swallowed whole, not chew or crushed.2. Do not stop taking the tablet gradually by reducing the dose over a number of days3. Tell the patient not to take alcohol, because effects of alcohol could made worse while taking xatral
IX. NURSING CARE PLAN: (Pre-operative)
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTION /RATIONALE
EVALUATION
SUBJECTIVE:
“Sakit kaayo akong likod, dili nako alihok sa kasakit ” as verbalized by the patient.
OBJECTIVE: Pain Scale :8/10 Restless Guarding on the left
side of the body
ACUTE (BACK) PAIN RELATED TO SLIPPAGE OF L4 AND L5 VERTEBRAE SECONDARY TO SPONDYLOLISTHESIS
Short-Term
Within 10 - 15 minutes of nursing care and interventions, the patent will:
1. Report controlled pain as evidenced by a decreased pain scale from 8/10 to 0/10.
2. Demonstrate use of relaxation skills.
Long-Term
After 8 hours of thorough nursing intervention, the client will be able to report relief of pain.
INDEPENDENT:1. Monitor V/S which is usually altered when patient is in acute pain.R - Changes in vital signs may indicate acute pain and discomfort.
2. Provide comfort measures to the patient such as providing appropriate ventilation.R - To promote relaxation.
3. Assist patient to find position of comfort.R - Position affects the patient’s ability to relax and rest/sleep effectively.
4. Teach patient deep-breathing exercise to help refocus attention and enhance coping abilities.R - This reduces muscle tension which reduces the intensity of the pain.
5. Provide quiet environment and calm activities.
Short- Term Goals:Goals met. After 15 minutes of Nursing interventions, the patient reported pain was relieved as evidenced by a pain scale of 0/10 and demonstrated relaxation techniques such as deep breathing exercise and reduction in stimulating activities.
Long-Term Goals:Goal partially met. After the 8-hour shift, the patient reported relieved pain with a pain scale of 0/10.
R - Decreases external stimuli, which may aggravate anxiety and cardiac strain, limits coping abilities and adjustment to current situation.
6. Limit activities of the patient and refrain from stimulating procedures R- Movement and activities trigger stimulation of pain nerve endings that may aggregate pain sensation.
DEPENDENT:1. Administer hydrocortisone 100 mg every 12 hoursR – Decreases inflammation and results to relief of pain.
ASSESSMENT DATA(Subjective & Objective)
NURSING DIAGNOSIS(Problem and Etiology)
GOALS AND OBJECTIVE NURSING INTERVENTIONS AND
RATIONALE
EVALUATION
SUBJECTIVE:
“dli kayo nako malihok akong right side sah ako lawas,” as verbalized by the patient.
OBJECTIVE:
Muscle strength of 3/5 (lower extremities)
Uncoordinated gait Back pain of 8/10
ACTIVITY INTOLERANCE RELATED TO SLIPPAGE OF L4 AND L5 VERTEBRAE SECONDARY TO SPONDYLOLITHESIS
Short-Term Goals:
At the end of 8 hrs. of nursing interventions, the patient will be able to:
1. Perform and improve ADL such as performing self-care gradually.
2. Participate and demonstrate exercises such as range-of-motion
Long- Term Goals:
At the end of 2 days of nursing interventions, the patient will be able to:
1. Improve muscle strength from 3/5 to 5/5.
2. Continue to demonstrate modified activities to promote activity tolerance.
INDEPENDENT:1. Assist and demonstrate passive and active range-of-motion.R - To strengthen muscle.
2. Instruct patient to do self-care such as combing his hair using the unaffected arm to assist the affected arm.R - To prevent misuse syndrome.
4. Provide rest between activities.R - To prevent fatigability.
5. Turn patient to side at intervals.R - To prevent skin breakdown.
COLLABORATIVE:1. Referred to to PT for regular physical therapy.R - To rehabilitate
Short-Term Goals:
Goals Met. At the end of 8 hrs. of nursing interventions, the patient was able to perform and improve ADL such as performing self-care gradually, Participated and demonstrate exercises such as range-of-motion and reported.
Long- Term Goals:Goals Partially met. At the end of 2 days of nursing interventions, the patient was able to continue to demonstrate modified activities to promote activity tolerance but still has the muscle strength of 3/5.
muscles.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS/ RATIONALE
EVALUATION
SUBJECTIVE CUES: IMPAIRED BED MOBILITY RELATED TO
After 8 hours of nursing care, patient will be able
INDEPENDENT1. Determine diagnoses that
Goals met. After 8 hours of nursing care, patient was
“Maglisod kog lihok kay sakit akong likod.” as verbalized by the patient
OBJECTIVE CUES:
Inability to reposition self in bed at any desired position
Functional level: Level 2 (requires help from another person)
INSUFFICIENT MUSCLE STRENGTH SECONDARY TO PAIN.
to:1. Maintain position of function and skin integrity as evidenced by absence of decubitus ulcer and footdrop.2. Verbalize to participate in repositioning program.
contribute to immobility.R - To identify causative factors
2. Determine functional level classification.R - To assess functional ability
3. Reposition patient n good body alignment using appropriate supports like utilizing bed linens and asking assistance from the SO. R - To promote optimal level of function and prevent injuries.
4. Observe skin for reddened areas and for presence of shearing. Provide pressure relief by the use of pillows or rolled linens on high risk areas e.g. sacral/bony areas.R - To reduce friction, maintain safe skin pressure, and to prevent moisture.
5. Assist with activities of hygiene, and toileting. R – To avoid injury
able to maintain position of function and skin integrity as evidenced by absence of decubitus ulcer and foot drop and verbalized partici0pation in repositioning program as well as physical movement program.
6. Provide extremity protection like padding on the foot and on elbows. R - To prevent growth and spread of microorganism.
7. Assist patient in passive ROM to enhance gains in strength and muscle control. R - To prevent disused syndrome and promote blood circulation
DEPENDENT:1. Administer hydrocortisone 100 mg every 12 hoursR – Decreases inflammation and results to relief of pain.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS/ RATIONALE
EVALUATION
SUBJECTIVE:“Nahadlok jud ko labi na
ANXIETY, MILD RELATED TO FEAR OF THE
After 30 minutes of nursing interventions, the
INDEPENDENT: Goals met. After 3 hours of nursing interventions,
adtong paigon nako sa operating room”, as verbalized by the patient.
OBJECTIVES: Irritability Facial flushing Restlessness
UNKNOWN SECONDARY TO SURGERY
patient will be able to:
1. Appear relaxed and report anxiety is reduced to a manageable level
2. Identify ways to deal with and express anxiety as evidenced by verbalization of feelings.
1. Monitor vital signsR: To identify physical responses associated with both medical and emotional conditions
2. Establish therapeutic relationship, conveying empathy and unconditional positive regard.R: To avoid the contagious effect/transmission of anxiety
3. Be available to client for listening and talking.R – Encourage verbalization of feelings
4. Provide accurate information about the situation.R: Helps client to identify what is reality based
5. Provide comfort measures such as back rub, calm environment.R – To help the patient to be at ease.
the patient was able to appear relaxed and reported anxiety was reduced to a manageable level and identified ways to deal with and expressed anxiety
Post-operative:
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTION /RATIONALE
EVALUATION
SUBJECTIVE: ACUTE PAIN AT Short term INDEPENDENT: Short term
“ Sakit jud sa akong likod, sa ubos dapit” as verbalized by the patient.
OBJECTIVES: Pain scale of 8/10 Moaning Facial grimace Protective behavior Operation site at L4,
L5 spinal column
SPINAL COLUMN RELATED TO DESTRUCTION OF LUMBAR TISSUE SECONDARY TO SURGICAL INCISION AS EVIDENCED BY THE OPERATION SITE AT L4, L5
Within 1hour of nursing interventions the patient will be able to:1. Report no pain as evidenced by absence of pain scale from 8/10 to 0/10.2. Demonstrate methods that will provide relief.
Long termAfter 8 hours of thorough nursing intervention, the client will be able to permanent relieve of pain and demonstrate use of relaxation skills and diversional activities
1. Monitor V/S which is usually altered when patient is in acute pain.R - Changes in vital signs may indicate acute pain and discomfort.
2. Provide comfort measures such as touch, repositioning, use of heat or cold packs and nurse’s presence, quiet environment and calm activitiesR - To promote nonpharmacological pain management.
3. Encourage adequate rest periods.R - To prevent fatigue
4. Assist patient to find position of comfort.R - Position affects the patient’s ability to relax and rest/sleep effectively.
5. Teach patient deep-breathing exercise to help refocus attention and enhance coping abilities.
GOALS PARTIALLY MET. After 1 hour of Nursing interventions, the patient demonstrated methods that relieved pain but reported pain partialyl relieved as evidenced by a pain scale of 4/10.
Long term
GOALS MET. After the 8-hour shift, the patient reported relieved pain with a pain scale of 0/10. Patient was able to demonstrate use of relaxation skills and diversional activities.
R - This reduces muscle tension which reduces the intensity of the pain.
6. Instruct and encourage use of relaxation techniques, such as listening to music and/or watching television.R: To distract attention and reduce tension.
DEPENDENT:1. Administer hydrocortisone 100mg every 12 hours, as orderedR: To decrease level of pain. Notify physician if regimen is inadequate to meet pain control goal.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS/ RATIONALE
EVALUATION
SUBJECTIVE:“ Sakit kayo diri dapit sa akong operasyon”, as verbalized by the patient.
IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL INCISION AT THE
Short term goal:After 8 hours of nursing interventions, the patient
INDEPENDENT:
1. Inspect skin on a daily basis and
Short term goal:Goals met. After 8 hours of nursing interventions, the
OBJECTIVE:
Pain scale of 8/10
Disruption of skin surface (epidermis)
Disruption of skin layers (dermis)
LUMBAR AREA will be able to:
Verbalize feelings of increased ability to manage situation.
Display wound free from infection.
Long term goal:After 4 days of nursing interventions, the patient will be able to display timely healing of operative wound without complications
describe changes.R – To note changes on the surgical incision.
2. Keep the area clean and dry, carefully dress wounds and prevent infectionR: To assist body’s natural process of repair
3. Use appropriate wound dressingR: To protect the wound and surrounding tissues
4. Encourage early ambulationR: Promotes circulation and reduces risk associated with immobility.
patient was able to verbalized feelings of increased ability to manage situation and displayed wound free from infection.
Long term goal:Goals met. After 4 days of nursing interventions, the patient was able to display timely healing of operative wound without complications.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTION /RATIONALE
EVALUATION
SUBJECTIVE:
“Dili pa kayo ko makalihok
IMPAIRED PHYSICAL MOBILITY RELATED TO POST-
Short term:
At the end of 30-45
INDEPENDENT:
1. Note situations such as surgery
Short term:
Goals met. At the end of 30-
ug makatindog basta bast anga ako ra tungod sa akong opera” as verbalized
OBJECTIVE:
Limited range of motion
Slowed movement
Operation site at L4 ,L5 of spinal column
Functional level classification:3 – requires help from another person and equipment device
OPERATIVE INCISION SITE AT L4,L5 OF SPINAL COLUMN AS EVIDENCED BY LIMITED RANGE OF MOTION AND SLOWED MOVEMENT
minutes of continuous health teachings, patient will be able to :
1. Verbalize willingness to and demonstrate participation in activities
2. Verbalize understanding of situation and individual treatment regimen and safety measures such as raising the side rails
Long term:
At the end of 16 hours of nursing intervention, patient will be able to:
1. Demonstrate techniques that enable resumption of activities
2. Maintain position of function and skin integrity as evidenced by absence of contractures, decubitus and so forth
that may restrict movement.R - To identify causative/ contributing factors
2. Determine degree of immobility in relation to previously suggested scale.R - To assess functional ability
3. Observe movement when client is unaware of observation.R - To note any incongruence’s with reports of abilities
4. Assist or have client reposition self on a regular schedule as dictated by individual situationR - To promote optimal level of function and prevent complications
5. Instruct in use of side rails, roller pads for position changes/transfersR – To secure safety for the client.
6. Support affected body part using pillows R - To maintain position of
45 minutes of continuous heath teachings the patient was able to verbalize willingness to and demonstrated participation in activities, verbalized understanding of situation and individual treatment regimen and safety measures such as raising the side rails.
Long term:
Goals met At the end of 16 hours of nursing intervention, the patient was able to demonstrate techniques that enable resumption of activities, maintained position of function and skin integrity as evidenced by absence of contractures and maintained or increased strength and function of affected or compensatory body part.
3. Maintain or increase strength and function of affected or compensatory body part.
function and reduce risk f pressure ulcers.
7. Schedule activities with adequate rest periods during the day to reduce fatigue. Provide client with ample time.R - To perform mobility related tasks
8. Encouraged participation in self-care,diversional/ recreational activitiesR - To enhance self-concept and sense of independence
9. Demonstrate use of adjunctive devices (walker).R - To promote independence and enhances safety.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS/ RATIONALE
EVALUATION
RISK FACTOR
1. Post operative wound at L4,L5 of spinal column.
RISK FOR INFECTION RELATED TO DESTRUCTION OF SKIN INTEGRITY SECONDARY
Short term:At the end of 30-45 minutes of continuous health teachings patient
INDEPENDENT1. Note risk factors for occurrence of infection such as break in skin integrity
Short term:Goals met . At the end of 30-45 minutes of continuous health teachings
TO POST OPERATIVE WOUND AT L4,L5 OF SPINAL COLUMN
will be able to:1. Verbalize understanding of individual causative/ factor2. Identify interventions to prevent/reduce risk of infectionLong term: At the end of 16 hours of nursing interventions patient will be able to:1. Demonstrate techniques, lifestyle changes to promote safe environment.2. Achieve timely wound healing; be free of purulent drainage or erythema; be afebrile
R - To assess causative/contributing factors.
2. Observe for localized signs of infection at surgical incisions/wounds.R – To give prompt action to avoid further complications.
3. Cover dressings with plastic when using bedpan R - To prevent contamination
4. Stressed proper hand washing techniques by all care givers between therapies/clients.R - A first line defense against nosocomial infection/contamination
5. Instruct client/significant others in techniques to protect the integrity of skin, care of lesions and prevention of spread of infectionR - To promote wellness.
DEPENDENT1. Administer Hydrocortisone
the patient was able to verbalize understanding of individual causative/ factor, and identified interventions to prevent/reduce risk of infection.
Long term: Goals met. At the end of 16 hours of nursing the patient was able to demonstrate techniques ,lifestyle changes to promote safe environment and achieved timely wound healing; purulent drainage or erythema; afebrile
(Solu-cortef) 100mg every 12 hours; Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D; Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week; Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID, as ordered.R – To act as Prophylaxis against bacterial invasion.
ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS/ RATIONALE
EVALUATION
SUBJECTIVE:
“mo-uli najud ko karon,” as verbalized by the
READINESS FOR ENHANCED THERAPEUTIC REGIMEN
At the end of 30mins. of nursing interventions, the patient will be able to:
INDEPENDENT:
1. Instruct patient about the home medications and its proper timing,
Goals met. At the end of 30mins. of nursing interventions, the patient was able to report
patient.
OBJECTIVE:
Stable vital signs:BP:130/70mmhgPR:67bpmRR:17cpmTemp:36.3°C
Healing wound
RELATED TO IMPROVED CONDITION. 1. Report understanding
of the disease condition and its management.2. Know the importance of rehabilitation.3. Report understanding on the prevention of further complications.
mechanism of action and dosage.R – To guide the patient accordingly with the discharge instructions.
2. Encourage patient to continue physical therapy.R - To improve condition.
3. Instruct patient to eat foods rich in carbohydrate and protein.R - To provide energy and facilitate muscle growth.
4. Instruct patient to perform range-of-motion every day.R - To strengthen muscle.
5. Instruct patient to have adequate rest between activities.R - To prevent fatigability.Dependent:1. Home medications (Xatral),(Uriflow),(Mecobalamin) as ordered.R – To continuously provide relief of the recent condition of the patient.
understanding of the disease condition and its management, Knew the importance of rehabilitation and Reported understanding on the prevention of further complications.
X. DISCHARGE PLANNING
MEDICATIONS
Explain to the patient and family members the importance of taking medications.
Take the entire course of medication.
Discuss to the patient and family the dosage, frequency and adverse effects of
the drugs.
Anti-inflammatory medications can help reduce pain by decreasing the
inflammation of the muscles and nerves.
ECONOMIC STATUS
Explain to significant others that the patient may undergo physical therapy in
order for the family to prepare for any financial needs.
Inform the patient to avail to some government health insurance programs such
as Philhealth that may help ease their financial burden for hospitalization.
TREATMENT
Patient must take a short period of rest or avoiding activities such as lifting and
bending.
Patient may undergo physical therapy that can help increase range of motion of
the lumbar spine and hamstrings as well as strengthen the core abdominal
muscles.
Control weight to prevent increased pressure on the lumbar vertebrae.
Use assistive and supportive devices as ordered like a lumbar corset.
HEATLH TEACHINGS
Advised patient to avoid prolonged sitting, walking and standing because it can
add pressure on the lumbar vertebrae.
Advised patient to consult the doctor before taking any medications, to prevent
any drug-drug interactions with the prescribed drugs.
Advised patient to balance work with rest.
Advised significant others to follow safety measures to prevent falls and injury.
Advised patient to follow proper body mechanics.
Advised patient to inform health care provider if complications may occur such as
chronic pain in the lower back or legs, as well as numbness, tingling or weakness
in the legs.
OUT-PATIENT
Keep all of follow-up appointments even though the patient feels better. Advised
to seek consultation from a physician whenever there will be recurrence of the
signs and symptoms. This is to prevent the occurrence of a far more serious
complication.
DIET
Eat protein rich foods to help repair the damage tissues and to provide muscle
strength. Sources of protein include meat and eggs.
Eat a well-balanced diet high in calcium and Vitamin D. Foods high in calcium
include milk, yogurt, cheese, salmon and dark green vegetables. Sources of
Vitamin D include fortified milk, liver, butter, eggs and sunlight.
Eat Vitamin C rich fruits like orange to help boost immune system.
SPIRITUALITY
Encouraged patient and Family members to go to church every Sunday and to
continue to seek God’s guidance and enlightenment.
Emphasized the importance of prayers in healing
Encouraged to ask for divine assistance in everything and to
encouragecontinuing to pray to God.
Encouraged to continue to have a positive outlook in life.
Encouraged to keep faith in God and not to give up easily when hard times come
XI. RELATED LEARNING EXPERIENCE
This rotation was never the easiest task, neither the hardest of all that we had
been through in our two years exposure to the clinical area. Thus, we were anxious that
we may not be able to live up to what is expected of us since we are now fourth year.
However, one thing has been sure, this rotation made us take a closer leap to what it is
like when we will finally be wearing our all white uniform someday.
The staffing rotation has inflicted upon us some values that we are to hold on as
we go through this profession, namely: humility, compassion, discipline and empathy.
These were taught to us few years back but we may have forgotten their essence, yet,
with this duty, we unconsciously regained them. Our duty for the staffing rotation in
Station 4 of Capitol University Medical City is probably one of the best experiences we
will ever have since we are meeting different kinds of personalities of patients and
watchers as well. Some might have accepted us warmly as their nurses others may
have rejected us at some points. In spite of that, we have taken it as a challenge to
prove ourselves worthy of their trust and take it as an opportunity to learn in handling
distrustful watchers, and agitated patients---to whom we consider bumps on our road to
success.
Basically our duty fell on the same pattern as with the other medical rotations we
had but this had taught on two new concepts: carrying out doctor’s orders and
leadership and management following the chain of command, in line of authority. We
have all experienced being a staff nurse, a head nurse and the nurse supervisor as well.
We exploited this rotation to the maximum in terms of carrying out doctor’s order since
we fell on an afternoon shift where fewer doctors make their orders after their rounds.
Nevertheless, we saw to it that everyone can try carrying out doctor’s orders and
nobody is left behind. We enjoyed this rotation so much while we were learning at the
same time.
The entire process of making this case study may have not been easy for all of
us but fortunately, we’ve manage to deal with the problems properly and thus, we were
able to finish this case study in the best way we could. Whether the outcome of this
case study is good or bad, we must take it as a lesson and a parameter to continue
seeking knowledge and improving our skills for we never stop learning.
This case study enabled the group to identify nursing intervention which are
appropriate to promote the well-being of the patient and as well as the medical
management for the case.
We would like to thank Mrs. Syvel Jane M. Caharian, for being the best teacher
we could ever ask for in the task of staffing, in teaching and molding us to be good and
competent nurses in the future. Furthermore, this rotation would have not been
successful without the guidance of our almighty God!
XII. REFERENCE
BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care
Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket
Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.).
Philadelphia, Pennsylvania
Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).
Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia
Karch, Amy M. ; 2006 Lippincott’s Nursing Drug Guide, 8th edition. Lippincott
Williams & Wilkins.
Nurses’ Pocket Guide, 10th edition F.A. Davis.
Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.
Patient’s Chart
Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for
Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005
Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition
Drug handbook by Saunders
Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th
edition By: Joyce Black and Jane Hokanson Hawks
Nursing Care of Infants and Children by Wong
INTERNET:
http://cpmcnet.columbia.edu/dept/gi/.html
http://www.drstandley.com/labvalues
http://ocw.tufts.edu/Content/14/lecturenotes/266736
http://www.medterms.com/script/main/art.asp?articlekey=16051
http://my.clevelandclinic.org/disorders/back_pain/hic_spondylolisthesis.aspx
http://www.nlm.nih.gov/medlineplus/spinalstenosis.html
http://orthoinfo.aaos.org/topic.cfm?topic=a00329
http://backandneck.about.com/od/conditions/f/radiculopathy.htm;
http://www.wisegeek.com/what-is-myelopathy.htm