Backbone

Lumbar Fracture,

Spinal Shock

IntroductionInjury to the spinal cord is a medical emergency that may result in severe

and permanent disability. The spinal cord which along with the brain comprises the central nervous system is a bundle of nerve cells that travels almost the entire length of the spine, connecting the brain to the nerves in the rest of the body. The vertebrae, the small bones that make up the spine, form a bony tunnel that surrounds the cord and protects it from injury. However, if a blow is severe enough, or if the bones are weekend by disease, the spinal cord is vulnerable to damage. Destroyed nerve cells cannot regenerate; injury to the spinal cord may thus result in permanent paralysis of the legs (paraplegia) or, in the case of the neck injury, the arms, torso, and legs (quadriplegia). About half of the cases of spinal cord injury involve the neck. However, partial or complete recovery may be expected in cases when neurons in the spinal cord have been traumatized but not completely destroyed. Outcome thus depends upon both the severity and the specific location of the injury. Damage to the spinal cord will affect nerves at the level of the injury and below. (John Hopkins Symptoms and Remedies; S.Margolis, MD, PhD.)

The immediate response to cord transaction is called spinal shock. The client with SCI experiences a complete loss of skeletal muscle function, bowel and bladder tone, sexualfunction, and autonomic reflexes. Loss of venous return and hypotension also occur. The hypothalamus cannot control temperature by vasoconstriction and increased metabolism; therefore the clients body assumes the svere in clients with higher levels of SCI. clients with nervous system is spared with these levels of injury.

Spinal shock may last for 1 to 6 weeks. Indications that spinal shock is resolving in clued return of reflexes, development of hyperreflexia rather than flaccidity and return of reflex emptying of the bladder. The earliest reflexes recovered are the flexor reflexes evoked by noxious cutaneous stimulation . the return of the buklbocavernosus reflex in male patients is also an early indicator of recovery from spinal chock. Babinski’s reflex (dorsoflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex (M.S. 7th Edition, J. black)

We choose this case for us to know what factors aggravate in problems with gallbladder. We also want to have a research and to gain more knowledge on how to prevent this case and what are the nursing management in this kind of complication. This study also brought us knowledge and information for us to share and deliver our knowing effectively.

A. General objectives

The overall objectives of the study are to detail fact about general principles of Lumbar Fracture, Spinal Shock. This study serves as basis and additional knowledge especially in knowing and determining the factors that contribute to the occurrence and management of the condition and status of having complications. This will also emphasize the important goals and criteria in establishing nursing abilities on how we will act, perform and apply them in dealing with the course treatment.

B. Specific Objectives• To discuss the Patient’s Profile, past medical history, personal and social

history as well as the present illness of the patient.

• To assess, describe and explain the overall condition of the patient.

• To know the management of care with this condition the nurse to act and response to proper needs of the patient.

• To utilize the nursing care process as baseline guide for the patient and its significant findings and analysis.

• To identify different laboratory examination done to the patient and its significant findings and analysis.

• To learn and classify the medications given to our patient for us to determine their uses and effectiveness.

• To provide and categorize information gathered in the prognosis of the disease of the patient.

• To share and contribute the knowledge and experiences gained by the nurse not only to other nurses but also to the individual or patients for them to have a broad knowledge about different problems during operation.

Patient’s ProfileName: Patient XAddress: Bauan, BatangasAge: 21 years oldReligion: Roman CatholicSex: female Date of Birth: April 11, 1991Civil Status: SingleNationality: FilipinoDate of admission: January 17, 2013Physician: Dr. Claudualdo G. CastilloAdmitting Diagnosis: Spinal ShockChief Complaint: FallVital Signs:

Temp: 36° CPR: 96 bpmRR: 22 cpmBP: 110/70 mmhg

Clinical Appraisal

Past Health History

The past health history of the patient showed that she had taken BCG, measles, hepa B and DPT immunization. She has no allergies to drugs, animals and insect bites. On her childhood life, she fell from the stairs though has not been seriously injured. She has never been confined in a hospital. Though she experienced simple colds, fever and pain, she had treated it with common, over-the-counter medicines such as paracetamol. She tend to go to the hospital whenever she had a routine medical check up for work.

Family History

She is the second to the youngest of five children in their family. Her mother and father are both in their fifties. Hypertension is a common disease in her father side, as well as heart disease. Her grandparents both died of complication of hypertension but other than that, no known family history of Diabetes, Asthma, TB and Cancer.

Personal History

The patient was a maintenance crew at KEPPEL Bauan shipyard and works daily. She enjoys playing guitar during her leisure time. Brought by pressure of work, she really craves for long hours of sleep. During her rest day, she does the laundry and other house chores. She’s fond of eating pork and chicken but she don’t eat vegetables. She doesn’t smoke and drink alcohol beverages. Her average sleep in a day is 5-6 hours.

Social History

She has a close family tie. She enjoys spending time with her niece and nephews. She usually plays with the little ones. She think she is a good daughter though sometimes there are instances when she does thing in her own way without consulting her mother which sometimes lead to bad results. They don’t believe in superstitions though they celebrate all civic and religious events. She finished her secondary education at Bauan high school and started his job as an inspector in Cavite. A year after she was employed at KEPPEL in the house keeping department. They have just enough for a living, being able to cope with life’s necessary comforts. They are in a peaceful neighborhood with friendly people. Some of them are also employees of KEPPEL.

Psychological History

The patient is experiencing stress due to her illness. Being bedridden gives her much worries and stress. It has been so hard to deal with the thought and fact that she is helpless and a sort of burden to her family. She just prays so hard every time to fight her depression. She gets strength from the people who love her and taking care of her. They make coping with her situation lighter by letting her know they are there for her. The patient is evasive while communicating. A sort of hesitant to show her vulnerability to the situation. She doesn’t open much of her emotional distress and how she feels. The patient is immobile with only her hands movable. When she attempts to move her head, it releases unbearable pain.

History of Present Illness

The patient broke a portion of her spine causing immobility. This was due to an accident when she fell down from the ladder at her work. When she cannot hold tightly in the ladder. She instantly could not move her lower part from the spine. Other than that she never experience any symptoms from falling. From then she was bedridden and could not move except for the hand only.

PHYSICAL ASSESSMENT

Date January 22, 2013

General Appearance

The patient was lying on bed, conscious with intravenous fluid of PNSS 1L on her right metacarpal vein regulated at 42 gtts/min.

Vital signs Temp:36° CPR:96 bpmRR: 26 cpmBP:110/70 mmHg

BODY PARTS METHODS FINDINGS ANALYSIS

Skin InspectionPalpation

Pale

No lesions

Warm to touch

Edema of 2cm on both lower extremities

Moist skin, good skin turgor.

It might indicate immobility that leads less blood flow.No damage to tissue structure.Indicates balance between heat produced and loss from the bodyFluid retention in the part of the body.

Due to room temperature. No signs of dehydration

Hair Inspection With good hair evenly distributed, thin, silky Proper nutritional intake and no signs of hair lossNormal and balanced distribution of natural oil

Nails InspectionPalpation

Convex curvatureSmooth, good intact Pale nail bedsCapillary refill of three seconds

No breaks in the skin and inflammation.Indicates poor blood and oxygen circulationPoor Peripheral blood circulation

Head InspectionPalpation

Symmetric, round, erect and in midline. No lesions are visible. Hard and smooth, no nodules or lumps

Normal amount of growth hormone.

Face InspectionPalpation

Symmetric with round appearanceNo abnormal movements notedTemporal artery is elastic and not tenderNo swelling or tender ness in temporomandibular joint

With proper functioning of facial muscle and bones.Indicates no trauma.

Neck InspectionPalpation

Symmetric with head centered and without bulging massesThyroid cartilage, cricoid cartilage and thyroid gland move upward as the client swallowsC7 is visible and palpable

Limited in motionTrachea is midline

Normal that no masses is present and have the possibility of the muscle to flex and extendIt might due to L1 fractureNo thyroid enlargement and sign of abnormalities

Lymph nodes Palpation Not palpable, no swelling or enlargement and no tenderness There is no enlargement of lymph due to the presence of microorganism that is trapped

Eyes Eyebrows EyelidsBulbar Conjunctiva and sclera Pupils

Inspection With eyebrows evenly distributed, symmetrical, with equal movementIntact skin without discharge; close symmetricallyClear, moist. Sclera is slightly yellowish. Black, round, equal in size

Proper functioning of eyebrow’s muscle; no sign of hair lossNo inflammation noted.It might indicate iron deficiency.

No injury and inflammation that indicates CNS disorder

Ears Inspection Palpation

Equal in size bilaterallyAuricles aligns with the corner of each eyeSkin is smooth with no lesions, lumps, or nodulesColor is consistent with facial hairAuricle, tragus, and mastoid process are not tenderPinna back to normal position when folded

Normal. Indicates good circulation of blood and oxygenNo inflammation; afebrile; not tender when moved or pressed.Tenderness suggests inflammation and infection.

Mouth Outer lips Teeth and gums Tongue Hard and soft palate

Inspection With moist lips, smooth and softSlightly yellowishWith pink gums, no retraction of gumsCan move freely, with pinkish tongue and in central position and with no areas of tendernessTongue’s ventral surface is smooth, shiny, slightly pale with no lesionsHard palate is intact and no discolorationSoft palate colors lighter pinkNo unusual or foul odor is noted

Not dehydratedSlightly yellowish due to excessive coffee use. Indicate normal and good hygiene.Normal functioning of hypoglossal; not dehydrated; freely movable.No presence of ulcerations and swelling.No presence of discoloration due to inadequate blood and oxygen circulation.Indicate normal and good hygiene.

Sinuses Palpation Frontal and maxillary sinuses are non-tender to palpate, and no crepitus is evident Normal. Good functioning of sinuses

Transillumination A red glow transilluminates the frontal sinuses and maxillary sinuses Absence of red glow indicates sinus filled with pus.

Thoracic General Anterior thorax

InspectionInspection

Nasal flaring is not observed.Evenly colored skin tone without unusual or prominent discolorationSymmetrical chest and normal chest expansionNormal respiration, quiet and have uniform rhythmRetraction not observedRespiration are relaxed, effortless, and quiet

The ratio between antero posterior to transverse diameter is 1:2; no congenital defects. No kyphosis and lordosis.No use of accessory muscle.

Breasts Inspection Soft, fatty enlargement of breast tissue.

No swelling, nodules and ulceration noted.

Normal due to body built.

No inflammation noted.

Heart Carotid arteryPeripheral vascular system

AuscultationPalpation

S1 and S2 heard at all sitesWith symmetric pulse volume With full pulsation

S1 louder at apical area and S2 louder at the base of the heart. S1 is the first sound or the “lub” and S2 is the 2nd sound or the “dub”.Indicates paired circulation.

Abdomen InspectionAuscultation

With uniform color and symmetrical in movement caused by respirationWith audible bowel sounds and no friction rub

No protrusion around umbilicus, no hernia or tumor or enlargement of an organ.Normal movement of intestines and no rubbing of pleura.

Musculoskeletal system joint ROM Inspection

Palpation

With signs of muscle weakness and numbness

Paralysis on both lower extremities

The client wasn’t able to perform active ROM.

It might due to L1 fracture.

Summary of Physical Assessment:

Patient X was physically assessed last January 22, 2013. The assessment was done in a cephalocaudal with the following findings.

Patient X was received at bed and conscious with intravenous line in his right metacarpal vein. She was jaundice, with edema of 2cm and paralysis on both lower extremities, with pale nail beds, limited motion on the neck, yellowish sclera and experienced sign of weakness and numbness due to L1 fracture.

Aside from that, all the findings were NORMAL.

Glasgow Coma Scale

- is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury.

Category Findings Score

Eye Opening Response Spontaneous 4

Verbal Response Oriented 5

Motor Response We assessed the upper and lower extremities, upper extremities had a score of 6 because it obeys command but since the patient is having a paralysis in both lower extremities we score it of 0.

Cranial Nerve Assessment

– for the nurse to be aware of specific nerve functions and need to assessed methods for each cranial nerve to detect abnormalities.

Cranial Nerves FindingsOlfactory nerve Detects and correctly identified the different aroma such as coffee and alcohol.Optic nerve Able to read written words on a piece of paperOculomotor nerve Able to use 6 cardinal movements. Pupils constrict and remain constricted with light;

pupils dilate when light is removed.Trochlear nerve Able to use 6 cardinal movements.Trigeminal nerve Unable to blinks her both eyes when lateral cornea was touch. Identifies the same

sensation bilaterally and able to distinguish dull from sharp object. Can clench her teeth tightly.

Abducens nerve Able to see through her peripheral vision.Facial nerve Symmetrical facial contours, lines, wrinkles and symmetrical facial movement.

Correctly identifies sweet, sour, salty, and bitter according to areas of tastes.Auditory nerve Equal hearing in both ears. Air conducted tone heard twice long in both ears as bone-

conducted tone. Able to hear whispered words.Glossopharyngeal nerve Correctly identifies bitter taste on posterior tongue. Able to move tongue freely.Vagus nerve When patient speaks, her uvula and soft palate move straight up. Voice clear and

strong.Accessory nerve Weak to shrug shoulders, and experience pain to turn head to side against

resistance. Hypoglossal nerve Able to protrude and move tongue freely.

Reflexes - automatic response of the body to a stimulus.

0 No response

+1 Minimal activity

+2 Normal response

+3 More active than normal

+4 Maximal activity

Reflexes Findings

Biceps reflex + 2

Triceps reflex +2

Brachioradialis reflex +2

Patellar reflex 0

Achiles Reflex 0

Plantar reflex 0

Sensory system- consists of sensory receptors, neural pathways, and parts of the

brain involved in sensory perception. Commonly recognized sensory systems are those for vision, hearing, somatic sensation (touch), taste and olfaction (smell).

Sensory system FindingsLight touch sensation Upper extremities: light tickling

Lower extremities: hypoesthesiaPain sensation Upper extremities: able to distinguished sharp from

dullLower extremities: absent of pain sensation

Temperature sensation Upper extremities: able to discriminate hot and cold sensationLower extremities: unable to discriminate temperature sensation

Kinesthetic sensation Upper extremities: can readily determine the position of fingersLower extremities: unable to determine the position of the toes

Stereognosis Able to recognize different shape of an objects

Graphestisia Able to distinguish and identify written numbers on the skin.

Proprioception Limited body movement.

DIAGNOSTIC AND

LABORATORY RESULTS

• Complete Blood Count (CBC) – an analysis of the blood that provides much information. It consists of a RBC count, hemoglobin and hematocrit count measurements, and a WBC count.

• Red Blood Cells (erythrocyte)- Transport oxygen from the lungs to the various tissues of the body and to assist in the transport of carbon dioxide and carbon dioxide from the tissues to the lungs.

• Hemoglobin- carries oxygen from the respiratory organs to the rest of the body (tissues) where it releases the oxygen to burn nutrients to provide energy to power the functions of the organism.

• Hematocrit- is the volume percentage (%) of red blood cells in blood.Platelet (thrombocyte)- releases chemicals necessary for blood clotting. And a cell fragments involved with preventing blood loss.

• Neutrophil- usually remain in the blood for a short time (10-12 hours) phagocytize microorganisms and other foreign substances.

• Lymphocyte- produces antibodies and other chemicals responsible for destroying microorganisms, contributes to allergic reactions, and regulates immune system.

• Monocyte- leaves the blood and becomes a macrophage, which phagocytizes bacteria, dead cells, cell fragments, and other debris within tissues.

Jan.21, 2013 Laboratory ExamsHematology

CBCLaboratory Exam Normal Values Result Significance

RBC M - 4.6-6.2x10/LF - 4.2-5.4x10/L

3.7310^6/uL Decrease(Due to chronic inflammatory disease that causes RBC destruction)

Hgb M - 140-180g/100mLF – 120-160g/100mL

112.00mL Decrease(Associated with decreased RBC that carries Hgb)

Hct M – 0.40-0.54 vol %F – 0.37-0.47 vol %

0.34 % Decrease(Due to decreased RBC in the blood)

Platelet count 250,000-400,000x10/L

29.6910^3/uL

Neutrophil 0.45-0.65 6.9 Increase(Due to bacterial infection)

Lymphocyte 0.2-0.35 0.04Monocyte 0.02-0.14 0.05

• Prothrombin Time- measure of how long it takes for the blood to start clotting.

• Prothrombin-Inactive clotting factor.• Thromboplastin-Released from injured tissues can cause

activation of clotting factors.• INR (International normalized ratio)- standardizes the

time it takes to clot on the basis of the slightly diff. thromboplastins used by diff. laboratories.

• HBA1C (Glycoselated Hemoglobin)- is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. It shows how well you are controlling your diabetes.

Jan.21, 2013

HematologyBlood ChemistryExamination Result Control Normal Values Significance

Creatinine 62.53umol/L

50-100umol/l

Protime 15.9sec. 13.1 sec 10-14 sec Increase(Due to Vitamin K Deficiency)

% Activity 71.3% 102.9% 70-120%INR 1.37 1.06HBA1C 5.7% Up to 5.80%Glucose/FBS 7.14mmol/L 4.10-5.90mmol/L Increase(Indicate

that the pancreas is not producing enough insulin)

Serum Electrolytes

Na 142.8 135-155K 3.93 3.40-5.30Ca 2.42 2.15-2.57

Diagnostic Exam

Jan.22, 2013

MRI(Magnetic resonance imaging)

- demonstrates narrowing of the lumbar canal with compression of the cauda equina nerve roots

by thickened posterior vertebral elements, facet joints, marginal osteophytes or soft tissue structures such

as the ligamentum flavum or herniated discs.

MRI of the Lumbar Spine with contrast(Procedure)Clinical Information: FallFindings:

There is moderate compression fracture involving the L1 vertebra, associated with diffuse marrow edema. There is retropulsion of the posterior vertebral body margin causing moderate compression of the conus. There is non-enhancing cord signal abnormality involving the mildly expanded distal cord from T11-12 to the conus, consistent with cord edema.

The rest of the lumbar vertebrae demonstrates normal vertebral body heights and alignment. There is mild marrow edema involving the T12 and L2 vertebrae. The Intervertebral discs from T12-L1 to L2-S1 are normal.

Impression:

Acute moderate compression fracture (burst fracture) involving for associated with retropulsion of the posterior vertebral body margin and moderate cord compression.

X-rays of the spine, neck, or back may be performed to diagnose back or neck pain, fractures or broken bones, arthritis, spondylolisthesis (the dislocation or slipping of one vertebrae over the one below it), degeneration of the disks, tumors, abnormalities in the alignment of the spine such as kyphosis or scoliosis, or congenital abnormalities.

Chest AP supine

Findings:Interstitio-alveolar densities are noted in the right peri-hilar

region.Heart size is magnified.Other visualized chest structures are unremarkable.

Impression:Peri-hilar region pneumonia, right. Follow up study after a

complete course of antibiotic treatment is suggested to rule out Koch’s etiology.

Magnified heart size due to supine AP projection.Non-enhancing cord signal abnormality and mild cord

expansion from T11-T12 level down to the conus, consistent with cord edema.

Mild marrow edema involving T12 and L2

ANATOMY

AND

PHYSIOLOGY

PATHOPHYSIOLOGY

Non-modifiable

age(21 y/o) Female

Applied force usually causes the anterior part of vertebral body to crush

Forming an anterior wedge fracture

Middle column remains intact and may act as hinge

Loss of anterior height of the vertebra

Spine bends forward causing kyphotic deformity

Modifiable

WorkStress

Fracture is really associated with neurologic comprise

Neural input from the brain due to spinal concussion become hyperpolarized and less responsive

Complete loss or weakening of all reflexes

Serious neurological injury

Spinal Shock

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:“walang pakiramdam ang tuhod hanggang paa ko.”Objective:

Edematous feet grade

+2

Skin is tight and shiny

Presence of bruise

Disturbed Sensory Perception related to Destruction of sensory tracts with altered sensory reception, transmission, and integration

Spinal shock following a spinal cord injury is a specific term that relates to the loss of all neurological activity below the level of injury. This loss of neurological activity includes loss of motor, sensory, reflex and autonomic function. Spinal shock is a short term temporary physiologic disorganisation of spinal cord function that can start between 30-60 minutes following a spinal cord injury. Spinal shock can last up to six weeks post injury. (apparelyzed.com)

After 8 hours of nursing intervention, patient will be free of injury.

Independent:Assess and document sensory function or deficit, such as by means of touch, pinprick, or heat and cold, progressing from area of deficit to neurologically intact area.Protect from bodily harm, such as falls, burns, and positioning of arm or objects.Assist client to recognize and compensate for alterations in sensation.Provide tactile stimulation by touching the client in intact sensory areas, such as shoulders, face, and head.Provide uninterrupted sleep and rest periods.

Changes may not occur during acute phase, but as spinal shock resolves, dermatome charts or anatomic landmarks should document changes.The client may not sense pain or be aware of body position.Increased attention to alterations in sensation may help reduce anxiety of the unknown and prevent injury.Touching conveys caring and fulfills normal physiological and psychological needs.Adequate sleep and rest reduce sensory overload, enhance orientation and coping abilities, and aid in reestablishing natural sleep patterns.

After 8 hours of nursing intervention, patient free of injury.





Subjective:“hindi ako nakakagalaw, ung dalwang kamay ko lang ang naiibo ko”Objective:

Inability to move

purposeful

Reluctance to attempt

movement

Limited ROM

No movements on

lower extremities

Impaired physical mobility related to skeletal paralysis of the lower extremities.

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis).With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation.(Nurse’s Pocket Guide-Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murrp.457)

After 2 hours of nursing intervention, patient will verbalize understanding of situation and individual treatment regimen and safety measure.

Independent:Determine presence of complication related to immobility.Support affected body parts or joints using pillows, rolls, foot supports.Provide regular skin care to include pressure area management.Schedule activities with adequate rest periods during the dayEncourage participation in self-care, diversional or recreational activities.Encourage adequate intake of fluids and nutritious foods.Dependent:Administer medication as prescribe prior to activity as needed for pain relief

For early detection and management

To maintain position of function and reduce risk of pressure.

To maintain skin integrity.

To reduce fatigue

Enhance self-concept and sense of independence.

Promotes well-being and maximizes energy production.

To permit maximal effort and involvement in activity

After 2 hours of nursing intervention, patient verbalizes understanding of situation and individual treatment regimen and safety measure.





Subjective:“masakit ang bali ko sa likod”Objective:Facial grimace connotes painWeaknessIrritabilityVital signs as follows:

BP: 110/70PR: 96bpmRR: 22cpm

Temp: 36 degree celcius

C- O- 5 days

L- lumbar area, radiating to the back

D- continuousS- 8/10

P- upon moving the back and neck

A- none

Alteration in comfort, pain related to movement of bone fracture.

Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds to 6 months. In cases of fracture, pain is continuous and increasing in severity until bone fragments. (www.scribd.com)

After 2 hours of nursing intervention, patient will demonstrate use of relaxation techniques and diversional activites for individual situation.

Independent:Monitor skin color and temperature and vital signs.Provide comfort measures, quiet environment, and calm activities.Instruct in and encourage use of relaxation technique.Encourage verbalization of feelings about pain.Encourage adequate rest periods.Dependent:Administer analgesics (ketorolac 30m every 8 hours) as prescribed as needed.

Vital signs are usually altered in acute pain.To promote non pharmacological pain management.To distract attention and reduce tension.Pain is a subjective experience and cannot be felt with others.To prevent fatigue.Notify physician if regimen is inadequate to meet pain control goal.

After 2 hours of nursing intervention, patient demonstrates use of relaxation techniques and diversional activities for individual situation.

Name of Drug Classification & Mechanism of

Action

Indication Adverse Effect

Contraindication Nursing Responsibilities

Monitoring Parameters

Generic Name:Ketorolac TromethamineBrand Name:ToradolDosage:30 mg/mLRoute:I.V.

Nonsteroidal

anti-

inflammatory

drugs

May inhibit

prostaglandin

synthesis to

produce anti-

inflammatory,

analgesic

and

antipyretic

effects

Short-

term

manage

ment of

pain

CNS: drowsiness, abnormal thinking, dizziness, euphoria, headacheRESP: asthma, dyspneaCV: edema, pallorGI: diarrhea, dry mouth, dyspepsiaGU: oliguria, urinary frequency

Use

cautiously

with patient

with

cardiovascular

disease or risk

factors for

cardiovascular

disease,

history of GI

bleeding,

renal

impairment

Assess pain level. May cause

drowsiness or dizziness.

Advise patient to avoid activities requiring alertness until response to the medication is known

Instruct patient to take the medication exactly as directed. Take missed doses as soon as remembered if not almost time for next dose. Do not double doses. Do not take for more than prescribed or for longer than five days.

May

increase

BUN,

serum

creatinine

,

potassium

concentra

tions,

AST and

ALT

Name of Drug Classification & Mechanism of Action

Indication Adverse Effect Contraindication Nursing Responsibilities


Generic Name:Methylprednisolone Sodium SuccinateBrand Name:Solu - MedrolDosage:40 mgRoute:I.V. Bolus

Glucocorticoid

Reduces

inflammation &

prevents edema by

stabilizing

membranes &

reducing

permeability of

leukocytic cells,

suppresses immune

system by interfering

with antigen –

antibody interactions

of macrophages and

T cells.

To treat

conditions

such as

arthritis, blood

disorder,

severe allergic

reaction,

certain

cancers, eye

conditions,

and immune

system

disorder.

CNS: headache, restlessness, nervousness, depression, euphoria, vertigo, insomnia, increased ICP, seizures CV: hypo/hypertension, arrhythmias, heart failure, shock, thrombophlebitis, thromboembolism EENT: cataracts, glaucoma, sneezing, epistaxis GI: nausea, vomiting, abdominal distention, rectal bleeding, anorexia, ulcer GU: amenorrhea, irregular menses Respiratory: cough, wheezing, bronchospasm Metabolic: fluid retention, hypokalemia Musculoskeletal: muscle wasting, osteoporosis, muscle pain and weakness Skin: facial edema, rash, pruritus Others: local pain & burning, irritation, hypersensitivity reactions

Use cautiously

with patient with

hypersensitivity to

drugs and

systemic fungal

infections

Tell pt. to take with food to avoid GI upset

Inform pt. that drug increases risk for infection. Urge the pt. to avoid exposure to people with infections such as measles and chickenpox.

Tell patient to immediately report signs or symptoms of adrenal insufficiency (including fatigue, appetite loss, nausea, vomiting, diarrhea, weight loss, weakness, and dizziness) after dosage reduction or drug withdrawal.

Monitor fluid and

electrolyte

balance, weight,

and blood

pressure.

After dosage

reduction or

drug withdrawal,

monitor patient

for signs and

symptoms of

adrenal

insufficiency.


Action




Generic Name:BisacodylBrand Name:DulcolaxDosage:10 mgRoute:PO

Stimulant

Laxative

Thought to

stimulate

colonic

mucosa,

producing

parasympathe

tic reflexes

that enhance

peristalsis and

increase water

and electrolyte

secretion,

thereby

causing

evacuation of

colon.

Constipation;

bowel

cleansing for

childbirth,

surgery, and

endoscopic

examination

CNS: dizziness, syncope GI: nausea, vomiting, diarrhea (with high doses), abdominal pain, burning sensation in rectum (with suppositories), laxative dependence, protein-losing enteropathyMetabolic: hypokalemia, fluid and electrolyte imbalances, tetany, alkalosisMusculoskeletal: muscle weakness (with excessive use)

Use

cautiously

with patient

with

hypersensiti

vity to drug,

intestinal

obstruction,

gastroenteriti

s,

appendicitis

Don't give tablets within 1 hour of dairy products or antacids (may break down enteric coating).

Suggest other ways to prevent constipation, such as by eating more fruits, vegetables, and whole grains to increase dietary bulk and by drinking 8 to 10 glasses of water daily.

Assess

stools for

frequency

and

consistency.

Monitor

patient for

electrolyte

imbalances

and

dehydration.


Action



Generic Name:BisacodylBrand Name:DulcolaxDosage:10 mgRoute:PO

Stimulant

Laxative

Thought to

stimulate

colonic

mucosa,

producing

parasympathe

tic reflexes

that enhance

peristalsis and

increase

water and

electrolyte

secretion,

thereby

causing

evacuation of

colon.

Constipation;

bowel

cleansing for

childbirth,

surgery, and

endoscopic

examination

CNS: dizziness, syncope GI: nausea, vomiting, diarrhea (with high doses), abdominal pain, burning sensation in rectum (with suppositories), laxative dependence, protein-losing enteropathyMetabolic: hypokalemia, fluid and electrolyte imbalances, tetany, alkalosisMusculoskeletal: muscle weakness (with excessive use)

Use cautiously

with patient with

hypersensitivity

to drug,

intestinal

obstruction,

gastroenteritis,

appendicitis

Don't give tablets within 1 hour of dairy products or antacids (may break down enteric coating).

Suggest other ways to prevent constipation, such as by eating more fruits, vegetables, and whole grains to increase dietary bulk and by drinking 8 to 10 glasses of water daily.

Assess

stools for

frequency

and

consistency.

Monitor

patient for

electrolyte

imbalances

and

dehydration.


Action




Generic Name:OmeprazoleBrand Name:ProlosecDosage:40 mgRoute:IVFrequency:OD

Proton Pump

Inhibitor

Reduces gastric

acid secretion

and increases

gastric mucus

and bicarbonate

production,

creating

protective

coating on

gastric mucosa

and easing

discomfort from

excess gastric

acid.

Treatment of

dyspepsia,

gastroesopha

geal reflux

disease,

disorders of

gastric

hypersecretio

n, and peptic

ulcer,

including that

associated

with

Helicobacter

pylori

infection.

CNS: dizziness, headache, astheniaGI: nausea, vomiting, diarrhea, constipation, abdominal painMusculoskeletal: back painRespiratory: cough, upper respiratory tract infectionSkin: rash

Use

cautiously

with patient

with

hypersensitivi

ty to drug.

Tell patient to

take 30 to 60

minutes

before a meal,

preferably in

morning.

Caution

patient to

avoid driving

and other

hazardous

activities until

he knows how

drug affects

concentration

and alertness.

Vital signs.

Check for

abdominal

pain, emesis,

diarrhea, or

constipation.

Evaluate fluid

intake and

output.

Watch for

elevated liver

function test

results.


Action



Generic Name:MetoclopramideBrand Name:PlasilDosage:1 ampRoute:IV

Prokinetic

Drug,

Antiemetic

Drug

Dopamine

antagonist

that acts by

increasing

receptor

sensitivity

and

response of

upper GIT

tissues to

acetylcholine

.

Management

of esophageal

reflux

Treatment

and

prevention of

postoperative

nausea and

vomiting

CNS: restlessness, anxiety, drowsiness, fatigue, fever, insomnia, seizure, headache, dizziness, sedationCV: transient hypertensionGI: nausea, bowel disturbanceHematologic: agranulocytosis, neutropeniaSkin: rashOthers: prolactin secretions, loss of libido

Use cautiously

with patient

with

hypersensitivit

y to drug.

Assess mental status during treatment.

Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration.

May cause drowsiness.

Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication.

Vital signs. Monitor for

and immediately report occurrence of extrapyramidal symptoms and tardive dyskinesia especially in elderly patients: rigidity, grimacing, shuffling gait, tremors, rhythmic involuntary movements of tongue, mouth, jaw, feet and hands.


Action




Generic Name:PregabalinBrand Name:LyricaDosage:75 mgRoute:POFrequency:1 tab OD

Antiepileptic Drug

Pregabalin binds to calcium channels on nerves and may modify the release of neurotransmitters (chemicals that nerves use to communicate with each other). Reducing communication between nerves may contribute to pregabalin's effect on pain and seizures.

Treating pain

caused by

neurologic

diseases such

as postherpetic

neuralgia as well

as seizures

dizziness, drowsiness, dry mouth, edema (accumulation of fluid), blurred vision, weight gain, and difficulty concentrating, reduced blood platelet counts, and increased blood creatinine kinase levels.

Use

cautiously

with patient

with

hypersensiti

vity to drug.

Seizure Precaution such as: raising side rails, loosen the clothing’s of patients, do not attempt to restrain the client during seizure attacks.

Assess patient’s mental status.

Monitor Vital Signs.

May cause drowsiness.

Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication.

Vital

signs.

Observe

for clinical

worsening

, suicidal

thoughts,

or unusual

changes

in

behavior.

Discharge Planning:

MEDICATION:• Advised the patient to take medication as prescribed.• Instruct to watch for possible adverse reaction of the drug.• Advised to take medication at the right time and dosage.

EXERCISE:• Encourage the patient to do physical therapy consists of

maintaining the joint in its functional position and providing passive range-of-motion exercises.

ENVIRONMENT:• Advised patient and relatives to provide a clean environment

conducive for patients recovery• Emphasized the importance of stress and injury free environment to

prevent accident and any other complications.

TREATMENT:• Informed the patient regarding the importance of her compliance of

treatment.• Advised the relatives to initiate therapy.• Advised the relatives change the position of the client every 2 hours.• Instructed the patient to assess and observe for signs of infection such

as swelling, redness and pain over the affected site.

HYGIENE: • Encourage the patient to change dressings and bandages

when they are soiled and wet.• Educate to cleanse hands before and after touching open

wounds.• Encouraged the patient to promote or perform activities

such as oral hygiene.

OPD:• Instruct to have follow up check-up at OPD department 1

month after discharge.

DIET:• Encourage to consume meals with high content of the

following:• Vitamin C• Protein• High fiber• Calcium• Instruct the patient to eat green leafy vegetables and other

nutritious vegetables and fruits.• Encourage the patient to increase fluid intake.

Prognosis

The patient was admitted at Bauan Doctors General Hospital on January 17,2013 having a chief complaint of pain at lumbar area due to fall, with a scale of 8/10 with a final diagnosis of Lumbar fracture spinal shock.

Intervention for the condition is still on going. She was given medications of Dulcolax, Lyrica, Omeprazole, Ketorolac and Solu-medrol. No complications are foreseen for the meantime. Her attending doctors ordered for a procedure of spinal implants titanium with rods, staples and cage.

The prognosis is fair, because inspite of her complicated condition, she shows willingness to help with her healthcare provider for her fast recovery.

Acknowledgement:

First of all we would like to thank Almighty God for guiding and enlighten our mind in finishing this case study. Also our parents who support us not only financially but also encourage us to do our tasks as their son and daughter and as nursing student of Lyceum of the Philippines University-Batangas. We would like to thank also our patient and her parents who corporate and gave the necessary information that we needed in this case study. We would like to extend our deepest gratitude to our clinical instructor Mrs. Liezl A. Arguelles for sharing her knowledge and ideas, giving us additional information about our two days duty and also regarding in this case study. Another is for the staff nurses of the Surgical ward and management of Bauan Doctors General Hospital for affiliating us and lastly for the members of our group who done their part in this case.

BSN III-3 GROUP B

Manjares, Allan JoePanaligan, Michelle D.

Panopio, Mryan M.Pastoral, Kristhyll Jay-Ann E.

Perez, Chlionne G.Perez, Irest Krissel C.

Perez, Sisley L.Quero, Mary Joannie B.

Ramos, Ronald R.

Thank You!!!

Backbone

Documents

losing enteropathy

give assess

nursing intervention

red blood

move tongue

spinal cord

electrolyte

spinal cord