case presentation about spinal shock syndrome

Chapter 1

PROBLEM AND its BACKGROUND

Introduction

Perception – the ability to recognize external stimuli

Coordination – the proper functioning of organs in relation to each other, such as

muscles and nerves to produce the desire result.

Injury 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 weakened 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,M.D.,Ph.D.)

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, sexual

function, and autonomic reflexes. Loss of venous return and hypotension also occur. The

hypothalamus cannot control temperature by vasoconstriction and increased metabolism;

therefore the client’s body assumes the environmental temperature. Spinal shock is most severe

in clients with higher levels of SCI. Clients with thoracic and lumbar injuries are often

unaffected because the sympathetic nervous system is spared with these levels of injury.

Spinal shock may last for 1 to 6 weeks. Indications that spinal shock is resolving include

return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex

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emptying of the bladder. The earliest reflexes recovered are the flexor reflexes evoked by

noxious cutaneous stimulation. The return of the bulbocavernosus reflex in male patients is also

an early indicator of recovery from spinal shock. 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)

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Background of the Study

The researchers conducted this study at St. Dominic Medical Center during the first

rotation duty in the ward unit.

They received their patient in station 3A room 308 in a rehabilitative situation but should

be managed with proper nursing care. 6days PTA, patient was accidentally hit his head after a

dive in a beach in Boracay, suddenly lost of motor function (upper and lower

extremities).Admitted at a hospital in Kalibo, Aklan where he is known to developed decubitus

ulcers in sacral area upon admission at SDMC.

The researchers drew interest upon the case due to the integration of different concepts

of the condition of Spinal Shock Syndrome. This includes the correlation of comprehensive and

other manifestations of the injury. As on the part of the researchers thorough study is required to

obtain accurate results and thus conclusion and to know and share the proper nursing

interventions to be done in caring of patients with this condition.

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Statement of the Problem

1. What is the Patient’s Profile?

2. What are the different assessment parameters of a patient with Spinal Shock Syndrome?

3. What are the different interrelated factors to the problem?

4. What are the different nursing diagnoses formulated based on the client’s manifestations?

5. Which of the Nursing Diagnosis identified, is the priority? What is the least prioritized?

6. What appropriate nursing interventions can be formulated based on the

identified problems?

Significance of the Study

A. Client and His Family

This study will provide knowledge about the client’s condition. It will enable the patient

to accept gradually his situation as well as his significant others. It can also help the relatives of

the patient to know their responsibilities in caring the patient.

B. Nursing Service Department

This study has comprehensive information about Spinal Shock Syndrome that will help

them enhance their knowledge and awareness about the case. It may also be a reference for

future studies and serve as a tool in teaching regarding clients with spinal shock syndrome.

C. Nursing Education

This study will make individuals who are part of the academic community more aware

and sensitive to their patient’s feeling in revealing the truth about the condition thus, this will

help them study and get knowledge about the condition and then improve the way of supporting

them emotionally and spiritually. It will provide facts that would uplift and improve the skills

and knowledge in handling this kind of case by enlightening them to engage in relevant and

future studies related to Spinal Shock Syndrome. Also it is relevant to know the promotive and

rehabilitative nursing care for the client.

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D. Nursing Students

This study will help them to have more knowledge about Spinal Shock Syndrome that

will help them on the development of their approach in dealing with patients with the same case,

as well as the appropriate procedure to be done to their patient. They will learn from the

experiences of the researchers and may this case set a guideline in giving care to the client.

E. Future Researcher

This will provide some information that might be useful for them in their future research.

This case study will give the information about Spinal Shock Syndrome and the right

interventions. Moreover, this may help them to have a reference for future studies to clients with

Spinal Shock Syndrome. Making them realize the need to engage in an in-depth or related

analysis of spinal shock syndrome cases so that the new improvements and trends in the care and

management of spinal shock syndrome be discovered and utilized.

F. Health Care Professional

The study could help the health care providers to have additional knowledge on how to

handle patients with spinal shock syndrome. They will be able to give comfort and be aware of

the nursing interventions in case that they are about to have this kind of case.

Scope and Limitation

The researchers had their clinical exposure from June 30 to July 16, 2008. Mr. Whiplash

was handled for 3 days in 3 consecutive weeks. First hand information was acquired from

Student Nurse – Patient Interaction and Patient’s Chart.

Nursing Diagnosis was made on the actual problems as manifested by the client during

the student’s exposure on the area. Potential problems may be developed but was not described

anymore due to existence of more complicated current medical problems.

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Chapter 2

REVIEW OF RELATED LITERATURE

Related Literature

Anatomy and Physiology of Neurologic System

The nervous system is the body's most organized and complex structural and functional

system. It profoundly affects both psychological and physiologic functions.

Central Nervous System

Three major functional Divisions:

higher – level brain, or cerebral cortex

lower brain level (basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla,

cerebellum)

spinal cord

these structures are protected by a rigid bony encasement, three layers of membranes, a

fluid cushion, and a blood – brain or blood – spinal barrier

The cerebellum integrates sensory information related to the position of body parts,

coordinates skeletal muscle movement, and regulate muscle tension, which is necessary for

balance and posture. Three pairs of nerve tracts (cerebellar peduncles) provide the

communication pathways. The inferior peduncles are sensory (afferent) pathway from the spinal

cord and medulla, which carry pathway from the spinal cord and medulla, which carry

information related to the position of the body parts of the cerebellum. The middle peduncles

carry information about voluntary (purposeful) motor activities from the cerebral cortex to the

cerebellum. The cerebellum also receives sensory input from the receptors in the muscles,

tendons, joints, eyes and inner ear. After this information is integrated and analyzed, the

cerebellum sends impulses via the superior peduncles (efferent pathways) to the brain stem,

thalamus, and cortex.

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Most of the tracts in the cerebellum travel through various nuclei without crossing.

Therefore the right cerebellar hemisphere predominantly affects the right (ipsilateral) side of the

body and vice versa.

Spinal Cord

The spinal cord, that portion of the CNS surrounded and protected by the vertebral

column, is continuous with the medulla and lies within the upper two thirds of the vertebral

canal (the cavity within the vertebral column). The lower spinal cord terminates caudally in a

cone-shaped structure known as the conus medullaris at the level of the first (L1) and second

(L2) lumbar vertebrae. The spinal cord is sub-divided into four areas: (1) cervical cord, (2)

thoracic cord, (3) lumbar cord, and (4) sacral cord (cons medullaris).

Within the spinal cord, butterfly – shaped gray matter (mostly unmyelinated) is

surrounded by mostly myelinated white matter. The white matter consists of ascending tracts

and descending tracts that conduct nerve impulses between the brain and the cells outside the

CNS. The cell bodies in the gray matter are grouped into cluster of nuclei and laminae (a define

group or column of cells). The tracts in the white matter are arranged into three paired column:

posterior, lateral, and anterior.

Ascending and Descending Pathways

The ascending (sensory) pathways carry sensory information through the spinal cord to

the brain. For example, the spinothalamic tract carries sensory information from the spinal cord

to the thalamus. After synapsing in the thalamus, information is relayed to regions of the brain

such as the parietal lobe. Descending (motor) pathways carry mostly efferent signals to the spinal

cord. The corticospinal tract (upper motor neuron) is a descending tract passing from the frontal

lobe of the cerebral cortex to the motor neurons of the spinal cord. Lower motor neurons are cells

that begin in the anterior horn of the spinal cord and pass through the spinal nerves to the muscle

cells. Propriospinal tracts remain within the cord.

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Many of the tracts communating with the cerebral cortex cross (decussate), but not all

cross at the same place. The term contralateral refers to the opposite side of the body and is used

to describe tracts that cross (often at the medulla) and ascend or descend; ipsilateral (same –

sided) tracts do not cross. For example, sensory tracts (including the anterior spinothalamic,

posterior, and anterior spinocerebellar tracts) cross in the medulla as they ascend to the cerebral

cortex. Therefore the sensory neurons in the cerebral cortex interpret sensory stimuli from the

contralateral side of the body. The lateral corticospinal tract (pyramidal tract) crosses at the

medulla as it descends from the frontal lobe of the cerebral cortex to the spinal cord. The

posterior spinocerebellar tracts are ipsilateral tracts and thus coordinate muscular function on the

same side of the body. The crossing of the lateral spinothalamic tract is unique.

Major nerve tracts of the Spinal Cord

Tract Location Function

Ascending tracts

Fasciculus gracilis

fasciculus cuneatus

Posterior column

Posterior column

Touch, pressure, body

movement, position

Spinothalamic Lateral and anterior columns Pain, temperature, light (crude)

touch

Spinocerebellar

Posterior

Anterior

Lateral Column

Lateral Column

Coordination of muscle

movements

Descending Tracts

Corticospinal

Lateral

Ventral

Lateral Column

Anterior Column

Voluntary Motor

Voluntary Motor

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Reticulospinal

Anterior

Medial

Anterior Column

Anterior Column

Muscle tone,

sweat glands

Rubrospinal Lateral Column Coordination of muscle

movements

Lateral Lateral Column Autonomic nervous system

fibers

Cranial and Vertebral Column

Eight bones that fuse early in childhood compose the cranium. The fused junctions are

called sutures. The cranium encloses the brain structures and serves as a source of protection.

The floor, or bacilar plate, of the cranial vault has three depressions, called fossae. The

frontal lobes lie in the anterior fossa. The temporal lobesand the base of the diencephalon lies in

the middle fossa. The cerebellum rests in the posterior fossa.

The vertebral column, a flexible series of vertebrae, surrounds and protects the spinal

cord. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral

vertebrae fused into a sacrum, and 4 coccygeal vertebrae fused into a coccyx. Ligaments hold the

vertebrae together, and disks between the vertebrae prevent the bone from rubbing together.

Meninges

The meninges, three membranes that envelope the brain and spinal cord, are

predominantly for protection. Each layer – the pia mater, arachnoid, and dura mater – is a

separate membrane.

The pia mater is a vascular layer of connective tissue that is so closely connected to the

brain and spinal cord that it follows every sulcus and fissure. This layer serves as a supporting

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strucuture for blood vessels passing through to the tissues of the brain and spinal cord. The pia

mater and astrocytes together form the membrane part of the blood-brain barrier.

The arachnoid, a thin layer of connective tissue, extends from the top of each gyrus to the

top of the adjacent gyrus; it does not extend into the sulci and fissures. The space between this

layer and pia mater is known as the subarachnoid space. Cerebrospinal fluid flows through this

space.

The cranial dura mater is a tough, nonstretchable vascular membrane with two layers.

The outer dura mater is actually the membrane (periosteum) of the cranial bones. The inner dura

matetr forms the plates that separate the two cerebral hemispheres (falx cerebri), the crebrum and

the brain stem and the crebellum (tentorium cerebelli), and the cerebellar hemispheres. The

tentorium cerebelli is a landmark term that is often used by clinicians to separate parts of the

brain; it is often referred to as tentorium. Supratentorial refers to the cerebrum and all the

structures superior to the tentorium cerebelli; infratentorial refers to the structures inferior to the

tentorium cerebelli: the brains stem and the cerebellum.

Brain spaces that often fill with blood after head trauma include the potential space

(subdural space) between the inner dura mater and the arachnoid and the epidural space between

the dura mater and the periosteum.

The meninges anchor the spinal cord. The pia mater, which closely surrounds the spinal

cord, continues from the tio of the conus as a thread-like structure ( filum terminale) to the end of

the vertebral column, where it is anchored into the ligament on the posterior side of the coccyx.

The denticulate ligaments extend laterally from the pia mate r to the dura mater to suspend the

spinal cord from the dura mater.

Two common spaces that are commonly accessed by physicians are the subarachnoid

space (for diagnostic studies) and the epidural space (for delivery of medications). The

subarachnoid space extends below the level of the spinal cord to the second sacral (S2) vertebral

level, and the epidural space lies between the dural sheath and the vertebral bones.

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Reflex Mechanisms

Our unconscious automatic responses to internal and external stimuli, known as reflex

responses, provide many homeostatic functions. Although the spinal cord is often thought of as

the reflex center, it is not the only site for reflex regulation. Many of the complex reflexes

controlling heart rate, breathing, blood pressure, swallowing, sneezing, coughing, and vomiting

are found in the brain stem.

Some intrinsic reflex circuits in the spinal cord create patterns of movement (flexion and

extension) that are the basis for posture and forward progression. Other reflex circuits are the

bases for the spinal cord reflexes, which include the myotatic (deep tendon, stretch) reflex, the

flexor withdrawal reflex, the crossed extension reflex, and the extensor thrust reflex. Visceral-

somatic reflexes can also excite or inhibit the motor neurons, producing changes in the muscle

tone and even in movement.

Neuromuscular spindles monitor muscle stretch. As a muscle stretches, increased firing

of spindles leads to contraction of the same muscle, commonly seen as the knee-jerk reflex. The

Golgi tendon organs are sensory nerve endings that protect against excessive contraction.

Simple reflexes require only two or three neurons; for example, the knee-jerk reflex

requires only a sensory and a motor neuron. The withdrawal reflex helps prevent or decrease

tissue injury when a body part touches a potentially harmful object. The harmful stimuli are sent

via the sensory neuron to the interneuron in the spinal cord for interpretation, and the response

message is sent via the motor neuron, resulting in the withdrawal response.

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AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system (ANS) is the part of the PNS that coordinates involuntary

activities, such as visceral functions, smooth and cardiac muscle changes, and glandular

responses. Although it can function independently, its primary control is the brain and spinal

cord. The ANS has two divisions: the sympathetic and the parasympathetic nervous systems. The

efferent ANS fiber travel within some cranial and spinal nerves. These two systems are highly

integrated and interact with each other to maintain a stable internal environment.

Unlike the somatic neurons, which usually are single neurons linking the CNS to a

muscle or gland, the ANS has a two – neuron chain leading to the effector organ. The terminal of

the first neuron is located in the CNS and synapses with nerve fibers whose cell bodies are

neuron (postgangliotic fiber) carries impulses to the target viscera. An exception is the adrenal

medulla, which is innervated directly by pregangliotic fibers. The medulla is actually composed

of postgangliotic neurons that secrete epinephrine into the bloodstream during an “adrenal rush”.

The sympathetic nervous system coordinates activities used to handle stress and is geared

for action as a whole for short periods. The preganglionic neurons of the sympathetic nervous

system emerge from the spinal cord via the motor (ventral) roots of the thoracic and upper two

lumbar spinal nerves (T1 – L2). Preganglionic axons are short; postganglionic axons are long.

The parasympathetic nervous system is associated with conservation and restoration of

energy stores and is geared to act locally and discretely for a long duration. The preganglionic

fibers emerge from the spinal cord via the sacral spinal nerves at S2 – 4. these preganglionic

fibers have long axons that synapse with the postganglionic neurons in the ganglia close to or

located within the organs to be innervated. Each postganglionic neuron has relatively short axon.

Most, but not all, organ system has both parasymphatetic and sympathetic innervations. About

75% of the parasymphatetic fibers are in the vagus nerves.

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Effects of symphatetic and parasympathetic nervous systems on organs

Organs Effect of sympathetic stimulation Effects of parasympathetic stimulation

Eye

pupil

ciliary muscle

Dilation (alpha)

slight relaxation (far vision)

Constriction

constriction (near vision)

Glands

nasal

lacrimal

parotid

submandibular

gastric

pancreatic

Sweat glands Copious sweating (cholinergic) Sweating on palms and hands

Apocrine glands Thick, odoriferous secretion None

Heart

muscle

coronaries

Increase rate (beta1)

increase force of contraction (beta1)

dilated (beta2); constricted (alpha)

Slowed rate

decrease force of contraction

(especially of atria)

dilation

Lungs

bronchi

blood vessels

Dilation (beta2)

mild constriction

Constriction

? dilation

Gut

lumen

sphincter

Decreased peristalsis and tone (beta2)

increased tone (alpha)

Increase peristalsis and tone

relaxation (most times)

Liver Glucogenesis, glycogenolysis (beta2) Slight glycogen sythesis)

Gall bladder and bile

ducts

Relaxation Contraction

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Kidney Decreased output and renin secretion None

Bladder

detrusor

trigone

Relaxation (slight) (beta2)

contraction (alpha)

Contraction

Relaxation

Penis Ejaculation Erection

Systemic Arterioles

abdominal viscera

muscle

skin

Constriction (alpha)

constriction (alpha)

dilation (beta2)

dialtion (cholinergic)

constriction

None

none

none

Blood

coagulation

glucose

lipids

Increase

increase

increase

None

none

none

Basal metabolism Increase up to 100% None

Adrenal medullary

secretion

Increase None

Mental activity Increase None

Piloerector muscles Contraction (alpha) None

Skeletal muscle Increased glycogenolysis (beta2)

increase strength

None

Fat cells Lipolysis (beta1) None

The functions and responses of the sympathetic and parasympathetic nervous system are

related to the type of neurotransmitters released. The preganglionic fibers of the sympathetic and

parasympathetic nerves and the postganglionic fibers of the parasympathetic nerves release

acetycholine. The postganglionic fibers of the sympathetic nerves release norepinephrine. Fibers

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that secrete acetycholine are called cholinergic fibers; fibers that secretes norepinephrine are

called adrenergic fibers.

The compexity of the sympathetic and parasympathetic response also depends on the type

of receptor that combines with the neurotransmitter. The sympathetic nervous system has four

types of receptors: alpha1, alpha2, beta1, and beta2. The parasympathetic nervous system has

muscarnic and nicotinic receptors.

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PATIENT’S PROFILE

Name: Mr. Whiplash

Age: 43 Years Old

Gender: Male

Religion: Roman Catholic

Occupation: Construction Worker

Company: David M Consulzhi Inc. (DCMI)

Leisure Activity: Swimming

Medical Abstract:

6days PTA, patient was accidentally hit his head after a dive in a beach in Boracay,

patient verbalized sudden lost of motor function (upper and lower extremities).Admitted at a

hospital in Kalibo, Aklan where he is known to developed decubitus ulcers sacral area upon

admission in SDMC.

Working Impression:

Spinal Cord Injury, Incomplete Asia B.C., Sacral sores grade III, neurogenic bladder

Clinical Impression:

6days PTA (June 6, 2008), patient was accidentally hit his head after a dive in a pool in

Boracay, suddenly lost of motor function (upper and lower extremities).

Admitted at a hospital in Kalibo, Aklan known developed decubitus ulcers sacral area.

Pertinent Findings:

Conscious, coherent, stretcher borne GCS 15

(-) facial asymmetry

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Motor:

1-2/5 1-2/5 801 100

0/5 0/5 40 60

Management:

CT scan done

Presently on physical Therapy session

Sacral sore management done

Debridement done 2x

On Senokot

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PATHOPHYSIOLOGY OF SPINAL SHOCK SYNDROME

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Certain event that lead to spinal shock (diving on shallow water)

Hyperextension of the head (whiplash effect)

Compression of the spinal cord (cervical cord)

Spinal Shock Syndrome

Incomplete paralysis (Quadriplegia)

Long term Bed Rest

Failure in nursing intervention (turning)

Formation of pressure sore in sacral area

Altered metabolic function

Gluconeogenesis Gluconeolysis

Blood glucose level (early effect of shock)

Loss of autonomic activity

Blockage of sympathetic response of the heart, and

lungs

Interference in the transmission of sensory cortex

Inhibition of the reflex emptying of the bowel

and bladder

Sympathetic stimulation of the liver

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Skin deformities (decubitus ulcer)

Worsted from Stage 1 to Stage IV pressure

ulcer

Exposure to pathogens

Spread of invading pathogens

Defense mechanism: temperature

Stimulation of the parasympathetic response of the

lungs, heart and reproductive organ

Vasodilation of blood vessels

Constriction of the bronchi

Uncontrolled bladder filling accompanied by (-) detrusor contraction and (-) sphincter

relaxation

GI motility

Urinary retention

Autonomic neurogenic bladder

Peristalsis of the small intestine

Fecal distention

Autonomic neurogenic bowel

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Total peripheral resistance

Venous pressure and venous volume

Cardiac output (bradycardia)

Blood pressure (hypotension)

Alveoli Perfusion

Gas exchange

Circulating blood volume

Oxygen level in blood

Carbon dioxide level

Compensatory mechanism: oxygenation

Respiratory rate

Respiratory insufficiency

CONCEPT MAP

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SPINAL SHOCK SYNDROME

(Whiplash Injury)

1. Impaired physical mobility

Quadriplegic

Nerve paralysis

2. Impaired Skin/ Tissue Integrity

Bed sores and (sacral region foot part)

5. Chronic Pain

Immobility

Nerve paralysis

3. Wound Tissue Infection

Presence of Decubitus ulcer with foul odor

6. Impaired urinary Function

Negative micturation

4. Acute pain

Decubitus ulcer

Debridement pain

7. Bowel Incontinence

Negative bowel movement

8. Self Care Deficit

Poor hygiene due to immobility RISK:

POTENTIAL PROBLEMS

PHYSICAL ASSESSMENT TEST

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Standard Neurological Classification of Spinal Cord Injury

MOTOR: Key Muscles

C2

C3

C4

C5 2 2 Elbow Flexors

C6 0 0 Wrist Extensors

C7 1 1 Elbow Extensors

C8 1 1 Finger Flexors (distal phalanx of middle finger)

T1 1 1 Finger Abductors (little finger)

T2

T3

T4

T5

T6

T7

T8

T9

T10

T11

T12

L1

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Legend:

0 = total paralysis1 = palpable or visible contraction2 = active movement gravity eliminated3 = active movement against gravity4 = active movement against some resistance5 = active movement against full resistanceNT= not testable

L2 3 3 Hip Flexors

L3 3 3 Knee extensors

L4 1 3 Ankle dorsiflexors

L5 1 3 Long toe extensors

S1 2 3 Ankle plantar extensors

S2

S3

S4 - 5 Voluntary anal contraction (Yes/No)

Total 17 + 20 = 37 Motor Score(Maximum) (50) (50) (100)

SENSORY

Light Touch Pin Prick

R L R L

C2 2 2 2 2

C3 1 1 2 2

C4 1 2 2 2

C5 2 2 2 2

C6 1 2 2 1

C7 1 1 1 1

C8 1 1 2 2

T1 1 1 2 2

T2 1 1 2 2

T3 1 1 2 2

T4 2 2 1 2

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T5 2 2 1 2

T6 2 2 1 2

T7 2 2 1 2

T8 2 2 1 2

T9 2 2 1 2

T10 1 1 1 1

T11 2 2 1 1

T12 1 1 1 1

L1 2 1 1 1

L2 1 1 1 1

L3 1 1 1 2

L4 1 1 1 1

L5 1 1 1 1

S1 1 1 1 1

S2 1 1 1 1

S3 NT NT NT NT

S4 - 5 NT NT NT NT

Total: Pin Prick Score: 34 + 41 = 75 (maximum 112)

Light Touch Score: 36 +37 = 73 (maximum 112)

Ultrasound Report

Kidney and Urinary bladder Ultrasound

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Both kidneys are in normal size, the right measuring 90 x 49 mm, while the left measures 95 x 48 mm. both cortico – medullary structures appear normal. There is no evidence of intra – renal mass, stones or signs of hydronephrosis.

The urinary bladder is distensible with no evidence of intra – luminal mass nor stones noted. The bladder wall is not thickened. The total volume of urine was approximately 108 ml.

Foley catheter noted.

IMPRESSION: Normal Kidneys, Bilateral

Normal Urinary Bladder

COMPUTERIZED TOMOGRAPHY REPORT (June 14, 08)

CRANIAL CT SCAN

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NON CONTRAST AND CONTRAST ENHANCED CRANIAL CT SCAN WITH BONE SETTING REVEALED THE FOLLOWING IMPRESSION / FINDINGS:

1. No abnormal density seen within the brain parenchyma. No evidence of extra axial hematoma

2. Midline structures are in place3. Posterior fossa structures are unremarkable4. There is satisfactory opacification of the major intracerebral vessels5. Bone settings show densities within the left maxillary, ethmoid and sphenoid sinus

indicative of sinusitis

CERVICAL CT SCAN

CERVICAL PLAIN: IMPRESSION / FINDINGS:

1. Incomplete hairline linear fracture involving the anterior and posterior aspect of C4 and C5 vertebrae are seen

2. There is a right sided neural foraminal narrowing at C5 – C6 level3. The atlanto – axial joint space and vertebral bodies are intact4. Rest of the vertebral bodies and hyoid bone are unremarkable

FUNCTIONAL INDEPENDENCE MEASURE (FIM) SCORE (July 11, 08)

LEVELS:

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7 complete independence (timely, safely)

6 modified independence (device)

Modified Independence

5 supervision (subject = 100%+)

3 minimal assist (subject = 75%+)

Complete Dependence

2 maximal assist (subject = 25%+)

1 total assist (subject = less than 25%)

Self Care:

A. EatingB. GroomingC. BathingD. Dressing upper bodyE. Dressing lower bodyF. Toileting

111

111

Sphincter Control

G. Bladder ManagementH. Bowel Management

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Transfers

I. Bed, Chair, WheelchairJ. ToiletK. Tub, Shower

111

Locomotion

L. Walk / Wheelchair M. Stairs

W= walkC = wheelchairB = both

1

1

Motor Subtotal Score 13

Communication

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N. ComprehensionO. Expression A = auditory

V = visualB = both

7 7

Social Cognition

P. Social InteractionQ. Problem SolvingR. Memory

V = VocalN = NonvocalB = both

777

Cognitive Subtotal Score 35

TOTAL FIM SCORE 48

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BLOOD CHEMISTRY (June 24, 08)

EXAMINATIONS REFERENCE RESULTS EXAMINATIONS REFERENCE RESULTS

Glucose (GodPap) 4.1 – 6.3 mmol/L Total Protein 7.0 – 9.0 g/dL

Glucose (hemoglucotest

mmol/L Albumin 3.5 – 5.2 g/dL

Urea Nitrogen 6.1 – 15.4 mmol/L Globulin 3.0 – 4.0 g/dL

Creatinine 53 – 106.1 umol/L A/G Ratio 1.0 – 2.5

Uric Acid M mmol/L

F mmol/L

Electrolytes

Total Cholesterol 0 – 5.7 mmol/L Potassium 3.5 – 5.0 Ommol/L 4.4

Triglycerides 0 – 2.2 mmol/L Sodium

HDL Chloride

LDL Calcium 8.6 – 10.3 mg/dL

Alkaline Phosphate 35 – 129 IU/L Blood Gas

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SGOT (AST) 0 -38 IU/L Other

SGPT(ALT) 0 – 41 IU/L

Total Bilirubin mmol/L

Direct Bilirubin mmol/L

Indirect Bilirubin mmol/L



Glucose (GodPap) 4.1 – 6.3 mmol/L 7.9 Total Protein 7.0 – 9.0 g/dL




Creatinine 53 – 106.1 umol/L A/G Ratio 1.0 – 2.5

Uric Acid M mmol/L Electrolytes

31

F mmol/L

Total Cholesterol 0 – 5.7 mmol/L 5.12 Potassium

Triglycerides 0 – 2.2 mmol/L 1.4 Sodium

HDL 0.8 – 1.8 mmol/L 1.80 Chloride

LDL 2.0 – 4.0 mmol/L 2.68 Calcium 8.6 – 10.3 mg/dL

Alkaline Phosphate 35 – 129 IU/L Blood Gas: Conventional Unit: FBS 75 – 115 mg/dL 143







32


Glucose (GodPap) 4.1 – 6.3 mmol/L Total Protein 7.0 – 9.0 g/dL




Creatinine 53 – 106.1 umol/L 70.7 A/G Ratio 1.0 – 2.5

Uric Acid M mmol/L

F mmol/L

0.19 Electrolytes

Total Cholesterol 0 – 5.7 mmol/L Potassium

Triglycerides 0 – 2.2 mmol/L Sodium

HDL Chloride

LDL Calcium 8.6 – 10.3 mg/dL

Alkaline Phosphate 35 – 129 IU/L Blood Gas:



33




HEMATOLOGY (June 13, 08)

EXAMINATIONS REFERENCE RESULT EXAMINATIONS

Hemoglobin F – 120 – 160

M – 140 - 180 142

Differential count

Neutrophils

Hemtocrit F – 0.36 – 0.43

M – 0.42 – 0.54 0.43

Myelocytes

Juveniles

Total RBC count F – 4.5 – 5.5

M – 5.0 – 6.2

Stabs

Segmenters 0.81

Total WBC 5 – 10 x 109/L 15.7 Blasts

Total Platelet count 150 – 350 x 109/L Adequate Lymphocytes 0.19

34

Reticulocyte count monocytes

Erythrocytes sed. Rate F – 0 – 20

M – 0 – 10

Eosinophils

Basophils

Clotting time 2 – 4 mins. Nucleated RBC

Bleeding time 1 – 3 mins. Toxic Granulations

Blood typing/RH typing Malarial Smear

Clot retraction time Peripheral Smear

Prothrombin time Others

URINALYSIS (June 13, 08)

PHYSICAL CHEMICAL OTHER TESTS

Color Yellow Albumin Trace 24 HOURS ALBUMIN

Reaction Alkaline Sugar negative

Transparency turbid Chloride

35


PREGNANCY TEST:

monoclonal test (TEST PACK)

gravindex (LATEX SLIDETEST)

PREGNANCY TEST:



Quantity Calcium

Specific Gravity 1.005 Bile Test

Acetone

MICROSCOPIC

CAST:HyalineGranularPus CellRBCEpithelial

(coarse): 1-3/lpf

CELLS:pus cellsred blood cellsyeast cellsepithelial cellsrenal cells

10 -15/hpf35 – 40/hpf

occasional

CRYSTALS:amorphous uratrescalcium oxalateuric acidtriple phosphateothers

PO4: moderateOTHERS:mucus threadsbacteriacylindroids

fewfew

URINALYSIS (June 18, 08)

36

PHYSICAL CHEMICAL OTHER TESTS


PREGNANCY TEST:



Reaction Alkaline Sugar negative

Transparency turbid Chloride

Quantity Calcium

Specific Gravity 1.010 Bile Test

Acetone

MICROSCOPIC

CAST:HyalineGranularPus CellRBCEpithelial

(coarse): 1-3/lpf

CELLS:pus cellsred blood cellsyeast cellsepithelial cellsrenal cells

0 - 2/hpf45 - 50/hpf

occasional

CRYSTALS:amorphous uratrescalcium oxalateuric acidtriple phosphateothers

PO4: rareOTHERS:mucus threadsbacteriacylindroids

fewrare

37

DRUG STUDY

38

AMOXICILLIN (Anti-infective)

Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Interferes with the cell wall replication of susceptible organisms by binding to the bacterial cell wall; the cell wall, rendered osmotically unstabled, swells and bursts from osmotic pressure.

Infections of respiratory tract, skin, skin structures, genitourinary tract, otitis media, meningitis, septicemia, sinusitis and bacterial endocarditis prophylaxis.

Adult: PO 500mg Nausea, vomiting, diarrhea, urticaria, rash

Hypersensitivity to penicillins

CAUTION:Pregnancy B, hypersensitivity to cephalosporins, neonates, renal disease

Assess patient for previous sensitivity reaction to penicillin or other cephalosporin, cross sensitivity between penicillin and cephalosporins is common.

Assess patient for signs and symptoms.

Assess for allergic reactions during treatment.

Teach patient to report sore throat, bruising, bleeding, and joint pain; may indicate blood dyscrasias.

Advise patient to contact prescriber if vaginal itching, loose foul- smelling stools, diarrhea, sore throat, fever, fatigue, furry tongue occur; may indicate superinfection or agranulo cytopenia

39

AMOXICILLIN/ CLAVULANATE (CO-amoxiclav) (Broad spectrum anti-infective)


Interferes with cell wall replication of susceptible organisms; the cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure; combination increases spectrum of activity, B – lactamase resistance

Infections of respiratory tract, skin, skin structures, genitourinary tract; otitis media, meningitis, septicemia, sinusitis and endocarditis prophylaxis

625mg/tabRoute: Oral

1 tab PO tid

8:00am- 2:00pm – 8:00pm

Nausea, vomiting, diarrhea, urticaria, rash

Hypersensitivity to penicillins

CAUTION:Pregnancy B, hypersensitivity to cephalosporins, neonates, renal disease

Assess patient for previous sensitivity reaction to penicillin or other cephalosporin, cross sensitivity between penicillin and cephalosporins is common.

Assess patient for signs and symptoms.

Assess for allergic reactions during treatment.

Teach patient to report sore throat, bruising, bleeding, and joint pain; may indicate blood dyscrasias.

Advise patient to contact prescriber if vaginal itching, loose foul- smelling stools, diarrhea, sore throat, fever, fatigue, furry tongue occur; may indicate superinfection or agranulo cytopenia

40

Ascorbic Acid (Vitamin C) (Vitamin C water-soluble vitamins)


Needed for wound healing, collagen synthesis, antioxidant, carbohydrate metabolism, protein, lipid synthesis, prevention of infection

Vitamin C deficiency, scurvy, delayed wound and bone healing, chronic disease, urine acidification, before gastrectomy; increase need ; lactation, pregnancy, hyperthyroidism, emotional stress, trauma, burns, acidification of urine, dietary supplement

Adult: PO 500mg Headache, insomnia, dizziness, fatigue, flushing, nausea and vomiting, diarrhea, anorexia, polyuria, urine acidification, oxalate or urate renal stones, dysuria

Tartrazine, sulfate sensitivity, G6PD deficiency

Caution:Pregnancy C, gout, diabetes, renal calculi (large doses)

Assess for nutritional status for conclusion of foods high in vit. C.

Assess for vit.C deficiency before, during and after treatment.

Monitor input and output ratio.

Monitor ascorbic acid levels throughout treatment if continued deficiency is suspected.

Teach patient the necessary foods to be included in diet that are rich in vitamin C, citrus fruits, cantaloupe, tomatoes

Teach patient that smoking decreases vitamin C levels; not to exceed prescribed dose; increases will be excreted in urine, except time release.

41

Azithromycin (Zithromax) (anti-infective)


Binds to 50s ribosomal sub-units of susceptible bacteria and suppresses protein synthesis; much greater spectrum of activity than erythromycin

Mild to moderate infections of the upper respiratory tract, lower respiratory tract, uncomplicated skin and skin structure infections, nongonococcal urethritis or cervicitis; prophylaxis of disseminated mycobacterium avium complex (MAC)

Adult: 500mg Nausea and vomiting, diarrhea, dizziness, headache, palpitations and chest pain

Hypersensitivity to azithromycin, erythromycin or any macrolide

Caution:Pregnancy B, lactation, hepatic/renal/cardiac disease, elderly, child < 6 mon. for otitis media, child < 2 yrs for pharyngitis and tonsillitis

Assess for signs and symptoms of infection

Monitor respiratory status

Monitor allergies before treatment, reaction of each medications, place allergies on chart, notify all people giving drugs.

Monitor input and output, renal studies

Monitor bowel pattern before, during treatment

42

Cefuroxime (Cephalosporins 2nd Generation)


Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death by binding to cell wall membrane.

UTI, otitis media, skin infection, gonorrhea

Adult: 75g Dizziness, headache, diarrhea, nausea, vomiting, vaginitis, dyspnea

Hypersensitivity to cephalosporins or related antibiotics, seizures

Caution: pregnancy B, lactation, children, renal disease

Assess patient for previous sensitivity reactions to penicillins or other cephalosporins

Assess patient for signs and symptoms of infection including characteristics of wounds, sputum, urine, stool, wbc >10,000/mm3, earache, fever, obtain baseline information and drug treatment.

Assess for anaphylaxis. Teach patient to report

sore throat, bruising, bleeding, joint pain; may indicate blood dyscarasias.

Instruct patient to take all medication prescribed for the length of time ordered; to use yogurt or buttermilk to maintain intestinal flora, decrease diarrhea.

43

DEXAMETHASONE (Corticosteroid, synthetic)

Action Indication Dosage and Routes

Adverse Effects Contraindications Nursing Responsibility

Decreases inflammation by suppression of migration of polymorphonuclear Leukocytes, fibroblasts, reversal of increased capillary permeability and lysosomal stabilization.

Inflammation, allergies, neoplasms, cerebral edema, septic shock, collagen disorders.

4mg/tab PO tid

8:00am – 2:00 pm 8:00pm

Depression, flushing, sweating, hypertension, diarrhea, nausea, abdominal distention, increased appetite.

Psychosis, hypersensitivity, idiopathic thrombocytopenia, acute glomerulonephritis, amebiasis, fungal infections, non asthmatic bronchial disease, child <2yr., AIDS, TB

CAUTION:Pregnancy C, lactation, diabetes mellitus, glaucoma, osteoporosis, seizure disorders, ulcerative colitis, CHF, myasthenia gravis, renal disease, peptic ulcer, esophagitis.

Monitor potassium, blood, urine glucose while on long term therapy.

Monitor weight daily.

Monitor BP q24h, pulse, notify prescriber cortisol levels during long term therapy.

Advise that emergency ID as steroid user should be carried or worn.

Teach symptoms of adrenal insufficiency.

Instruct patient to notify prescriber of infectio n.

44

GABAPENTIN (Anticonvulsant)


Mechanism unknown; may increase seizure threshold; structurally similar to GABA; gabapentin binding sites in neocortex, hippocampus.

Adjunct treatment of partial seizures, with or without generalization in patients >12yr; adjunct in partial seizures in children 3-12yr, postherpic neuralgia.

300mg/tab

PO OD 9:00pm

Dizziness, fatigue, anxiety, vasodilation, peripheral edema, hypotension, dry mouth, bluured vision, constipation, increased appetite

Hypersensitivity to this drug

CAUTION:Pregnancy C, renal disease, lactation, chil <12yr, elderly, hemodialysis

Assess seizures; aura, location, duration, activity at onset.

Assess renal studies Assess mental status Teach patient avoid

driving, other activities that requires alertness.

Teach patient to gradually withdraw over 7days; abrupt withdrawal mat precipitate seizures.

45

Lactulose (Laxative)

Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

> Increases osmotic pressure; draws fluid into colon; prevents absorption of ammonia in colon; increases water in stool.

> Chronic constipation, portal- systemic encephalopathy in patients with hepatic disease.

Syrup

2 tbsp PO OD 9:00pm

Nausea, vomiting, anorexia, abdominal cramps, diarrhea

Hypersensitivity, low- galactose diet

CAUTION:

Pregnancy B, lactation, diabetes mellitus, elderly and debilitated patient.

- Monitor glucose level of the patient

- Monitor blood ammonia level; monitor for clearing of confusion, lethargy, restlessness, irritability; may decrease ammonia level by 50%.

- Discuss with patient that adequate fluid consumption is necessary.

46

Ranitidine HCL(H2 histamine receptor antagonist)


> Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.

> Short- term treatment of duodenal and gastric ulcers and maintenance; management of GERD, active duodenal ulcers with Helicobacter pylori in combination with clarithromycin

150mg/tab

Route: Oral

1 tab PO bid

8:00 am – 8:00pm

Constipation, abdominal pain, diarrhea, nausea, vomiting, headache, dizziness.

Hypersensitivity

CAUTION:

Pregnancy B, lactation, child<12yr, hepatic disease, renal disease

- Assess patient with ulcers or suspected ulcers: epigastric or abdominal pain, hematemesis, occult blood in stools, blood in gastric aspirate before and throughout treatment, monitor gastric pH

- Monitor input and output, BUN, Creatinine, CBC with differential monthly.

47

Senna, Sennosides (Laxative- stimulant)


> Stimulates peristalsis by action on Auerbach’s plexus; softens feces by increasing water and electrolytes in large intestine.

> Acute constipation; bowel preparation for surgery or exam.

1 tab

PO tid

8:00am – 2:00pm – 8:00pm

> Nausea, vomiting, anorexia, abdominal cramps, Pink- red or brown- black discoloration of urine.

>Hypersensitivity, GI bleeding, intestinal obstruction, CHF, lactation, abdominal pain, nausea/ vomiting, appendicitis, acute surgical abdomen.

CAUTION:

Pregnancy C

- Monitor blood, urine electrolytes if used often by patient; check I&O ratio to identify fluid loss.

- Assess cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, drug should be discontinued; identify whether fluids, bulk, or exercise is missing from lifestyle.

- Hold if ≥ 2 BM

48

Thiamine (Vitamin B1)


Needed for pyruvate metabolism, carbohydrate metabolism.

Vit. B1 deficiency or polyneuritis, cheilosis adjunct with thiamine beriberi, Wernicke- Korsakoff syndrome, pellagra, metabolic disorders.

1 tab PO tid

8 – 2 – 8

Nausea, diarrhea, weakness, restlessness

Hypersensitivity

CAUTION:

Pregnancy A

- Assess nutritional status: yeast, beef, liver, whole or enriched grains, legumes.

- Teach patient necessary foods to be included in diet: yeast, beef, liver, legumes, whole grains.

49

Trimethoprim/ Sulfamethoxazole (Antiinfective)


Sulfamethoxazole (SMZ) interferes with bacterial biosynthesis of proteins by competitive antagonism of PABA when adequate levels are maintained; trimethoprim (TMP) blocks synthesis of tetrahydrofolic acid; combination blocks two consecutive steps in bacterial synthesis of essential nucleic acids, proteins.

UTI, otitis media, acute and chronic prostatitis, shigellosis, Pneumocystis jiroveci, pneumonitis, chronic bronchitis, chancroid, traveler’s diarrhea.

Nausea, vomiting, abdominal pain

Hypersensitivity to trimethoprim or sulfonamides, pregnancy at term, megaloblastic anemia, infants <2mo., CCr <15 ml/min, lactation, porphyria

CAUTION:Pregnancy C, renal disease, elderly, glucose-6-phosphate dehydrogenase deficiency, impaired hepatic/ renal function, possible folate deficiency, severe allergy, bronchial asthma.

- Assess allergic reactions; rash, fever.

- Monitor kidney function studies.

- Teach patient to take each oral dose with full glass of water to prevent crystalluria.

-

50

NCP

51

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INTERVENTION

Rationale EVALUATION

/

Subjective: “ hirap akong igalaw ang aking mga kamay at paa” as verbalized by the patient

Objective: bedridden, bedsores, quadriplegic

Impaired physical mobility related to neuromuscular impairment as evidence by inability to purposefully move of the body parts, contractures.

In our 9 days of clinical duty, active support and assistance will be provided for both the health care providers and to the patient to optimize rendering of care, so as to improve clients’ physical mobility by performing simple task such as: raising of arms up to 5in. above the bed in supine position, stronger squeezing of hands.

Monitor the blood pressure before and after activity. Change position slowly.

Inspect skin daily. Observe for pressure areas, and provide meticulous skin care.

Stimulate holding and grasping reflex.

Turn patient with care every 2 hours. Assist with encourage pulmonary hygiene ( deep breathing, coughing, suctioning). Assist client and health care provider as necessary. Perform/assist with full ROM exercise and joints, using slow, smooth movements.

orthostatic hypotension may occur as result of side to side movement or elevation of head can aggravate hypotension and cause syncope.

altered circulation, loss of sensation, and paralysis potentiate pressure sores formation.

To promote circulation.

immobility and bedrest increase risk of pulmonary infection.

To further improve the patient’s condition.

Enhances circulation, restores/ maintains muscle tone and joint mobility and prevents disuse contractions and muscle atrophy.

After our 9 days of our clinical duty, the condition of the patient has improved: The patient was able to raise his both arms approximately 6”- 8” above his bed in supine position for 4 seconds, has stronger squeezing of hands.

52




Subjective:

Objective:

bed sores (sacral region and foot part)

Impaired tissue integrity related to prolong physical immobilization as evidence by bedsores.

After 9 days of clinical rotation the patient’s bed sores will be visibly reduce in size as sign of wound healing and increase tissue perfusion.

Turning of patient’s every two hours.

Protect pressure points by use of heel pads(on the foot part).

Assess the needs to change soak dressing

Administer medication as ordered; such as anti infective and anti-inflammatory.

to promote adequate circulation and to prevent further tissue necrosis.

reducing risk of ulceration.

to reduce inflammation

for faster wound cleaning and to prevent infection.

After 9 days of clinical rotation the patients bed sores has been visibly reduced.

53



RATIONALE EVALUATION

Subjective:

Objective:

Bed sore (sacral region)

(+)catheter

Wound infection related to exposure of affected open tissue

After our 8 hours shift the patient will manifest reduction of signs and symptoms of infection.

Proper care of wound: Clean the wounds once a day

Note risk factors for occurrence of infection.

Monitor vital signs esp. Temp.

Monitor clients visitors/caregivers for respiratory illness. Offer mask and tissue to clients visitors who are coughing sneezing Report to the staff the need to change wound dressings as indicated (soaked).

Proper disposal of contaminated materials.

Administer anti-infective as ordered.

To prevent spread of infection.

To limit exposures, thus reduce cross contamination

To prevent infection and possible cross contamination

To provide clean dressings so as to prevent infection

By the end of 8 hours shift, the patient is free from any signs and symptoms of infection.

54




Subjective: verbal report of pain “ aray”..

Objective: facial grimace,

Acute pain related to stimulation of nerve endings around bed sores as evidence by facial grimace

After 2 hours of administration of prescribed medication ordered and encouragement of divertional activities, the patient will verbalize control and understanding over the situation specifically wound debridement procedure.

Assess for presence of pain. Help client identify the quantity of pain using the pain scale.

Evaluate increased irritability, muscle tension, restlessness, and unexplained vital changes.

Administer medications as indicated (analgesics)

maintain proper spinal column alignment.

To know the proper care needed for the pain felt by the patient.

To obtain knowledge and clue for assessing pain experienced by the patient.

To lessen or eliminate pain through medications.

To prevent added injury that may possibly cause pain.

After administration of ordered medication and giving of health teachings, the patient had understand and verbalized control over pain and is observed managing pain.

55




Subjective:

The patient reported pain in extremities.

Objective:

Fear of injury

(+)irritability

(+)Facial grimace

Chronic pain related to chronic physical disability as evidence by paralysis and facial grimace

After 9 days of clinical rotation the patient will verbalize and demonstrate relief and for control of pain/ discomfort

Evaluate pain using the pain scale

Assess for condition associated with long term pain

Evaluate pain behaviors.

Promote divertional activities

Notify the physician for severity of pain

Administer pain relief medications as ordered

to identify client with potential for pain lasting beyond normal healing period.

may be exaggerated because clients perception of pain is not believed or because client believes caregivers are discounting reports of pain

to release endorphins, enhancing sense of well-being

may indicate a new physical problem

provides opportunity to re-energize and refocus on tasks at hand.

After 9 days of clinical rotation, he patient is still observed as suffering from chronic pain supported by verbal reports of pain and facial grimace, further medications of treatment regimen and reassessments of patients condition is to be considered.

56




Subjective.

“ Di pa rin ako makaihi ng normal”

Objective:

(-) micturation

Positive catheter

Impaired urinary elimination related to impaired urinary reflex (disruption in bladder innervations )as evidence by foley catheter.

At the end of our duty the client will maintain balance of input and output with clear, odor free urine, free of bladder distention, urinary leakage.

Clamp catheter every 2 to 3 hours and released.

Assess voiding pattern; example, frequency and amount. Compare urinary output with fluid intake.

Provide catheter care as appropriate

Promotes voluntary urinary control.

identifies characteristics of bladder function (example, effectiveness of bladder emptying, renal function, and fluid balance)

decreases risk of skin irritation/breakdown the developing of urinary infection.

At the end of our duty, the patient had maintained balance input and output with clear, yellow, odor- free urine and with the absence of bladder distention.

57




Subjective:

“Ilang araw na hindi ako nakadumi” as patient verbalized.

Objective:

(+)flatus

(-)bm

Bowel incontinence r/t disruption of innervation to bowel and rectum as evidence by loss of ability to elimination bowel voluntarily.

Within the shift, the patient will have a bowel elimination.

Recognize signs of/check for presence of impaction; example, no formed stool for several days, semiliquid stool, restlessness, increased feelings of fullness in/distention of abdomen, presence of nausea, vomiting, and possibly urinary retention.

Advised pt. to have a well-balance diet. Increase fiber diet intake and fluids intake.

. Administer

laxative as prescribed.

early intervention is necessary to effectively treat constipation/retained stool and reduce risk of complications.

improves consistency of stool for transit through the bowel.

To induce BM

The patient had a BM 10 hrs after the administrating the prescribed medicine.

58




Subjective:

Objective:

poor hygiene, rashes,

bed sores,

muscle wasting

Self-care deficit related to immobility as evidence by quadriplegia

After providing the appropriate instruction to the relative of the patient the relatives would identify and demonstrate proper hygiene to the patient as indicated for the patients condition

Provide health teaching with regards to giving bed bath.

Provide assistance to the relatives when performing bed bath.

Assess for needs to change linens and bed sheets.

Turning patient side to side every two hours.

Encourage client to verbalize need for hygiene.

to provide adequate knowledge to the relatives

to enhance the skills of the relatives

to provide comfort and a clean bed environment

to prevent developing pressure ulcer and rashes

Due to lack of time with the relatives, teachings about adequate and proper hygiene care was not given, but the relatives demonstrated hygiene care that could be notified to suit the clients condition pertaining to safety.

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case presentation about spinal shock syndrome

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