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case presentation about spinal shock syndrome.. case done by BSN 3H group 3 of St. Dominic College Of Arts and Sciences s.y 2008...hope you like it.. post a comment for clarifications or even recommendations..we'll appreciate it.. Goodluck..
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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
1
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)
2
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.
3
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.
4
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.
5
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.
6
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.
7
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
8
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
9
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.
10
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.
11
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.
12
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
13
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
14
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.
15
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
16
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
17
PATHOPHYSIOLOGY OF SPINAL SHOCK SYNDROME
18
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
19
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
20
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
21
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
22
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
23
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
24
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
25
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
26
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:
27
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
11
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
28
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
29
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
30
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
BLOOD CHEMISTRY (June 14, 08)
EXAMINATIONS REFERENCE RESULTS EXAMINATIONS REFERENCE RESULTS
Glucose (GodPap) 4.1 – 6.3 mmol/L 7.9 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 2.0 – 4.0 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
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
BLOOD CHEMISTRY (June 13, 08)
32
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 2.0 – 4.0 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:
SGOT (AST) 0 -38 IU/L Other
SGPT(ALT) 0 – 41 IU/L
33
Total Bilirubin mmol/L
Direct Bilirubin mmol/L
Indirect Bilirubin mmol/L
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
Color Yellow Albumin Trace 24 HOURS ALBUMIN
PREGNANCY TEST:
monoclonal test (TEST PACK)
gravindex (LATEX SLIDETEST)
PREGNANCY TEST:
monoclonal test (TEST PACK)
gravindex (LATEX SLIDETEST)
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
Color Yellow Albumin Trace 24 HOURS ALBUMIN
PREGNANCY TEST:
monoclonal test (TEST PACK)
gravindex (LATEX SLIDETEST)
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)
Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
> 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)
Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
> 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)
Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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)
Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
Rationale EVALUATION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
Rationale EVALUATION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
Rationale EVALUATION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
Rationale EVALUATION
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
ASSESSMENT NURSING DIAGNOSIS
PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
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.
59