Final_Spinal Stenosis L4, L5 Secondary to Spondylolisthesis L4, L5 Grade II With Hypertrophized Ligament Um and Radiculopathy With Myelopathy Right Sided

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided

I. INTRODUCTION

Spondylolisthesis is a condition in which one of the bones of the spine

(vertebrae) slips out of place onto the vertebra below it. If it slips too much, the bone

might press on a nerve, causing pain. Usually, the bones of the lower back are affected.

The word spondylolisthesis comes from the Greek words spondylos, which

means "spine" or "vertebra," and listhesis, which means "to slip or slide."

Spondylolisthesis is the most common cause of back pain in teens. Symptoms of

spondylolisthesis often begin during the teen-age growth spurt. Degenerative

spondylolisthesis occurs most often after age 40.

Types of spondylolisthesis

There are different types of spondylolisthesis. The more common types include.

Congenital spondylolisthesis — Congenital means "present at birth."

Congenital spondylolisthesis is the result of abnormal bone formation. In this

case, the abnormal arrangement of the vertebrae puts them at greater risk for

slipping.

Isthmic spondylolisthesis — this type occurs as the result of spondylolysis, a

condition that leads to small stress fractures (breaks) in the vertebrae. In some

cases, the fractures weaken the bone so much that it slips out of place.

Degenerative spondylolisthesis — this is the most common form of the

disorder. With aging, the discs — the cushions between the vertebral bones —

lose water, becoming less spongy and less able to resist movement by the

vertebrae.

Less common forms of spondylolisthesis include:

Traumatic spondylolisthesis, in which an injury leads to a spinal fracture or

slippage

Pathological spondylolisthesis, which results when the spine is weakened by

disease — such as osteoporosis — an infection, or tumor

Post-surgical spondylolisthesis, which refers to slippage that occurs or

becomes worse after spinal surgery

A radiologist determines the degree of slippage upon reviewing spinal X-rays.

Slippage is graded I through IV:

Grade I — 1 percent to 25 percent slip

Grade II — 26 percent to 50 percent slip

Grade III — 51 percent to 75 percent slip

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Grade IV — 76 percent to 100 percent slip

Generally, Grade I and Grade II slips do not require surgical treatment and are

treated medically. Grade III and Grade IV slips might require surgery if persistent,

painful, slips are present.

http://my.clevelandclinic.org/disorders/back_pain/hic_spondylolisthesis.aspx

This condition might lead to spinal stenosis causes narrowing of the spine. The

narrowing can occur at the center of the spine, in the canals branching off the spine

and/or between the vertebrae, the bones of the spine. The narrowing puts pressure on

your nerves and spinal cord and can cause pain. Spinal stenosis occurs mostly in

people older than 50. Younger people with a spine injury or a narrow spinal canal are

also at risk. Diseases such as arthritis and scoliosis can cause spinal stenosis, too.

(http://www.nlm.nih.gov/medlineplus/spinalstenosis.html)

Spinal stenosis occurs when the space around the spinal cord narrows. This puts

pressure on the spinal cord and the spinal nerve roots, and may cause pain, numbness,

or weakness in the legs.

As we age, the bone in our spines

may harden and become overgrown.

This can lead to a narrowing of the

spinal canal, called stenosis. When

stenosis occurs in the lower back, it is

called lumbar spinal stenosis. It often

results from the normal aging process.

As people age, the soft tissues and

bones in the spine may harden or

become overgrown. These degenerative changes may narrow the space around the

spinal cord and result in spinal stenosis.

Degenerative changes of the spine are seen in up to 95% of people by the age of

50. Spinal stenosis most often occurs in adults over 60 years old. Pressure on the

spinal cord is equally common in men and women, although women are more likely to

have symptoms that require treatment. A small number of people are born with back

problems that develop into lumbar spinal stenosis. This is known as congenital spinal

2

http://www.nlm.nih.gov/medlineplus/spinalstenosis.html



stenosis. It occurs most often in men. People usually first notice symptoms between the

ages of 30 and 50. (http://orthoinfo.aaos.org/topic.cfm?topic=a00329)

On the other hand, hypertrophy of the ligaments in the vertebral canal of the spinal

column can increase their mass enough that they narrow the canal (stenosis)

sometimes to the point that the spinal cord and/or nerve roots running through the canal

are compressed further worsening then the spinal stenosis which may cause the

condition called Radiculopathy. It is usually a result of nerve root compression, which

occurs when something puts pressure on the nerve root. Most of the time the pressure

comes from a herniated disc. Above conditions will then result to myelopathy which is

described as the gradual loss of nerve function caused by disorders of

the spine. Myelopathy can be directly caused by spinal injury resulting in either reduced

sensation or paralysis. Degenerative disease may also cause this condition, with varied

degrees of loss in sensation and movement.

(http://backandneck.about.com/od/conditions/f/radiculopathy.htm;

http://www.wisegeek.com/what-is-myelopathy.htm)

Spinal stenosis complications vary, depending on which nerves are compressed.

One of the most common is incontinence, you may lose the ability to control your

bowels or bladder or it can even reach Cauda equina syndrome is a rare but serious

complication, in which the bundle of nerve roots at the lower end of the spinal cord is

compressed. This can cause numbness and paralysis, and emergency surgery may be

necessary to relieve the pressure.

(http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=complications)

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http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=complications

http://www.wisegeek.com/what-is-myelopathy.htm

http://backandneck.about.com/od/conditions/f/radiculopathy.htm

http://www.wisegeek.com/what-is-the-spine.htm

http://adam.about.net/encyclopedia/infectiousdiseases/Herniated-nucleus-pulposus-slipped-disk.htm

http://orthoinfo.aaos.org/topic.cfm?topic=a00329


II. SCOPE AND LIMITATIONS OF THE STUDY

This case study tackles about Spinal Stenosis L4, L5 secondary to

Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy

with Myelopathy Right Sided and the operation performed to improve the condition

specifically on the case of the patient. It includes essential concepts in relation to the

said condition such as the patient’s profile and health history, nursing assessment and

clinical manifestations, drug study and diagnostic exams done. The anatomy and

physiology is also included as well as the pathophysiology of the above said diagnosis

with its associated factors. The Medical and Nursing Management along with the

discharge plans and other relevant data are also being covered.

The scope of the plan encompasses during the course of duty and date of

operation last August ____, 2011 with the assigned students who have assessed the

client with cumulative interaction postoperatively and established good rapport to the

patient and significant other. Nursing Management covers the above mentioned dates

which encompasses the client’s Recovery Phase. Data gathering about the Laboratory

results covers from August __ 2011 to August __ 2011 and other previous laboratory

results, the date and time of operation is also included and how it was performed.

The areas of concerns are limited to the discussions of Spinal Stenosis L4, L5

secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and

Radiculopathy with Myelopathy Right Sided and the quality of nursing care to the

patient. The quantity and quality of the information are limited to the data gathered from

the client, significant others and his medical records.

OBJECTIVES OF THE STUDY

The study aims to explore the concepts about the condition and the quality of

nursing care being rendered to our client.

Primarily, the primordial reason why we have chosen this as our case study

because it is our first time to encounter such health condition and we want to further

brush up our knowledge conditions associated with the indispensable anatomical

structure of our body. Secondly, in order to learn more about the health condition of the

patient, the study wants to fathom about the predisposing and precipitating factors,

anatomy and physiology and the pathophysiology of the condition experienced by the

client. Basically, the main goal of this study in relation to knowledge is to identify the

nursing interventions after the patient undergone an operation.

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The study aims to critically analyze the qualitative and quantitative data gathered

in order to establish connection between the different manifestations experienced by the

patient with that of the disease process. To be able to improve skills, the students also

endeavors to come up with nursing care plans that will alleviate patient’s condition. The

presentors also intend to compare and contrast the ideal management for Spinal

Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized

Ligamentum and Radiculopathy with Myelopathy Right Sided with that of the actual

management. In addition, the study seeks to disseminate essential information to

everybody for awareness.

Furthermore, by this study, the provider will be able to exercise that attitude of

determination and in order to come up with a successful study.

SIGNIFICANCE OF THE STUDY

The study is significant to the following people: the client, the client’s family, and

nursing students.

The study is significant to the client, because it enlightens the client’s queries and

doubts regarding his condition. Allowing him to understand the situation of his

present state, this would allow him to be more aware of the importance of following the

treatment regimen.

Client’s family must also be aware of the condition of the client. With the study,

the client’s family will be able to participate in the client’s continuous treatment, and they

will be able to realize the importance of the support system in participating in the client’s

care.

The study is also important to the nursing students, since it allows them to

explore the client’s condition, giving them firsthand experience in observing the

manifestations of the disease condition and allowing them to apply theoretical

knowledge regarding nursing managements for the manifested signs and symptoms.

5


III. CLIENT’S PROFILE

A. Socio-demographic Date

Patient AL is a 64-year old male, Roman Catholic, married to his 60-year

old wife and is currently residing at #270 Demetrio Velez St. Pinikitan, Cagayan

de Oro City, was admitted last August 17, 2011 due to tingling sensation felt at

gluteal area and numbness to the right leg since the year 2008 and lower

extremity weakness.

B. Vital Signs

Upon assessment, the patient’s vital signs were: BP: 120/80 mmHg,

Temperature: 36.9 degree Celsius, PR: 76 beats per minute, and RR: 20 cycles

per minute and 22 cycles per minute upon exertion. The patient weighs 73.6

kilograms and is 170 centimeters tall.

C. Health Pattern Assessment

Aside from the current condition, patient has also persistent problem in

voiding. Generally, he looks normal, neat, conscious and coherent but irritable,

mildly anxious and unable to ambulate and change positions without careful

assistance from the healthcare provider or significant other. Patient used to

smoke 10 sticks per day but had stopped since the year 1996 as well as alcohol

consumption of 1-2 cups thrice a week. He’s taking a cupful of coffee every

morning. No allergies were reported.

1. Past Medical History

Client AL has never been hospitalized until the date of admission

(August 17, 2011) but only seeks and visits the doctor for follow-up check

up. He was diagnosed at this institution-CUMC to have Spinal Stenosis

L4, L5 secondary to spondylolisthesis L4, L5 Grade II with hypertrophized

ligamentum and radiculopathy with myelopathy right sided. He has family

history of hypertension but doesn’t have any home medication to control

elevated blood pressure. He was also diagnosed to have Benign Prostatic

Hyperplasia (BPH) and was given (Xatral) alfuzosin 10 mg, 1 tab @ Hours

of sleep, 8pm and (Uriflow) Bethanicol, 1 tab TID at the specific time of 8

am, 1 pm, and 6 pm.

2. History of Present Illness

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Fifteen years ago patient had sudden onset of tingling sensation on

his right gluteal area; CT-Scan was made, result showed:

Hypertrophic degenerative osteoarthropathy, lumbar spine

Disc herniation, L4-L5

Mild spondylolisthesis, L4-L5

Compression deformity of L1 due to degenerative changes

Five years ago before the admission, patient noticed urine voiding

changes consulted a urologist, diagnosed to have BPH recalled meds

given, 4 years ago, there is persistence of voiding problem, 3 weeks ago

patient had MRI result herniated slip disc L4-L5, L1-2 x L5-S1.

3. Physical Assessment

Before operation, patient AL was hooked with an IVF infusion of

D5NM 1L @ 10 gtts/min and D5LR @ 20 gtts/min on NPO. After

operation, patient AL was hooked with an IV infusion pump of PLR 1L

regulated @ 30 gtts/min. and PNSS 1L regulated @ 30 gtts/min side drip

infusing well at the right arm. It was terminated before the duty on August

25, 2011.

HEENT:

Head, hair and scalp Normocephalic with fine dry hair and clean scalp.

Eyes: sclera, pupils Sclerae are anicteric, pupils are equal in size and

reaction to light. Periorbital region is not sunken

or edematous. Cornea and lens are not opaque

and conjunctiva is pink.

Ears and tympanic membrane Equal in size with no discharges and has equal

auditory function. Intact tympanic membrane.

Nose No nasal flaring noted. Septum is medial. Mucosa

is pink in color. Gross smell is normal and

symmetrical.

Mouth, lips, tongue, teeth and

oral mucosa

Lips and oral mucosa are pale. No lesions noted

in the mouth. Tongue is midline. With dentures.

Gums are pallor.

Throat and neck Trachea and uvula are midline. Thyroids are non

palpable. Tonsils are not inflamed.

Facial movements Symmetrical.

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4. Cognitive/ Neurological Assessment

5. Nutritional and Metabolic Pattern

At home, Client AL usually eats three times a day with red meat

which sometimes combined with vegetables and rice with good appetite.

He drinks water and other fluids at most 6 glasses a day. He takes Fern-C

and Centrum as his supplement.

Upon hospital stay, he was on soft diet, with fair appetite and still drinks fluid at

most 6 glasses a day.

ACTIVITIES OF DAILY LIVING

Feeding 2 – Assist with person

Bathing 3 – Assist with device and person

DRESSING 2 – Assist with person

Grooming 2 – Assist with person

Meal preparation 4 - Total dependence

Cleaning 4 - Total dependence

Laundry 4 - Total dependence

Toileting 3 – Assist with device and person

Bed mobility 3 - Assist with device and person

Chair/toilet transfer 3 - Assist with device and person

Ambulation 3 - Assist with device and person

R.O.M 2 – Assist with persons

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Level of consciousness Conscious, coherent and responsive

Orientation Oriented to time, place and person

Emotional state Irritable, and mildly anxious but can answer short

simple questions answerable by “yes” or “no”

Primary language Visayan

Educational attainment AB Graduate


6. Elimination Pattern

Patient AL’s defecation is usually not consistent; he used to

defecate once a day and sometimes defecates every other day. His stool

appears soft in consistency, greenish to brown in color and in minimal

amount with no discomforts upon defecating.

He urinates at about 5-6 times a day with amber to yellow colored

urine in minimal amount. He has an enlarged prostate and had difficulty

urinating.

7. Activity-Exercise Pattern

He used to jog and walk around twice a week. His leisure activities

include watching TV, sleeping, bonding with his family and reading news

paper.

CARDIOVASCULAR STATUS

Chest pain, radiation No chest pain or radiation

Point of maximal impulse,

Precordial area

5th intercostal space, midclavicular line

Flat

Heart sounds Distinct and regular, no murmurs noted

Peripheral pulses Regular and symmetrical

Capillary refill time 2 seconds, no clubbing noted

RESPIRATORY STATUS

Breathing pattern Regular

Lung expansion Symmetrical

Vocal/tactile fremitus Symmetrical

Percussion Resonant

Breath sounds Vesicular

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Abdominal configuration Symmetrical, no superficial veins, with no lesions

and scars

Bowel sounds Hypoactive upon auscultation, 4 bowel sounds

per minute

Percussion Tympanic and dullness noted on right upper

quadrant


Cough None

8. Sleep and Rest Pattern

Client AL usually sleeps about 6-8hours a day with naps during day

time, he sleeps early at night and wakes up early morning. He said this

number of hours is adequate enough for his activities the following day.

He does not have any history of sleep disturbances, by just merely closing

his eyes for a moment can make him easily fall asleep, he prays and

meditates before sleeping to promote a good and sound sleep.

9. Role and Relationship Pattern

Client AL is married to his 60- year old healthy wife and a father to

four healthy children- two females and two male ages 30, 29, 23, and 20

years old. He lives with his family. He has a sound and good relationship

to his family; he is very close to them.

10.Value and Belief Pattern

Client X is a Roman Catholic; He usually goes to church every

Sunday together with his family. He said that he needs God the most

especially that he’s hospitalized. He gets his strength in facing his

condition from his faith that gives him hope. He believes his hospitalization

will not interfere with his religious rites but he finds ways to communicate

with God through prayers as an alternative, he knows that he can go to

church when he will get well because he believes that God will answer his

prayer. He considers his family as his support group and thinks they can

help him the most.

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REVIEW OF SYSTEMS

(ANTERIOR)

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Pale oral mucosa, gums and lips

Irritable and mildly anxious

Prostate Enlargement

Lower extremity weakness

3/5

Difficulty in urination

Hypoactive, 4 bowel sounds per

minute

Uncoordinated gait


POSTERIOR

I N T R O D U C T I O N Page 63

Tingling sensation (right

gluteal area)

Pain scale: 8/10 – L4,L5

Right leg numbness


IV. ANATOMY AND PHYSIOLOGY

The spinal cord begins below the medulla and ends just above the small of the

back at the conus medularis. The area within the vertebral column beyond the end of

the spinal cord is called the cauda equina.

Meninges

Dorsal (sensory) and

ventral (motor) horn cells

The spinal cord is protected by the vertebrae and the meninges. The dura mater,

arachnoid mater and pia mater of the spinal cord are continuous with those of the brain.



Cerebrospinal fluid is in the subarachnoid space that lies between the arachnoid and pia

mater and in the central canal, a space in the middle of the gray matter of the cord. It

provides a hydraulic cushion for the spinal cord.

When the cord is viewed in a cross-section, its gray matter is "H" shaped or, as

described by Bhatnagar, 2002, butterfly shaped. It has two ventral and two dorsal horns.

The white matter surrounding the cell bodies of the cord is made up of ascending

and descending fibers. Motor tracts are found on the ventral and lateral aspects of the

cord while sensory tracts run along its dorsal area.

Neuronal types

Motor neurons

These lower motor neurons are located on the ventral aspect of the cord. They

are either alpha or gamma cells.

Alpha cells are the principle lower motor neurons of the spinal cord and form the

main portion of the final common pathway. They conduct rapid motor impulses, with

each alpha cell innervating approximately 200 muscle fibers.

Gamma neurons are also part of the final common pathway according to some

sources but they are only half as numerous as alpha cells. Gamma cells conduct slow

motor impulses. Their major function is to stretch muscle spindles.

Association neurons

Interneurons connect the anterior and posterior horns of the gray matter and are

involved in the reflex arc. They work within the same segment of the spinal cord, with a



segment being defined as the horizontal section of the cord that gives rise to one pair of

spinal nerves.

Internuncial Neurons travel between segments, sending projections up to the

brain stem and cerebellum. They project in an ascending, not descending manner.

These association neurons are found throughout the central nervous system.

They are much more numerous than motor neurons; the ratio between the two types of

cells is 30:1.

The main function of the association neurons in the spinal cord is that of

inhibitory control. They also interconnect other cells with one another.

Some sources, including Bhatnager and Andy, (1995), do not distinguish

between interneurons and internuncial neurons. Even if these two types of association

neurons are grouped together, they should definitely be distinguished from the spinal

nerves which are lower motor neurons, forming a final common pathway for information

descending from the brain.

The Spinal Nerves

There are thirty-one pairs of spinal nerves. These nerves are mixed, having both

a sensory and a motor aspect. Their motor fibers begin on the ventral part of the spinal

cord at the anterior horns of the gray matter. The roots of their sensory fibers are

located on the dorsal side of the spinal cord in the posterior root ganglia. When the

motor and sensory fibers exit the spinal column through the intervertebral foramina and

pass through the meninges, they join together to form the spinal nerves.

Spinal nerves receive only contralateral innervation from first order neurons:

Eight pairs of spinal nerves are located in the uppermost, cervical region of the

cord

Twelve pairs are found in the thoracic region.

Five pairs are in the lumbar area.

Five pairs are in the sacral area.

One pair is found in the most inferior, coccygeal region.



These second order lower motor neurons, the spinal nerves, form part of the final

common pathway for information traveling from the central nervous system to the

periphery. The spinal nerves provide innervation to body areas below the neck while

cranial nerves (also second order neurons) carry impulses only to the head and neck,

except for the vagus. (You will understand shortly that cranial nerves can be sensory,

motor or both).

Reflex arc

Also, the sensory and motor fibers of the spinal nerves form a reflex arc. This

type of reflexive behavior occurs when a message from afferent fibers causes a motor

reaction before going to the brain. For example, if you touch a hot burner on the stove,

sensory information about the temperature of the burner travels along spinal nerves to

your spinal cord and are carried directly to their motor nuclei by interneurons; the motor

command goes out along the axons of the lower motor neuron causing you to move

your hand away from the stove. As messages do not have to travel up to the brain to be

processed, reactions mediated by this reflex arc can occur very rapidly. Of course you

will feel pain shortly thereafter (milliseconds) as the information gets to the parietal lobe

via the thalamus

The Autonomic (self regulating) Nervous System

The autonomic nervous system is involved in the control of the heart, glands and

smooth muscles of the body and plays a major role in regulating unconscious,

vegetative functions. It works together with the endocrine system to control the

secretion of hormones and is itself controlled by the hypothalamus.

Because motor fibers make up the bulk of the autonomic system, some

anatomists consider it to be purely motoric although it does include some afferent axons

that carry information from the viscera.

Although the autonomic nervous system is considered to be one of the three

main divisions of the human nervous system in its own right, parts of both the central

nervous systems and the peripheral nervous systems play a role in its functions.

The autonomic nervous system has two components,

the sympathetic system and the parasympathetic system. These two aspects have

antagonistic functions.

Sympathetic System



The sympathetic system prepares the body for fight or flight reactions. Action of

this system results in accelerated heart rate, increased blood pressure and blood flow

away from the periphery and digestive system toward the brain, heart and skeletal

muscles. It also causes adrenaline to be released, temporarily increasing physical

strength.

Parasympathetic System

The parasympathetic system brings the body back to a state of equilibrium. It

slows heart rate and decreases the release of hormones into the blood stream. The

activity of the parasympathetic system causes more localized reactions than does the

sympathetic system as much of its output is to specific organs.

The autonomic nervous system consists of four chains of nuclei or ganglia, two of

which are located on either side of the spinal cord. The outer chains of nuclei form

the parasympatheticdivision of the system while those closest to the spinal cord make

up its sympathetic element.

Rami communicantes

The rami of the autonomic nervous system are the axons of pre-ganglionic and

ganglionic fibers. Most of the axons of pre-ganglionic fibers are myelinated. Their cell

bodies are found in the gray matter of the brain stem and spinal cord. Their axons

synapse with neurons within the two ganglionic chains.

Pre-ganglionic cells of the autonomic nervous system are neurons located in

some of the cranial nerves of the brain stem and in some of the spinal nerves that

project to the ganglionic chains of the autonomic nervous system. The autonomic

nervous system is closely connected with the central and peripheral nervous systems.

Ganglionic cells originate within the ganglia. They project to post-ganglionic

neurons.

Post-ganglionic cells are neurons that are located in the target organs and

muscles of the autonomic nervous system.

It can be said that the motor pathways of the autonomic nervous system are

made up of its pre-ganglionic and ganglionic cells.



The fibers of the ganglionic chain of the parasympathetic system are not as well-

defined as those of the sympathetic chain. All pre-ganglionic neurons of the sympathetic

system synapse with the sympathetic chain. This is not true of the parasympathetic pre-

ganglionic cells, however. Some of them synapse with the chain, but others go directly

to end organs or muscles.


LEGEND:

Predisposing Factors

Precipitating Factors

Disease Process

Treatment (either through medication or surgery)

Diagnostic Examination

Surgery effects

Signs and symptoms


V. PATHOPHYSIOLOGY

Predisposing Factors:

Age: 64 years old

Gender: Male

Predisposing Factors:

Age: 64 years old

Gender: Male

Precipitating Factors:

Frequent rotational forces

Precipitating Factors:

Frequent rotational forces

dessication between the cushion of vertebral bones

Decrease the spongy feature of the vertebral bones

Increase the number of cells as well as to its size

Decrease androgen secretion and other

male hormones

Formation of fibrous nonunionDegeneration of L4 and

L5 spinal discs

Less resistance to vertebral locomotion

Compression of male urethral meatus

Inability to urinate adequate amount

of urine

Inability to urinate adequate amount

of urine

Administration of alfuzocin (Xatral) 10 mg P.O@ HS

Administration of alfuzocin (Xatral) 10 mg P.O@ HS

Male catheterization done

Male catheterization done

Administration of bethanecol (Uriflow) 1 tab PO T.I.D

Administration of bethanecol (Uriflow) 1 tab PO T.I.D

Partial resistance of pars interarticularis



Progressive shearing of articular facets

Herniates other important spinal components

posteriorly migrated nucleus pulposus ligaments

hypertrophy

Microfractures of the involved vertebral bones

Slippage of lumbar vertebrae ( L4 and L5)

Annulus fibrosis degeneration occurs

Radial tears take place

Intersegmental instability

Facets incompetence will occur

(+) Stork Test(+) Stork Test

Elongation of pars

Inevitable spinal subluxation

Back pain of 8/10Back pain of 8/10

XRAY (08/17 and 24/11) show Mild

to moderate osteodegenerative changes) and

Disk Disease

XRAY (08/17 and 24/11) show Mild

to moderate osteodegenerative changes) and

Disk Disease

XRAY (08/ 24/11) shows Grade 1

Spondylolithesis

XRAY (08/ 24/11) shows Grade 1

Spondylolithesis



Gradual significant loss of nerve sensation

Compression of indispensable nerve roots

Progressive narrowing of the spineXRAY (08/24/11) shows

Mild compression deformity

XRAY (08/24/11) shows

Mild compression deformity

Uncoordinated gait

Uncoordinated gait

Walker provided

Walker provided

Administration of the following:

Hydrocortisone (Solu-cortef) 100mg every 12 hours

Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D

Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week

Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID

(


Hydrocortisone (Solu-cortef) 100mg every 12 hours

Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D

Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week

Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID

(

Tingling sensation on the right gluteal area

Tingling sensation on the right gluteal area

Right leg numbnessRight leg numbness TENS givenTENS givenLaminectomy + Foraminotomy

L4L5 Posterior Instrumentation

Pedicular Screw Fixation L4L5 +

Post-spinal Fusion

Laminectomy + Foraminotomy

L4L5 Posterior Instrumentation

Pedicular Screw Fixation L4L5 +

Post-spinal Fusion

NPO temporarily (preoperatively and

postoperatively

NPO temporarily (preoperatively and

postoperatively

Hypoactive bowel dounds of 4

clicks/minutes

Hypoactive bowel dounds of 4

clicks/minutes

Destruction of primary defenses

Destruction of primary defenses


1. ranitidine (Zantac) 150 mg 1 tab PO @ HS

2. esomeprazole (Nexium) 40 mg IVTT OD


1. ranitidine (Zantac) 150 mg 1 tab PO @ HS

2. esomeprazole (Nexium) 40 mg IVTT OD

Muscle weakness of both lower

extremities 3/5

Muscle weakness of both lower

extremities 3/5

Referred to Physical

Therapist for Rehabilitation.

Referred to Physical

Therapist for Rehabilitation.

Pain at the incision site

Pain at the incision site



VI. OPERATION PERFORMED

Esophagogastroduodenoscopy (EGD)

Esophagogastroduodenoscopy, or EGD for short, is a procedure used by your

doctor to gain more information about your esophagus, stomach, and small intestine.

Your doctor can look at the insides of these structures by placing an endoscope (a

small, bendable tube that acts like a video camera) into your throat. If any unusual

growths or foreign bodies are found by your doctor, the endoscope may also be used to

treat them.

Preoperative:

When you are ready, medication may be given through your IV to make you

sleepy and relaxed.

In order to make this examination more comfortable, your healthcare provider

may spray a numbing medication into the back of your throat, or you may gargle with it.

This may taste slightly bitter and will make your mouth and throat numb for

approximately 30 minutes. Then you will be positioned on your left side.

Intraoperative:

The use of a long, soft, bendable tube endoscope is utilized. This instrument acts

as a camera and allows your doctor to view the inside of your digestive system on a

video screen. It can also take pictures and videotape the procedure.

A small plastic mouthpiece or guard will be put into your mouth to protect your

teeth when the tube is slowly placed into your esophagus (or food pipe), and to keep

you from accidentally biting the tube.

In order to help relax the muscles in the back of your throat and help open the

passageway, you will need to take slow, deep breaths. You will then be instructed to put

your chin to your chest and open your mouth. As the doctor begins to push the tube in,

you will be asked to swallow. Swallowing makes the tube go down more easily. You

may experience some gagging or nausea during the tube placement into your

esophagus -- this is normal.

Once the endoscope is inside, your doctor will examine your esophagus,

stomach, and the first part of the small intestine. To better see this area, these

structures may be gently filled with a small quantity of air through the endoscope. While

this air may cause you to feel full, it should not be painful. Your saliva may be suctioned

from your mouth using a small plastic tube similar to the ones used by dentists.

Depending on what is found during the endoscopy, your doctor may perform

several procedures through the endoscope. A photograph, biopsy, or cytology may be

taken. A biopsy involves taking a small sample of tissue, and cytology is a brushing of


http://digestive-system.emedtv.com/digestive-system/digestive-system.html

http://digestive-system.emedtv.com/egd/egd.html

http://digestive-system.emedtv.com/egd/egd.html


cells. Other procedures that may be performed include stretching narrowed areas of the

esophagus, stomach, or duodenum; removing polyps and swallowed objects; or treating

bleeding vessels and ulcers.

When the examination is finished, the doctor will slowly pull the endoscope out

through your mouth. You'll be asked to clear your throat and spit out any saliva or

phlegm. This procedure usually takes about 20 to 30 minutes.

Postoperative:

After the upper endoscopy (also known as an EDG), you will either be closely

monitored in the recovery room or return to your hospital room. If this was done as an

outpatient procedure, you will remain in the clinic area for about one hour. If a

procedure was done that requires more observation, you may stay in the hospital

overnight.

During this time, you may feel slightly bloated from the air that was placed in your

stomach during the examination. Your throat may also feel numb and slightly sore. You

should expect this to last two to four hours.

You will stay in the recovery room long enough for the drugs that make you

sleepy to wear off and to be sure that you are recovering normally. Remember that your

healthcare provider wants you to recover without any problems, so be sure to report

anything that does not feel normal or "right."

Laminectomy + Foraminotomy L4L5 Posterior Instrumentation Pedicular

Screw Fixation L4L5 + Post-spinal Fusion

For an open laminectomy and foraminotomy procedure, the patient is placed under

general anesthesia. The surgeon makes an incision in the back over the area of the

spine more the spinal compression is located.

The surgeon uses small instruments to scrape away or remove portions of the

lamina in the disc or discs causing the problem. He then shaves or cuts away small

portions of the foramen, or the space where nerve roots branch off from the spinal cord

in the cervical, thoracic or lumbar area to make more room for these nerves. The

surgeon may need to use a surgical microscope to see this area more clearly.

At this time, the surgeon will also determine the overall health and condition of the

vertebra and vertebral discs adjacent to the problem area. In some cases, other

procedures made at this time, such as removal of a herniated or bulging disc, called a

discectomy, or spinal fusion if vertebra has slipped out of position.

For a laparoscopic laminectomy or foraminotomy, a small incision is made over the

affected spine area. A very small camera attached to the end of a long tube is inserted

into the incision, which allows the surgeon to view the operating field on a video monitor

in the surgical suite. Very small surgical instruments are inserted into one or more small


http://digestive-system.emedtv.com/upper-endoscopy/upper-endoscopy.html


incisions around the affected disc area and the operation proceeds in much the same

way and open laminectomy procedure is performed.

However, if the surgeon feels you may have a herniated or bulging disc or any spine

instability, the patient may not be considered a good candidate for this approach.

Following the procedure, the surgeon will use stitches or staples to close the incision

area.

In most cases, you will stay in the hospital for 1 to 3 days, depending on your overall

health and wellness, your physical condition and your response to the surgery. A

physical therapist may be offered to help you ambulate and perform daily functions,

depending on the area where the laminectomy occurred.

The Spinal Fusion Operation

Spinal fusion is performed under general anesthesia. During the procedure, the

target vertebrae are exposed. Protective tissue layers next to the bone are removed,

and small chips of bone are placed next to the vertebrae. These bone chips can either

be from the patient's hip or from a bone bank. The chips increase the rate of fusion.

Using bone from the patient's hip (an autograft) is more successful than banked bone

(an allograft), but it increases the stresses of surgery and loss of blood.

Fusion of the lumbar and thoracic vertebrae is done by approaching from the rear,

with the patient lying face down. Cervical fusion is typically performed from the front,

with the patient lying on his or her back.

Many spinal fusion patients also receive spinal instrumentation . During the fusion

operation, a set of rods, wires, or screws will be attached to the spine. This

instrumentation allows the spine to be held in place while the bones fuse. The

alternative is an external brace applied after the operation.

An experimental treatment, called human recombinant bone morphogenetic protein-

2, has shown promise for its ability to accelerate fusion rates without bone chips and

instrumentation. This technique is only available through clinical trials at a few medical

centers.

Spinal fusion surgery takes approximately four hours. The patient is intubated (tube

placed in the trachea), and has an IV line and Foley (urinary) catheter in place. At the

end of the operation, a drain is placed in the incision site to help withdraw fluids over the

next several days. The fusion process is gradual and may not be completed for months

after the operation.


http://www.surgeryencyclopedia.com/Pa-St/Spinal-Instrumentation.html


VII. LABORATORY RESULTS

Hematology Report (August 18, 2011)

TEST RESULTS REFERENCE VALUES INTERPRETATION

WBC 7,700 5,000-10,000 cell/mm3 Within Normal Range

RBC 4.78 4.7-6.1 10^6/uL Within Normal Range

Hgb 14.6 13.7-16.7 g/dL Within Normal Range

Hct 44.0 37.0- 47.0 gm% Within Normal Range

MCV 95.2 80.0-96.0 fL Within Normal Range

MCH 31.0 27.0-31.0 pg Within Normal Range

MCHC 33.5 32.0-36.0% Within Normal Range

Differential Count

Lymphocytes 30.0 18-45% Within Normal Range

Monocytes 2.0 4-8% Below Normal Range

Platelet count 200,000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting factor is good.



Hematology Report

(August 22, 2011)

TEST RESULTS REFERENCE VALUES INTERPRETATION

WBC 15,300 5,000-10,000 cell/mm3 An increase in the WBC level indicates that there is an infection.

RBC 4.78 4.7-6.1 10^6/uL Within Normal Range

Hgb 12.7 13.7-16.7 g/Dl Low hemoglobin levels indicate the oxygen carrying capacity of the blood is decreased. Low hemoglobin

levels may also indicate anemia.

Hct 38.0 37.0- 47.0 gm% Within Normal Range

MCH 23.3 27.0-31.0 pg A low MCH number might indicate the presence of anemia. The Mean Corpuscular Hemoglobin indicates

the weight of hemoglobin in each cell.MCHC 24.3 32.0-36.0% Below Normal Range

Differential Count

Segmenters 93.0 45-70% Above Normal Range

Lymphocytes 5.0 18-45% Below Normal Range

Monocytes 2.0 4-8% Below Normal Range

Platelet count 333,000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting factor is good.



X-ray Report

(August 17, 2011)

Examination: Chest AP

No active parenchymal infiltrates.

The heart is not enlarged.

The aortic knob is calcified.

Both costophernic sulci and hemidiaphragm are intact.

Degenerative changes are seen in the visualized osseous structures.

Impression:

Atherosclerotic Aorta

Osteodegenerative changes.

(August 24, 2011)

Examination: Lumbo Sacral Spine APL

No old film available for comparison.

Spurformations are seen in the antero-lateral aspects of the lumbar spine. (Mild to moderate osteodegenerative changes)

Mild anterior wedging of L1 is noted. (Mild compression deformity)

L1-L2 and L5-S1 intervertebral disc spaces are narrowed with intra-disctal gas formation. (Disk Disease)

L4 is slightly displaced anteriorly in relation to L5 with metallic brackets and screws at these levels as well as vertebral foraminal narrowing. (Grade 1 Spondylolithesis)

No lytic or blastic lesion seen.

Mild lumbar straightening noted probably secondary to muscle spasm and or fixators.

Alignment is sustained.

Midline surgical staples seen in site.

Drainage tube in site.


CT SCAN OF THE LUMBAR

(September 24, 1996)

Findings:

Multiple axial tomographic sections of the lumbar spine without contrast were obtained.

Plain axial images revealed the ff:

Osteophytic spurs seen along the margins of lumbar spine.

Disc hernation noted at the level of L4-L5, centrally located and with some extension

into the intervertebral foramina.

Ligamentum flavum are hypertrophied, (L2-4)

Compression changes of L1 seen as well mild spondylolisthesis of L4 over L5 by

scanogram.

Rest of findings are unremarkable.

Impression:

Hypertrophic degenerative osteoarthropathy, lumbar spine disc hernation, L4 over 5

Mild spondylolisthesis, L4 over 5

Compression deformity of L1 due to degenerative changes.

ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER

(August 18,2011)

Dimension Measurement Normal

LV (ed) 4.3 (4.5- 5.0)

LV (es) 2.6

IVS (ed) 1.1 (0.8 – 1.1)

IVS (es) 1.6

LVPW (ed) 1.5 (0.8 – 1.1)

LVPW (es) 1.7

Aorta 2.2

LA (AP diameter) 3.6 (3.0 – 3.5)

MPA 1.9

LVET 0.2

EPSS 0.6

LVOT 1.9

RV 2.7 (2.2 – 4.0)

RA 2.7 (3.5 – 4.5)

MV Annalus 2.2

TV Annalus 1.7

LVEDV 77.35

LVES 24.24

SV 53.11

CO 3.6

EF 69 % (55.0 – 77.0)

FS 38% (29.0 - 42.0)

VCF (0.5 - 1.5)

LV Mass

Diastolic Function

Parameter Patient Normal

Decel. Time 265

IVRT 71

SPECTRAL and Color Flow Doppler

Valve Maximum Velocity

Peak Gradient

Orifice Area

Regurgitation

Ratio Jet Area cm

GRADIENT

Aorta 0.91 1.08

3.29 4.66

T 42.42

Mitral 0.42 0.56

0.72 2.58

Tricuspid 0.67 0.80

1.81 2.58

Pulmonic 0.82 2.96

RA Pressure

PAt: 134.6

PRJ:

Notes:

Study done in normal sinus rhythm Normal left ventricular cavity with hypertrophied walls with adequate wall motion

contractility and systolic function Normal left atrium, right atrium, right ventricle, main pulmonary artery and aortic

root dimension. Thickened none coronary cusp and left coronary cusp of the aortic valve but

without restriction of motion Thickened mitral valve leaflet but without restriction of motion Structurally normal tricuspid valve and pulmonic valve No pericardial effusion nor intracardiac thrombus noted

Doppler:

Mosaic color flow display noted across the aortic valve during diastole Reverse mitral valve E/A velocity ratio at prolonged deceleration time Normal pulmonary atrial pressure

Conclusion:

Concentric left ventricular hypertrophy with adequate contractility and systolic function but with Doppler evidence of impaired left ventricular relaxation

Aortic sclerosis with aortic regurgitation +/- Mitral sclerosis Normal pulmonary arterial pressure

Urinalysis

(August 17, 2011)

Test Result Normal Value

Color Light yellow Yellow

Reaction Clear Clear

Transparency 7.0

Specific Gravity 1.005

Sugar Negative Negative

Protein

Pus Cells 0-2 cells/HPF

RBC 0-2 cells/HPF

Epithelial Cells

Bacteria Few

Amorphous phosphate Moderate

Clotting Time and Bleeding Time

(August 18, 2011)

Result Normal Value Interpretation

Clotting Time 4 minutes 00 seconds

2-6 minutes Within Normal Range

Bleeding Time 1 minute 00 seconds

1-3 minutes Within Normal Range

Hematology

(August 19, 2011)

Cardiac NT-proBNP

Result: 156 pg/mL

Normal Value: less than 125 pg/mL

Interpretation: Levels above 125 pg/ml may indicate the presence or development of cardiac dysfunction and are associated with an increased risk of cardiac events.

Fecalysis

(August 18, 2011)

Consistency: Soft

Color: Greenish Brown

RBC: --

Pus Cells: --

NO PARASITES SEEN

VIII. DRUG STUDY

DRUG ORDER(Generic name,

brand name, classification, dosage, route,

frequency)

MECHANISM OF ACTION

INDICATON CONTRAINDICATION ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/

PRECAUTION

Generic Name:ranitidine

Brand Name:Zantac

Classification:Histamine 2 antagonist

Dosage:150 mg 1 tab

Route:PO

Frequency:HS

Timing: 8pm

Competitively inhibit the actions of histamine at the H2 receptors of the parietal cell of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food

Short term treatment of active duodenal ulcer

Short term treatment of GERD

With allergy to ranitidine

Use cautiously with impaired renal or hepatic function

CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo

CV: tachycardia, bradycardia,

DERMATOLOGIC: rash, alopecia,

GI: constipation, diarrhea, nausea, vomiting, abdominal pain

1. Administer oral drug with meals and HS.2. Decrease doses in renal and liver failure.3. Provide concurrent antacid therapy to relieve pain.4. Arrange for regular follow-up, including blood test, to evaluate effects.



frequency)

MECHANISM OF ACTION

INDICATON CONTRAINDICATION ADVERSE EFFECT OF THE DRUG


PRECAUTION

Generic Name:cefuroxime

Brand Name:Zinacef

Classification:Antimicrobila agent

Dosage:1.5 g ----- 500 mg 1 tab

Route:IVTT ---- PO

Frequency:PRN ----- TID

Timing:

8pm-1pm-6pm

A second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usuallu bacterial

Skin and skin structure infections, bone and joint infection

Contraindicated in patient with hypersensitivity to cefuroxime or other cephalosporin

Use cautiously in patient with history to sensitivity to penicillin

CNS: headache, malaise, paresthesia, dizziness

GI:pseudomemebranous colitis, nausea, anorexia, vomiting, diarrhea, glossitis, dyspepsia

GU: genital pruritus

HEMATOLOGIC: hemolytic anemia, decrease in hemoglobin

1. With large doses or prolonged therapy monitor for superinfection, especially in high risk patient 2. Give oral drug with food to decrease GI upset and enhanced absorption3. Have vit. K available in case of hypoprothrombinemia occurs

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG


PRECAUTION

Generic Name:bethanecol

Brand Name:Uriflow

Classification:Cholinergic (parasympathomimetic)

Dosage:1 tab

Route:PO

Frequency:T.I.D

Timing:

8pm-1pm-6pm

Binds to cholinergic (muscarinic) receptors, mimic the action of acetylcholine

Acute postoperative nonobstructive (functional) urine retention

Contraindicated with unusual sensitivity to bethanicol, hyperthyroidism, peptic ulcer, latent or active asthma, bradycardia, vasomotor instability, CAD.

CV: Transient heart block, cardiac arrest, arthostatic hypotension

GI: abdominal discomfort, salivation, nausea, vomiting, abdominal cramps, diarrhea

GU: Urinary urgency

RESPIRATORY: Dyspnea

Other: Malaise, headache, sweating, flushing

1. Give on empty stomach, otherwise may cause nausea and vomiting2. Monitor vital signs frequently, especially respirations

3. Never give IM or IV it could cause circulatory collapse, hypotension, severe abdominal cramping, bloody diarrhea, shock or cardiac arrest



frequency)

MECHANISM OF ACTION



PRECAUTION

Generic Name:metoprolol

Brand Name:Neobloc

Classification:Antihypertensive

Dosage:50 mg tab

Route:PO

Frequency:T.I.D

Timing:

8pm-1pm-6pm

A beta1-selective blocking agent that decreases myocardial contractility, heart rate and cardiac output; lower blood pressure and reduce myocardial oxygen consumption. Also depresses renin secretion

Hypertension Contraindicated in patient with hypersensitivity to the drugs or other beta blockers and in patient with bradycardia, and cardiogenic shock

Metoprolol masks common signs of shock and hypoglycemia

CNS: fatigue, lethargy, dizziness,

CV:bradycardia. Hypotension, CHF, peripheral vascular disease

GI: nausea, vomiting, diarrhea

RESPIRATORY: dyspnea, bronchospasm

SKIN: rash

Other: fever and arthralgia

1. Always check the patient apical pulse rate before giving drugs. If it is slower than 60 bpm withhold drug and call the doctor immediately.2. Monitor BP frequently and watch out for hypotension.3. Food may increase absorption of metoprolol. Give consistently with meals



frequency)

MECHANISM OF ACTION



PRECAUTION

Generic Name:ipratropium & salbutamol

Brand Name:Combivent

Classification:Bronchodilators

Dosage:1 neb

Route:Inhalation

Frequency:Every 8 hours

Timing:10am-6pm-2am

Salbutamol:

Relaxes bronchial and uterine smooth muscle by actine on beta2-adrenergic receptors

Ipratropium:

Inhibits vagally mediated reflexes by antagonizing acetylcholine, an anticholinergic

Bronchospasm and viscous sputum

Contraincated in patient with hypesensitivity to drugs or any component of the formulation

Use cautiously in patient with cardiovascular disorders, including any insufficiencies and hypertension; in patient with hyperthyroidism or DM

CNS: tremor, nervousness, insomnia, headache

CV: tachycardia, palpitation, hypertension

EENT: drying and irritation of nose and throat( with inhaled form)

GI: heartburn, nausea, vomiting

RESPIRATORY: bronchospasm

1. Monitor closely the patient for toxicity2. Teach the patient to perform oral inhalation correctly3. Aeresol form may be prescribed for use 15 minutes before exercise. induced bronchospasm4. Do chest tapping after every treatment in not contraindicated.



frequency)

MECHANISM OF ACTION



PRECAUTION

Generic Name:esomeprazole

Brand Name:Nexium

Classification:Proton pump inhibitor

Dosage:40 mg

Route:IVTT

Frequency:OD

Timing:6am

Gastric acid-pump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the first step of acid production

Reduction in occurrence of gastric ulcer

Treatment of duodenal ulcer

Patient with hypersensitivity to drugs

Use cautiously with hepatic dysfunction

CNS: headache, dizziness, vertigo, insomnia, anxiety

DERMATOLOGIC: rash, inflammation, pruritus, alopecia, dry skin

GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth,

1. Ensure that the patient swallow whole capsule; do not crush or chew.2. Provide additional comfort measures to alleviate discomfort from GI effects and headache.3. Establish safety precaution if dizziness or other CNS effects occur



frequency)

MECHANISM OF ACTION



PRECAUTION

Generic Name:hydrocortisone

Brand Name:Solu-cortef

Classification:corticosteroids

Dosage:100 mg

Route:IVTT

Frequency:Every 12h

Timing: 8am-8pm

Decrease inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses the immune response; stimulate bone marrow, and influences protein, fat and carbohydrate metabolism

Severe inflammation Contraindicated in patient allergy to any component of the formulation, and in those with systemic fungal infections. Certain injectable forms contain sulfites which can cause allergy

Use cautiously in patient with GI ulceration or renal disease, and hypertension

CNS: euphoria, insomnia, psychotic behavior, pseudomotorcerebri

CV: CHF, hypertension, edema

EENT: cataract, glaucoma

GI: peptic ulceration, GI irritation increased appetite, pancreatitis

1. Elderly patients may be more susceptible to oesteoporosis. Advise patients receiving long term therapy to consider exercise or physical therapy.2. Gradually reduce drug dosage after long term therapy.

3. Do not give IM injections if patient has thrombocytopenic purpura



frequency)

MECHANISM OF ACTION



PRECAUTION

Generic Name:metronidazole

Brand Name:Dazomet

Classification:Antimicrobial

Dosage:5oo mg

Route:PO

Frequency:B.I.D for 1 week

Timing:8am-6pm

A direct acting trichomonocide and amebicide that works at both intestinal and extra intestinal site

Bacterial infections caused by anaerobic microorganisms,

Prevention of post operative infection in contaminated or potentially contaminated surgery

This drug has shown to be carcinogenic in mice and possibly in rats. Unnecessary use should be avoided.

Use cautiously in patient with a history of CNS disorder and in patient with retinal or visual field changes.

CNS: vertigo, headache, ataxia, incoordination, confusion, irritability, depression, restless

GI: unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps

GU: dysuria, incontinence, darkening of the urine

1. Tell the patient to avoid alcohol or alcohol-containing medications during therapy or at least 48hrs after therapy is completed.2. Tell the patient that the metallic taste and dark or red-brown urine may occur.

3. Give with meals to minimize GI distress



MECHANISM OF ACTION



PRECAUTION

frequency)

Generic Name:amoxicillin

Brand Name:Amoxil

Classification:Antibiotic

Dosage:500 mg 1 tab

Route:PO

Frequency:B.I.D

Timing:8am-6pm

Bactericidal: inhibits synthesis of cell wall of sensitive organism, causing cell death

Helicobacter pyloric infection

Contraindicated with allergy to penicillin, cephalosporin, other allergen

Use cautiously with renal disorders

CNS: lethargy, hallucination, seizures

GI: stomatitis, sore mouth

GU: nephritis

HEMATOLOGIC: anemia, thrombocytopenia

HYPERSENSITI-VITY

Rash, fever, wheezing, anaphylaxis

1. Culture infected area prior to treatment2. Give in oral preparation only; amoxicillin is not affected by blood3. Use corticosteroids or antihistamines for skin reaction.

4. Take this drug around the clock

DRUG ORDER

(Generic name, brand name,

classification, dosage, route,

MECHANISM OF ACTION



PRECAUTION

frequency)

Generic Name:alfuzocin

Brand Name:Xatral

Classification:Alpha adrenergic blocker

Dosage:10 mg

Route:P.O

Frequency:HS

Timing:8pm

Blocks alpha receptors in the muscle of the prostate gland, which causes the muscle in the prostate to relax. This allow urine to flow freely past the prostate and relieve th urinary symptoms

Relieving the urinary symptoms of enlarged prostate gland

Contraindicated in elderly patient, history of decreased liver function, allergy to alpha blocker, CAD and angina pectoris

CNS: dizziness, headache

CV: orthostatic hypotension, syncope, tachycardia, chest pain

GI: abdominal pain, dyspepsia, constipation

GU: impotence, bronchitis, URI

1. Taken after meal, the tablet should swallowed whole, not chew or crushed.2. Do not stop taking the tablet gradually by reducing the dose over a number of days3. Tell the patient not to take alcohol, because effects of alcohol could made worse while taking xatral

IX. NURSING CARE PLAN: (Pre-operative)

ASSESSMENT NURSING DIAGNOSIS GOALS AND OBJECTIVES

NURSING INTERVENTION /RATIONALE

EVALUATION

SUBJECTIVE:

“Sakit kaayo akong likod, dili nako alihok sa kasakit ” as verbalized by the patient.

OBJECTIVE: Pain Scale :8/10 Restless Guarding on the left

side of the body

ACUTE (BACK) PAIN RELATED TO SLIPPAGE OF L4 AND L5 VERTEBRAE SECONDARY TO SPONDYLOLISTHESIS

Short-Term

Within 10 - 15 minutes of nursing care and interventions, the patent will:

1. Report controlled pain as evidenced by a decreased pain scale from 8/10 to 0/10.

2. Demonstrate use of relaxation skills.

Long-Term

After 8 hours of thorough nursing intervention, the client will be able to report relief of pain.

INDEPENDENT:1. Monitor V/S which is usually altered when patient is in acute pain.R - Changes in vital signs may indicate acute pain and discomfort.

2. Provide comfort measures to the patient such as providing appropriate ventilation.R - To promote relaxation.

3. Assist patient to find position of comfort.R - Position affects the patient’s ability to relax and rest/sleep effectively.

4. Teach patient deep-breathing exercise to help refocus attention and enhance coping abilities.R - This reduces muscle tension which reduces the intensity of the pain.

5. Provide quiet environment and calm activities.

Short- Term Goals:Goals met. After 15 minutes of Nursing interventions, the patient reported pain was relieved as evidenced by a pain scale of 0/10 and demonstrated relaxation techniques such as deep breathing exercise and reduction in stimulating activities.

Long-Term Goals:Goal partially met. After the 8-hour shift, the patient reported relieved pain with a pain scale of 0/10.

R - Decreases external stimuli, which may aggravate anxiety and cardiac strain, limits coping abilities and adjustment to current situation.

6. Limit activities of the patient and refrain from stimulating procedures R- Movement and activities trigger stimulation of pain nerve endings that may aggregate pain sensation.

DEPENDENT:1. Administer hydrocortisone 100 mg every 12 hoursR – Decreases inflammation and results to relief of pain.

ASSESSMENT DATA(Subjective & Objective)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS AND OBJECTIVE NURSING INTERVENTIONS AND

RATIONALE

EVALUATION

SUBJECTIVE:

“dli kayo nako malihok akong right side sah ako lawas,” as verbalized by the patient.

OBJECTIVE:

Muscle strength of 3/5 (lower extremities)

Uncoordinated gait Back pain of 8/10

ACTIVITY INTOLERANCE RELATED TO SLIPPAGE OF L4 AND L5 VERTEBRAE SECONDARY TO SPONDYLOLITHESIS

Short-Term Goals:

At the end of 8 hrs. of nursing interventions, the patient will be able to:

1. Perform and improve ADL such as performing self-care gradually.

2. Participate and demonstrate exercises such as range-of-motion

Long- Term Goals:

At the end of 2 days of nursing interventions, the patient will be able to:

1. Improve muscle strength from 3/5 to 5/5.

2. Continue to demonstrate modified activities to promote activity tolerance.

INDEPENDENT:1. Assist and demonstrate passive and active range-of-motion.R - To strengthen muscle.

2. Instruct patient to do self-care such as combing his hair using the unaffected arm to assist the affected arm.R - To prevent misuse syndrome.

4. Provide rest between activities.R - To prevent fatigability.

5. Turn patient to side at intervals.R - To prevent skin breakdown.

COLLABORATIVE:1. Referred to to PT for regular physical therapy.R - To rehabilitate

Short-Term Goals:

Goals Met. At the end of 8 hrs. of nursing interventions, the patient was able to perform and improve ADL such as performing self-care gradually, Participated and demonstrate exercises such as range-of-motion and reported.

Long- Term Goals:Goals Partially met. At the end of 2 days of nursing interventions, the patient was able to continue to demonstrate modified activities to promote activity tolerance but still has the muscle strength of 3/5.

muscles.


NURSING INTERVENTIONS/ RATIONALE

EVALUATION

SUBJECTIVE CUES: IMPAIRED BED MOBILITY RELATED TO

After 8 hours of nursing care, patient will be able

INDEPENDENT1. Determine diagnoses that

Goals met. After 8 hours of nursing care, patient was

“Maglisod kog lihok kay sakit akong likod.” as verbalized by the patient

OBJECTIVE CUES:

Inability to reposition self in bed at any desired position

Functional level: Level 2 (requires help from another person)

INSUFFICIENT MUSCLE STRENGTH SECONDARY TO PAIN.

to:1. Maintain position of function and skin integrity as evidenced by absence of decubitus ulcer and footdrop.2. Verbalize to participate in repositioning program.

contribute to immobility.R - To identify causative factors

2. Determine functional level classification.R - To assess functional ability

3. Reposition patient n good body alignment using appropriate supports like utilizing bed linens and asking assistance from the SO. R - To promote optimal level of function and prevent injuries.

4. Observe skin for reddened areas and for presence of shearing. Provide pressure relief by the use of pillows or rolled linens on high risk areas e.g. sacral/bony areas.R - To reduce friction, maintain safe skin pressure, and to prevent moisture.

5. Assist with activities of hygiene, and toileting. R – To avoid injury

able to maintain position of function and skin integrity as evidenced by absence of decubitus ulcer and foot drop and verbalized partici0pation in repositioning program as well as physical movement program.

6. Provide extremity protection like padding on the foot and on elbows. R - To prevent growth and spread of microorganism.

7. Assist patient in passive ROM to enhance gains in strength and muscle control. R - To prevent disused syndrome and promote blood circulation

DEPENDENT:1. Administer hydrocortisone 100 mg every 12 hoursR – Decreases inflammation and results to relief of pain.



EVALUATION

SUBJECTIVE:“Nahadlok jud ko labi na

ANXIETY, MILD RELATED TO FEAR OF THE

After 30 minutes of nursing interventions, the

INDEPENDENT: Goals met. After 3 hours of nursing interventions,

adtong paigon nako sa operating room”, as verbalized by the patient.

OBJECTIVES: Irritability Facial flushing Restlessness

UNKNOWN SECONDARY TO SURGERY

patient will be able to:

1. Appear relaxed and report anxiety is reduced to a manageable level

2. Identify ways to deal with and express anxiety as evidenced by verbalization of feelings.

1. Monitor vital signsR: To identify physical responses associated with both medical and emotional conditions

2. Establish therapeutic relationship, conveying empathy and unconditional positive regard.R: To avoid the contagious effect/transmission of anxiety

3. Be available to client for listening and talking.R – Encourage verbalization of feelings

4. Provide accurate information about the situation.R: Helps client to identify what is reality based

5. Provide comfort measures such as back rub, calm environment.R – To help the patient to be at ease.

the patient was able to appear relaxed and reported anxiety was reduced to a manageable level and identified ways to deal with and expressed anxiety

Post-operative:



EVALUATION

SUBJECTIVE: ACUTE PAIN AT Short term INDEPENDENT: Short term

“ Sakit jud sa akong likod, sa ubos dapit” as verbalized by the patient.

OBJECTIVES: Pain scale of 8/10 Moaning Facial grimace Protective behavior Operation site at L4,

L5 spinal column

SPINAL COLUMN RELATED TO DESTRUCTION OF LUMBAR TISSUE SECONDARY TO SURGICAL INCISION AS EVIDENCED BY THE OPERATION SITE AT L4, L5

Within 1hour of nursing interventions the patient will be able to:1. Report no pain as evidenced by absence of pain scale from 8/10 to 0/10.2. Demonstrate methods that will provide relief.

Long termAfter 8 hours of thorough nursing intervention, the client will be able to permanent relieve of pain and demonstrate use of relaxation skills and diversional activities

1. Monitor V/S which is usually altered when patient is in acute pain.R - Changes in vital signs may indicate acute pain and discomfort.

2. Provide comfort measures such as touch, repositioning, use of heat or cold packs and nurse’s presence, quiet environment and calm activitiesR - To promote nonpharmacological pain management.

3. Encourage adequate rest periods.R - To prevent fatigue

4. Assist patient to find position of comfort.R - Position affects the patient’s ability to relax and rest/sleep effectively.

5. Teach patient deep-breathing exercise to help refocus attention and enhance coping abilities.

GOALS PARTIALLY MET. After 1 hour of Nursing interventions, the patient demonstrated methods that relieved pain but reported pain partialyl relieved as evidenced by a pain scale of 4/10.

Long term

GOALS MET. After the 8-hour shift, the patient reported relieved pain with a pain scale of 0/10. Patient was able to demonstrate use of relaxation skills and diversional activities.

R - This reduces muscle tension which reduces the intensity of the pain.

6. Instruct and encourage use of relaxation techniques, such as listening to music and/or watching television.R: To distract attention and reduce tension.

DEPENDENT:1. Administer hydrocortisone 100mg every 12 hours, as orderedR: To decrease level of pain. Notify physician if regimen is inadequate to meet pain control goal.



EVALUATION

SUBJECTIVE:“ Sakit kayo diri dapit sa akong operasyon”, as verbalized by the patient.

IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL INCISION AT THE

Short term goal:After 8 hours of nursing interventions, the patient

INDEPENDENT:

1. Inspect skin on a daily basis and

Short term goal:Goals met. After 8 hours of nursing interventions, the

OBJECTIVE:

Pain scale of 8/10

Disruption of skin surface (epidermis)

Disruption of skin layers (dermis)

LUMBAR AREA will be able to:

Verbalize feelings of increased ability to manage situation.

Display wound free from infection.

Long term goal:After 4 days of nursing interventions, the patient will be able to display timely healing of operative wound without complications

describe changes.R – To note changes on the surgical incision.

2. Keep the area clean and dry, carefully dress wounds and prevent infectionR: To assist body’s natural process of repair

3. Use appropriate wound dressingR: To protect the wound and surrounding tissues

4. Encourage early ambulationR: Promotes circulation and reduces risk associated with immobility.

patient was able to verbalized feelings of increased ability to manage situation and displayed wound free from infection.

Long term goal:Goals met. After 4 days of nursing interventions, the patient was able to display timely healing of operative wound without complications.



EVALUATION

SUBJECTIVE:

“Dili pa kayo ko makalihok

IMPAIRED PHYSICAL MOBILITY RELATED TO POST-

Short term:

At the end of 30-45

INDEPENDENT:

1. Note situations such as surgery

Short term:

Goals met. At the end of 30-

ug makatindog basta bast anga ako ra tungod sa akong opera” as verbalized

OBJECTIVE:

Limited range of motion

Slowed movement

Operation site at L4 ,L5 of spinal column

Functional level classification:3 – requires help from another person and equipment device

OPERATIVE INCISION SITE AT L4,L5 OF SPINAL COLUMN AS EVIDENCED BY LIMITED RANGE OF MOTION AND SLOWED MOVEMENT

minutes of continuous health teachings, patient will be able to :

1. Verbalize willingness to and demonstrate participation in activities

2. Verbalize understanding of situation and individual treatment regimen and safety measures such as raising the side rails

Long term:

At the end of 16 hours of nursing intervention, patient will be able to:

1. Demonstrate techniques that enable resumption of activities

2. Maintain position of function and skin integrity as evidenced by absence of contractures, decubitus and so forth

that may restrict movement.R - To identify causative/ contributing factors

2. Determine degree of immobility in relation to previously suggested scale.R - To assess functional ability

3. Observe movement when client is unaware of observation.R - To note any incongruence’s with reports of abilities

4. Assist or have client reposition self on a regular schedule as dictated by individual situationR - To promote optimal level of function and prevent complications

5. Instruct in use of side rails, roller pads for position changes/transfersR – To secure safety for the client.

6. Support affected body part using pillows R - To maintain position of

45 minutes of continuous heath teachings the patient was able to verbalize willingness to and demonstrated participation in activities, verbalized understanding of situation and individual treatment regimen and safety measures such as raising the side rails.

Long term:

Goals met At the end of 16 hours of nursing intervention, the patient was able to demonstrate techniques that enable resumption of activities, maintained position of function and skin integrity as evidenced by absence of contractures and maintained or increased strength and function of affected or compensatory body part.

3. Maintain or increase strength and function of affected or compensatory body part.

function and reduce risk f pressure ulcers.

7. Schedule activities with adequate rest periods during the day to reduce fatigue. Provide client with ample time.R - To perform mobility related tasks

8. Encouraged participation in self-care,diversional/ recreational activitiesR - To enhance self-concept and sense of independence

9. Demonstrate use of adjunctive devices (walker).R - To promote independence and enhances safety.



EVALUATION

RISK FACTOR

1. Post operative wound at L4,L5 of spinal column.

RISK FOR INFECTION RELATED TO DESTRUCTION OF SKIN INTEGRITY SECONDARY

Short term:At the end of 30-45 minutes of continuous health teachings patient

INDEPENDENT1. Note risk factors for occurrence of infection such as break in skin integrity

Short term:Goals met . At the end of 30-45 minutes of continuous health teachings

TO POST OPERATIVE WOUND AT L4,L5 OF SPINAL COLUMN

will be able to:1. Verbalize understanding of individual causative/ factor2. Identify interventions to prevent/reduce risk of infectionLong term: At the end of 16 hours of nursing interventions patient will be able to:1. Demonstrate techniques, lifestyle changes to promote safe environment.2. Achieve timely wound healing; be free of purulent drainage or erythema; be afebrile

R - To assess causative/contributing factors.

2. Observe for localized signs of infection at surgical incisions/wounds.R – To give prompt action to avoid further complications.

3. Cover dressings with plastic when using bedpan R - To prevent contamination

4. Stressed proper hand washing techniques by all care givers between therapies/clients.R - A first line defense against nosocomial infection/contamination

5. Instruct client/significant others in techniques to protect the integrity of skin, care of lesions and prevention of spread of infectionR - To promote wellness.

DEPENDENT1. Administer Hydrocortisone

the patient was able to verbalize understanding of individual causative/ factor, and identified interventions to prevent/reduce risk of infection.

Long term: Goals met. At the end of 16 hours of nursing the patient was able to demonstrate techniques ,lifestyle changes to promote safe environment and achieved timely wound healing; purulent drainage or erythema; afebrile

(Solu-cortef) 100mg every 12 hours; Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D; Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week; Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID, as ordered.R – To act as Prophylaxis against bacterial invasion.



EVALUATION

SUBJECTIVE:

“mo-uli najud ko karon,” as verbalized by the

READINESS FOR ENHANCED THERAPEUTIC REGIMEN

At the end of 30mins. of nursing interventions, the patient will be able to:

INDEPENDENT:

1. Instruct patient about the home medications and its proper timing,

Goals met. At the end of 30mins. of nursing interventions, the patient was able to report

patient.

OBJECTIVE:

Stable vital signs:BP:130/70mmhgPR:67bpmRR:17cpmTemp:36.3°C

Healing wound

RELATED TO IMPROVED CONDITION. 1. Report understanding

of the disease condition and its management.2. Know the importance of rehabilitation.3. Report understanding on the prevention of further complications.

mechanism of action and dosage.R – To guide the patient accordingly with the discharge instructions.

2. Encourage patient to continue physical therapy.R - To improve condition.

3. Instruct patient to eat foods rich in carbohydrate and protein.R - To provide energy and facilitate muscle growth.

4. Instruct patient to perform range-of-motion every day.R - To strengthen muscle.

5. Instruct patient to have adequate rest between activities.R - To prevent fatigability.Dependent:1. Home medications (Xatral),(Uriflow),(Mecobalamin) as ordered.R – To continuously provide relief of the recent condition of the patient.

understanding of the disease condition and its management, Knew the importance of rehabilitation and Reported understanding on the prevention of further complications.

X. DISCHARGE PLANNING

MEDICATIONS

Explain to the patient and family members the importance of taking medications.

Take the entire course of medication.

Discuss to the patient and family the dosage, frequency and adverse effects of

the drugs.

Anti-inflammatory medications can help reduce pain by decreasing the

inflammation of the muscles and nerves.

ECONOMIC STATUS

Explain to significant others that the patient may undergo physical therapy in

order for the family to prepare for any financial needs.

Inform the patient to avail to some government health insurance programs such

as Philhealth that may help ease their financial burden for hospitalization.

TREATMENT

Patient must take a short period of rest or avoiding activities such as lifting and

bending.

Patient may undergo physical therapy that can help increase range of motion of

the lumbar spine and hamstrings as well as strengthen the core abdominal

muscles.

Control weight to prevent increased pressure on the lumbar vertebrae.

Use assistive and supportive devices as ordered like a lumbar corset.

HEATLH TEACHINGS

Advised patient to avoid prolonged sitting, walking and standing because it can

add pressure on the lumbar vertebrae.

Advised patient to consult the doctor before taking any medications, to prevent

any drug-drug interactions with the prescribed drugs.

Advised patient to balance work with rest.

Advised significant others to follow safety measures to prevent falls and injury.

Advised patient to follow proper body mechanics.

Advised patient to inform health care provider if complications may occur such as

chronic pain in the lower back or legs, as well as numbness, tingling or weakness

in the legs.

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OUT-PATIENT

Keep all of follow-up appointments even though the patient feels better. Advised

to seek consultation from a physician whenever there will be recurrence of the

signs and symptoms. This is to prevent the occurrence of a far more serious

complication.

DIET

Eat protein rich foods to help repair the damage tissues and to provide muscle

strength. Sources of protein include meat and eggs.

Eat a well-balanced diet high in calcium and Vitamin D. Foods high in calcium

include milk, yogurt, cheese, salmon and dark green vegetables. Sources of

Vitamin D include fortified milk, liver, butter, eggs and sunlight.

Eat Vitamin C rich fruits like orange to help boost immune system.

SPIRITUALITY

Encouraged patient and Family members to go to church every Sunday and to

continue to seek God’s guidance and enlightenment.

Emphasized the importance of prayers in healing

Encouraged to ask for divine assistance in everything and to

encouragecontinuing to pray to God.

Encouraged to continue to have a positive outlook in life.

Encouraged to keep faith in God and not to give up easily when hard times come

XI. RELATED LEARNING EXPERIENCE

This rotation was never the easiest task, neither the hardest of all that we had

been through in our two years exposure to the clinical area. Thus, we were anxious that

we may not be able to live up to what is expected of us since we are now fourth year.

However, one thing has been sure, this rotation made us take a closer leap to what it is

like when we will finally be wearing our all white uniform someday.

The staffing rotation has inflicted upon us some values that we are to hold on as

we go through this profession, namely: humility, compassion, discipline and empathy.

These were taught to us few years back but we may have forgotten their essence, yet,

with this duty, we unconsciously regained them. Our duty for the staffing rotation in

Station 4 of Capitol University Medical City is probably one of the best experiences we

will ever have since we are meeting different kinds of personalities of patients and

watchers as well. Some might have accepted us warmly as their nurses others may

have rejected us at some points. In spite of that, we have taken it as a challenge to

prove ourselves worthy of their trust and take it as an opportunity to learn in handling

distrustful watchers, and agitated patients---to whom we consider bumps on our road to

success.

Basically our duty fell on the same pattern as with the other medical rotations we

had but this had taught on two new concepts: carrying out doctor’s orders and

leadership and management following the chain of command, in line of authority. We

have all experienced being a staff nurse, a head nurse and the nurse supervisor as well.

We exploited this rotation to the maximum in terms of carrying out doctor’s order since

we fell on an afternoon shift where fewer doctors make their orders after their rounds.

Nevertheless, we saw to it that everyone can try carrying out doctor’s orders and

nobody is left behind. We enjoyed this rotation so much while we were learning at the

same time.

The entire process of making this case study may have not been easy for all of

us but fortunately, we’ve manage to deal with the problems properly and thus, we were

able to finish this case study in the best way we could. Whether the outcome of this

case study is good or bad, we must take it as a lesson and a parameter to continue

seeking knowledge and improving our skills for we never stop learning.

This case study enabled the group to identify nursing intervention which are

appropriate to promote the well-being of the patient and as well as the medical

management for the case.

We would like to thank Mrs. Syvel Jane M. Caharian, for being the best teacher

we could ever ask for in the task of staffing, in teaching and molding us to be good and

competent nurses in the future. Furthermore, this rotation would have not been

successful without the guidance of our almighty God!

XII. REFERENCE

BOOKS:

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care

Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket

Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.).

Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).

Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippincott’s Nursing Drug Guide, 8th edition. Lippincott

Williams & Wilkins.

Nurses’ Pocket Guide, 10th edition F.A. Davis.

Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.

Patient’s Chart

Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for

Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005

Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.

Davis drug handbook, 10th edition

Drug handbook by Saunders

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th

edition By: Joyce Black and Jane Hokanson Hawks

Nursing Care of Infants and Children by Wong

INTERNET:

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Documents

Final_Spinal Stenosis L4, L5 Secondary to Spondylolisthesis L4, L5 Grade II With Hypertrophized Ligament Um and Radiculopathy With Myelopathy Right Sided