SCI Case Presentation Final

8/4/2019 SCI Case Presentation Final

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SPINAL CORD INJURY

A Case Presentation

As Partial Fulfillment for the subject NCM 102E, Care of Mother, Child, Family and group at risk with Problems

STI College Baguio Branch


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I. PATIENTS PROFILE A. BIOGRAPHIC DATA

Name: Patient XAge: 41 Years oldAddress: Supang, Sabangan, MountainProvinceCivil Status: MarriedSex: MaleOccupation: LaborerReligious Preference/Affiliation: AnglicanHealthcare Finances: None

Chief Complain: Inability to move his body

B. HISTORY OF PRESENT ILLNESSThe present condition started 17 hours prior to admission when patient was riding

on his tricycle going home when he lost control and fell to a clift in Bauko, MountainProvince. He was brought to Abatan Bauko General Hospital where first aid andintubation was done. X-ray was also done. He was then referred to Baguio GeneralHospital Medical Center for further evaluation and suggestion.

C. PAST MEDICAL HISTORYPatient was hospitalized in Abatan Bauko General Hospital for fracture on his left

Tibia last August 1993. No known allergies as to environmental, food and drugs asinformed by patients sister .

D.

FAMILY HISTORY OF ILLNESSNo known hereditary familial disease running in the family. There are no historiesof Hypertension, CVA/Stroke, Heart problems, Asthma, Mental Illness, KidneyProblems, Cancer, and Epilepsy from both parents. Neither are there known such


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Social Development StatusThe patient is a 41 year old male and is married. His sister says that he

prefers going out to look for a laboring job or sometimes farming job ratherthan going out with his friends.

B. MENTAL AND EMOTIONAL STATUS Mental Status

The patient is awake. He was not able to respond to touch and painfulstimuli as to anatomical structures below the level of spinal cord affectationbut was able to respond it as to anatomical structures above the level of spinalcord affectation, verbal stimuli, noise and light. He is oriented to place andpersons. He has the ability to comprehend and give signals as necessary. Hehas a Glasgow Coma Scale of 11.

Emotional StatusHis mood and emotional response are observable through his facial

expression. He is able to react with stressful situations which were expressedthrough changes in facial expression and crying. No stimulant or depressantwas given to alter his emotional response.

C. ENVIRONMENTAL STATUS Safety factors

The patient was placed in a position that his head was near the pathway of the ward which could pose as potential hazard since people (watcher, visitoror other healthcare members) might accidentally collide or sideswipe the

weights of the halo traction of the patient. There are no side rails present in the patients bed and the space is not enough for the personal and medical thingsneeded by the patient.


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D. SENSORY STATUS

EyeHis palpebral conjunctiva is pale and his bulbar conjunctiva is white and

clear. Both of his pupils constrict in response to light. His eyes aresymmetrical in shape.

Auditory StatusHe is able to distinguish voice. The external ears are equally patent. The

ears are symmetrical. He has poor ear hygiene as evidenced by the presence of earwax in the ear canal.

NoseThe nose is symmetrical. There is a presence of Nasogastric Tube.

Cranial Nerve assessment:Cranial nerve Assessment outcome

CN I(Olfactory) Not TestedCN II (Optic) IntactCN V (Trigeminal) IntactCN VII (Facial) IntactCN VIII (Acoustic) IntactCN IX (Glossopharyngeal) Not TestedCN X (Vagus) Intact

Tactile StatusThe patient was not able to feel discriminative and non-discriminative


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Patellar 0 0Ankle Reflex 0 0

E. MOTOR STATUS Medical restrictions on Activity

Patient is bedbound restricted by the presence of Halo traction and inability tomove.

Musculoskeletal Range of Motion

Full range of motion of both the upper and lower extremities wasachieved through passive movement with firm end feel. Range of motion for the cervical and thoracic spine was not assessed due tomedical restriction (Presence of Halo Brace).

Muscle Strength Upper ExtremitiesHe has a Grade of 0 muscle strength for both the upper extremities.

Muscle Strength Lower ExtremitiesHe has a Grade of 0 muscle strength for both the lower extremities.

CerebellarUnable to assess since patients muscle for both upper and lower extremities are flaccid thereby restricting the assessment for thecerebellum function.

Cranial nerve assessmentCranial Nerve Assessment Outcome

CN III (Oculomotor) Intact

CN IV (Trochlear) IntactCN V (Trigeminal) IntactCN VI (Abducens) IntactCN VII (F i l) I t t


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MobilityPatient is totally dependent with functional level classification of 4. He is

non-ambulatory and needs full assistance in activities of daily living. He isunable to do active bed mobility. Passive bed mobility is minimized due to therestriction of the halo traction.

F. NUTRITIONAL STATUS Dietary Habits

Patient prefers to eat vegetables and seldom eats fish and pork due tofinancial status.

Adequacy of DietPatient uses NGT and is given osteorized food three times a day

(breakfast, lunch and dinner). Signs of diet inadequacy cannot be assessedfully since most of the signs seen are also a typical signs for denervation andits complications. The patients sister verbalized that there is no change inphysique of the patient.

Non-oral means of feedingThe patient uses NGT.

G. ELIMINATION STATUS Normal Patterns

The patients normal defecation is daily or once a day with normal amountand consistency as verbalized by her sister. He also urinates regularly and

there were no known reports of hematuria, past stones Aids to Elimination

Patient is immobile and consumes less amount of water which is a


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pH 6.0 4.5-8.0 NormalSpecific

Gravity:

1.030 1.015-1.025 High; Increased concentration of dissolved

solutes probably due to large amount of medications given. Indicative of early signsof dehydration

Sugar: Negative Negative NormalProtein: Negative -

TraceNegative Normal

RBC: Toonumerous tocount

Negative orrare

High; Indicative of Urinary tract injury

Method: Immunochromatography*** January 30, 2011; 12:48 A.M.

H. FLUID AND ELECTROLYTE STATUS

Specific gravity is 1.030 (taken last January 30, 2011) which is indicative of earlysigns of dehydration, PNSS IL X 8 was infused. Patient has decreased input of water.An IFC is connected with a range from 850 1,100 cc output per day. Currently,PNSS 1L X 16 hours with side drip of Dopamine x 5ugtts/min is infused.

I. CIRCULATORY STATUS

He has good skin turgor and a capillary refill of


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RDW CV 12.9% 11.5 14.5 NormalRDW SD 41.4 fL 35.0 56. 0 Normal

PLT 208 x 10^9/L 150 450 NormalMPV 10.9 fT 7. 0 11.0 NormalPDIV 15.1 15.0 17.0 NormalPCT 0.226% 0.108 0.282 Normal*** January 29, 2011

Hematology Result form

Parameter Result ReferenceRange

Interpretation

WBC 11.8 x 10^9/L 5.0 10.0 High; Indicative of infectionLYMPH 1.5 x 10^9/L 0.8 4.0 Normal MIDH 0.4 x 10^9/L 0.1 0.9 Normal GRANH 9.9 x 10^9/L 2.0 7.0 High; Indicative of infection

LYMPH% 12.9% 20.0 45.0 Low; Indicative of low immune systemMID% 3.8% 3.0 9.0 NormalGRAN% 83.3% 40.0 75.0 High; Indicative of infectionHGB 130 g/L 140 180 Low; Indicative of defects in the balance of

red blood cells in the blood RBC 4.50 x 10^12/L 4.00 5.50 NormalHCT 37.4% 42. 6 54.0 Low; Indicative of nutritional deficiencies of

iron, folate, vitamin B12, and vitamin B6 MCV 83.3 fL 82.0 95.0 NormalMCH 28.8pg 27.6 31.0 NormalMCHC 374 g/L 326 360 High; Indicative of vitamin B12 deficiency


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RANGELDL 1.1 mmoL/L 0 - 5.2 Normal

Sodium 141.1 mmoL/L 136 - 145 NormalPotassium 4.0 mmoL/L .35 5.1 NormalChloride 168.7 mmoL/L 98 107 High; Indicative of respiratory

alkalosisTriglycerides 0.59 mmoL/L 0 1.69 NormalBlood UreaNitrogen

13.99 mmoL/L 2.56 6.49 High; Patient is in statecharacterized by decreasedeffective circulating blood volumewith decreased renalperfusion; Patient is possibly in astate of shock

Cholesterol 2.69 mmoL/L 0 5.2 Normal;Glucose 5.41 mmoL/L 3.85 6.05 Normal;Creatinine 136.99 ummoL/L 71 115.00M High; Indicative of renal failureHDL

Cholesterol

1.33 umMmoL/L 53 88.4F

1.04 1.56

Normal

Conventional UnitsTEST NAME RESULT UNIT REFERENCE

RANGEInterpretation

LDL 42.31 mg/dl 0 200 NormalSodium 141.10 mg/dl 136 145 NormalPotassium 4.00 mg/dl 3.5 5.1 NormalChloride 108.70 mg/dl 98 107 High; Indicative of respiratory

alkalosisTriglycerides 52.44 mg/dl 0 150 NormalBlood UreaNit

39.19 mg/dl 7.0 18.0 High; Patient is in stateh t i d b d d


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Arterial Blood GasResult Normal values Interpretation

pH 7.481 7.35 7.45 Alkalinic; Indicative of possible hyperventilationor shock

pCO2 17.4 mmhg 35 45 mmhg Low; indicative of hyperventilation or hypoxiapO2 80.4 mmhg 80 100 mmhg NormalHCO3 12.7 mmol/L 22 26 mEq/L Low; indicative of respiratory alkalosis (which

can be caused by hyperventilation),metabolic acidosis, shock, starvation, and orkidney failure.

SO2 96.5 % 95 98 % NormalBE - 7.7 mmol/L -2 - +2

-5 - +3Indicates a base deficit in the blood equivalent toan acid excess

F1O2 60 % 60% or less NormalTHb _____g/dl No data / measurement furnished in the

laboratory resultHct 37.4 % 39 54% Low; indicative of loss of blood

Na 136.7 mmol/L 135-145 mmol/L NormalK 2.80 mmol/L 3.4-4.6 mmol/L LowICa .522 mmol/L*** January 30, 2011

J. RESPIRATORY STATUS Inspection

Color of the thorax is lighter as compared to the skin color of the face andextremities. He has no visible deformity over the anterior aspect of the thoraxarea.


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Result Heavy Growth of Klebsiella Pneumoniae

Amikacin SAmpicillin RAmoxicillin / Clavulanic Acid

S

Ampicillin / Sulbactan

I

Aztreonam SCefepime SCefexime SCefatoxime ICefuroxime RCefoxitin RCeftrioxone S

Cytazidine IChloramphenicol RCiprofloxacin SCotrimoxazole RGentamycin SImepenem SErtapenem SMeropenem SPipracillin RPiperocillin /

TazobactamI


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K. TEMPERATURE STATUSHis temperature ranged from 36.3 to 36.6 degrees Celsius on his first week with

elevation ranged from 37.7 to 38 degrees Celsius noted during the second week takenin axillary area. He uses a blanket as a usual measure for temperature comfort.

L. INTEGUMENTARY STATUSHis skin is dark brown, dry and flaky. Nail beds are light brown to reddish with

nails not trimmed. Skin is warm to touch. With bruise on medial aspect of the leftelbow, lateral aspect of the left knee, anterior proximal third of the left leg, antero-medial side of the right distal leg and hematoma on postero-lateral side of leftshoulder with approximately 1 inch in diameter, lateral side of the left hip withapproximately half inch in diameter. With clean and dry pinholes in the anterior andlateral portions of the scalp due to insertion of the pins of the halo traction. Palpablelymph node enlargement was noted on both sides of the neck. With Braden Scale asfollows:

Date Total Score InterpretationFebruary 3, 2011 10 High Risk for Pressure SoreFebruary 4, 2011 10 High Risk for Pressure Sore February 11, 2011 10 High Risk for Pressure Sore


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III. PATHOPHYSIOLOGY

Spinal Cord Injury: PathophysiologyComplete

Risk for infection(e.g Pneumonia)

Spinal Shock:Loss of Somatic Sensation;Loss of visceral Sensation;

loss of motor Function;Loss of muscle tone; loss

of reflex activity

Ischemia from damage / Impingement on the spinalarteries

Compression/ directtrauma of the SpinalCord by the Bonefragments

Fracture of vertebraeand tear of ligaments onthe cervical vertebrae(C3 C4); dislocation of facet oints

Motor Vehicle Accident

IneffectiveBreathing Pattern

Microscopic hemorrhagesappear in the central graymatter & pia-arachnoidcausing reduced vascularperfusion & development of ischemic areas


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Stage of Flexor Muscle SpasmIncreasing tone in flexor muscleStronger flexor response to nociceptivewhich progressively involve more proximal

rou

Stage of Predominant Extensor Spasticity

Stage of alternate Flexor and ExtensorSpasticity

Both flexor and extensor spasms occur,patient can momentarily support his weightin standin osition

A


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IV. LIST OF PROBLEMS

1. Ineffective airway clearance related to neuromuscular dysfunction and infection secondaryto C 3 C4 jump facet.2. Ineffective breathing pattern related to musculoskeletal impairment secondary to C 3 C4

jump facet.3. Impaired mobility related to loss of muscle function as manifested by paralysis of both

upper and lower extremity secondary to C 3 C4 jump facet.4. Risk for impaired skin integrity related to physical immobility secondary to C 3 C4 jump

facet.

5. Risk for decrease cardiac output related to neurogenic shock secondary to C 3-C4 jump facet.


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V. NURSING CARE PLANProblem 1: Ineffective airway clearance

ASSESSMENT EXPLANATION OFTHE PROBLEM

OBJECTIVES INTERVENTION RATIONALE EVALUATION

S: Ado tirumrumuar ngaterkak ditoy kwa na(pointing to theBVM) as verbalized

by the patients sister

O: With

tracheostomyconnected toBVM with 8-9lpm oxygeninhalation

Alteredrespiratory depthand rate noted

Withtracheobronchialsecretions (dark yellow to lightgreen in color)

With oxygensaturation of 94to 97 %

With excessivesalivation

Impairedcoughing reflexnoted

Presence of

Trauma to the C3 C4Cervical spine

Injury to the spinal cord

Denervationand loss of function of respiratory

muscles

Intubation

Invasionand

colonizationof

microorganismin the

respiratorytract

Infection

Inflammatory

STO:Maintain oxygensaturation not togo below normalrange.

LTO:Maintain optimaloxygen saturationwhile patient is inthe hospitalthroughappropriatenursingintervention

Diagnostic: Monitoredoxygensaturation asappropriate

Assessed skincolor andtemperature

Monitoredairwayresistance

IncreasingPaCo2 anddecreasingPaO2 are signsof respiratoryfailure. As thepatients beginto fail therespiratory ratedecreases andPaCO2 begin toincrease.

To assesscyanosis whichcan occur whenat least 5 g of hemoglobin isdesaturated orcool pale skinwhich canoccursecondary to acompensatoryresponse tohypoxemia.

Increase of resistancesignals

Goals Met.Maintainedoxygen saturation

Goal Partiallymet:Continue nursinginterventions asneeded

O v e r r o

d u c t

i o n o

f s a l

i v a

A f f e c

t a t i o n o f

t h e

A N S


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KleibsiellaPneumoniae inbacteriologyresult

No cyanosisnoted with skinwarm to touch

Sputumyellowish togreenish

Nursing Diagnosis:Ineffective airwayclearance related toneuromusculardysfunction andinfection secondaryto C 3 C4 jumpfacet.

process

Fever,sputum

production

Ineffectiveairway

clearance

Observedsputum colorand amount

Checked forthe position of the patient

Therapeutic: Suctioningdone as needed

Provided oralcare

accumulationof secretions of fluids

Signs of infection couldalso be seen incolor

Improperpositioningmay also causeabdominalcontents frompushingupwards thatmay causeairway

To removesecretions

impediment

Providing oralcare maydecrease

colonizationand increase of bacteria

For monitoringrespiratoryinfection thatmay increase


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Increased fluidintake

Collaborative: Collected andsent sputumspecimen forculture andsensitivitytesting, asappropriate

Administeredmedication (N-acetylcysteine,terbutiline) asordered notingeffectivenessand side effects

Educative: Emphasizedimportance of hand washingtechnique

sputumproduction.

Helps inliquefying andlooseningsecretions

To promoteclearance of airwaysecretions andbronchodilationdecreasesairwayresistance

This willdecrease if noteliminate thetransmission of microorganismto therespiratory tractwhileperforming the

bag valve mask ventilation.

Certainallergens canincrease mucusproductions.


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Explainedaboutenvironmentalfactors that canprecipitaterespiratoryproblems


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Problem 2: Ineffective Breathing Pattern

ASSESSMENT EXPLANATIONOF THE

PROBLEM


O: With

tracheostomyconnected toBVM with 8-9lpm oxygeninhalation

Paralyzedmuscles forbreathing noted

Alteredrespiratory depthand rate noted

With alteredinspiratory andexpiratorypressure.

Altered chestexcursion

Withtracheobronchialsecretions

With oxygensaturation of 94to 97 %

Improper bodypositioning noted

Trauma to the C3 C4 Cervical spine

Injury to the spinalcord

Loss of function of phrenic nerve and

other nervessupplying the

respiratoryaccessory muscles

Denervation of diaphragm and

accessory musclesof respiration

Paralyzeddiaphragm and

accessory musclesof respiration

Ineffectivebreathing pattern

STO:

Within 1 hour of nursing interventionthe oxygen saturationwill increase from 94-97% to 96 100%

LTO:Maintain optimaloxygen saturationwhile patient is in thehospital throughappropriate nursingintervention

Diagnostic: Monitoredoxygen saturationas appropriate

Assessed skincolor andtemperature

Therapeutic:Independent:

Positioned thepatient withproper bodyalignment

Increasing PaCo2and decreasingPaO2 are signs of respiratory failure.As the patientsbegin to fail therespiratory ratedecreases andPaCO2 begin toincrease.

To assess cyanosiswhich can occurwhen at least 5 g of hemoglobin isdesaturated or coolpale skin whichcan occursecondary to acompensatoryresponse to

hypoxemia.

for optimal chestexcursion or lungexpansion

Goals Met.Oxygen saturationincreased from 94-97% to 96 100%

Goal partially met:Continue nursinginterventions asneeded


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Nursing Diagnosis:Ineffective breathingpattern related toNeuromusculardysfunctionsecondary to C 3 C4

jump facet.

Demonstratedproper rate,rhythm and depthof ambubagging

Collaborative: Administeredmedicine(dopamine,Terbutaline) asneeded

Educative: Emphasizedimportance of properambubagging

Emphasized towatcher theimportance of proper bodyalignment / positioning of thepatient.

To educate thewatcher on properambubagging

DopamineReplaces the actionfor sympatheticnervous systemand terbutaline forbronchodilation

This preventsexacerbation of the

patients condition

To educate watcheron its advantageand disadvantage


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Problem 3: Impaired mobility


PROBLEM


S: haan na ngamaikuti ti baggi naas verbalized by

patients sister

O: With muscle

grade of 0 onboth upper andlowerextremities

Inability toperform ActiveRange of motionnoted

With score of 4 totallydependent infunctionalactivities of

daily living

Impaired bedmobility noted

Nursing Diagnosis:Impaired mobilityrelated to loss of muscle function as



Loss of function of peripheral nerves

Denervation of upper extremity,

thoracic, abdominaland lower extremity

muscles

Impaired Mobility

STO:Within 3 hours of nursing interventionwatcher willverbalizeunderstanding onimportance of health teaching andwill be able todemonstrate properperformance of activities related topreventing thecomplications of immobility.

LTO:While patient is inthe hospital, he willbe free of complications of

immobility, throughappropriate nursinginterventions.

Diagnostic: Assessed for joint mobility / Range of motionand muscle tone

Assessedeliminationstatus

Assessed thewatchersknowledge of immobility anditscomplications

Therapeutic: Positioned thepatient withproper bodyalignmentthroughtrochanter rollsand pillows.Supported feet

Regularexaminations of the joint andmuscle tone willallow forprevention orearly recognitionand treatment forcontractures.

Immobilitypromotesconstipation

Inappropriateknowledge of the watcher willincrease the risksof complication

To preventsecondarymusculoskeletaldeformities thatmay occur

Goal met:Patient verbalizedunderstanding of thehealth teachings andwas able to properlydemonstrateactivities taught.

Goals Partially met:Continue nursinginterventions asneeded


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manifested byparalysis of bothupper and lowerextremity secondaryto C 3 C4 jumpfacet.

in dorsiflexedposition

Performedpassive range of motion exerciseson all joints of the extremitiesusing slow andsmoothmovements.

Repositionedperiodically

(every 2 hours)to changepressure sites

Elevated lowerextremities atregular intervals

Collaborative: Consulted withphysicaltherapist

To enhancecirculation,restore ormaintain muscletone and jointmobility andprevent disusecontractures anddelay muscleatrophy

Promotesperipheral

circulation andreduces pressure.

To prevent bloodpooling andvenous stasisand decrease risk of thrombus

formation

Helpful inplanning andimplementingindividualizedexercise


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Educative: Instructedwatcherregardinghazards of immobility

Emphasized towatcher theimportance of proper bodyalignment /

positioning of the patient.

Emphasizedimportance of passive range of motion exercises

program.

Informationpromotesawareness of thecomplications sothat watcher willbe able toidentify andreport signsimmediately.

To educatewatcher on itsadvantage anddisadvantage

To provideinformation onpreventingdelayingpossiblemusculoskeletalcomplications


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Problem 4: Risk for impaired skin integrity


PROBLEM


O:

With bradenscore of 10(high risk forpressure sores)

Patient wearsdiaper

Uses flatsurfaced

mattress

With score of 4 totallydependent infunctionalactivities of daily living

Nursing Diagnosis:

Risk for impairedskin integrityrelated to physicalimmobilitysecondary to C 3 C4

jump facet.



Denervation of bothupper extremity,thoracic , back,abdominal, and

lower extremity

Prolongedimmobilization

Risk for skin

integrity

STO: After 1 hour of

nursingintervention thewatcher will beable to verbalizeunderstandingof the healthteaching

After 2 hours of nursing

intervention thewatcher will beable to performproperprocedures onpreventingpressure sores

LTO: While patient is

in the hospital,there will be aminimizedemergence of pressure sores,throughappropriatenursinginterventions

Diagnostic: Assessed abilityto move

Assessed generalcondition of skin,specifically overbonyprominences

Assessed foredema

Assessed forenvironmentalmoisture

Therapeutic: Performedpassive range of motion exercises

Immobility is thegreatest risk factor in skinbreakdown

Areas where skinis stretched tautlyover bonyprominences areat higher risk forbreakdown

because thepossibility of ischemia to skinis high.

Skin stretchedtautly overedematous tissueis at risk forimpairment

Moisture maycontribute to skinmaceration.

Promotesperipheralcirculation and

Goals met:Watcher verbalizedunderstanding of thehealth teaching andwas able to performproper procedureson preventingpressure sores

Goals Partially met:Continue nursing

interventions asneeded


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and cooperationof the watcher.

on all joints of the extremitiesusing slow andsmoothmovements.

Demonstratedand Cleaned,dried andmoisturized skin

Repositionedperiodically(every 2 hours)to changepressure sites

Educative: Teach the

watcher the

causes of pressure ulcerdevelopment:pressure on skin,especially overbonyprominencesShearing of friction against

reduces pressure.

These measuresreduce skinbreakdown fromprolongedimmobility

Because of sensorydisturbance thepatient will beunable to detect

painful pressure.Lift shits reduceshear forceswhich furthercontribute to skinbreak down

Thisinformationcan assist

the watcherin findingmethods toprevent skinbreakdown.


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skin.

. Teach the

watcher toinspect the skindaily

Skinbreakdownis anongoing,lifetimeconcern forthe patient.


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Problem 5: Risk for Decreased Cardiac outputASSESSMENT EXPLANATION OF THE

PROBLEMOBJECTIVES INTERVENTION RATIONALE EVALUATION

O: With blood

pressure of 100/60 mmhgand pulse rate of 51 56 beats perminute

Alert

Capillary refill of < 2 seconds

Nursing Diagnosis:Risk for decreasecardiac outputrelated to neurogenicshock secondary toC3-C4 jump facet.

Trauma to the C3 C4Cervical spine

Injury to thespinal cord

Neurogenic shock

Decreased Cardiac Output

STO:Within 8 hoursof nursingintervention

patients heartrate will increasefrom 51 56beats per minuteto 60 100 beats

LTO:During the stayin the hospital,

patients heartrate of 60-100beats per minuteand systolicblood pressuregreater than 90mm hg will bemaintainedthrough propernursing

intervention

Diagnostic: Assessed Heart

rate and BPclosely

Assessedperipheral pulses

and capillaryrefill.

Monitored intakeand output

Therapeutic: Avoided

elevating headof bed

Loss of sympatheticintervention resultsin bradycardia andvasodilation of vessels below theinjury resultingfrom an unopposedParasympatheticnervous system.

Peripheralvasodilation

decrease venousreturn, furtherdecreasing cardiacoutput and bloodpressure.

Changes in intakeand urine outputare an indicationsof fluid balance.

Because of sympatheticdisruption andresultant loss of vasoconstrictortone below theinjury, head

Goal met: patients heartrate increasedfrom 51 56beats per minuteto 65 70 beatsper minute

Goals Partiallymet:

Continue nursinginterventions asneeded


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Performedpassive range of motion exercises

on all joints of the extremitiesusing slow andsmoothmovements.

Collaborative: Administered

medicine asnecessary

Emphasizedimportance of passive range of motionexercises

elevation willresult in furtherdrop of BP.

Promotesperipheralcirculation

Dopamineincreases heart rateand blood pressure

To provideinformation aboutthe effects of PROME


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VI. DRUG STUDY.Tradename/Genericname

Classification/Indication Mechanism of action

Adverse effect/Contraindication Nursing Intervention

Ketorolac nonsteroidalantiinflammatory drugs(NSAIDs)

IndicationIt is for short-termmanagement of moderate to severepostoperative pain.

Short-term

management of

pain (up to 5

days)

Ophthalmic:

relief of ocular

itching due to

seasonal

conjunctivitis

and relief of

post-operativeinflammation

after cataract

surgery.

Inhibitsprostaglandinsynthesis by

decreasing theactivity of theenzyme, cyclo-oxygenase,which results indecreasedformation of prostaglandinprecursors

Percentage unknown: Renal impairment,wound bleeding (with I.M.), postoperativehematomas

1% to 10%:

Cardiovascular: Edema

CNS: Drowsiness, dizziness, headache, pain

Gastrointestinal: Nausea, dyspepsia, diarrhea,gastric ulcers, indigestion

Local: Pain at injection site

Miscellaneous: Diaphoresis (increased)


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ketorolac, aspirin, or other NSAIDs prophylaxis before major surgery suspected or confirmed

cerebrovascular bleeding, hemorrhagic diathesis

6 hrs to maintainserum levels andcontrol pain.

Tradename/Genericname

Classification/Indication Mechanism of action Adverseeffect/Contraindication

Nursing Interventions

Cefuroxime ANTIINFECTIVE;ANTIBIOTIC; SECOND-GENERATIONCEPHALOSPORIN

Treatment of infections causedby staphylococci,group Bstreptococci, H.influenzae (typeA and B), E. coli,Enterobacter ,Salmonella , andKlebsiella ;

treatment of susceptible

infections of the lower respiratory

tract

otitis media

urinary tract,

Inhibits bacterial cellwall synthesis bybinding to one or moreof the penicillin-binding proteins(PBPs) which in turninhibits the finaltranspeptidation stepof peptidoglycansynthesis in bacterialcell walls, thusinhibiting cell wallbiosynthesis. Bacteriaeventually lyse due toongoing activity of cellwall autolytic enzymes(autolysins and murein

hydrolases) while cellwall assembly isarrested.

1% to 10%:

Hematologic: Eosinophilia(7%), decreased hemoglobinand hematocrit (10%)

Hepatic: Increasedtransaminases (4%), increasedalkaline phosphatase (2%)

Local: Thrombophlebitis (1.7%)


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skin and soft tissue, bone andjoint, sepsis andgonorrhea

cephalosporins include toxicnephropathy, cholestasis,agranulocytosis, colitis,pancytopenia, aplastic anemia,hemolytic anemia, hemorrhage,prolonged PT, encephalopathy,asterixis, neuromuscularexcitability, serum-sicknessreactions, superinfection

Contraindication:

Hypersensitivity to cefuroxime,any component, orcephalosporins

potentially life-threatening complicationshould be ruled out asthe cause of diarrheaduring and afterantibiotic therapy.

Monitor formanifestations of hypersensitivity (seeAppendix F). Discontinuedrug and report theirappearance promptly.

Monitor I&O rates andpattern: Especiallyimportant in severely illpatients receiving highdoses. Report anysignificant changes.


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Classification/Indication Mechanism of action Adverse effect/Contraindication Nursing Interventions

Paracetamol Non-opioid analgesic

Indications:

Treatment of postoperativepain

Treatment of mild tomoderate pain and fever;does not have antirheumaticeffects (analgesic)

It isalso used to bringdown a hightemperature. Forthis reason,paracetamol can begiven to childrenafter vaccinationsto prevent post-immunizationpyrexia (hightemperature).

Inhibits the synthesisof prostaglandins inthe central nervoussystem andperipherally blockspain impulsegeneration; producesantipyresis frominhibition of hypothalamic heat-regulating center

Adverse effect:

Percentage unknown: Mayincrease chloride, bilirubin, uricacid, glucose, ammonia, alkalinephosphatase; may decreasesodium, bicarbonate, calcium

Contraindications:

Patients with known G-6-PDdeficiency; hypersensitivity toacetaminophen

Suppositories: Do not freeze

Suspension, oral: Shake

well before pouring a dose

Monitor for S&S of:

hepatotoxicity, evenwith moderateacetaminophen doses,especially inindividuals with poornutrition.


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Classification/Indication Mechanism of action Adverse effect/Contraindication Nursing Interventions

Terbutaline beta adrenergicreceptor agonists(stimulators)

Indications:Bronchodilator inreversible airwayobstruction andbronchial asthma

Relaxes bronchial smoothmuscle by action on beta 2-receptors with less effect on heart rate also inhibitsuterine activity.

Adverse effect:

>10%:

Central nervous system:Nervousness, restlessness

Neuromuscular & skeletal:Trembling

1% to 10%:

Cardiovascular: Tachycardia,hypertension

Central nervous system:Dizziness, drowsiness, headache,insomnia

Gastrointestinal: Xerostomia,nausea, vomiting, bad taste inmouth

Neuromuscular & skeletal: Musclecramps, weakness

Miscellaneous: Diaphoresis


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any component, cardiacarrhythmias associated withtachycardia, tachycardia causedby digitalis intoxication


Classification/Indication Mechanism of action Adversereaction/Contraindication

Nursing intervention

N -Acetylcysteine Classification: Mucolytic

Indications: Adjunctive mucolytic

therapy in patientswith abnormal orviscid mucoussecretions in acute andchronic

bronchopulmonarydiseases; pulmonarycomplications of surgery and cysticfibrosis; diagnosticbronchial studies;

antidote for acuteacetaminophen toxicity

Exerts mucolytic actionthrough its freesulfhydryl group whichopens up the disulfidebonds in themucoproteins thuslowering mucousviscosity. The exact mechanism of action in

acetaminophen toxicityis unknown; thought toact by providingsubstrate for conjugationwith the toxic metabolite

Adverse reaction:

>10%:

Gastrointestinal:Vomiting

Miscellaneous:Unpleasant odor during

administration

1% to 10%:

Central nervous system:Drowsiness, chills

Gastrointestinal:Stomatitis, nausea

Local: Irritation

Respiratory:Bronchospasm,rhinorrhea, hemoptysis

Miscellaneous:Clamminess

Assess patient fornausea, vomiting,and skin rash


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name/Genericname

reaction/Contraindication intervention

Omeprazole Classification:proton pump inhibitors (PPI)

Indication:

Short-term treatment of activeduodenal ulcer

First-line therapy in treatment of heartburn or symptoms of GERD

Short-term treatment of activebenign gastric ulcer

GERD, severe erosiveesophagitis, poorly responsivesymptomatic GERD

Long-term therapy: Treatment of pathologic hypersecretoryconditions (Zollinger-Ellisonsyndrome, multiple adenomas,systemic mastocytosis)

Eradication of H. pylori withamoxicillin or metronidazole andclarithromycin

Prilosec OTC: Treatment of frequent heartburn (2 or more daysper week)

Unlabeled use: Posteriorlaryngitis; enhance efficacy of pancreatin for the treatment of steatorrhea in cystic fibrosis

Suppresses gastric acidsecretion by inhibitingthe parietal cell H+/K+ATP pump. By blockingthe production of acidis decreased, and thisallows the stomach andesophagus to heal.

Adverse reaction:

CNS: Headache,dizziness, asthenia,vertigo, insomnia,apathy, anxiety,paresthesias, dreamabnormalities

Dermatologic: Rash, inflammation,urticaria, pruritus,alopecia, dry skin

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

dry mouth, tongueatrophy

Respiratory: URI symptoms, cough,epistaxis

Other: Cancer inpreclinical studies, back pain, fever

Contraindication

Known hypersensitivity toomeprazole

Capsuleshould beswallowedwhole; not chewed,crushed, oropened


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Trade name/Generic Classification/Indication Mechanism of action Adversei /C i di i



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name reaction/ContraindicationDopamine Classification:

Adrenergic Agonist Agent

Indication:

Increase cardiac output

Increase blood pressure

Increase urine flow

To correct hemodynamicimbalance in shock

syndrome due to MI(cardiogenic shock),trauma, endotoxicsepticemia (septic shock),open heart surgery, andCHF.

Stimulates bothadrenergic anddopaminergicreceptors, lowerdoses are mainlydopaminergicstimulating andproduce renal andmesentericvasodilation, higherdoses also are bothdopaminergic andbeta 1-adrenergicstimulating andproduce cardiacstimulation andrenal vasodilation;large doses stimulatealpha-adrenergicreceptors

Adverse reaction:

Cardiovascular:Ectopic beats,tachycardia, anginalpain, palpitations,hypotension,vasoconstriction

Central nervoussystem: Headache

Gastrointestinal:Nausea and vomiting

Respiratory: Dyspnea

Infrequent: Aberrant conduction,bradycardia,piloerection, widenedQRS complex,azotemia, elevatedpressure, polyuria,dilated pupils,ventriculararrhythmias (highdose), gangrene (highdose), hypertension,azotemia, anxiety,elevations in serumglucose (usually not

Extravasation: Due to short half-life, withdrawal of drug is often onlynecessarytreatment.

Use phentolamineas antidote; mix 5mg with 9 mL of NS; inject a smallamount of thisdilution intoextravasated area;blanching shouldreverseimmediately.

Monitor site; if blanching shouldrecur, additionalinjections of phentolamine maybe needed.

Monitor bloodpressure, pulse,peripheral pulses,and urinary output at intervalsprescribed by

physician. Precisemeasurements areessential foraccurate titrationof dosage.

Report the


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above normal limits);extravasation of dopamine can causetissue necrosis andsloughing of surrounding tissues.

Contraindication:

Hypersensitivity to sulfites(commercial preparationcontains sodium bisulfite);pheochromocytoma;ventricular fibrillation

followingindicators likereduced urine flowrate in absence of hypotension;ascendingtachycardia;dysrhythmias;disproportionaterise in diastolicpressure ,signs of peripheralischemia (pallor,cyanosis, mottling,coldness,complaints of tenderness, pain,numbness, or

burningsensation).


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Trade name/Genericname



Lactulose Classification:Ammonia detoxicant,laxative

Indication: Adjunct in the

prevention andtreatment of portal-systemicencephalopathy(PSE) includinghepatic andprehepatic coma(Cephylac,Cholac, Enulose,

Evalose, Heptalacare used). treatment of

chronicconstipation

The bacterialdegradation of lactuloseresulting in an acidic pHinhibits the diffusion of NH3 into the blood bycausing the conversion of NH3 to NH 4+; alsoenhances the diffusion of NH3 from the blood intothe gut where conversionto NH 4+ occurs; producesan osmotic effect in thecolon with resultant distention promotingperistalsis

Adverse reaction:

>10%:Gastrointestinal:Flatulence,

diarrhea ,(excessive dose)

1% to 10%:Gastrointestinal:Abdominaldiscomfort,nausea, vomiting

Contraindication:

Patients withgalactosemia andrequire a low galactosediet, hypersensitivity toany component

Dilute lactulosein water, usually60-120 mL, priorto administeringthrough a gastricor feeding tube

Instruct the patient to:

Take sufficient liquid with eachdose and increasefluid intakeduring the day

Do not takeconcomitantlywith mineral oil

Do not take forprolongedperiods in lieu of proper dietarymanagement ortreatment andunderlyingcauses of constipation


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Trade name/Genericname



Sulbactam-ampicillin Classification:Antibiotic, Penicillin

Indication:

Dental: Parenteralbeta-lactamase-resistant antibioticcombination to treat more severe orofacialinfections where beta-lactamase-producingstaphylococci and beta-lactamase-producingBacteroides are present

Medical: Treatment of susceptible bacterialinfections involvedwith skin and skinstructure, intra-abdominal infections,gynecological

infections; spectrum isthat of ampicillin plusorganisms producingbeta-lactamases suchas S. aureus , H.influenzae , E. coli,Klebsiella , Acinetobacter ,Enterobacter , and

The addition of sulbactam, a beta-lactamase inhibitor, toampicillin extends thespectrum of ampicillin toinclude some beta-lactamase producingorganisms; inhibitsbacterial cell wallsynthesis by binding toone or more of thepenicillin bindingproteins (PBPs); which inturn inhibits the final

transpeptidation step of peptidoglycan synthesisin bacterial cell walls,thus inhibiting cell wallbiosynthesis. Bacteriaeventually lyse due toongoing activity of cellwall autolytic enzymes(autolysins and mureinhydrolases) while cellwall assembly is

arrested.

Adverse reaction:

>10%: Local: Pain at

injection site (I.M.)1% to 10%:

Dermatologic: Rash

Gastrointestinal:Diarrhea

Local: Pain at injection

site (I.V.)

Miscellaneous: Allergicreaction (may includeserum sickness,urticaria,bronchospasm,hypotension, etc)


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anaerobes vomiting, enterocolitis,pseudomembranouscolitis, hairy tongue,dysuria, vaginitis,leukopenia,neutropenia,thrombocytopenia,

decreased hemoglobinand hematocrit,increased liverenzymes,thrombophlebitis,increasedBUN/creatinine,interstitial nephritis(rar

Contraindication:Hypersensitivity toampicillin, sulbactam orany component, orpenicillins

Type of I.V fluids Components of I.V fluid Class of I.V fluid Effect

Normal saline solution Sodium chloride, water, glucose isotonic mimics the bodiesnatural blood salt concentration andcontains 0.9% salt solution

prevent dehydration inpatients

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SCI Case Presentation Final