Chapter 1

PROBLEM AND its BACKGROUND

Introduction

• Perception – the ability to recognize external stimuli

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

muscles and nerves to produce the desire result.

Injury to the spinal cord is a medical emergency that may result in severe and permanent
disability. The spinal cord – which along with the brain comprises the central nervous system –
is a bundle of nerve cells that travels almost the entire length of the spine, connecting the brain to
the nerves in the rest of the body. The vertebrae, the small bones that make up the spine, form a
bony tunnel that surrounds the cord and protects it from injury. However, if a blow is severe
enough, or if the bones are weakened by disease, the spinal cord is vulnerable to damage.

Destroyed nerve cells cannot regenerate; injury to the spinal cord may thus result in
permanent paralysis of the legs (paraplegia) or, in the case of the neck injury, the arms, torso,
and legs (quadriplegia). About half of the cases of spinal cord injury involve the neck. However,
partial or complete recovery may be expected in cases when neurons in the spinal cord have been
traumatized but not completely destroyed. Outcome thus depends upon both the severity and the
specific location of the injury. Damage to the spinal cord will affect nerves at the level of the
injury and below. (John Hopkins Symptoms and Remedies; S.Margolis,M.D.,Ph.D.)

The immediate response to cord transaction is called SPINAL SHOCK. The client with
SCI experiences a complete loss of skeletal muscle function, bowel and bladder tone, sexual
function, and autonomic reflexes. Loss of venous return and hypotension also occur. The
hypothalamus cannot control temperature by vasoconstriction and increased metabolism;
therefore the client’s body assumes the environmental temperature. Spinal shock is most severe
in clients with higher levels of SCI. Clients with thoracic and lumbar injuries are often
unaffected because the sympathetic nervous system is spared with these levels of injury.

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

2
Background of the Study

The researchers conducted this study at St. Dominic Medical Center during the first
rotation duty in the ward unit.

They received their patient in station 3A room 308 in a rehabilitative situation but should
be managed with proper nursing care. 6days PTA, patient was accidentally hit his head after a
dive in a beach in Boracay, suddenly lost of motor function (upper and lower
extremities).Admitted at a hospital in Kalibo, Aklan where he is known to developed decubitus
ulcers in sacral area upon admission at SDMC.

The researchers drew interest upon the case due to the integration of different concepts
of the condition of Spinal Shock Syndrome. This includes the correlation of comprehensive and
other manifestations of the injury. As on the part of the researchers thorough study is required to
obtain accurate results and thus conclusion and to know and share the proper nursing
interventions to be done in caring of patients with this condition.

3
Statement of the Problem

1. What is the Patient’s Profile?

2. What are the different assessment parameters of a patient with Spinal Shock Syndrome?
3. What are the different interrelated factors to the problem?
4. What are the different nursing diagnoses formulated based on the client’s manifestations?
5. Which of the Nursing Diagnosis identified, is the priority? What is the least prioritized?
6. What appropriate nursing interventions can be formulated based on the
identified problems?

Significance of the Study

A. Client and His Family

This study will provide knowledge about the client’s condition. It will enable the patient
to accept gradually his situation as well as his significant others. It can also help the relatives of
the patient to know their responsibilities in caring the patient.

B. Nursing Service Department

This study has comprehensive information about Spinal Shock Syndrome that will help
them enhance their knowledge and awareness about the case. It may also be a reference for
future studies and serve as a tool in teaching regarding clients with spinal shock syndrome.

C. Nursing Education

This study will make individuals who are part of the academic community more aware
and sensitive to their patient’s feeling in revealing the truth about the condition thus, this will
help them study and get knowledge about the condition and then improve the way of supporting
them emotionally and spiritually. It will provide facts that would uplift and improve the skills
and knowledge in handling this kind of case by enlightening them to engage in relevant and
future studies related to Spinal Shock Syndrome. Also it is relevant to know the promotive and
rehabilitative nursing care for the client.

4
 D. Nursing Students

This study will help them to have more knowledge about Spinal Shock Syndrome that
will help them on the development of their approach in dealing with patients with the same case,
as well as the appropriate procedure to be done to their patient. They will learn from the
experiences of the researchers and may this case set a guideline in giving care to the client.

E. Future Researcher

This will provide some information that might be useful for them in their future research.
This case study will give the information about Spinal Shock Syndrome and the right
interventions. Moreover, this may help them to have a reference for future studies to clients with
Spinal Shock Syndrome. Making them realize the need to engage in an in-depth or related
analysis of spinal shock syndrome cases so that the new improvements and trends in the care and
management of spinal shock syndrome be discovered and utilized.

F. Health Care Professional

The study could help the health care providers to have additional knowledge on how to
handle patients with spinal shock syndrome. They will be able to give comfort and be aware of
the nursing interventions in case that they are about to have this kind of case.

Scope and Limitation

The researchers had their clinical exposure from June 30 to July 16, 2008. Mr. Whiplash
was handled for 3 days in 3 consecutive weeks. First hand information was acquired from
Student Nurse – Patient Interaction and Patient’s Chart.

Nursing Diagnosis was made on the actual problems as manifested by the client during
the student’s exposure on the area. Potential problems may be developed but was not described
anymore due to existence of more complicated current medical problems.

5
 Chapter 2

REVIEW OF RELATED LITERATURE

Related Literature

Anatomy and Physiology of Neurologic System

The nervous system is the body's most organized and complex structural and functional
system. It profoundly affects both psychological and physiologic functions.

Central Nervous System

 Three major functional Divisions:

 higher – level brain, or cerebral cortex
 lower brain level (basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla,
cerebellum)
 spinal cord
 these structures are protected by a rigid bony encasement, three layers of membranes, a
fluid cushion, and a blood – brain or blood – spinal barrier

The cerebellum integrates sensory information related to the position of body parts,
coordinates skeletal muscle movement, and regulate muscle tension, which is necessary for
balance and posture. Three pairs of nerve tracts (cerebellar peduncles) provide the
communication pathways. The inferior peduncles are sensory (afferent) pathway from the spinal
cord and medulla, which carry pathway from the spinal cord and medulla, which carry
information related to the position of the body parts of the cerebellum. The middle peduncles
carry information about voluntary (purposeful) motor activities from the cerebral cortex to the
cerebellum. The cerebellum also receives sensory input from the receptors in the muscles,
tendons, joints, eyes and inner ear. After this information is integrated and analyzed, the
cerebellum sends impulses via the superior peduncles (efferent pathways) to the brain stem,
thalamus, and cortex.

6
 Most of the tracts in the cerebellum travel through various nuclei without crossing.
Therefore the right cerebellar hemisphere predominantly affects the right (ipsilateral) side of the
body and vice versa.

Spinal Cord

The spinal cord, that portion of the CNS surrounded and protected by the vertebral
column, is continuous with the medulla and lies within the upper two thirds of the vertebral
canal (the cavity within the vertebral column). The lower spinal cord terminates caudally in a
cone-shaped structure known as the conus medullaris at the level of the first (L1) and second
(L2) lumbar vertebrae. The spinal cord is sub-divided into four areas: (1) cervical cord, (2)
thoracic cord, (3) lumbar cord, and (4) sacral cord (cons medullaris).

Within the spinal cord, butterfly – shaped gray matter (mostly unmyelinated) is
surrounded by mostly myelinated white matter. The white matter consists of ascending tracts
and descending tracts that conduct nerve impulses between the brain and the cells outside the
CNS. The cell bodies in the gray matter are grouped into cluster of nuclei and laminae (a define
group or column of cells). The tracts in the white matter are arranged into three paired column:
posterior, lateral, and anterior.

Ascending and Descending Pathways

The ascending (sensory) pathways carry sensory information through the spinal cord to
the brain. For example, the spinothalamic tract carries sensory information from the spinal cord
to the thalamus. After synapsing in the thalamus, information is relayed to regions of the brain
such as the parietal lobe. Descending (motor) pathways carry mostly efferent signals to the spinal
cord. The corticospinal tract (upper motor neuron) is a descending tract passing from the frontal
lobe of the cerebral cortex to the motor neurons of the spinal cord. Lower motor neurons are cells
that begin in the anterior horn of the spinal cord and pass through the spinal nerves to the muscle
cells. Propriospinal tracts remain within the cord.

7
 Many of the tracts communating with the cerebral cortex cross (decussate), but not all
cross at the same place. The term contralateral refers to the opposite side of the body and is used
to describe tracts that cross (often at the medulla) and ascend or descend; ipsilateral (same –
sided) tracts do not cross. For example, sensory tracts (including the anterior spinothalamic,
posterior, and anterior spinocerebellar tracts) cross in the medulla as they ascend to the cerebral
cortex. Therefore the sensory neurons in the cerebral cortex interpret sensory stimuli from the
contralateral side of the body. The lateral corticospinal tract (pyramidal tract) crosses at the
medulla as it descends from the frontal lobe of the cerebral cortex to the spinal cord. The
posterior spinocerebellar tracts are ipsilateral tracts and thus coordinate muscular function on the
same side of the body. The crossing of the lateral spinothalamic tract is unique.

Major nerve tracts of the Spinal Cord

Tract Location Function
Ascending tracts
Fasciculus gracilis Posterior column Touch, pressure, body
movement, position
fasciculus cuneatus Posterior column
Spinothalamic Lateral and anterior columns Pain, temperature, light (crude)
touch
Spinocerebellar
Posterior Lateral Column Coordination of muscle
Anterior Lateral Column movements
Descending Tracts
Corticospinal
Lateral Lateral Column Voluntary Motor
Ventral Anterior Column Voluntary Motor
Reticulospinal
Anterior Anterior Column Muscle tone,
Medial Anterior Column sweat glands

8
 Rubrospinal Lateral Column Coordination of muscle
movements
Lateral Lateral Column Autonomic nervous system
fibers

Cranial and Vertebral Column

Eight bones that fuse early in childhood compose the cranium. The fused junctions are
called sutures. The cranium encloses the brain structures and serves as a source of protection.

The floor, or bacilar plate, of the cranial vault has three depressions, called fossae. The
frontal lobes lie in the anterior fossa. The temporal lobesand the base of the diencephalon lies in
the middle fossa. The cerebellum rests in the posterior fossa.

The vertebral column, a flexible series of vertebrae, surrounds and protects the spinal
cord. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral
vertebrae fused into a sacrum, and 4 coccygeal vertebrae fused into a coccyx. Ligaments hold the
vertebrae together, and disks between the vertebrae prevent the bone from rubbing together.

Meninges

The meninges, three membranes that envelope the brain and spinal cord, are
predominantly for protection. Each layer – the pia mater, arachnoid, and dura mater – is a
separate membrane.

The pia mater is a vascular layer of connective tissue that is so closely connected to the
brain and spinal cord that it follows every sulcus and fissure. This layer serves as a supporting
strucuture for blood vessels passing through to the tissues of the brain and spinal cord. The pia
mater and astrocytes together form the membrane part of the blood-brain barrier.

9
 The arachnoid, a thin layer of connective tissue, extends from the top of each gyrus to the
top of the adjacent gyrus; it does not extend into the sulci and fissures. The space between this
layer and pia mater is known as the subarachnoid space. Cerebrospinal fluid flows through this
space.

The cranial dura mater is a tough, nonstretchable vascular membrane with two layers.
The outer dura mater is actually the membrane (periosteum) of the cranial bones. The inner dura
matetr forms the plates that separate the two cerebral hemispheres (falx cerebri), the crebrum and
the brain stem and the crebellum (tentorium cerebelli), and the cerebellar hemispheres. The
tentorium cerebelli is a landmark term that is often used by clinicians to separate parts of the
brain; it is often referred to as tentorium. Supratentorial refers to the cerebrum and all the
structures superior to the tentorium cerebelli; infratentorial refers to the structures inferior to the
tentorium cerebelli: the brains stem and the cerebellum.

Brain spaces that often fill with blood after head trauma include the potential space
(subdural space) between the inner dura mater and the arachnoid and the epidural space between
the dura mater and the periosteum.

The meninges anchor the spinal cord. The pia mater, which closely surrounds the spinal
cord, continues from the tio of the conus as a thread-like structure (filum terminale) to the end of
the vertebral column, where it is anchored into the ligament on the posterior side of the coccyx.
The denticulate ligaments extend laterally from the pia mate r to the dura mater to suspend the
spinal cord from the dura mater.

Two common spaces that are commonly accessed by physicians are the subarachnoid
space (for diagnostic studies) and the epidural space (for delivery of medications). The
subarachnoid space extends below the level of the spinal cord to the second sacral (S2) vertebral
level, and the epidural space lies between the dural sheath and the vertebral bones.

Reflex Mechanisms

Our unconscious automatic responses to internal and external stimuli, known as reflex
responses, provide many homeostatic functions. Although the spinal cord is often thought of as

10
the reflex center, it is not the only site for reflex regulation. Many of the complex reflexes
controlling heart rate, breathing, blood pressure, swallowing, sneezing, coughing, and vomiting
are found in the brain stem.

Some intrinsic reflex circuits in the spinal cord create patterns of movement (flexion and
extension) that are the basis for posture and forward progression. Other reflex circuits are the
bases for the spinal cord reflexes, which include the myotatic (deep tendon, stretch) reflex, the
flexor withdrawal reflex, the crossed extension reflex, and the extensor thrust reflex. Visceral-
somatic reflexes can also excite or inhibit the motor neurons, producing changes in the muscle
tone and even in movement.

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

of spindles leads to contraction of the same muscle, commonly seen as the knee-jerk reflex. The
Golgi tendon organs are sensory nerve endings that protect against excessive contraction.

Simple reflexes require only two or three neurons; for example, the knee-jerk reflex
requires only a sensory and a motor neuron. The withdrawal reflex helps prevent or decrease
tissue injury when a body part touches a potentially harmful object. The harmful stimuli are sent
via the sensory neuron to the interneuron in the spinal cord for interpretation, and the response
message is sent via the motor neuron, resulting in the withdrawal response.

AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system (ANS) is the part of the PNS that coordinates involuntary
activities, such as visceral functions, smooth and cardiac muscle changes, and glandular

11
responses. Although it can function independently, its primary control is the brain and spinal
cord. The ANS has two divisions: the sympathetic and the parasympathetic nervous systems. The
efferent ANS fiber travel within some cranial and spinal nerves. These two systems are highly
integrated and interact with each other to maintain a stable internal environment.

Unlike the somatic neurons, which usually are single neurons linking the CNS to a
muscle or gland, the ANS has a two – neuron chain leading to the effector organ. The terminal of
the first neuron is located in the CNS and synapses with nerve fibers whose cell bodies are
neuron (postgangliotic fiber) carries impulses to the target viscera. An exception is the adrenal
medulla, which is innervated directly by pregangliotic fibers. The medulla is actually composed
of postgangliotic neurons that secrete epinephrine into the bloodstream during an “adrenal rush”.

The sympathetic nervous system coordinates activities used to handle stress and is geared
for action as a whole for short periods. The preganglionic neurons of the sympathetic nervous
system emerge from the spinal cord via the motor (ventral) roots of the thoracic and upper two
lumbar spinal nerves (T1 – L2). Preganglionic axons are short; postganglionic axons are long.

The parasympathetic nervous system is associated with conservation and restoration of

energy stores and is geared to act locally and discretely for a long duration. The preganglionic
fibers emerge from the spinal cord via the sacral spinal nerves at S2 – 4. these preganglionic
fibers have long axons that synapse with the postganglionic neurons in the ganglia close to or
located within the organs to be innervated. Each postganglionic neuron has relatively short axon.
Most, but not all, organ system has both parasymphatetic and sympathetic innervations. About
75% of the parasymphatetic fibers are in the vagus nerves.

Effects of symphatetic and parasympathetic nervous systems on organs

Organs Effect of sympathetic stimulation Effects of parasympathetic stimulation
Eye
pupil Dilation (alpha) Constriction

12
 ciliary muscle slight relaxation (far vision) constriction (near vision)
Glands
nasal
lacrimal
parotid
submandibular
gastric
pancreatic
Sweat glands Copious sweating (cholinergic) Sweating on palms and hands
Apocrine glands Thick, odoriferous secretion None
Heart
muscle Increase rate (beta1) Slowed rate
increase force of contraction (beta1) decrease force of contraction
dilated (beta2); constricted (alpha) (especially of atria)
coronaries dilation
Lungs
bronchi Dilation (beta2) Constriction
blood vessels mild constriction ? dilation
Gut
lumen Decreased peristalsis and tone (beta2) Increase peristalsis and tone
sphincter increased tone (alpha) relaxation (most times)
Liver Glucogenesis, glycogenolysis (beta2) Slight glycogen sythesis)
Gall bladder and bile Relaxation Contraction
ducts
Kidney Decreased output and renin secretion None
Bladder
detrusor Relaxation (slight) (beta2) Contraction
trigone contraction (alpha) Relaxation
Penis Ejaculation Erection
Systemic Arterioles
abdominal viscera Constriction (alpha) None
muscle constriction (alpha) none

13
 dilation (beta2)
dialtion (cholinergic)
skin constriction none
Blood
coagulation Increase None
glucose increase none
lipids increase none
Basal metabolism Increase up to 100% None
Adrenal medullary Increase None
secretion
Mental activity Increase None
Piloerector muscles Contraction (alpha) None
Skeletal muscle Increased glycogenolysis (beta2) None
increase strength
Fat cells Lipolysis (beta1) None

The functions and responses of the sympathetic and parasympathetic nervous system are
related to the type of neurotransmitters released. The preganglionic fibers of the sympathetic and
parasympathetic nerves and the postganglionic fibers of the parasympathetic nerves release
acetycholine. The postganglionic fibers of the sympathetic nerves release norepinephrine. Fibers
that secrete acetycholine are called cholinergic fibers; fibers that secretes norepinephrine are
called adrenergic fibers.

The compexity of the sympathetic and parasympathetic response also depends on the type
of receptor that combines with the neurotransmitter. The sympathetic nervous system has four
types of receptors: alpha1, alpha2, beta1, and beta2. The parasympathetic nervous system has
muscarnic and nicotinic receptors.

14
PATIENT’S PROFILE

Name: Mr. Whiplash

Age: 43 Years Old

Gender: Male

Religion: Roman Catholic

Occupation: Construction Worker

Company: David M Consulzhi Inc. (DCMI)

Leisure Activity: Swimming

Medical Abstract:

6days PTA, patient was accidentally hit his head after a dive in a beach in Boracay,
patient verbalized sudden lost of motor function (upper and lower extremities).Admitted at a
hospital in Kalibo, Aklan where he is known to developed decubitus ulcers sacral area upon
admission in SDMC.

Working Impression:

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

Clinical Impression:

6days PTA (June 6, 2008), patient was accidentally hit his head after a dive in a pool in
Boracay, suddenly lost of motor function (upper and lower extremities).

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

Pertinent Findings:

Conscious, coherent, stretcher borne GCS 15

(-) facial asymmetry

15
 Motor:

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

0/5 0/5 40 60

Management:

CT scan done

Presently on physical Therapy session

Sacral sore management done

Debridement done 2x

On Senokot

16
 PATHOPHYSIOLOGY OF SPINAL SHOCK SYNDROME

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

Hyperextension of the head (whiplash effect)

Compression of the spinal cord (cervical cord)

Spinal Shock Syndrome

Loss of autonomic activity

Sympathetic stimulation
Incomplete paralysis of the liver
(Quadriplegia)

Gluconeogenesis Interference in the

Long term Bed Gluconeolysis Blockage of sympathetic
transmission of
Rest response of the heart, and
sensory cortex lungs
Blood glucose level
Failure in nursing
(early effect of shock)
intervention (turning) Inhibition of the reflex
emptying of the bowel
and bladder
Altered metabolic
Stimulation of the
function 17
Formation of pressure sore in parasympathetic response of the
sacral area lungs, heart and reproductive
organ
 Skin deformities
(decubitus ulcer)

GI motility Uncontrolled bladder filling

Worsted from Stage 1 accompanied by (-) detrusor
to Stage IV pressure contraction and (-) sphincter
ulcer relaxation
Peristalsis of the
small intestine
Exposure to Urinary retention
pathogens
Fecal distention
Autonomic neurogenic
Spread of invading bladder
pathogens Autonomic neurogenic
bowel

Defense mechanism:
temperature

Constriction of Vasodilation of
the bronchi blood vessels

18
 Alveoli Perfusion Total peripheral
resistance

Gas exchange

Oxygen level in
blood Venous pressure
Circulating and venous volume
blood volume

Carbon dioxide level

Cardiac output
(bradycardia)
Compensatory mechanism:
oxygenation

Respiratory rate Blood pressure

(hypotension)

Respiratory insufficiency

CONCEPT MAP

19
 1. Impaired 2. Impaired Skin/
physical mobility Tissue Integrity

Quadriplegic Bed sores and

(sacral region foot
Nerve paralysis part)

5. Chronic Pain 3. Wound Tissue

Infection
Immobility
Presence of
Nerve paralysis Decubitus ulcer
SPINAL SHOCK SYNDROME with foul odor

(Whiplash Injury)

6. Impaired 4. Acute pain

urinary Function
Decubitus ulcer
Negative micturation
Debridement pain

7. Bowel 8. Self Care Deficit

Incontinence
Poor hygiene due to
Negative bowel immobility RISK:
movement
POTENTIAL
PROBLEMS

20
PHYSICAL ASSESSMENT TEST

21
 Standard Neurological Classification of Spinal Cord Injury

MOTOR: Key Muscles

C2
C3
C4
C5 2 2 Elbow Flexors
C6 0 0 Wrist Extensors
C7 1 1 Elbow Extensors
C8 1 1 Finger Flexors (distal phalanx of middle finger)
T1 1 1 Finger Abductors (little finger)
T2
T3 Legend:
T4
0 = total paralysis
T5 1 = palpable or visible
T6 contraction
2 = active movement
T7 gravity eliminated
T8 3 = active movement
against gravity
T9
4 = active movement
T10 against some resistance
T11 5 = active movement
against full resistance
T12 NT= not testable
L1
L2 3 3 Hip Flexors
L3 3 3 Knee extensors
L4 1 3 Ankle dorsiflexors
L5 1 3 Long toe extensors
S1 2 3 Ankle plantar extensors
S2
S3
S4 - 5 Voluntary anal contraction (Yes/No)
Total 17 + 20 = 37 Motor Score
(Maximum) (50) (50) (100)

22
SENSORY

Light Touch Pin Prick

R L R L
C2 2 2 2 2
C3 1 1 2 2
C4 1 2 2 2
C5 2 2 2 2
C6 1 2 2 1
C7 1 1 1 1
C8 1 1 2 2
T1 1 1 2 2
T2 1 1 2 2
T3 1 1 2 2
T4 2 2 1 2
T5 2 2 1 2
T6 2 2 1 2
T7 2 2 1 2
T8 2 2 1 2
T9 2 2 1 2
T10 1 1 1 1
T11 2 2 1 1
T12 1 1 1 1
L1 2 1 1 1
L2 1 1 1 1
L3 1 1 1 2
L4 1 1 1 1
L5 1 1 1 1
S1 1 1 1 1
S2 1 1 1 1
S3 NT NT NT NT
S4 - 5 NT NT NT NT

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

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

23
 Ultrasound Report

Kidney and Urinary bladder Ultrasound

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

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

Foley catheter noted.

IMPRESSION: Normal Kidneys, Bilateral

Normal Urinary Bladder

24
 COMPUTERIZED TOMOGRAPHY REPORT (June 14, 08)

CRANIAL CT SCAN

NON CONTRAST AND CONTRAST ENHANCED CRANIAL CT SCAN WITH BONE

SETTING REVEALED THE FOLLOWING IMPRESSION / FINDINGS:

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

2. Midline structures are in place

3. Posterior fossa structures are unremarkable

4. There is satisfactory opacification of the major intracerebral vessels

5. Bone settings show densities within the left maxillary, ethmoid and sphenoid sinus
indicative of sinusitis

CERVICAL CT SCAN

CERVICAL PLAIN: IMPRESSION / FINDINGS:

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

2. There is a right sided neural foraminal narrowing at C5 – C6 level

3. The atlanto – axial joint space and vertebral bodies are intact

4. Rest of the vertebral bodies and hyoid bone are unremarkable

25
 FUNCTIONAL INDEPENDENCE MEASURE (FIM) SCORE (July 11, 08)

LEVELS:

7 complete independence (timely, safely)

6 modified independence (device)

Modified Independence

5 supervision (subject = 100%+)

3 minimal assist (subject = 75%+)

Complete Dependence

2 maximal assist (subject = 25%+)

1 total assist (subject = less than 25%)

Self Care:

A.Eating 1
B. Grooming 1
C. Bathing
1
D.Dressing upper body

E. Dressing lower body

1
F. Toileting
1

1
Sphincter Control

G.Bladder Management 1
1
H.Bowel Management
Transfers

26
 I. Bed, Chair, Wheelchair 1
1
J. Toilet 1

K.Tub, Shower
Locomotion

L. Walk / Wheelchair W= walk 1

M. Stairs C = wheelchair 1

B = both
Motor Subtotal Score 13
Communication

N.Comprehension A = auditory 7
7
O.Expression V = visual

B = both
Social Cognition

P. Social Interaction V = Vocal 7

7
Q.Problem Solving N = Nonvocal 7

R. Memory B = both
Cognitive Subtotal Score 35
TOTAL FIM SCORE 48

27
 BLOOD CHEMISTRY (June 24, 08)

EXAMINATIONS REFERENCE RESULTS EXAMINATIONS REFERENCE RESULTS

Glucose (GodPap) 4.1 – 6.3 mmol/L Total Protein 7.0 – 9.0 g/dL
Glucose mmol/L Albumin 3.5 – 5.2 g/dL
(hemoglucotest
Urea Nitrogen 6.1 – 15.4 mmol/L Globulin 3.0 – 4.0 g/dL
Creatinine 53 – 106.1 umol/L A/G Ratio 1.0 – 2.5
Uric Acid M mmol/L Electrolytes

F mmol/L
Total Cholesterol 0 – 5.7 mmol/L Potassium 3.5 – 5.0 Ommol/L 4.4
Triglycerides 0 – 2.2 mmol/L Sodium
HDL Chloride
LDL Calcium 8.6 – 10.3 mg/dL
Alkaline Phosphate 35 – 129 IU/L Blood Gas
SGOT (AST) 0 -38 IU/L Other
SGPT(ALT) 0 – 41 IU/L
Total Bilirubin mmol/L
Direct Bilirubin mmol/L
Indirect Bilirubin mmol/L

28
 BLOOD CHEMISTRY (June 14, 08)

EXAMINATIONS REFERENCE RESULTS EXAMINATIONS REFERENCE RESULTS

Glucose (GodPap) 4.1 – 6.3 mmol/L 7.9 Total Protein 7.0 – 9.0 g/dL
Glucose mmol/L Albumin 3.5 – 5.2 g/dL
(hemoglucotest
Urea Nitrogen 6.1 – 15.4 mmol/L Globulin 2.0 – 4.0 g/dL
Creatinine 53 – 106.1 umol/L A/G Ratio 1.0 – 2.5
Uric Acid M mmol/L Electrolytes

F mmol/L
Total Cholesterol 0 – 5.7 mmol/L 5.12 Potassium
Triglycerides 0 – 2.2 mmol/L 1.4 Sodium
HDL 0.8 – 1.8 mmol/L 1.80 Chloride
LDL 2.0 – 4.0 mmol/L 2.68 Calcium 8.6 – 10.3 mg/dL
Alkaline Phosphate 35 – 129 IU/L Blood Gas:
Conventional Unit:
FBS 75 – 115 mg/dL 143
SGOT (AST) 0 -38 IU/L Other
SGPT(ALT) 0 – 41 IU/L
Total Bilirubin mmol/L

29
Direct Bilirubin mmol/L
Indirect Bilirubin mmol/L

BLOOD CHEMISTRY (June 13, 08)

EXAMINATIONS REFERENCE RESULTS EXAMINATIONS REFERENCE RESULTS

Glucose (GodPap) 4.1 – 6.3 mmol/L Total Protein 7.0 – 9.0 g/dL
Glucose mmol/L Albumin 3.5 – 5.2 g/dL
(hemoglucotest
Urea Nitrogen 6.1 – 15.4 mmol/L Globulin 2.0 – 4.0 g/dL
Creatinine 53 – 106.1 umol/L 70.7 A/G Ratio 1.0 – 2.5
Uric Acid M mmol/L 0.19 Electrolytes

F mmol/L
Total Cholesterol 0 – 5.7 mmol/L Potassium
Triglycerides 0 – 2.2 mmol/L Sodium
HDL Chloride
LDL Calcium 8.6 – 10.3 mg/dL
Alkaline Phosphate 35 – 129 IU/L Blood Gas:
SGOT (AST) 0 -38 IU/L Other
SGPT(ALT) 0 – 41 IU/L

30
Total Bilirubin mmol/L
Direct Bilirubin mmol/L
Indirect Bilirubin mmol/L

HEMATOLOGY (June 13, 08)

EXAMINATIONS REFERENCE RESULT EXAMINATIONS

Hemoglobin F – 120 – 160 Differential count

M – 140 - 180 142 Neutrophils

Hemtocrit F – 0.36 – 0.43 Myelocytes

M – 0.42 – 0.54 0.43 Juveniles

Total RBC count F – 4.5 – 5.5 Stabs

M – 5.0 – 6.2 Segmenters 0.81

Total WBC 5 – 10 x 109/L 15.7 Blasts
Total Platelet count 150 – 350 x 109/L Adequate Lymphocytes 0.19
Reticulocyte count monocytes
Erythrocytes sed. Rate F – 0 – 20 Eosinophils

M – 0 – 10 Basophils

31
 Clotting time 2 – 4 mins. Nucleated RBC
Bleeding time 1 – 3 mins. Toxic Granulations
Blood typing/RH typing Malarial Smear
Clot retraction time Peripheral Smear
Prothrombin time Others

URINALYSIS (June 13, 08)

PHYSICAL CHEMICAL OTHER TESTS

Color Yellow Albumin Trace 24 HOURS ALBUMIN

Reaction Alkaline Sugar negative
Transparency turbid Chloride
Quantity Calcium
Specific Gravity 1.005 Bile Test
Acetone
MICROSCOPIC
CAST: CELLS:
Hyaline pus cells 10 -15/hpf
Granular (coarse): 1-3/lpf red blood cells 35 – 40/hpf
Pus Cell yeast cells PREGNANCY TEST:
RBC epithelial cells occasional
Epithelial renal cells monoclonal test (TEST PACK)

32
 Color Yellow Albumin Trace 24 HOURS ALBUMIN
CRYSTALS: OTHERS:
amorphous uratres PO4: moderate mucus threads few
calcium oxalate bacteria few
uric acid cylindroids
triple phosphate
others

gravindex (LATEX SLIDETEST)

URINALYSIS (June 18, 08)

PHYSICAL CHEMICAL OTHER TESTS

Color Yellow Albumin Trace 24 HOURS ALBUMIN

Reaction Alkaline Sugar negative
Transparency turbid Chloride
Quantity Calcium
Specific Gravity 1.010 Bile Test
Acetone
MICROSCOPIC
CAST: CELLS:
Hyaline pus cells 0 - 2/hpf

33
 Color Yellow Albumin Trace 24 HOURS ALBUMIN
Granular (coarse): 1-3/lpf red blood cells 45 - 50/hpf
Pus Cell yeast cells PREGNANCY TEST:
RBC epithelial cells occasional
Epithelial renal cells monoclonal test (TEST PACK)
CRYSTALS: OTHERS:
amorphous uratres PO4: rare mucus threads few
calcium oxalate bacteria rare
uric acid cylindroids
triple phosphate
others
gravindex (LATEX SLIDETEST)

DRUG STUDY

34
 AMOXICILLIN (Anti-infective)

Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

35
Interferes with the Infections of Adult: PO 500mg Nausea, vomiting, Hypersensitivity to  Assess patient for
cell wall respiratory tract, diarrhea, urticaria, penicillins previous sensitivity
replication of skin, skin rash reaction to penicillin or
susceptible structures, CAUTION: other cephalosporin,
organisms by genitourinary Pregnancy B, cross sensitivity
binding to the tract, otitis media, hypersensitivity to between penicillin and
bacterial cell wall; meningitis, cephalosporins, cephalosporins is
the cell wall, septicemia, neonates, renal disease common.
rendered sinusitis and  Assess patient for signs
osmotically bacterial and symptoms.
unstabled, swells endocarditis  Assess for allergic
and bursts from prophylaxis. reactions during
osmotic pressure. treatment.
 Teach patient to report
sore throat, bruising,
bleeding, and joint pain;
may indicate blood
dyscrasias.
 Advise patient to
contact prescriber if
vaginal itching, loose
foul- smelling stools,
diarrhea, sore throat,
fever, fatigue, furry
tongue occur; may
indicate superinfection
or agranulo cytopenia

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

36
 Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Interferes with cell Infections of 625mg/tab Nausea, vomiting, Hypersensitivity to  Assess patient for
wall replication of respiratory tract, Route: Oral diarrhea, urticaria, penicillins previous sensitivity
susceptible skin, skin rash reaction to penicillin or
organisms; the cell structures, 1 tab PO tid CAUTION: other cephalosporin,
wall, rendered genitourinary Pregnancy B, cross sensitivity
osmotically tract; otitis media, 8:00am- 2:00pm – hypersensitivity to between penicillin and
unstable, swells meningitis, 8:00pm cephalosporins, cephalosporins is
and bursts from septicemia, neonates, renal disease common.
osmotic pressure; sinusitis and  Assess patient for signs
combination endocarditis and symptoms.
increases spectrum prophylaxis  Assess for allergic
of activity, B – reactions during
lactamase treatment.
resistance  Teach patient to report
sore throat, bruising,
bleeding, and joint pain;
may indicate blood
dyscrasias.
 Advise patient to
contact prescriber if
vaginal itching, loose
foul- smelling stools,
diarrhea, sore throat,
fever, fatigue, furry
tongue occur; may
indicate superinfection
or agranulo cytopenia

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

37
 Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Needed for wound Vitamin C Adult: PO 500mg Headache, insomnia, Tartrazine, sulfate  Assess for nutritional
healing, collagen deficiency, scurvy, dizziness, fatigue, sensitivity, G6PD status for conclusion of
synthesis, delayed wound flushing, nausea and deficiency foods high in vit. C.
antioxidant, and bone healing, vomiting, diarrhea,  Assess for vit.C
carbohydrate chronic disease, anorexia, polyuria, Caution: deficiency before,
metabolism, urine acidification, urine acidification, Pregnancy C, gout, during and after
protein, lipid before oxalate or urate diabetes, renal calculi treatment.
synthesis, gastrectomy; renal stones, dysuria (large doses)  Monitor input and
prevention of increase need ; output ratio.
infection lactation,  Monitor ascorbic acid
pregnancy, levels throughout
hyperthyroidism, treatment if continued
emotional stress, deficiency is suspected.
trauma, burns,  Teach patient the
acidification of necessary foods to be
urine, dietary included in diet that are
supplement rich in vitamin C, citrus
fruits, cantaloupe,
tomatoes
 Teach patient that
smoking decreases
vitamin C levels; not to
exceed prescribed dose;
increases will be
excreted in urine,
except time release.

Azithromycin (Zithromax) (anti-infective)

38
 Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Binds to 50s Mild to moderate Adult: 500mg Nausea and Hypersensitivity to  Assess for signs and
ribosomal sub- infections of the vomiting, diarrhea, azithromycin, symptoms of
units of upper respiratory dizziness, erythromycin or any infection
susceptible tract, lower headache, macrolide  Monitor respiratory
bacteria and respiratory tract, palpitations and status
suppresses uncomplicated chest pain Caution:  Monitor allergies
protein skin and skin Pregnancy B, before treatment,
synthesis; much structure lactation, reaction of each
greater spectrum infections, hepatic/renal/cardiac medications, place
of activity than nongonococcal disease, elderly, allergies on chart,
erythromycin urethritis or child < 6 mon. for notify all people
cervicitis; otitis media, child < giving drugs.
prophylaxis of 2 yrs for pharyngitis  Monitor input and
disseminated and tonsillitis output, renal studies
mycobacterium  Monitor bowel
avium complex pattern before, during
(MAC) treatment

Cefuroxime (Cephalosporins 2nd Generation)

39
 Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Inhibits bacterial UTI, otitis media, Adult: 75g Dizziness, headache, Hypersensitivity to  Assess patient for
cell wall synthesis, skin infection, diarrhea, nausea, cephalosporins or previous sensitivity
rendering cell wall gonorrhea vomiting, vaginitis, related antibiotics, reactions to penicillins
osmotically dyspnea seizures or other cephalosporins
unstable, leading  Assess patient for signs
to cell death by Caution: pregnancy B, and symptoms of
binding to cell lactation, children, infection including
wall membrane. renal disease characteristics of
wounds, sputum, urine,
stool, wbc
>10,000/mm3, earache,
fever, obtain baseline
information and drug
treatment.
 Assess for anaphylaxis.
 Teach patient to report
sore throat, bruising,
bleeding, joint pain;
may indicate blood
dyscarasias.
 Instruct patient to take
all medication
prescribed for the
length of time ordered;
to use yogurt or
buttermilk to maintain
intestinal flora, decrease
diarrhea.

DEXAMETHASONE (Corticosteroid, synthetic)

40
 Action Indication Dosage and Adverse Effects Contraindications Nursing Responsibility
Routes

Decreases Inflammation, 4mg/tab Depression, Psychosis,  Monitor potassium,

inflammation by allergies, PO tid flushing, hypersensitivity, blood, urine glucose
suppression of neoplasms, sweating, idiopathic while on long term
migration of cerebral edema, 8:00am – 2:00 pm hypertension, thrombocytopenia, therapy.
polymorphonuclear septic shock, 8:00pm diarrhea, nausea, acute  Monitor weight
Leukocytes, collagen abdominal glomerulonephritis, daily.
fibroblasts, disorders. distention, amebiasis, fungal  Monitor BP q24h,
reversal of increased appetite. infections, non pulse, notify
increased capillary asthmatic bronchial prescriber cortisol
permeability and disease, child <2yr., levels during long
lysosomal AIDS, TB term therapy.
stabilization.  Advise that
CAUTION: emergency ID as
Pregnancy C, steroid user should
lactation, diabetes be carried or worn.
mellitus, glaucoma,  Teach symptoms of
osteoporosis, seizure adrenal insufficiency.
disorders, ulcerative  Instruct patient to
colitis, CHF, notify prescriber of
myasthenia gravis, infectio n.
renal disease, peptic
ulcer, esophagitis.

41
 GABAPENTIN (Anticonvulsant)

Action Indication Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Mechanism Adjunct 300mg/tab Dizziness, fatigue, Hypersensitivity to  Assess seizures; aura,

unknown; may treatment of anxiety, this drug location, duration,
increase seizure partial seizures, PO OD 9:00pm vasodilation, activity at onset.
threshold; with or without peripheral edema, CAUTION:  Assess renal studies
structurally generalization in hypotension, dry Pregnancy C, renal  Assess mental status
similar to patients >12yr; mouth, bluured disease, lactation,  Teach patient avoid
GABA; adjunct in partial vision, chil <12yr, elderly, driving, other
gabapentin seizures in constipation, hemodialysis activities that requires
binding sites in children 3-12yr, increased appetite alertness.
neocortex, postherpic  Teach patient to
hippocampus. neuralgia. gradually withdraw
over 7days; abrupt
withdrawal mat
precipitate seizures.

42
 Lactulose (Laxative)

Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

> Increases > Chronic Syrup Nausea, vomiting, Hypersensitivity, - Monitor glucose
osmotic pressure; constipation, anorexia, low- galactose diet level of the
draws fluid into portal- systemic 2 tbsp PO OD abdominal cramps, patient
colon; prevents encephalopathy in 9:00pm diarrhea
absorption of patients with - Monitor blood
CAUTION: ammonia level;
ammonia in hepatic disease.
colon; increases Pregnancy B, monitor for
water in stool. lactation, diabetes clearing of
mellitus, elderly confusion,
and debilitated lethargy,
patient. restlessness,
irritability; may
decrease
ammonia level
by 50%.

- Discuss with
patient that
adequate fluid
consumption is
necessary.

43
 Ranitidine HCL(H2 histamine receptor antagonist)

Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

> Inhibits > Short- term 150mg/tab Constipation, Hypersensitivity - Assess patient with
histamine at H2 treatment of abdominal pain, ulcers or suspected
receptor site in the duodenal and Route: Oral diarrhea, nausea, ulcers: epigastric
gastric parietal gastric ulcers and vomiting, headache, or abdominal pain,
CAUTION:
cells, which maintenance; dizziness. hematemesis,
inhibits gastric management of 1 tab PO bid Pregnancy B, occult blood in
acid secretion. GERD, active lactation, child<12yr, stools, blood in
duodenal ulcers hepatic disease, renal gastric aspirate
with Helicobacter 8:00 am – 8:00pm disease before and
pylori in throughout
combination with treatment, monitor
clarithromycin gastric pH

- Monitor input and

output, BUN,
Creatinine, CBC
with differential
monthly.

44
 Senna, Sennosides (Laxative- stimulant)

Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

> Stimulates > Acute 1 tab > Nausea, vomiting, >Hypersensitivity, GI - Monitor blood,
peristalsis by constipation; bowel anorexia, abdominal bleeding, intestinal urine electrolytes
action on preparation for PO tid cramps, Pink- red or obstruction, CHF, if used often by
Auerbach’s surgery or exam. brown- black lactation, abdominal patient; check I&O
8:00am – 2:00pm –
plexus; softens discoloration of pain, nausea/ ratio to identify
8:00pm
feces by increasing urine. vomiting, fluid loss.
water and appendicitis, acute
electrolytes in surgical abdomen. - Assess cramping,
large intestine. rectal bleeding,
nausea, vomiting;
if these symptoms
CAUTION: occur, drug should
be discontinued;
Pregnancy C
identify whether
fluids, bulk, or
exercise is missing
from lifestyle.

- Hold if ≥ 2 BM

45
 Thiamine (Vitamin B1)

Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Needed for Vit. B1 1 tab PO tid Nausea, diarrhea, Hypersensitivity - Assess

pyruvate deficiency or weakness, nutritional status:
metabolism, polyneuritis, 8–2–8 restlessness yeast, beef, liver,
carbohydrate cheilosis adjunct CAUTION: whole or
metabolism. with thiamine enriched grains,
beriberi, Pregnancy A legumes.
Wernicke-
Korsakoff - Teach patient
syndrome, necessary foods
pellagra, to be included in
metabolic diet: yeast, beef,
disorders. liver, legumes,
whole grains.

Trimethoprim/ Sulfamethoxazole (Antiinfective)

46
 Action Uses Dosage and Routes Adverse Effects Contraindications Nursing Responsibility

Sulfamethoxazole UTI, otitis media, Nausea, vomiting, Hypersensitivity to - Assess allergic

(SMZ) interferes acute and chronic abdominal pain trimethoprim or reactions; rash,
with bacterial prostatitis, sulfonamides, fever.
biosynthesis of shigellosis, pregnancy at term,
proteins by Pneumocystis megaloblastic anemia, - Monitor kidney
competitive jiroveci, infants <2mo., CCr function studies.
antagonism of pneumonitis, <15 ml/min, lactation, - Teach patient to
PABA when chronic porphyria take each oral
adequate levels bronchitis, dose with full
are maintained; chancroid, CAUTION:Pregnancy
C, renal disease, glass of water to
trimethoprim traveler’s prevent
(TMP) blocks diarrhea. elderly, glucose-6-
phosphate crystalluria.
synthesis of
tetrahydrofolic dehydrogenase -
acid; combination deficiency, impaired
blocks two hepatic/ renal
consecutive steps function, possible
in bacterial folate deficiency,
synthesis of severe allergy,
essential nucleic bronchial asthma.
acids, proteins.

47
 NCP

ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION

48
 DIAGNOSIS INTERVENTION

Subjective: “ Impaired physical In our 9 days of Monitor the blood  orthostatic After our 9 days
hirap akong mobility related to clinical duty, active pressure before and after hypotension may occur of our clinical
igalaw ang aking neuromuscular support and activity. Change position as result of side to side duty, the
mga kamay at impairment as assistance will be slowly. movement or elevation condition of the
of head can aggravate
paa” as evidence by inability provided for both the patient has
hypotension and cause
verbalized by the to purposefully health care providers syncope. improved: The
patient move of the body and to the patient to patient was able
parts, contractures. optimize rendering of Inspect skin daily.  altered to raise his both
care, so as to improve Observe for pressure areas, circulation, loss of arms
clients’ physical and provide meticulous sensation, and paralysis approximately
Objective: skin care. potentiate pressure sores
mobility by 6”- 8” above his
bedridden, formation.
performing simple bed in supine
bedsores, Stimulate holding and  To promote
task such as: raising grasping reflex. position for 4
quadriplegic circulation.
of arms up to 5in. seconds, has
 immobility and bedrest
above the bed in Turn patient with care increase risk of stronger
supine position, every 2 hours. pulmonary infection. squeezing of
stronger squeezing of  Assist with encourage hands.
hands. pulmonary hygiene ( deep
breathing, coughing,
suctioning).
 Assist client and  To further improve the
health care provider as patient’s condition.
necessary.  Enhances circulation,
 Perform/assist with restores/ maintains
full ROM exercise and muscle tone and joint
joints, using slow, smooth mobility and prevents
movements. disuse contractions and
muscle atrophy.

49
ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Impaired tissue After 9 days of  Turning of patient’s  to promote After 9 days of
integrity related to clinical rotation the every two hours. adequate circulation clinical rotation
prolong physical patient’s bed sores and to prevent the patients bed
immobilization as will be visibly further tissue sores has been
Objective: necrosis.
evidence by reduce in size as visibly reduced.
bed sores (sacral bedsores. sign of wound
region and foot healing and
part) increase tissue Protect pressure points  reducing risk of
perfusion. by use of heel pads(on ulceration.
the foot part).

 Assess the needs to  to reduce

change soak dressing inflammation

 Administer  for faster wound

medication as ordered; cleaning and to
such as anti infective prevent infection.
and anti-inflammatory.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

50
 DIAGNOSIS INTERVENTION

Subjective: Wound After our 8 hours  Proper care of wound:  To prevent spread By the end of 8
infection related shift the patient will Clean the wounds once of infection. hours shift, the
to exposure of manifest reduction a day patient is free
Objective: affected open of signs and from any signs
tissue symptoms of  Note risk factors for  To limit exposures, and symptoms
occurrence of infection. thus reduce cross
Bed sore (sacral infection. of infection.
contamination
region)
 Monitor vital signs
(+)catheter esp. Temp.

 Monitor clients  To prevent

visitors/caregivers for infection and
respiratory illness. Offer possible cross
mask and tissue to contamination
clients visitors who are
coughing sneezing
 To provide clean
 Report to the staff
dressings so as to
the need to change
prevent infection
wound dressings as
indicated (soaked).

 Proper disposal of
contaminated materials.

 Administer anti-
infective as ordered.

51
ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Acute pain related After 2 hours of  Assess for presence of To know the proper After
verbal report of to stimulation of administration of pain. Help client care needed for the administration of
pain “ aray”.. nerve endings prescribed identify the quantity of pain felt by the ordered
around bed sores medication ordered pain using the pain patient. medication and
scale.
as evidence by and encouragement giving of health
Evaluate increased
Objective: facial grimace of divertional irritability, muscle To obtain teachings, the
facial grimace, activities, the tension, restlessness, and knowledge and clue patient had
patient will unexplained vital for assessing pain understand and
verbalize control changes. experienced by the verbalized control
and understanding patient. over pain and is
over the situation observed
 Administer
specifically wound To lessen or managing pain.
medications as indicated
debridement (analgesics) eliminate pain through
procedure. medications.

 maintain proper
spinal column To prevent added
alignment. injury that may
possibly cause pain.

52
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Chronic pain After 9 days of  Evaluate pain using  to identify client After 9 days of
related to chronic clinical rotation the pain scale with potential for pain clinical rotation,
The patient physical disability the patient will lasting beyond normal he patient is still
reported pain in as evidence by verbalize and  Assess for condition healing period. observed as
extremities. paralysis and facial demonstrate relief associated with long  may be suffering from
term pain exaggerated because
grimace and for control of clients perception of chronic pain
pain/ discomfort pain is not believed or supported by
Objective: Evaluate pain because client believes verbal reports of
behaviors. caregivers are pain and facial
Fear of injury discounting reports of grimace, further
pain medications of
(+)irritability
 to release treatment regimen
(+)Facial grimace endorphins, enhancing
and reassessments
sense of well-being
 may indicate a of patients
new physical problem condition is to be
 provides considered.
 Promote divertional
activities opportunity to re-
energize and refocus
 Notify the physician on tasks at hand.
for severity of pain

 Administer pain
relief medications as
ordered

53
ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION
DIAGNOSIS INTERVENTION

Subjective. Impaired At the end of our  Clamp catheter  Promotes At the end of our
urinary duty the client every 2 to 3 hours and voluntary urinary duty, the patient
“ Di pa rin ako elimination will maintain released. control. had maintained
makaihi ng related to balance of input balance input and
normal” impaired urinary and output with output with clear,
 Assess voiding  identifies
Objective: reflex (disruption clear, odor free pattern; example, characteristics of yellow, odor- free
in bladder urine, free of frequency and amount. bladder function urine and with the
(-) micturation innervations )as bladder Compare urinary (example, absence of bladder
evidence by foley distention, urinary output with fluid effectiveness of distention.
Positive catheter intake. bladder emptying,
catheter. leakage.
renal function, and
fluid balance)

 decreases risk
 Provide catheter of skin
care as appropriate irritation/breakdow
n the developing of
urinary infection.

54
ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Bowel Within the shift, the  Recognize signs  early The patient had
incontinence r/t patient will have a of/check for presence of intervention is a BM 10 hrs
disruption of bowel elimination. impaction; example, no necessary to after the
innervation to formed stool for several effectively treat administrating
“Ilang araw na days, semiliquid stool, constipation/retain
hindi ako bowel and rectum the prescribed
restlessness, increased ed stool and reduce
nakadumi” as as evidence by loss feelings of fullness risk of medicine.
patient of ability to in/distention of complications.
verbalized. elimination bowel abdomen, presence of
voluntarily. nausea, vomiting, and
possibly urinary
retention.
Objective:
 Advised pt. to
(+)flatus have a well-balance  improves
diet. Increase fiber diet consistency of
(-)bm intake and fluids stool for transit
intake. through the bowel.
.
 Administer
laxative as prescribed.  To induce
BM

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

55
 DIAGNOSIS INTERVENTION

Subjective: Self-care deficit After providing  Provide health  to provide Due to lack of
related to the appropriate teaching with regards to adequate knowledge time with the
immobility as instruction to giving bed bath. to the relatives relatives,
Objective: evidence by the relative of teachings about
 Provide assistance to  to enhance the
quadriplegia the patient the adequate and
the relatives when skills of the relatives
poor hygiene, relatives would proper hygiene
performing bed bath.
rashes, identify and care was not
demonstrate given, but the
bed sores,
proper hygiene  Assess for needs to  to provide relatives
muscle wasting to the patient as change linens and bed comfort and a clean demonstrated
indicated for the sheets. bed environment hygiene care
patients that could be
 Turning patient side  to prevent
condition notified to suit
to side every two hours. developing pressure
ulcer and rashes the clients
condition
 Encourage client to pertaining to
verbalize need for safety.
hygiene.

56