I. INTRODUCTION.

Compression injuries are often caused by falls or jumps in which the person lands directly on the head, sacrum, or feet. The force of impact fractures the vertebrae and the fragments compress the cord. Disk and bone fragments may be propelled into the spinal cord on impact. The lumbar and the lower thoracic vertebrae are the most commonly injured regions after a compression impact when the person lands on the feet. If the person lands on the head, the injury is to the cervical spine. About 50% of these injuries result in incomplete lesions. Incomplete lesions occur when some of the spinal tracts remain intact. Injury to the spinal cord can range in severity from mild flexion-extension whiplash injuries to complete transaction of the cord with permanent quadriplegia. Trauma to the cord can occur at any level but most commonly occurs in the cervical and lower thoracic-upper lumbar vertebrae. These common cord injuries are due in part to the support given by the ribs to the thoracic spine and the flexibility of the cervical and lumbar spinal segments. Trauma is the most common cause of SCI. Each year about 10,000 people sustain such injury. Most victims are males between the ages of 16 ND 30 years; only 9% of injuries occur in people over the age of 60. Traumatic SCI is most often caused by automobile or motorcycle accidents, gunshots or knife wounds, falls, and sports mishaps. More than half of all SCIs involve the cervical spine, and the rest occur in the thoracic, lumbar, and sacral spinal segments. The feeling of immortality often experienced by adolescents and young adults contributes strongly to their risk of SCI. Young people may believe they can engage in dangerous behavior without being injured. The use of alcohol and illicit drugs can reinforce this belief in immortality. A young person who has experienced the devastation of SCI may best deliver the message to primary prevention. In several nationwide programs, head-injured and spinal cord-injured people are available to speak at school-sponsored educational programs. Whatever the cause, SCI produces distinctive and debilitating damage. Nowhere else in the body can a local insult produce such devastation in

proportion to the extent of tissue involved. Advances in research are giving doctors and patients hope that all spinal cord injuries will eventually be repairable. With new surgical techniques and exciting developments in spinal nerve regeneration, the future for spinal cord injury survivors looks brighter every day.

II. OVERVIEW OF THE DISEASE

A. ANATOMY AND PHYSIOLOGY 1. Spinal Column

The vertebral column, or backbone, is the central axis of the skeleton, extending from the base of the skull to slightly past the end of the pelvis. It is usually consists of 26 individual bones, grouped into five regions: 7 Cervical vertebrae, 12 Thoracic vertebrae, 5 Lumbar vertebrae, 1 Sacral vertebrae, 1 Coccygeal bone. The vertebral column performs the following five major functions: (1) supports the weight of the head and trunk; (2) protects the spinal cord; (3) allows the spinal nerves to exit the spinal cord; (4) provides a site for muscle attachment; and (5) permits movement of the head and trunk.

Figure 1

Figure 2

Bony Anatomy
Cervical Spine There are seven cervical bones or vertebrae. The cervical bones are designed to allow flexion, extension, bending, and turning of the head. They are smaller than the other vertebrae, which allow a greater amount of movement. Each cervical vertebra consists of parts, a body and a protective arch for the spinal cord called the neural arch. Fractures or injuries can occur to the body, lim pedicles, or processes. Each vertebra articulates with one above it and the one below it. Thoracic spine In the chest region the thoracic spine attach to the ribs. There are 12 vertebrae in the thoracic region. The spinal canal in the thoracic region is relatively smaller than the cervical or lumbar areas. This makes the thoracic spinal cord at greater risk if there is a fracture. The motion that occurs in the thoracic spine is mostly rotation. The ribs prevent bending to the side. A small amount of movement occurs in bending forward and backward. Lumbosacral spine The lumbar vertebrae are large, wide, and thick. There are five vertebrae in the lumbar spine. The lowest lumbar vertebrae, L5, articulate with the sacrum. The sacrum attaches to the pelvis. The main motions of the lumbar area are bending forward and extending backwards. Bending to the side also occurs.

2.Spinal Cord
The spinal cord is a long, thin, tubular bundle of nervous tissues and support cells that extends from the brain. The brain and spinal cord together make-up the Central Nervous System (CNS). The spinal cord begins at the occipital bone and extends down to the space between the first and second lumbar vertebrae; it does not extend the entire length of the vertebral column. It is around 45 cm (18 in) in men and around 43 cm (17 in) long in women. Also, the spinal cord has a varying width, ranging from 1/2 inch thick in the cervical and lumbar regions to 1/4 inch thick in the thoracic area. The enclosing bony vertebral column protects the relatively shorter spinal cord. The spinal cord functions primarily in the transmission of neural signals between the brain and the rest of the body but also contains neural circuits that can independently control numerous reflexes and central pattern generators.

Figure 3

The spinal cord has three major functions: as a conduit for motor information, which travels down the spinal cord, as a conduit for sensory information in the reverse direction, and finally as a center for coordinating certain reflexes. The spinal cord consists of nerves that connect the brain to

nerves in the body. It is a superhighway for messages between the brain and the rest of the body. The spinal cord is surrounded for most of its length by the bones (vertebrae) that form the spine. There are 31 pairs of spinal nerves that connect with the spinal cord through nerve roots and travel to specific parts of the body. For example, the pair of spinal nerves connecting with the spinal cord in the region of the C2 vertebra travel to the head and neck, while the spinal nerves attaching to the cord in the region of the L4 vertebra run to specific muscles in the legs and specific areas of skin in the calves. The spine works as the main support for the spinal cord and the nerve pathways that carry information from the arms, legs, and rest of the body, and carries signals from the brain to the body. The back is composed of 33 bones called the vertebrae, 31 pairs of nerves, 40 muscles and numerous connecting tendons and ligaments running from the base of your skull to your tailbone. Between your vertebrae are fibrous, elastic cartilage called discs. These shock absorbers keep your spine flexible and cushion the hard vertebrae as you move.

B. DISEASE PROFILE SPINAL CORD INJURY

Spinal cord injury (SCI) refers to any injury to the spinal cord that is caused by trauma instead of disease. Spinal cord injuries are described at various levels of "incomplete", which can vary from having no effect on the patient to a "complete" injury which means a total loss of function. INCIDENCE: Occurs more often in males 85% than in females 18% Young people between the ages 16 and 30 years old

RISK FACTORS: Trauma Gender Age CAUSES: Motor vehicle Crashes 35% Violence-related injuries 24% Fall Tumors Ischemia Sports and recreational activities Pathologic Course CLASSIFICATIONS: 1. Central Cord Syndrome- often is associated with a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs, with sacral sensory sparing. 2. Brown-Sequard Syndrome- which often is associated with a hemisection lesion of the cord, causes a relatively ipsilateral proprioceptive and motor loss, with contralateral loss of sensitivity to pain and temperature. 3. Anterior Cord Syndrome- often is associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature; proprioception is preserved. 4. Cauda Equina Syndrome- L2-L5 is affected, shows bladder, bowel, and depleted function of the lower extremities. Shows no sensation on sacral part. 5. Conus medullary syndrome- shows flaccidity, decreased bladder and bowel reflex, as well as erection is preserved.

DIAGNOSTIC TESTS: Spinal x-ray CT-scan MRI Myelography Motor and Sensory Testing Muscle Strengths CLINICAL MANIFESTATIONS: Loss of movement Loss of sensation Loss of bowel and bladder control Exaggerated reflex act Changes in sexual function Pain Difficulty breathing, coughing or clearing secretions NURSING DIAGNOSIS: Pain Impaired physical mobility Self-care deficit Impaired skin integrity Bowel Incontinence Impaired urinary elimination Risk for injury Ineffective breathing pattern Sexual dysfunction

MANAGEMENT A. Medical Management Corticosteroids Oxygen therapy Immobilization (Halo devices, Crutchfield tongs and Vinkis tongs Opioids- Tramadol Laxatives/ drugs that enhance bowel elimination B. Nursing Management Respiratory and Neurologic assessment Maintenance of spinal alignment Frequent turnings or changing of positions Skin care Institute active and passive ROM exercises Increased fluid intake, as tolerated Avoid complications of immobility Adequate intake of CHON, Vit. C, and other mineral-rich foods COMPLICATIONS: Pneumonia Hypotension Blood clots Bed Sores Neurologic pain Spasms Urinary and bowel impairment Sexual dysfunction and fertility problems Spinal shock Autonomic Dysreflexia PREVENTION: - Avoid different types of injury - Follow standard precautions when playing sports

C. PATHOPHYSIOLOGY
Precipitating Factors (PTB, Aging, Habitual Alcohol consumption, Smoking) Loss of bone mass and decreased absorption of Ca Fragility of the bone
+

Fall

Injury to the spine (Loading force is applied) Disruption of the spines integrity

Compression of T12 Hemodynamic Response Microscopic Bleeding Cellular Response

Vasodilation

Increased cap. Permeability

Chemotaxis

Calor and Rubor

Swelling and Edema formation Inflammation

Increased WBC and elevated ESR

Pressure to the Nerve endings

Impairment to motor and sensory function below neurologic level

Pain Motor Limited motor activity Sensory

- Decreased muscle tone - Hyporeflexia and flaccidity Limited ROM Constipation Respiratory Infection

- Numbness of lower ext. - Decreased sensation to touch, Pain and temp.

The injury started through a trauma applied to the spine, primarily fall. Pulmonary Tuberculosis, smoking, and habitual drinking were also considered as factors that precipitated the condition. Due to these factors, loss of bone mass and bone density occur, while as the primary cause of the condition happened, injury to the spine took place. As the bones loss its density, fragility may occur. Trauma caused by fall causes the disruption of the spines integrity. Thus, these situations led to nerve compression, primarily the T12. As the nerves compresses, hemodynamic response, microscopic bleeding of the spinal cord, and cellular response occur. Symptoms, such as redness and heat were being exhibited as a action of vasodilation. As separated response of the body, swelling or edema formation began to happen from the action of capillary permeability and bleeding. As a chemotaxic response of the body, the WBCs aggregated at the main site of the injury and promotes inflammatory response.

As the inflammation takes place, elevation of the ESR was also evidenced. Edema progresses, which caused further rise in pressure which was being applied to the nerve endings. Pain was being manifested as the sign of compression. The same consequences as edema formation happened when the inflammation progresses. Motor and sensory impairment happened as its result thus symptoms, such as paresthesia and paralysis also took place. Complications, such as constipation and respiratory impairment may also result from the course of the condition.

III. BIOGRAPHIC DATA

Patients Name: Armando Resma De Lara Age: 59 y/o Gender: Male Civil Status: Married Religion: Iglesia Ni Cristo Nationality: Filipino Date of Admission: March 12, 2012 Diagnosis: Compression Fracture T12 probably Pathologic t/c Bone Metastasis Date of Assessment: April 13, 2012

IV. ASSESSMENT
A. HISTORY A1. Present Health History Several weeks after admission when the attending physician identified presence of Compression Fracture on the thoracic level, specifically on the T 12 due to pathologic course. He used to be a carpenter before and claimed that the probable cause may be due to an incident happened last January 2012. He fell in his back from the stairs when he was working, but didnt pay much attention on it. Few days after the incident, he began to feel hip pain. The condition worsened that he cant walk or even stand as well. The pain attacks intermittently in tolerable state. This usually characterized as radiating and tearing pain which turns active during cold and extremely hot weather or even during brisk movements.

He sought followed-up check-ups last February 2012 at Sta. Anna Clinic, but the diagnosis was Urinary Tract Infection, instead of bone affection. Last week of the said month, the patient was referred to a private clinic and was then diagnosed having cord compression. The condition was treated with various pharmacological management and therapies, but his family refused to continue because they thought that those therapies were ineffective. Theyve decided to bring him at Philippine Orthopedic Center or further observations and management of the condition. March 12, 2012, the patient was admitted at POC with diagnosis of Compression Fracture at T12 probably pathologic to consider bone metastasis. Presently, under the management of the said institution in Male B Ward.

A2. Past Health History Patient acquired past bone affection, including Right Carpal bone as evidenced by scars which shows heavy lacerations of the extremities due to his occupation as a carpenter. He also acquired Pulmonary Tuberculosis before and was immediately treated with anti-TB drugs for almost two months. He didnt avail confinement and rather chose homecare management. The client claimed that he received basic immunizations during his childhood but not complete. He has no history of allergies from any kind of foods nor drugs. The patient childhood diseases were Mumps and Varicella. Other than that, acute attacks of common cough, colds, and fever are treated with over-the-counter drugs instead of herbal medicines.

A3. Family Health History Patients parents died due to old age and denied of having serious medical condition. The family usually seeks medical attention at the Barangay and other health care facilities only during chronic and severe episodes of a

certain health condition. Mild cases are treated with over-the-counter drugs and rest.

A4. Psychosocial History The patient worked as a carpenter. He was a chain smoker and alcohol drinker. He consumes 1 pack of cigarettes per day and usually drinks two 300mL bottles of alcoholic beverage per day. The family is an active member of Iglesia Ni Cristo, but due to the current condition, their religious routines were greatly affected. The patient acquired membership from the DSWD which offered financial assistance to sustain the needs for medications. Aside from that, the family has no active participation in other community organizations. The patient is the breadwinner but because of his vices, it often result to an argument with his wife. Hes a high school undergraduate and didnt pursue the rest of his educational degree due to lack of financial support.

V. PHYSICAL EXAMINATION
General Appearance: Conscious and coherent Assumes bed rest most of the time With limited ROM on both lower extremities Dyspneic; with O2 inhalation Weak in appearance Easily gets fatigue With facial grimace upon turnings With flushed skin With profused sweating Vital Signs: T- 38.1 C P- 98 bpm R- 31 bpm BP- 150/80 mmHg Cephalocaudal Assessment SKIN With flushed skin Skin warm to touch HEAD Normocephalic Hair evenly distributed throughout the whole scalp Without dandruff, lice nor nits With moist, black, and slightly thin hair strands Without lesions nor masses

EYES With slightly yellowish sclera and pinkish conjunctiva Pupil equally round, reactive to light and accommodation With teary eyes With good visual acuity, as evidenced by following gestures of nurse-onduty EARS Symmetrical In line with the outer canthus of the eyes No ear infections With few dry cerumen With good hearing acuity NOSE With nasal flaring With O2 inhalation via nasal cannula Without nasal discharges nor tenderness With patent nares but in respiratory distress With moist mucous membranes MOUTH With slightly dry lips; with redness on the inner aspect of the lips With brownish gingiva Without gingival bleeding Tongue able to move freely with strength Pinkish in appearance with whitish patches

NECK Neck is straight Without jugular venous distention Without palpable nor inflamed lymph nodes With good range of motion THORAX With labored breathing; with use of abdominal muscles upon inspiration and exhalation With slight chest indrawing With equal chest expansion With vesicular breath sounds in the peripheral lungs With productive cough, draining to a whitish sputum ABDOMEN Not bloated With bowel sounds of 7 per minute With tympanitic sounds Firm and non-tender With positive flatus and negative bowel movement for 3 days GENITO-URINARY Bladder not distended Able to void freely to a pinkish to reddish-colored urine, moderate in amount UPPER EXTREMITIES Symmetrical Without lesions noted With right distal ulnar bone prominence

 Muscle tone: 3/5 With active ROM of both arms LOWER EXTREMITIES Symmetrical With pain upon raising the legs With limited ROM of both legs With grade 1 pitting edema (-) Babinski reflex Able to flex legs but only in a short duration Unable to localize pain at times Muscle tone: 3/5 With pale nail beds With desquamation in the sole of the feet SPINE With sacral and hip pain Without mass nor lesions noted

VI. LABORATORY ANALYSIS

Blood Chemistry (03/13/2012) Tests Glucose Normal Range 4.20-6.40 Result 6.80 mmol/L
Organic wastes present in the urine. Indicator of renal The kidneys have adequate filtration and excretion ability.

Functions
Provides energy to the cell.

Interpretations
Result is elevated. This indicates active liver blood conversion of sugar.

Urea

1.70-8.30

3.96 mmol/L

function, specifically the ability of the kidneys to excrete urea and protein. Indicator of renal function,

Creatinine

44-115.00

66.54 mmol/L

specifically the ability of the kidneys to excrete urea and protein. Indicates the level of

The kidneys have adequate filtration and excretion ability.

PCO2

29.9

Carbon Dioxide level present in the blood.

PO2

59.4

Indicates the level of Oxygen in the blood.

Complete Blood Count (04/11/12) Blood Component Normal Range Result Functions
Responsible for the pigmentation of the RBCs

Interpretations

Hemoglobins

127-183 g/L

99 g/L

which carries oxygen from the lungs to be transported to different organs. It measures the

Indicates previous or present anemia.

Hematocrit

0.37-0.54 vol%

0.31 vol%

percentage of total blood volume composed of red blood cells. Protect the body against invading microorganisms

Shows previous or present anemia.

Indicates respiratory infection/ active immune response.

Leukocytes

4.5-10 x 10^9/ L

24.00 x 10^9/L

and remove dead cells and debris from the tissue by phagocytosis.

Differential Count
Production of antibodies and other chemicals that Result shows previous WBC-pathogen clash. Increased destruction of WBC due to numerous pathogen encountered.

Lymphocytes

0.20-0.40

0.03

destroy microorganisms, contribute to allergic reactions, reject grafts, control tumors, and

regulate the immune system. Turns into macrophages which phagocytize The body has sufficient protection from active infection.

Monocytes

0.00-0.07

0.02

bacteria, dead cells, cell fragments, and other debris within the tissues. Releases chemicals that reduce inflammation. Also

The body has adequate protection from any active parasitic infection.

Eosinophils

0.00-0.05

0.01

responsible for the destruction of certain worm parasites. Responsible for the formation of platelet plugs, which seal holes in small

The body has adequate blood clotting components that suppress bleeding.

Platelet

150-400 x 10^9/L

190 x 10^9/L

vessels and formation of clots, which help seal off larger wounds in the vessels.

Indices
Measures the erythrocyte The patients blood hemoglobin has normal size and contents. Patients RBCs has

MCV MCH

82-92 fL 28-32 pg

82 26

size and hemoglobin content. Measures hemoglobin

content within one RBC of average size. Measures the length of

inadequate hemoglobin content present in it. Platelet agglutination effect in the patients blood act very slowly.

Prothrombin Time

11-15 secs

19.9 secs

blood clotting.

VII. DRUG STUDY

Name of drug/s Tramadol 50mg IVP q8 PRN for pain (Centrally-acting Analgesic) Indications For moderate to moderately severe pain Mechanism of Action Binds with mu receptors and inhibits the reuptake of norepinephrine and serotonin, which may account for tramadols analgesic effect. Contraindications Hypersensitivity to tramadol or its components Nursing Responsibilities Reassess patient level of pain @ least 30min. after admin. Monitor RR Monitor bowel and bladder function Monitor patient @ risk for seizure Monitor patient for drug dependence Withdrawal symptoms may occur if drug is stopped abruptly Assess signs of infection Obtain history of hypersensitivity to drug before administration Observe patient for signs of anaphylaxis Cautiously given for patients with renal and hepatic failure Assess temp. from time to time Assess characteristics of pain TSB continuously Instruct pt. to increase fluid intake

Cefuroxime 750 mg IVP q8 nd (Anti-infective agent/ 2 generation Cephalosporin)

Treatment of respiratory tract infections

Bind to bacterial cell wall membrane, causing cell death.

Hypersensitivity to cephalosporins and serious hypersensitivity to penicillins

Paracetamol 1 TAB PRN (Antipyretic)

For mild pain and fever

Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever.

Previous hypersensitivity

Name of drug/s Salbutamol 1neb q4 (Bronchodilator)

Indications Used as a bronchodilator in the management of reversible airway obstruction caused by asthma and COPD

Mechanism of Action Binds to beta2-adrenergic receptors in the airway smooth muscles, leading to activation of adenycyclase and increased levels of cyclic3,5-adenosine monophosphate.

Contraindications Hypersensitivity to adrenergic amines and fluorocarbons

Nursing Responsibilities Assess v/s before and after administration of meds. Provide adequate amount of fluid intake after administration Provide back tapping during and after administration of this meds. Pregabalin therapy should be stopped gradually over at least 1 week to decrease risk of seizure activity and avoid unpleasant symptoms such as diarrhea, headache, insomnia, and nausea. If patient has evidence of hypersensitivity (red skin, urticaria, rash, dyspnea, facial swelling, wheezing), stop drug at once, notify prescriber, and give supportive care. Monitor patient closely for adverse reactions. behavior, especially when therapy starts or dosage changes.

Pregabalin 75mg/tab OD (GABA)

Relieve neuropathic pain associated with diabetic peripheral neuropathy

Binds to alpha2-delta site, an auxiliary subunit of voltage calcium channels, in CNS tissue where it may reduce calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. With fewer neurotransmitters, pain sensation and seizure activity decline.

Hypersenstivity to pregabalin or its components

Name of drug/s Fixcom 4 4TABS OD in AM x 1 more month (Anti-TB Agents) (Rifampicin 150 mg, INH 75 mg, Pyrazinamide 400 mg, Ethambutol 275 mg) (Anti-Tuberculosis)

Indications Pulmonary Tuberculosis

Mechanism of Action Agents: Rifampicin: Bactericidal. Inhibits mycobacterial RNA synthesis by binding to DNA-dependent RNA polymerase, thereby blocking RNA synthesis and subsequent translation to proteins. Isoniazid: Bactericidal. Inhibits mycolic acid synthesis resulting in loss of acid-fastness and bacterial cell wall disruption. Pyrazinamide:Bactericidal. Inhibits the growth of Mycobacterium tuberculosis by decreasing its pH level. Ethambutol: Bactericidal. Interferes with RNA synthesis, causing suppression of Mycobac.terium multiplication. It acts on rapidly growing pathogens in cavity walls.

Contraindications Rifampicin: Hepatitis, orange-red urine, sweat and tears, GI disturbances, nausea& vomiting, rashes, fever, headache Isoniazid:Peripheral neuritis, hepatitis, fever, rash, visual disturbances

Nursing Responsibilities The tablets should be taken 1 hr before or 2 hrs after meals to facilitate absorption. Monitor liver function test results before and every 2 to 4 weeks during therapy. Immediately report abnormalities. Expect skin to discolor and body fluids reddish orange to reddish brown, nausea and vomiting ,epigastric distress, skin rashes, drowsiness, fatigue. Take this drug regularly; avoid missing any doses; do not discontinue this drug without consulting your health care provider. Have periodic medical checkups , including eye examinations and blood tests, to evaluate the drug effects. Do not drink alcohol, or drink as little as possible. There is an increased risk of hepatitis. Instruct patient to report darkened urine, fever, chills, nausea, severe

Ethambutol: Retrolobular neuritis, visual field constriction, central or peripheral scotoma, greenred color blindedness, fever, confusion, headache, rashes, GI disturbance Pyrazinamide: Hypersensitivity, Hepatitis, Fever, porphyria, dysuria, GI disturbances,

pain in feet or toes, vomiting and yellowing of skin and eyes, muscle and bone pain, excessive tiredness or weakness, loss of appetite, unusual bleeding or bruising,

VIII. NURSING CARE PLAN

Assessment S: Mabilis ako hapuin kaya di ako masyado makagalaw at makakilos ng matagal. Nursing Diagnosis Impaired gas exchange r/t alteration in the alveolar-capillary membrane capacity Planning After the nursing interventions, the patient will be able to demonstrate ways and techniques in order to promote O: With O2 inhalation via nasal cannula RR-28 bpm With slight chest indrawing Seen patient in pursed-lip effective gas exchange and ventilation. Assessed factors which aggravates or palliates the condition Interventions Assessed and monitored the respiratory rate frequently Rationale Serves as baseline for identifying the degree of air sufficiency Certain attacks of the condition are influenced by several factors, such as: environment or the pathologic course itself and to prevent the frequency of attacks Evaluation Goal was met. Seen patient maintained semifowlers position, doing deep breathing and coughing exercises

breathing With limited activity performance

Provided and monitored level of O2 inhalation

O2 supplementation aids in respiration

Positioned the client in semifowlers

To facilitate good breathing pattern and to maintain airway

Encouraged and provided frequent position changes, deep breathing and coughing exercises Provided quiet, calm, and

Promotes optimal chest expansion and to mobilize secretions

To limit patients activity performance

restful sleep/ uninterrupted sleep

and in order to conserve bodys oxygen consumption

Assessment S: Medyo nahihilo ako.

Nursing Diagnosis Decreased cardiac output r/t

Planning At the end of the nursing interventions,

Interventions Assessed BP of the patient Assessed for mental status of the patient

Rationale Serves as baseline data Altered level of LOC indicates hypoperfusion of the brain tissues

Evaluation

O: BP- 150/80 mmHg PR- 98bpm Seen pt. frequently touching his head and nape With flushed face Slightly lethargic

Maintained patent airway and monitored supplemental O2, as ordered

Supplemental O2 helps to improve cardiac function by increasing available O2 and reducing O2 consumption

Positioned patient with

Promotes sufficient

head elevated Instructed patient to limit fluid intake, as prescribed

venous return Increased in fluid consumption contributes to the elevation of the blood pressure.

Assessment O: T- 38.1C PR- 98bpm RR- 31bpm With flushed skin Skin warm to touch With profused sweating

Nursing Diagnosis Hyperthermia r/t disturbance in the thermo-regulating center of the brain

Planning After the shift, patients temperature will subside within the normal range.

Interventions Assessed temperature, respiratory rate and pulse rate from time to time Provided TSB continuously

Rationale Serves as baseline data in identifying the degree of fever

Evaluation Goal was partially met. The temperature of the patient remains abnormally high, seen patient

Reduces the temperature through heat evaporation

taking oral fluids frequently and SO performing TSB for the patient continuously,

Removed extra blankets and changed pts garments into loose clothing Provided wellventilated room

Promotes coolness and heat evaporation Promotes comfort and lessens heat

 Encouraged on increased fluid intake

Provides adequate hydration for the patient, thus decreasing the risk for dehydration nor dryness of the mucous membranes

Instructed S.O. on continuous TSB for the patient and adherence to PRN meds.

Promotes heat evaporation

Assessment S: Di ako masyado makagalaw.

Nursing Diagnosis Impaired physical mobility r/t nerve compression and spinal trauma

Planning At the end of the nursing interventions, the patient will show positive signs of inhibition of further complications caused by immobility

Interventions Assessed patients muscle tone of both upper and lower extremities

Rationale Poor muscle tone implies lesser tolerance upon doing physical activities and mobility

Evaluation

O: With limited Range of motion of both hips With muscle tone of 3/5 on lower extremities With slightly flaccidity of both lower limbs

Provided passive ROM for the patient and active ROM, if tolerable Provided adequate and proper skin care

Promotes physical mobility and prevents possible contractures Prevents skin breakdown caused primarily by decreased

participation in activity Encouraged on frequent turnings and changing of positions with assistance Instructed and demonstrated massage to S.O. to be provided for the patient Provided soft pillows on the pressured parts(buttocks, back) Pressure applied to the weight-bearing areas can cause skin breakdown Promotes comfort and prevents muscles to be atrophized This promotes good peristalsis movement

Assessment S: 4 na araw na akong hindi dumudumi.

Nursing Diagnosis Constipation r/t decreased gastric motility secondary to immobility

Planning After the entire shift, the patient will be able to learn ways on how to initiate good defecation.

Interventions Assessed patterns of elimination

Rationale Serves as baseline data for identifying alteration in the regular bowel patterns.

Evaluation Goal was met. Seen patient eating fruits, such as ripe banana and ripe papaya, as well as taking oral fluids frequently.

O: With firm and non-tender abdomen at both lower quadrant With tympanitic sound heard on the lower quadrants of the abdomen With bowel

Assessed privacy upon defecation

Inadequacy in privacy may interfere defecation

Noted factors that hinder or stimulate bowel activity

These factors contribute mainly either on good/ poor elimination

sounds of 7 per minute With decreased motor activity Pt. maintained lying on bed most of the time

Note the characteristics and frequency of stool Instructed S.O to give patient fiber-rich foods, such as ripe banana and ripe papaya Provided patient adequate fluid intake, at least 8 glasses or more per day, as indicated. Assisted client on ROM exercise ROM activities help to mobilize the passing of Water softens the stool Fiber helps to form bulk in the stool which helps in the passing of stool.

stool and enhances peristalsis Provided frequent changes in position and turnings To mobilize passing of stool