HERNIATION OF THE LUMBAR DISK

HERNIATION OF LUMBAR DISK

Overview of the Disease

Lumbar disk disease is due to a change in the structure of the normal disk.

Most of the time, disk disease comes as a result of aging, degenerati on and trauma

that occurs within the disk. Occasionally, severe trauma can cause a normal disk to

herniate. Trauma may also cause an already herniated disk to worsen. Most lumbar

disk herniations occur at the L4-5 or the L5-S1 interspaces (Humphreys & Eck, 1999)

.
A herniated lumbar disk produces low back pain accompanied by varying

degrees of sensory and motor impairment. As

we age, the intervertebral disk may lose fluid

and become dried out. As this happens, the

disk compresses. This may lead to the

deterioration of the tough outer ring allowing

the nucleus, or the inside of the ring, to bulge

out. This is considered a bulging disk. As the

disk continues to degenerate, or with

continued stress on the spine, the inner

nucleus pulposus may actually rupture out from the annulus. This is considered a

ruptured, or herniated, disk. The fragments of disk material can then press on the

nerve roots that are located just behind the disk space. This can cause pain, weakness,

numbness, or changes in sensation.

The prevalence of symptomatic herniated lumbar disc is about 1-3% in

Finland and Italy, depending on age and sex. The highest prevalence is among people

aged 30-50 years, with a male to female ratio of 2:1. In people aged 25-55 years,
HERNIATION OF THE LUMBAR DISK
about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level);

disc herniation above this level is more common in people aged over 55 years.

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages, 1994-1995.
HERNIATION OF THE LUMBAR DISK

Assessment

Assessment

The patient complains of low back pain with muscle spasms, followed by

radiation of the pain into one hip and down into the leg (sciatica). Pain is aggravated

by actions that increase intraspinal fluid pressure (bending, lifting, straining, as in

sneezing and coughing) and usually is relieved by bed rest. Usually there is some type

of postural deformity, because pain causes an alteration of the normal spinal

mechanics. If the patient lies on the back and attempts to raise a leg in a straight

position, pain radiates into the leg because this maneuver, called the straight leg-

raising test, stretches the sciatic nerve. Additional signs include muscle weakness,

alterations in tendon reflexes, and sensory loss.

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages, 1994-1995.
HERNIATION OF THE LUMBAR DISK

Pathophysiology

Pathophysiology

A herniated disk fragment comes from the nucleus pulposus of the disc (a

remnant of the embryonic notochord). In the normal condition, this nucleus is in the

disk center securely contained by the annulus fibrosus. When a fragment of nucleus

herniates, it irritates and/or compresses the adjacent nerve root. This can cause the

pain syndrome known as sciatica and, in severe cases, dysfunction of the nerve.

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages, 1994-1995.
HERNIATION OF THE LUMBAR DISK

Medical Management

Medical Management

Diagnostic test Indication Nursing Responsibility

X-ray Application of radiation to Preparation

produce a film or picture

No prior radionuclide studies
of a part of the body can
for 2 weeks
show the structure of the No barium contrast tudies for

vertebrae and the outline 2 weeks

No metal in clothing (i.e.
of the joints. X-rays of the
zippers)
spine are obtained to

search for other potential After the procedure

causes of pain, i.e.
Perform neurological checks
tumors, infections,

fractures, etc. and vital signs and compare

with baselines
Complications and

precautions: Note and report

suspected fracture or injury

to the cervical spine or neck

pain.
HERNIATION OF THE LUMBAR DISK

Medical Management

Computed A diagnostic image Before the test, asked the patient

tomography created after a computer if they have the following:

scan (CT or CAT reads X-rays; can show

Pregnant
scan): the shape and size of the Are allergic to any

spinal canal, its contents, medicines, including iodine

and the structures around dyes.
Have a heart condition, such
it. .
as heart failure
Have diabetes
Have had kidney problems
Have asthma

Post Test

Instruct the patient to resume

usual diet, fluids,

medications and activity

Monitor vital signs and

neurological status every

15mins for 1hr, then every

2hr for 4hr.

Monitor temperature every

4hr for 24 hr. Monitor intake

HERNIATION OF THE LUMBAR DISK

Medical Management

and output at least every 8hr.

Observe for delayed allergic

reactions, such as rash,

urticarial, tachycardia,

hyperpnea, hypertention,

palpitations, nausea, or

vomiting.
Instruct the patient in the care

and assessment of the site.

Recognize anxiety related to

test results.

Magnetic resonance A diagnostic test that a. Before the procedure

imaging (MRI) produces 3-D images

Patient may be asked not to
of body structures
eat or drink anything for 4 - 6
using powerful
hours before the scan.
magnets and computer Asked patient if they are

technology; can show afraid of close spaces or

the spinal cord, nerve claustrophobia and inform
roots and surrounding the doctor. Patient may be
areas, as well as given a medicine to help
enlargement, them feel sleepy and less
degeneration, and anxious, or the doctor may
tumors. suggest an "open" MRI, in

which the machine is not as

HERNIATION OF THE LUMBAR DISK

Medical Management

close to the body.

Before the test, asked the

patient if they have the

following:
Artificial heart valves
Brain aneurysm clips
Heart defibrillator or

pacemaker
Inner ear (cochlear)

implants
Kidney disease or

dialysis (patient may

not be able to receive

contrast)
Recently placed

artificial joints
Vascular stents
Worked with sheet

metal in the past

(patient may need tests

to check for metal

pieces in their eyes)

4. Asked patients to remove the

following:

Items such as jewelry,

watches, credit cards,

and hearing aids - may

HERNIATION OF THE LUMBAR DISK

Medical Management

be damaged.
Pens, pocketknives,

and eyeglasses - may

fly across the room.

Pins, hairpins, metal

zippers, and similar

metallic items - can

distort the images.

Removable dental

work should be taken

out just before the

scan.

Because the MRI

contains strong magnets,

metal objects are not

allowed into the room

with the MRI scanner. It is

important to inform the

health care provider of any

pregnancy or suspected

pregnancy prior to the

procedure.

b. During the procedure

Patient will be asked to

HERNIATION OF THE LUMBAR DISK

Medical Management

remain perfectly still during

the time the imaging takes

place, but between sequences

some minor movement may

be allowed. The MRI

Technologist will advise

accordingly.
When MRI procedure begins,

patient may breathe normally,

however, for certain

examinations it may be

necessary for you to hold

your breath for a short period

of time.
Monitoring is indicated to

patients who are great

potential for change in

physiologic status

(respiratory rate, oxygen

saturation, temperature, heart

rate and blood pressure)

during the procedure or

whenever a patient requires

observations of vital

physiologic parameters due

HERNIATION OF THE LUMBAR DISK

Medical Management

to an underlying health

problem.
Monitoring is imperative to

patients who are using

sedative or anesthesia to

ensure patient safety

Patients that require monitoring

and support during MRI

procedures.

Physically or mentally

unstable patients.
Patients with compromised

physiologic functions.
Patients who are unable to

communicate.
Neonatal and pediatric

patients.
Sedated or anesthetized

patients.
Patients undergoing MR-

guided interventional

procedures.
Patients who may have a

reaction to an MRI contrast

agent.
Critically ill or high-risk
HERNIATION OF THE LUMBAR DISK

Medical Management

patients.

c. After the procedure

There is no recovery time, unless

you were given a medicine to

relax. After an MRI scan, you can

resume your normal diet, activity,

and medications.

If patient is sedated, patient is

transferred to the recovery room

for continue monitoring.

Especially important for pediatric

patients because certain

medications have relatively long

half-lives (e.g., chloral hydrate,

pentobarbitol, etc.).

Myleogram An X-ray of the spinal Preparation of the Client

canal following injection

Ensure a signed informed consent.
of a contrast material into

the surrounding The meal prior to the

cerebrospinal fluid procedure is usually

spaces; can show pressure omitted.

The client should be well
on the spinal cord or
HERNIATION OF THE LUMBAR DISK

Medical Management

nerves due to herniated hydrated.

Administer enemas or
discs, bone spurs or
laxatives as ordered to
tumors.
ensure visualiza-tion of

lumbar spine.
Administer prescribed

pretest medications, such as

a sedative or diazepam

(Valium).

Client and Family

Teaching

Remain NPO several hours

before the test.

The examination lasts about

1 hour.
The position used to

perform the examination

will depend onthe physician.

You may have to lie on your

stomach, sit andlean

forward, or sit with the

knees to the chest.

Astrap may be used to

prevent falls, and the table

will be tilted during the

HERNIATION OF THE LUMBAR DISK

Medical Management

examination.
A lumbar puncture (spinal

tap) is performed to inject

the dye. A local anesthetic is

used where the needle will

be in-serted. There may be a

feeling of pressure during

needle insertion. The needle

is inserted below the level of

the spinal cord.

Tell the physician if you

experience pain.
It is important to stay in bed

with the head of the bed

elevated for at least 6 to 12

hours (the length of time

will depend on physician

preference and hospital

policy).
The nurse will check your

blood pressure, pulse, and

respira-tions. The nurse will

also check your ability to

feel and move at least every

4 hours (or more often) after

HERNIATION OF THE LUMBAR DISK

Medical Management

the examination.

Postexamination Nursing

Care

Take and record vital signs

and assess neurologic status

as prescribed (and at least

every 4 hours) for 24 hours

postexam-ination. Record

and report any changes.

Assess the site of the lumbar

puncture for leakage of cere-

brospinal fluid or bleeding

every 4 hours. Notify the

physician of leakage or

bleeding.
Encourage increased intake

of oral fluids to replace that

with-drawn during the

examination. ( This may

also help decrease a

postmyelogram headache).
Make sure that the client

voids within 8 hours after

the exami- nation. If policy

HERNIATION OF THE LUMBAR DISK

Medical Management

permits, allow male clients

to stand at the bedside, or

clients of either gender to

use the bathroom. No-tify

the physician if the client

has not voided within 8

hours.
Administer analgesics as

prescribed for

postexamination pain,

headache, or muscle spasms.

Keep the clients head

elevated at least 30 degrees

(in bed or in a chair) for 12

hours, or as ordered.
Resume diet if there is no

nausea or vomiting.
Force oral fluids to 2400 to

3000 mL in 24 hours,

beginning immediately after

the procedure.
Admin ister prescribed

medications for nausea.

Do not give any

phenothiazine derivatives

for 48 hours (to re-duce the

HERNIATION OF THE LUMBAR DISK

Medical Management

possibility of seizures).

Electromyogram and These tests measure the Preparation

Nerve Conduction electrical impulse along

Make sure the patient has
Studies (EMG/NCS) nerve roots, peripheral
signed an appropriate
nerves and muscle tissue.
consent form.
This will indicate whether Note and report all allergies.
Check for and note drugs
there is ongoing nerve
that may interfere with test
damage, if the nerves are
results such as cholinergics,
in a state of healing from
anticholinergics,
a past injury or whether
anticoagulants, and skeletal
there is another site of
muscle relaxants.
nerve compression.
Tell the patient he need not

restrict food and fluids

before the test but that it

may be necessary to restrict

cigarettes, coffee, tea, and

cola for 2 to 3 hours

beforehand.
Warn the patient that he

might experience some

discomfort as a needle is

inserted into selected

muscles.
Explain that the test takes at
HERNIATION OF THE LUMBAR DISK

Medical Management

least 1 hour.

Implementation

The patient is positioned in a

way that relaxes the muscle

to be rested.
Needle electrodes are quickly

inserted into the selected

muscle.
A metal plate lies under the

patient to serve as a reference

electrode.
The resulting electrical signal

is recorded during rest and

contraction, amplified 1

million times, and displayed

on an oscilloscope or

computer screen.
Lead wires are usually

attached to an audio-

amplifier so that voltage

fluctuations within the

muscle are audible.

Nursing Interventions

Assess the patients pain level.

HERNIATION OF THE LUMBAR DISK

Medical Management

If the patient experiences

residual pain, apply warm

compresses and administer

prescribed analgesics.
Tell the patient that he may

resume his usual medications

as ordered.
Monitor the patient for signs

and symptoms of infection at

the needle electrode sites.

American association of neurological surgeons 2017 (http://www.aans.org/Patient%20Information/Conditions

%20and%20Treatments/Herniated%20Disc.aspx)
The objectives of treatment are to relieve pain, slow disease progression, and

increase the patients functional ability. Bed rest for 1 to 2 days on a firm mattress (to

limit spinal flexion) is encouraged to reduce the weight load and gravitational forces,

thereby freeing the disk from stress (Humphrey & Eck, 1999). The patient is allowed

to assume a comfortable position; usually, a semi-Fowlers position with moderate hip

and knee flexion relaxes the back muscles. When the patient is in a side-lying

position, a pillow is placed between the legs. To get out of bed, the patient lies on one

side while pushing up to a sitting position. Because muscle spasm is prominent during
HERNIATION OF THE LUMBAR DISK

Medical Management
the acute phase, muscle relaxants are used. NSAIDs and systemic corticosteroids

may be administered to counter the inflammation that usually occurs in the supporting

tissues and the affected nerve roots. Moist heat and massage help to relax spastic

muscles and have a sedative effect. Antidepressant agents appear to help in low back

pain that is neuropathic in origin (Fishbain, 2000).

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages, 1994-1995

Drug Study

Name of Drug Mechanism of Indication Contraindicatio Adverse Nursing

Action n effect Responsibi

lity

NSAIDs

aspirin Blocks the To Allergy to CNS:

celecoxib
activity of reliev tartrazine Confusio Instruct

cyclooxyge n, CNS patient

HERNIATION OF THE LUMBAR DISK

Medical Management

(Celebrex) nase, the e dye, depressi to take

diclofenac asthma,
mild bleeding on aspirin
(Cambia, enzyme
pain problems with food
Cataflam, needed for EENT:
or (such as
Voltaren- prostagland Hearing or after
fever hemophili
XR, Zipsor, in loss, meals
a)
Zorvolex) synthesis. hypersen tinnitus because
diflunisal
sitivity to it may
(Dolobid - Prostaglandi GI:
aspirin or cause GI
discontinue ns, Diarrhea,
its
d brand) important compone GI upset if
etodolac
mediators bleeding, taken on
ntpeptic
(Lodine -
in the heartbur an
ulcer
discontinue
n, empty
disease
d brand) inflammator
ibuprofen stomach.
y response, hepatoto
(Motrin,
cause local xicity,
Advil)
ketoprofen nausea, Instruct
vasodilation
(Active- stomach patient
with
Ketoprofen pain, to stop
swelling
[Orudis - taking
and pain. vomiting
discontinue aspirin
With
d brand]) HEME: and
ketorolac
blocking of Decrease
(Toradol - notify
cyclooxyge d blood
discontinue prescribe
HERNIATION OF THE LUMBAR DISK

Medical Management

d brand) nase and iron r if any

nabumeton
inhibition level, symptom
e (Relafen -
s of
discontinue of leukopen

d brand) prostagland ia, stomach

naproxen
ins, prolonge or
(Aleve,
inflammator d intestinal
Anaprox,
y symptoms bleeding bleeding
Naprelan,
time, occur
Naprosyn) subside.
oxaprozin such
Pain is also shortene
(Daypro)
piroxicam( relieved d life as

Feldene) because span of passage

RBCs, of black,
prostagland
bloody,
ins play a thrombo
or tarry
role in pain cytopeni
stools
a
transmissio
or if
n from the SKIN:
patient is
periphery to To Ecchymo
coughing
the reliev sis, rash,
up blood
e urticaria
spinal cord. or vomit
symp
Aspirin Other:
toms that
inhibits Angioed
of looks like
HERNIATION OF THE LUMBAR DISK

Medical Management

platelet spast ema, coffee

icity Reyes grounds.

aggregation
caus syndrom
by Advise
ed by e,
interfering spast patient

with icity salicylis with

production from m tartrazin

spina (dizzines e allergy

of
l cord s, not
thromboxan injury
tinnitus,
e A2, a or to take
difficulty
substance disea aspirin.

that se hearing,

and vomiting
stimulates
brain ,
platelet
injury diarrhea,
aggregation
confusio
. Aspirin
n,
acts

CNS
Muscle on the heat-
depressi
relaxants regulating
on,
center in
diaphore
the
sis,
Baclofen
Chlorzoxaz hypothalam headach
HERNIATION OF THE LUMBAR DISK

Medical Management

one us and e,

(Lorzone, causes
hyperve
Parafon peripheral
ntilation,
Forte DSC)
Carisoprod vasodilation and

ol (Soma) , lassitude
Dantrolene
diaphoresis, ) with
(Dantrium)
Diazepam and heat
regular
(e.g. loss.
use of
Valium)
large

doses

May inhibit

transmissio
Hypersen
n of
sitivity to
monosynap Expec
baclofen;
tic treatment t to

start
HERNIATION OF THE LUMBAR DISK

Medical Management

and of CNS: baclof

skeletal
polysynapti Abnorma en
muscle
c impulses, l gait, thera
spasm
similar to anxiety, py at
resulting
effects of ataxia, a low
from dose
gamma- rheumati chills,
and
aminobutyri c
coma, gradu
c acid disorders
confusio ally
(GABA).
n, increa

Baclofen depressi se

may work in on, until

the spinal dizziness desire

cord at the , d
effect
afferent
drowsine s are
spinal end
ss, achie
of upper
dystonia, ved.
motor Asses
emotion
neurons, s for
al
where it signs
lability,
hyperpolari of

zes nerve euphoria effecti

fibers and , venes

exciteme s,
inhibits
HERNIATION OF THE LUMBAR DISK

Medical Management

impulse nt, such

transmissio fatigue, as
relief
n. This fever,
of
reduces
hallucina spas

excess tions, ms,

muscle headach pain,

activity e, and

caused by hyperton muscl

muscle ia, e

rigidit
hypertonia, hypother
y.
spasms, mia, Becau

and hypotoni se

spasticity. a, CNS

impaired depre

ssion
concentr
can
ation,
occur,
insomnia
take
, lack of preca

utions
coordina
to
tion,
preve
lethargy,
nt
memory
HERNIATION OF THE LUMBAR DISK

Medical Management

loss, injury.
Also

paresthe take
preca
sia,
utions
personali
for
ty
patien
disorder,
ts
seizures,
who

somnole use

nce, spasti

stroke, city
to
syncope,
maint
tremor,
ain

weaknes locom

s otion

or
CV:
uprig
Bradycar
ht
dia,
postur
chest
e
pain, and

chest balan

tightness ce.

, Relief
HERNIATION OF THE LUMBAR DISK

Medical Management

deep of

vein spasti

thrombo city

sis, may
increa
hyperten
se
sion,
risk of

orthostat falls

ic and

hypotens injury.
Repor
ion,
t
palpitati
imme
ons,
diatel

peripher y any

al edema of the

follow
EENT:
ing:
Amblyopi worse

a, ning

blurred spasti

vision, city,

diplopia, return

of
dry
spasti
mouth,
HERNIATION OF THE LUMBAR DISK

Medical Management

miosis, city
when
mydriasi
previo
s, nasal
usly

congesti well

on, contro

nystagm lled,
withdr
us,
awal
photoph
sympt
obia,
oms,
ptosis,
poor

rhinitis, respo

slurred nse

speech,

strabism

us, taste

loss,

tinnitus

ENDO:

Hypergly

cemia

GI:
HERNIATION OF THE LUMBAR DISK

Medical Management

Abdomin

al pain,

anorexia,

constipat

ion,

dysphagi

a,

elevated

liver

function

test

results,

flatulenc

e, ileus,

indigesti

on,

nausea,

vomiting

GU:

Albumin

uria,

bladder
HERNIATION OF THE LUMBAR DISK

Medical Management

spasms,

dysuria,

enuresis,

hematuri

a,

impotenc

e, renal

failure,

sexual

dysfuncti

on,

urinary

frequenc

y,

urinary

incontine

nce,

urine

retention

HEME:

Anemia
HERNIATION OF THE LUMBAR DISK

Medical Management

MS:

Muscle

twitching

RESP:

Aspiratio

pneumo

nia,

pulmona

ry

embolis

m,

respirato

ry

depressi

on

Jones & Barlett learning Nurses Drug Handbook 2015

HERNIATION OF THE LUMBAR DISK

Surgical Management

Surgical Management
In the lumbar region, surgical treatment includes lumbar disk excision through a

posterolateral laminotomy and the newer techniques of microdiscectomy and

percutaneous discectomy. In microdiscectomy, an operating microscope is used to

visualize the offending disk and compressed nerve roots; it permits a small incision

(2.5 cm [1 inch]) and minimal blood loss and takes about 30 minutes of operating

time. Generally, it involves a short hospital stay, and the patient makes a rapid

recovery. Percutaneous discectomy is an alternative treatment for herniated

intervertebral disks of the lumbar spine at the L4-5 level. One approach in current use

is through a 2.5-cm (1-inch) incision just above the iliac crest. A tube, trocar, or

cannula is inserted under x-ray guidance through the retroperitoneal space to the

involved disk space. Special instruments are used to remove the disk. The operating

time is about 15 minutes. Blood loss and postoperative pain are minimal, and the

patient is generally discharged within 2 days after surgery. The disadvantage of this

procedure is the possibility of damage to structures in the surgical pathway.

Artificial disc surgery - Surgical replacement of a diseased or herniated

lumbar disc with a manufactured disc.

Discectomy - Surgical removal or partial removal of an intervertebral disc.
Laminectomy - Surgical removal of most of the bony arch, or lamina of a

vertebra.
Laminotomy - An opening made in a lamina, to relieve pressure on the nerve

roots.
Spinal Fusion - A procedure in which bone is grafted onto the spine, creating

a solid union between two or more vertebrae; and in which instrumentation

such as screws and rods may be used to provide additional spinal support

Complications of Disk Surgery

HERNIATION OF THE LUMBAR DISK

Surgical Management
A patient undergoing a disk procedure at one level of the vertebral column

may have a degenerative process at other levels. A herniation relapse may occur at the

same level or elsewhere, so that the patient may become a candidate for another disk

procedure. Arachnoiditis (inflammation of the arachnoid membrane) may occur after

surgery (and after myelography); it involves an insidious onset of diffuse, frequently

burning pain in the lower back, radiating into the buttocks. Disk excision can leave

adhesions and scarring around the spinal nerves and dura, which then produce

inflammatory changes that create chronic neuritis and neurofibrosis. Disk surgery

may relieve pressure on the spinal nerves, but it does not reverse the effects of neural

injury and scarring and the pain that results. Failed disk syndrome (recurrence of

sciatica after lumbar discectomy) remains a common cause of disability.

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages, 1994-1995.
HERNIATION OF THE LUMBAR DISK

Nursing Diagnosis

Nursing Diagnosis
Acute pain related to nerve compression, muscle spasm
Impaired physical mobility related to pain, muscle spasms, and damage

neuromuscular restrictive therapy

Anxiety related to ineffective individual coping
Knowledge deficient related to the lack of information about the condition,

prognosis
HERNIATION OF THE LUMBAR DISK

Nursing Management

Nursing Management
PROVIDING PREOPERATIVE CARE
Most patients fear surgery on any part of the spine and therefore need

explanations about the surgery and reassurance that surgery will not weaken the back.

When data are being collected for the health history, any reports of pain, paresthesia,

and muscle spasm are recorded to provide a baseline for comparison after surgery.

Preoperative assessment also includes an evaluation of movement of the extremities

as well as bladder and bowel function. To facilitate the postoperative turning

procedure, the patient is taught to turn as a unit (called logrolling) as part of the

preoperative preparation. Before surgery, the patient is also encouraged to take deep

breaths, cough, and perform muscle-setting exercises to maintain muscle tone.

ASSESSING THE PATIENT AFTER SURGERY
After lumbar disk excision, vital signs are checked frequently and the

wound is inspected for hemorrhage because vascular injury is a complication of disk

surgery. Because postoperative neurologic deficits may occur from nerve root injury,

the sensation and motor strength of the lower extremities are evaluated at specified

intervals, along with the color and temperature of the legs and sensation of the toes. It

is important to assess for urinary retention, another sign of neurologic deterioration. In

discectomy with fusion, the patient has an additional surgical incision if bone

fragments were taken from the iliac crest or fibula to serve as wedges in the spine.

The recovery period is longer than for those patients who underwent discectomy

without spinal fusion because bony union must take place.

POSITIONING THE PATIENT
To position the patient, a pillow is placed under the head and the knee rest is

elevated slightly to relax the back muscles. When the patient is lying on one

side, however, extreme knee flexion must be avoided. The patient is

encouraged to move from side to side to relieve pressure and is reassured that
HERNIATION OF THE LUMBAR DISK

Nursing Management
no injury will result from moving. When the patient is ready to turn, the bed is

placed in a flat position and a pillow is placed between the legs. The patient

turns as a unit (logrolls), without twisting the back. To get out of bed, the

patient lies on one side while pushing up to a sitting position. At the same

time, the nurse or family member eases the patients legs over the side of the

bed. Coming to a sitting or standing posture is accomplished in one long,

smooth motion. Most patients walk to the bathroom the same day as surgery.

Sitting is discouraged except for defecation.

PAIN MANAGEMENT
Non pharmacologic interventions
Although pain medication is the most powerful pain relief tool

available to nurses, it is not the only one. Non pharmacologic nursing activities can

assist in relieving pain with usually low risk to the patient. Although such measures

are not a substitute for medication, they may be all that is necessary or appropriate to

relieve episodes of pain lasting only seconds or minutes. In instances of severe pain

that lasts for hours or days, combining non pharmacologic interventions with

medications may be the most effective way to relieve pain.

Cutaneous Stimulation and Massage
The gate control theory of pain proposes that the stimulation of fibers

that transmit non painful sensations can block or decrease the transmission of pain

impulses. Several non pharmacologic

pain relief strategies, including rubbing the skin and using heat and cold, are

based on this theory. Massage, which is generalized cutaneous stimulation of

the body, often concentrates on the back and shoulders. A massage does not

specifically stimulate the non-pain receptors in the same receptor field as the

pain receptors, but it may have an impact through the descending control
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Nursing Management
system. Massage also promotes comfort because it produces muscle

relaxation.
Ice and Heat Therapies
Ice and heat therapies may be effective pain relief strategies in some

circumstances; however, their effectiveness and mechanism of action need further

study. Proponents believe that ice and heat stimulate the non-pain receptors in the

same receptor field as the injury. For greatest effect, ice should be placed on the injury

site immediately after injury or surgery. Ice therapy after joint surgery can

significantly reduce the amount of analgesic medication required subsequently. Ice

therapy may also relieve pain if applied later. Care must be taken to assess the skin

prior to treatment and to protect the skin from direct application of the ice. Ice should

be applied toan area for no longer than 20 minutes at a time. This prevents the

rebound phenomenon that occurs as the body attempts to warm up, rendering the

treatment useless. Long applications of ice may result in frostbite or nerve injury.

Both ice and heat therapy must be applied carefully and monitored closely to avoid

injuring the skin. Neither therapy should be applied to areas with impaired circulation

or used with patients with impaired sensation. Application of heat increases blood

flow to an area and contributes to pain reduction by speeding healing. Both dry and

moist heat may provide some analgesia, but their mechanisms of action are not well

understood. Application of heat to inflamed joints, for example, may provide

temporary comfort, but increasing the intra-articular temperature may impair healing

(Oosterveld & Rasker, 1994a, 1994b).

Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) uses a battery

operated unit with electrodes applied to the skin to produce a tingling, vibrating, or
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Nursing Management
buzzing sensation in the area of pain. It hasbeen used in both acute and chronic pain

relief and is thought to decrease pain by stimulating the non-pain receptors in the

same area as the fibers that transmit the pain. This mechanism is consistent with the

gate control theory of pain and explains the effectiveness of cutaneous stimulation

when applied in the same area as an injury. For example, when TENS is used in a

postoperative patient, the electrodes are placed around the surgical wound. Another

possible explanation for the effectiveness of TENS is the placebo effect (the patient

expects it to be effective). In a review of the literature, Carroll, Tramer, McQuay et al.

(1996) found that in 15 of 17 studies with randomized control group designs, TENS

was ineffective in relieving postoperative pain. In 17 of 19 studies that did not use this

design, the authors of these studies concluded that TENS had a positive analgesic

effect. The review of these studies suggests that a placebo effect may explain the

effectiveness of TENS.
TEACHING PATIENT SELF-CARE
The patient is advised to gradually increase activity as tolerated

because it takes up to 6 weeks for the ligaments to heal. Excessive activity may result

in spasm of the para spinal muscles. Activities that produce flexion strain on the spine

(eg, driving a car) should be avoided until healing has taken place. Heat may be

applied to the back to relax muscle spasms. Scheduled rest periods are important, and

the patient is advised to avoid heavy work for 2 to 3 months after surgery. Exercises

are prescribed to strengthen the abdominal and erector spinal muscles. A back brace or

corset may be necessary if back pain persists.

Brunners and Suddharts textbook of medical surgical nursing 10th edition volume 2 pages

1827-1829, 1994-1995.