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Spinal Cord Injuries (SCIs) are a major health problem. Most spinal cord
injuries result from motor vehicle crashes. Other causes include falls, violence, and
recreational sporting activities. Half of the victims are between 16 and 30 years of
age; most are males.
The level of injury will determine the degree of disability the patient is likely to
sustain. A high-level injury, such as cervical injury, will more likely result in
quadriplegia and compromise of the respiratory drive. A complete spinal cord injury
will result in greater disability than an incomplete injury. Spinal cord tissue does not
regenerate after an injury. Swelling that occurs immediately following an injury may
be controlled with medications and some clinical improvement may occur, but the
damage to the cord cannot be undone.
1
Objectives of the Study
General Objectives
The general objectives for conducting this case study is for the
students in their Orthopedic Ward rotation to be able to integrate concepts of
Orthopedic nursing, apply appropriate nursing management and
consequently develop a meticulous attitude on rendering nursing
interventions to patients with this health condition.
Specific Objectives
At the end of 1 hour of case presentation this case study specifically
aims to:
a. Present the condition of patient ADAM suffering from Acute
Spinal Cord Injury.
b. To acquire knowledge and understanding of the
pathophysiology of Spinal Cord Injuries.
c. Design a nursing care plan appropriate in providing care to
prevent further complications associated with Spinal Cord Injuries.
d. To manage efficiently the complications that the patient have
experience.
e. To identify and provide the health teaching needs for the
continuum of care.
f. To apply knowledge in Medical Surgical Nursing, particularly on the
management of a client with Spinal Cord Injury.
g. To apply and enhance our skills in nursing procedures and to
demonstrate appropriate attitude in relation to the management of a
client with Spinal cord injury.
h. To use the nursing process as the framework of care for the
patient.
2
Scope and Limitations
This care study conducted, concentrates mainly to the case of patient
ADAM having Acute Spinal Cord Injury - Complete. The areas of concern are limited
to the discussion of the disease process and the Medical and Nursing management
of Spinal Cord Injury. The quantity and quality of the information are limited to the
data gathered from the client, significant others and his medical records and an
approximately 24 hours of cumulative interaction with the client and with his
Significant other, specifically on December 13-14, 2010. The source of information is
limited to the patient’s chart, interview, nursing history and assessment records.
3
Patient’s Profile
Name of Patient: ADAM
Age: 44 years old
Gender: Male
Date of Birth: April 14, 1966
Address: Purok 4, Guinoyuran, Valencia Bukidnon
Occupation: Farmer
Civil Status: Married
Religion: Baptist
Nationality: Filipino
Informant: ABRAHAM
Relation to Informant: Brother
Chief Complaint: Quadriplegia (Paralysis on Upper and
Lower Extremities)
Date of Admission: December 9, 2010
Time of Admission: 2:30 am
Attending Physician: Dr. Bernard Antolin
Allergies: ADAM has no known allergies both food
and drugs
Diagnosis/Impression: Acute Spinal Cord Injury, Complete, C4
level secondary to bilateral facet dislocation
(C4-C5), spontaneously reduced secondary
to Vehicular accident (Motorcycle).
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PART 2: HEALTH HISTORY and PRESENT ILLNESS
Personal History
ADAM, a 44 year-old male, married, has 2 daughters and a son. He was born
on April 14, 1966. ADAM was a farmer and part time driver (habal-habal). He works
having 2 jobs since his wife is not here in the Philippines. A day prior to his
admission he drove home with his motorcycle. On his way home, he lost balance
with the motorcycle and fell, feeling a snap in his back which caused his upper and
lower extremities paralysis. He was rushed to the nearest hospital in Valencia and
consequently referred at Northern Mindanao Medical Center.
Family History
As the group conducted the assessment, the informant (ABRAHAM) that the
family only experiences common illnesses like fever, cough, colds, toothaches,
headaches, etc. but has never occurred to them any major diseases or illnesses.
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PART 3: NURSING ASSESSMENT
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
__ Hearing Loss Comments: __ Glasses __ Languages
X Visual Changes “Dili naman kaayo na siya __ Contact Lens __ Hearing Aide
makastorya tungod sa
__ Denied R L X Speech Difficulties
tubo nga gitaod. Amo lang
na siya ipa-hunghung Due to tracheostomy tube inserted .
kung unsa iyang gusto,” as
verbalized by the patient’s
Pupil Size: Both Right and Left eye 3mm
SO. Reaction: Pupil Equal Round Reactive to light Accomodation.
OXYGENATION:
X Dyspnea Comments: Respiration: __ Regular X Irregular
X Smoking History “Sa una raman siya Describe: Shallow and labored breathing with
gapanigarilyo. Mahurot
One pack per week Increased respiratory rate (31cpm)
ang tunga sa kaha sa isa
__ Cough ka simana. Galisod naman
X Sputum siya ug ginhawa karon kay R: Anatomically, the right lung is symmetrical to the
__ Denied dili na malihok iyang baga, Left lung.
ingon sa doctor nga
paralyze daw siya tibook L: The left lung is also symmetrical to the right lung.
lawas” As verbalized by But due to the body paralysis the diaphragm is
patient’s SO. helping the lungs exert effort when breathing.
CIRCULATION:
__ Chest Pain Comments: Heart Rhythm: __ Regular X Irregular
__ Leg Pain “Gareklamo siya nga Ankle Edema: present in both ankles and non-pitting
X Numbness of sakit kaayo iyang ulo.”
As verbalized by the Pulse Car Rad DP Fem*
extremities
patient’s SO. Right 79 weak weak Not taken
__ Denied
Left 82 weak weak Not taken
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ELIMINATION:
Usual bowel pattern: __ Urinary Frequency Comments: Bowel sounds:
Every morning (PTA) FBC in place “Sa wala pa siya na admit, kada Hypoactive
X Constipation __ Urgency buntag malibang siya. Sukad Abdominal Distension
X Remedy __ Dysuria pag-admit niya wala pa siya Present:
Analgesic Agents naka-libang,” – Dec. 12, 2010 X Yes __ No
__ Hematuria
(Tramadol) __ Incontinence Urine:
__ Date of last BM __ Polyuria Color: Yellow(iced tea)
Dec. 14, 2010 afternoon X Foly in place Odor: Not Assessed
__ Diarrhea __ Denied Consistency:
__ Character 50-70ml per urination
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patient’s SO.
COPING:
Occupation: Motorized Driver & Farmer Observe non-verbal behavior: Patient uses his eyes
Members of household: 7 members eyes to points at the things he needs in assistance.
Most supportive person: Wife, mother and his The person and his phone number that can
Brother. Be reached anytime: Not taken
Gardner-Wells EENT:
EENT Tracheostomy Tube
Tong Impaired vision – Using of glasses
Teeth – Full of cavities
[X] Impaired Vision [ ] Blind NGT Gums – Dry and has mouth ulcers
[ ] Arrhythmia [ ] Tachycardia
Dry Scalp with Dandruff
[X] Numbness [X] Diminished Pulse
Dry Skin
[ ] Edema [ ] Fatigue
[X] Irregular [ ] Bradycardia
[ ] Mur-mur [X] Tingling
[ ] Absent Pulse [ ] Pain
Assess heart sounds, rate, rhythm, pulse,
Blood pressure, circulation, fluid retention, IV Line PNSS 1L
regulated at 20gtts/min
Comfort
Untrimmed and dirty
[ ] No Problem fingernails both hands
FBC in place
GASTROINTESTINAL
Untrimmed and dirty
[ ] Obese [X] Distension fingernails on feet
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GENITO – URINARY and GYNE
[ ] Pain [ ] Urine
[ ] Color [ ] Vaginal Bleeding
[ ] Hematruia [ ] Discharges
[ ] Nucturia
Assess Urine frequency, control, color, odor,
Comfort, Gyne Bleeding, Discharges
[X] No Problem
NEUROLOGIC
[X] Paralysis [ ] Stuporus
[ ] Unsteady [ ] Seizure
[ ] Lethargic [ ] Comatose
[ ] Vertigo [ ] Tremors
[ ] Confused [ ] Vision
[X] Grip
Assess motor function, sensation, LOC,
Strength, Grip, gait, coordination, speech
[ ] No Problem
10
Assess mobility, motion gait, alignment, joint function,
Skin color, texture, turgor, integrity
[ ] No Problem
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Oral Birth to 1 year
Anal 2 – 3 years
Phallic 4 – 5 years
Latency 6 – 12 years
Genital 13 – Up
12
Cognitive development refers to how a person perceives, thinks, and gains
understanding of his or her world through the interaction and influence of genetic
and learning factors. This is divided into five major phases:
Sensorimotor Phase Birth to 2 years
Pre-conceptual Phase 2 – 3 years
Intuitive Thought Phase 4 – 6 years
Concrete Operations Phase 7 – 11 years
Formal Operational Phase 12 – adulthood
♣ Basing on Cognitive Theory of Jean Piaget Mr. Adam belongs to the
Formal operational stage in which he has solved previously encountered
problems in a logical manner and has used rational thinking. These include
financial problems and also with regards to his health.
> Secure consent to care > To allow the medical team give
appropriate medical and surgical
interventions.
> TPR every 4 hours > To monitor the vital signs and changes
> Laboratory: CBC with Platelet > To screen the patient’s blood to detect
any abnormalities that might contribute
to further complications.
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> IVFTF with PNSS sedimentation > Sedimentation rate is done to find out if
rate inflammation is present, check on the
progress of the disease, and see how
well the treatment is working.
> For Insertion of Tracheostomy > Consent to grant that the patient will
Tube have a Tracheostomy tube inserted.
> Secure Consent > Referred ENT for any signs of Vision
lost.
> May feed with OF through NGT > To note for a kidney failure and
poisoning of the blood.
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> For Serum Creatinine
> For Tracheostomy Care daily > To minimized secretions and to clear
the airway.
> Start Cefuroxime 750mg IVTT > Tramadol for pain relief.
q8H Negative ANST
> To monitor respiratory failure
> Continue Tramadol for pain relief
> Continue Tracheostomy care > So the patient will not be irritated
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> Deflate Tracheostomy Balloon > To minimized secretions and to clear
q2H every 15 minutes the airway.
4:00pm
> May give paracetamol 300mg
IVTT then PRN for fever q4H
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PART 6: LABORATORY EXAMS
Blood Chemistry
Date Taken: December 9, 2010
Component Unit Reference Results Interpretation
Within normal range but at
Creatinine mg/dL 0.59 – 1.20 0.90
high risk for Kidney failure
The Attending Physician ordered a Complete Blood Count test for the patient and
CT-Scan but the results were not placed / attached in the Patient’s Chart.
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PART 7: DRUG STUDY
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seizure (convulsions), a red, blistering, peeling skin rash, shallow breathing,
weak pulse.
Nursing Precaution: Assess BP & RR before and periodically during
administration. Assess bowel function routinely. Prevention of constipation should be
instituted with increased intake of fluids and bulk and with laxatives to minimize
constipating effects. Monitor patient for seizures. Encourage patient to cough and
breathe deeply every 2 hr to prevent atelactasis and pneumonia.
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smoking and ETOH. Watch for signs of GI bleeds.
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Mechanism of Action: Reduces fever by acting directly on the hypothalamic heat-
regulating center to cause vasodilation and sweating, which helps dissipate heat.
Specific Indication: Common cold, flu, other viral and bacterial infections with pain
and fever.
Contraindication: Contraindicated with allergy to acetaminophen. Use cautiously
with impaired hepatic function, chronic alcoholism, pregnancy, lactation.
Side Effects/Toxic Effects: Headache, dizziness, lethargy, nausea, vomiting,
jaundice, acute kidney failure, rash
Nursing Precaution: Inspect IM and IV injection sites frequently for signs of
phlebitis. Do not exceed the recommended dosage. Monitor for manifestations of
hypersensitivity.
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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 vertebra, which allows a greater amount of movement.
Each cervical vertebra consists of two 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 the one above it and the one
below it.
Thoracic Spine
In the chest region the thoracic
spine attaches 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.
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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 vertebra, L5, articulates 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.
Just like the spinal column is divided into cervical, thoracic, and lumbar
regions, so is the spinal cord. Each portion of the spinal cord is divided into specific
neurological segments.The cervical spinal cord is divided into eight levels. Each
level contributes to different functions in the neck and the arms (see diagram).
Sensations from the body are similarly transported from the skin and other areas of
the body from the neck, shoulders, and arms up to the brain.In the thoracic region
the nerves of the spinal cord supply muscles of the chest that help in breathing and
coughing. This region also contains nerves in the sympathetic nervous system.
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The lumbosacral spinal cord and nerve supply legs, pelvis, and bowel and
bladder. Sensations from the feet, legs, pelvis, and lower abdomen are transmitted
through the lumbosacral nerves and spinal cord to higher segments and eventually
the brain.
There are many nerve pathways that transmit signals up and down the spinal
cord. Some supply sensation from the skin and outer portions of the body. Others
supply sensation from deeper structures such as the organs in the belly, the pelvis,
or other areas. Other nerves transmit signals from the brain to the body. Still others
work at the level of the spinal cord and act as "go betweens" in the signal
transmission process.
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The upper motor neuron refers to injuries that are above the level of the
anterior horn cell. This results in a spastic type of paralysis. Conversely, the lower
motor neuron injury refers to an injury at or below the anterior horn cell that results in
the flaccid type paralysis. This is usually seen in nerve root injuries or in the cauda
equina syndrome that was mentioned previously. The terms neurogenic bowel and
neurogenic bladder are used to describe abnormal bowel and bladder function and
can be classified as either an upper motor neuron or lower motor neuron type of
problem. In general, those patients with an upper motor neuron paralysis will have
an upper motor neuron bowel and bladder, and those with lower motor neuron
injuries will have a lower motor neuron picture of the bowel and bladder.
Adequate bowel and bladder management is critical for adequate reintegration of the
patient/client into the community and hopefully into the work place.
Feelings from the body such as hot, cold, pain, and touch, are transmitted to
the skin and other parts of the body to the brain where sensations are "felt." These
pathways are called the sensory pathways.
Once signals enter the spinal cord, they are sent up to the brain. Different
types of sensation are sent in different pathways, called "tracts." The tracts that carry
sensations of pain and temperature to the brain are in the middle part of the spinal
cord. These tracts are called the "spinothalamic." Other tracts carry sensation of
position and light touch. These nerve impulses are carried along the back part of the
spinal cord in what are called "dorsal columns" of the spinal cord.
Another type of special nerves are the autonomic nerves. In spinal cord
injuries, they are very important. The autonomic nerves are divided into two types:
the sympathetic and parasympathetic nerves.
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hormones. It controls cardiovascular, digestive, and respiratory systems. These
systems work in a generally "involuntary" fashion. The primary role of the autonomic
nervous system is to maintain a stable internal environment within the body. The
heart and blood vessels are controlled by the autonomic nervous system. The
sympathetic nerves help to control blood pressure based on the physical demands
placed on the body. It also helps to control heart rate. The sympathetic nerves, when
stimulated, cause the heart to beat faster.
When spinal cord injury is at or above the T6 level the sympathetic nerves
below the injury become disconnected from the nerves above. They continue to
operate automatically once the period of spinal shock is over. Anything that
simulates the sympathetic nerves can cause them to become overactive. This
overactivity of the sympathetic nerves is what is called autonomic dysreflexia.
The parasympathetic nerves arise from two areas. The fibers that supply the
organs of the abdomen, heart, lungs, and skin above the waist begin at the level of
the brain and very high spinal cord. The nerves that supply the reproductive organs,
pelvis, and leg begin at the sacral level, or lowest part of the spinal cord. After a
spinal cord injury, the parasympathetic nerves that begin at the brain continue to
work, even during the phase of spinal shock. When dysreflexia occurs, the
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parasympathetic nerves attempt to control rapidly increasing blood pressure by
slowing down the heart.
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stimuli. Although the speed at which the information travels from the body to the
brain and back to the body is very fast, sometimes we need the information to travel
at a greater speed. This is where the reflex action triggered by the spinal cord comes
into the picture. the situation is generally referred to as fight or flight response. As a
defense mechanism, the body reacts faster than the normal time it usually takes.
The best example of this reflex action would be the way you take your hand back,
within split seconds, as soon as you touch some hot object.
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PART 9: PATHOPHYSIOLOGY
Narrative Pathophysiology
Upon initial impact or injury, there is immediate mechanical damage to neural
and other soft tissue, including endothelial cells of the vasculature. Thus necrosis, or
cell death, results from these mechanical and ischemic insults, is instantaneous,
and, in a contusion injury, appears to be more predominant in the grey matter of the
spinal cord than in the white matter, resulting in a ring of preserved white matter at
the contusion site. After the insult, over the next few minutes, the injured nerve cells
respond with an injury-induced barrage of action potentials.
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In the secondary phase (which occurs over the time course of minutes to
weeks), the ischemic cellular death, electrolytic shifts, and edema continue from the
acute phase. Within the first 15 minutes after injury, extracellular concentrations of
glutamate and other excitatory amino acids reach cytotoxic concentrations that are
six- to eightfold higher than normal as a result of cell lysis from mechanical injury
and both synaptic and nonsynaptic transport. In addition, lipid peroxidation and free-
radical production also occur as a result of glutamate receptor-activated and
subsequently mediated pathways.
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31
PART 10: IDEAL NURSING MANAGEMENT
Dependent
Administer oxygen by appropriate Method is determined by level of injury,
method degree of respiratory insufficiency, and
amount of recovery of respiratory
muscle function after spinal shock
phase.
32
IMPAIRED PHYSICAL MOBILITY
ACTIONS/INTERVENTIONS RATIONALE
Independent
Provide means to summon help. Enables client to have a sense of
control, and reduces fear of being left
alone.
33
RISK FOR IMPAIRED SKIN INTEGRITY
ACTIONS/INTERVENTIONS RATIONALE
Independent
Inspect all skin areas, noting capillary Skin is especially prone to breakdown
blanching/refill, redness, swelling. Pay because of changes in peripheral
particular attention to back of head, skin circulation, inability to sense pressure,
under halo frame or vest, and folds immobility, altered temperature
where skin continuously touches. regulation.
Observe halo and tong insertion sites. These sites are prone to inflammation
Note swelling, redness, drainage. and infection and provide route for
pathologic
microorganisms to enter cranial cavity.
34
PART 11: ACTUAL NURSING MANAGEMENT
Priority Number 1
“Ga lisod naman siya ug ginhawa karon kay dili na daw malihok iyang
S baga, ingon sa doctor nga paralyzed daw siya tibuok lawas.” As
verbalized by the patient’s SO.
● Shallow/labored breathing
O ● Respiration rate of: 31 cpm
●
Ineffective breathing pattern related to paralysis of abdominal and
A
intercostals muscles secondary to spinal cord injury.
At the end 2 days of nursing intervention, the patient will be able to
P maintain adequate ventilation as evidenced by the patient’s o2 sat and
respiratory rate are within normal range.
1. Suctioned secretions in ● Since cough is ineffective,
tracheostomy tube. suctioning is needed to remove
secretions, enhance gas
exchange and reduce risk of
respiratory infection.
35
Priority Number 2
“Dili naman siya makalihok. Tabangan na gyud siya sa tanan
S buhatonon. Sa pagilis sa iyaha, pagilis sa diaper, kung trapuhan pud
namo siya.” As verbalized by the patient’s SO.
● Limited range of motion
O ● Numbness of the extremities
● Inability to perform gross and fine motor skills
Impaired physical mobility related to motor and sensory impairment
A
secondary to spinal cord injury
At the end 2 days of nursing intervention, the patient will be able to
P maintain position of function and skin integrity as evidenced by absence
of contractures, decubitus and so forth.
1. Performed passive ROM ● This enhances circulation,
exercises on all extremities and maintains muscle tone and joint
joints, using slow, smooth mobility and prevents muscle
movements. atrophy.
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Priority Number 3
“Init kayo siya, nag hilantan man siya bago lang ug gahunghung siya sa
S
ako nga sakit kuno iyang ulo.” As verbalized by the patient’s SO.
● Skin Warm to touch
O ● Flushed and dry skin
● Temperature of 38.7°C
Hyperthermia related to autonomic disruption secondary to spinal cord
A
injury.
At the end 2 days of nursing intervention, the patient will be able to have
P
a reduce in body temperature.
1. Tepid sponge bath done. ● Results in heat loss by
evaporation and conduction.
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PART 12: REFERRALS and FOLLOW-UP
Health Teachings
1. The client’s significant others is advice to let the client
follow strict compliance with the medications being given.
2. Teach the client’s significant others the importance of
medication regimen
Medications
3. Tell the client’s significant others to report to the
nearest emergency care center of hospitals any
abnormalities or unusual changes or reactions during the
treatment course.
Since the patient is completely paralyzed below the neck, the
patient’s significant others will be taught on how to do the
passive exercises, this is to prevent pressure ulcers, further
injury by keeping joints and muscle flexible. This can also help
Exercise
maintain muscles and encourage circulation between joints.
38
7. In the acute phase, severe SCI, especially after high lesions, requires
the attention of a specialized trauma team.
8. For long-term management, consultations with many specialists are
often necessary because of the multiple organ complications that follow
SCI.
9. Specifically, referral to a urologist, a gastroenterologist, a psychiatrist,
a plastic surgeon, a dermatologist, and a pain management specialist may
be necessary.
10. Rehabilitation specialists such as physiatrists or neurologists become
involved after the immediate hospitalization.
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PART 13: EVALUATION
For two days of clinical duty at Northern Mindanao Medical Center –
Orthopedic Ward, the proponents was able to assess the patient thoroughly and
gave appropriate nursing interventions dependently and independently. It was a
challenge for us to have assessed the patient for a very limited time. Though the
information gathered was insufficient, we were able to finish a fairly accurate care
study paper.
This care study enabled us more knowledge about the disease condition of
the patient as well as the signs and symptoms he manifested and the possible
complications that might occur.
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Interventions, and Rationales.11th edition. F.A Davis Company:
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McCann Schilling, Judith A. Lipincott Manual of Nursing Practice
series.Diagnostic Tests. Lipincott Williams & Wilkins.
Smeltzer, Suzanne C. et.al Brunner and Suddarth’s textbook of Medical-
Surgical Nursing 12th edition Vol. 2. Lippincott Williams and Wilkins.
(2010).
Nowak, Thomas J. et.al. Essentials of Pathophysiology: Concepts and
Applications for Health Care Professional 2nd edition. McGraw-Hill
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Black, Joyce M. et.al. Medical-Surgical Nursing: Clinical Management for
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McCann, Judith A. et.al. Pathophysiology: Made Incredibly Visual. Lippincott
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Internet
http://www.spinalinjury.net/html/_anatomy_of_the_spinal_cord_co.html
http://advan.physiology.org/content/26/4/238.full
http://www.buzzle.com/articles/spinal-cord-function.html
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