COMPARATIVE ANALYSIS

COMPARATIVE ANALYSIS:

a) INTRODUCTION:

As a part of my Medical surgical posting I was posted in OF1(K2) ward from 28/2/11 to 5/3/11. I took 3 patients for my comparative analysis assignment. They were Mrs. Shabhana Banu, Mrs Pankaja and Mrs Ruckiya. All of them were diagnosed to have intervertebral disc prolapse and were managed conservatively with medications and traction.

b) PATIENTS PROFILE:

MRS SHABANA BANU MRS PANKAJA MRS RUCKIYA

Name

Hospital number

Age/ sex

Address

Religion

Marital status

Date & time of admission

Diagnosis

Mrs Shabhana Banu

01612973

36 yrs/ F

KM Manzil, Kodavoor, Udupi

Muslim

Married

19/2/2011

L5-S1 Acute IVDP

Mrs. Pankaja

02097215

40 yrs

Chennagiri TQ, Davangere.

Hindu

Married

24/2/2011

Cervical disc disease with radiculopathy. IVDP L4-L5 with right lower limb radiculopathy.

Mrs. Ruckiya

02124693

40 yrs

Thupnalu village, chaltur post. Davengere

Muslim

Married

22/2/2011

L4-L5 IVDP with right sided radiculopathy

c) CHIEF COMPLAINTS WITH DURATION:

Patient came with complaints of:Low back pain since 2 days, radiating to right lower limb.

Patient came with complaints of neck pain radiating to left upper limb since 1 year.Low back pain radiating to right lower limb since 3 months.

Patient came with complaints of low back pain with right sided radiation.

d) HISTORY OF PRESENT ILLNESS:

Patient came with complaints of low back pain since 2 days. The pain is acute in nature, sever in nature, radiating to right lower limb, more during strenuous activities. She also gives history of not being able to get up and walkHistory of tingling and numbness of the right lower limb.

She is a known case of B/L

Patient was apparently normal 1 yr back when she started noticing pain in the neck which was radiating to left upper limb. The neck pain was insidious in onset and gradually progressive. She also gives history of Paresthesia of the left upper limb. Patient gives history of fall 6 months back. Was asymptomatic for 2 months but started noticing low back pain since last 4 months, which was insidious in onset. History of radiation to right lower limb. Paresthesia present over right leg.

Patient came with complaints of lower back pain radiating to right leg till great toe.Pain is moderate to severe in nature, rapidly progressive, more in night, aggravated by movement and relieved by rest and analgesic.She also complains of tingling and numbness over sole of right foot, more in the night and hence sleepless.Aggravated during standing, walking and relieved by lying down.Also complains of pain over buttocks while sitting.

e) HISTORY OF PAST ILLNESS:

f) FAMILY HISTORY:

g) SOCIO-ECONOMIC STATUS:

h) Nearest health care facility:

i) Personal history:

endometrial cyst, left cystectomy with adhesiolysis done on 22/12/2004. She was on Inj. Depo-Provera till 2007. She is also a known case of hypothyroidism on T.Thyronorm 75mg od.

No family history of DM, HTN or any other illness.She is married with one child and lives in a nuclear family.

i. Social aspect:Her husband makes decision on health matters. Has good support system & neighborhood relations.

ii. Economic status:Education- B.AOccupation- housewifeType of house- own houseToilet & water facility available.

Kasturba Hospital, Sonia clinic.

Immunization history: immunizedDietary history:Non-vegetarian3 meals / dayPrefers Indian home made foodFluid intake- 8-10 glasses/day

Personal hygiene:Oral- once/dayBath- once/day

No past history of any illness like DM, HTN etc.

No family history of DM, HTN or any other illness. She is married with four children. She lives with her joint family.


ii. Economic status:Education- V th stdOccupation- housewifeType of house- own houseToilet & water facility available.

Bapuji hospital, various small clinics.

Immunization history: immunizedDietary history:Vegetarian3 meals / dayPrefers Indian home made foodFluid intake- 8-10 glasses/day


No past history of any illness like DM, HTN etc.

No family history of DM, HTN or any other illness.She is married with two children and lives in a nuclear family.


ii. Economic status:Education- Xth stdOccupation- housewifeType of house- own houseToilet & water facility available.

Bapuji hospital, various small clinics

Immunization history: immunizedDietary history:Non-vegetarian3 meals / dayPrefers Indian home made foodFluid intake- 8-10 glasses/day


j) Marital/ sexual history:

Sleep & rest:UninterruptedNo drugs used for sleepingDay time naps: 1-2 hrs/dayActivity & exercise:Daily walksModerate workerHabits/ hobbies:No use of alcohol/ any drugs.Elimination:Bowel: once/ dayRegular bowel movements

Married Spouse general health: goodSpouse job status: workingStaying together: yesRelationship with spouse: satisfactory.

Female:Menstrual history:She was diagnosed with B/L endometrial cyst, Left cystectomy with adhesiolysis done in 2004.She was on Inj. Depo provera once a month till 2007.Her periods were highly irregular. She underwent IVF in 2007.

Sleep & rest:UninterruptedNo drugs used for sleepingDay time naps: 1-2 hrs/dayActivity & exercise:No exerciseModerate workerHabits/ hobbies:No use of alcohol/ any drugs.Elimination:Bowel: once/ dayRegular bowel movements


Menstrual history: Nil significantRegular periodsNormal pregnancy & delivery

Sleep & rest:UninterruptedNo drugs used for sleepingDay time naps: 1-2 hrs/dayActivity & exercise:No exerciseModerate workerHabits/ hobbies:No use of alcohol/ any drugs.Elimination:Bowel: once/ dayRegular bowel movements


Menstrual history: Nil significantRegular periodsNormal pregnancy & delivery

2) PHYSICAL EXAMINATION:

MRS SHABANA BANU MRS PANKAJA MRS RUCKIYA

GENERAL APPEARANCE

SKIN

HAIR. FACE, SCALP

Vital signs Temperature : 98.6 0F Pulse : 88 beats/min Respiration :22 breaths/ min Blood pressure : 120/80 mmhg

Height : 156 cm Weight : 80 kg BMI : 33( obese) Body built : heavily built Nourishment: well nourished Dependency status : partially

dependent Sensorium : alert & conscious

The skin is warm to touch. Periphery is warm There is no lesion or masses. The skin texture is normal. No hyper or hypo pigmentation.Temperature: 98.6 0 F.

The hair is black in color and equally distributed. No hair loss or pediculosis. No lesions or masses over the scalp. No asymmetry and involuntary movements of faces.

Eyelids are healthy without drooping or

Vital signs Temperature : 98.6 0F Pulse : 72beats/min Respiration :20 breaths/ min Blood pressure : 110/70 mmhg

Height : 160cm Weight : 60 kg BMI : 23(normal) Body built : moderately built Nourishment: well nourished Dependency status : partially





Vital signs Temperature : 98.6 0F Pulse :80 beats/min Respiration :18 breaths/ min Blood pressure : 110/80 mmhg

Height : 155 cm Weight : 68 kg BMI : 28(overweight) Body built : heavily built Nourishment: well nourished Dependency status : partially





EYES

EARS

NOSE AND SINUSES

MOUTH

NECK

edema. Conjunctiva is pink in color and sclera is white in color. Visible blood vessels are present over the conjunctiva. Pupils are equally responding to light. Visual acuity is normal.

No hearing aids are used. Both the ears are placed symmetrically. Pinna is in alignment. No ear discharge, foreign bodies are present. Some wax collection is present in the ear canal.Weber’s Test and Rinne’s Test are normal.

No nasal discharge is present. Both the nares are symmetrically placed. There is no deviation of septum, masses or lesions. Sinuses are palpated and there is no tenderness or pain.

No signs of dehydration are present. Oral hygiene is adequate. Lips are moist. Tongue is not coated. Teeth are in alignment. No ulcers are present. Tonsils are not enlarged.

Trachea is in position and there is no enlargement of lymph nodes or thyroid gland. No bruits are heard over the thyroid gland.











THORAX

HEART AND VASCULAR STATUS

Inspection: RR-22/min. No congenital deformities are present. AP diameter is half the lateral diameter. Normal shape & symmetry.PalpationNo tenderness or masses are present. Percussion Resonance sound is heard all over the lungs except over the heart. AuscultationBronchial, broncho-vesicular and vesicular sounds are heard. No adventititious sound.

Inspection:No visible apex pulsations, no JVP pulsations. Normal capillary refill. No varicose veins, cyanosis.PalpationPeripheral pulses well felt. No thrills or vibrations. AuscultationS1 and s2 is heard at the apex and base of the heart respectively. No murmurs are heard.

Abdominal contour is round. Abdominal



Abdominal contour is round. Abdominal



Abdominal contour is round.

ABDOMEN

BACK AND EXTREMITIES

pulsations are not felt. Bowel elimination pattern is normal. No Pain or tenderness while palpating. Normal bowel sounds.

Inspection:Back: no abnormal curvature. altered gait presentstiff posture, loss of lumbar lordosis present.Extremities: normal length, no deformities. Normal ROM in the upper extremities.Restricted ROM in the lower limbs. Unable to bend forward.Decreased muscle strength in the right leg. No cyanosis or clubbing. Normal capillary refill.Palpation:No swelling or masses. Tenderness present over L4-L5. Normal muscle tone. Straight leg test:RT 30LT 80Lasegue test: POSITIVE ON RT SIDENeurologic examination:Motor weakness: nil Loss of reflexes: nil Sensory loss: Tingling and numbness of

pulsations are not felt. Bowel elimination pattern is normal. No Pain or tenderness while palpating. Normal bowel sounds.

Inspection:Back: no abnormal curvature. altered gait presentstiff posture, loss of lumbar lordosis present.Extremities: normal length, no deformities. Normal ROM in the upper extremities.Restricted ROM in the lower limbs. Unable to bend forward.Decreased muscle strength in the right leg. No cyanosis or clubbing. Normal capillary refill.Palpation:No swelling or masses. Tenderness present over L3-L5. Normal muscle tone. Straight leg test:RT 40LT 90Lasegue test: POSITIVE ON RT SIDENeurologic examination:Motor weakness: nilLoss of reflexes: nil Sensory loss: Paresthesia present over

Abdominal pulsations are not felt. Bowel elimination pattern is normal. No Pain or tenderness while palpating. Normal bowel sounds.

Inspection:Back: no abnormal curvature. altered gait presentstiff posture, loss of lumbar lordosis present.Extremities: normal length, no deformities. Normal ROM in the upper extremities.Restricted ROM in the lower limbs. Unable to bend forward.Decreased muscle strength in the right leg. No cyanosis or clubbing. Normal capillary refill.Palpation:No swelling or masses. Tenderness present over L4-L5. Normal muscle tone. Straight leg test:RT 40LT 80Lasegue test: POSITIVE ON RT SIDENeurologic examination:Motor weakness: nil Loss of reflexes: nil Sensory loss: Tingling and numbness

NEUROLOGIC SYSTEM

the right lower limb.

LOCOriented to time, place and person. Memory is intact. Pattern and content of speech is normal.Sensation & motor functioningAdequate sensation to pain, touch, heat and cold. No abnormal movements. Muscle tone and muscle strength has decreased. Cerebellar functioning

Fine coordination of hands.ReflexesAll the reflexes are normal like corneal, deep and superficial reflexes.

right leg.


Fine coordination of hands.ReflexesAll the reflexes are normal like corneal, deep and superficial reflexes

over sole of right foot


Fine coordination of hands.ReflexesAll the reflexes are normal like corneal, deep and superficial reflexes

INVESTIGATIONS:

NORMAL VALUESMrs. Shabhana Mrs Pankaja Mrs. Ruckiya

Hb HctRBC countTotal WBCPlateletESR

PP glucose Urea CreatinineSodiumPotassium

THROID PROFILE:T3T4TSH

LIVER FUNCTION TEST:

12-15 gm/dl36-46%3.80-4.80 million/cumm4000-10,000 cells/cumm1.5-4 lakh cells/cumm0-20 mm/hr

90-140 mg/dl8-35 mg/dl0.6-1.6 mg/dl130-143 mEq/L3.5-5 mEq/L

0.8-2 ng/ml4.5-12 ug/dl0.3-5 UIU/ML

12.4 gm/dl37.4%4.22 million/ cumm6300 cells/cummm3,05,000 cells/cummm33 mm/hr

97 mg/dl17 mg/dl0.7 mg/dl136 mEq/L4.4 mEq/L

1.33 ng/ml11.64 ug/dl0.035 UIU/ML

13.1 gm/dl36.6%4.03 million/cumm9900 cells/cumm2,91,000 cells/cumm07 mm/hr


12.2 gm/dl35.4%8600 cells/cumm2,47,000 cells/cumm16 mm/hr


Total BilirubinDirect BilirubinTotal proteinAlbuminGlobulinAST ALTALK Phosphatase

CHEST X-RAY

MRI

STRAIGHT LEG TEST

LASEGUES TEST

0.2-1.3 mg/dl0.0-0.4 mg/dl6-8 g/dl3.5-5 g/dl1.8-3.4 g/dl5-40 U/L5-40 U/L40-140 U/L

No abnormality.

L5-S1 ACUTE IVDP

RT 30LT 80

Positive on right side

0.2 mg/dl0.1 mg/dl6.4 g/dl3.8 g/dl2.60 g/dl22 U/L12 U/L36 U/L

No abnormality

L4-L5 DISC PROLAPSE

RT 40LT 90


0.3 mg/dl0.1 mg/dl 7.3 g/dl4.7 g/dl2.6 g/dl32 U/L40 U/L35 U/L

No osseous deformity.

L4-L5 DISC PROLAPSE.

RT 40LT 80

Positive on right side.

MEDICATIONS:

S.No Mrs. Shabhana Mrs. Pankaja Mrs. Ruckiya Action of Medicines

1.

2.

3.

4.

5.

6.

T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs

Cap. Myoril 8mg 0-1-0

T. Meganeuron od

Inj Dynapar 75 mg IM sos

T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs


T. Neugaba ER 75mg hs


T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs


T. Meganeuron od


Analgesic & anti pyretic

Proton pump inhibitor

Muscle relaxant

Muscle relaxant

Multi-vitamin

Analgesic

DISEASE CONDITION:

INTERVERTEBRAL DISC PROLAPSE

INTRODUCTION:

A herniated intervertebral disk is one in which the gelatinous substance (nucleus pulposus) has protruded through the fibrocartilaginous substance (annulus fibrosus).

The herniation of the intervertebral disk is a major cause of chronic back pain. Intervertebral disk disease is most common in the lumbar region, followed by the cervical region. These two regions are the most flexible areas of the spine and the most susceptible to injury.

Most lumbar disk disorders develop at L4-L5 to S1. The C6-C7 and C5-C6 levels are the most commonly affected cervical regions. Thoracic herniations are rare.

Anatomy of the spinal column: The spinal column, also called the vertebral column or backbone, is made up of 33 vertebrae that are separated by spongy disks and classified into four distinct areas. The cervical area consists of seven vertebrae in the neck; the thoracic spine consists of 12 vertebrae in the back area; the lumbar spine consists of five vertebrae in the lower back area; five sacral bones (fused into one bone, the sacrum); and four coccygeal bones (fused into one bone, the coccyx).

Lamina - the bony arch on the posterior part of the vertebrae that is over the spinal column.

Disks - soft pads between the bones of the vertebrae that allow the back to bend and act as shock absorbers.

Spinal Cord - the bundle of nerves that connects the brain to the rest of the body. The spinal cord passes through the center of the

vertebrae.

Spinal Nerves - nerves that connect the spinal cord to the rest of the body. Muscles And Ligaments - support the spinal column, providing both strength and movement

STRUCTURE OF THE INTERVERTEBRAL DISK:

Discs consist of an outer annulus fibrosus, which surrounds the inner nucleus pulposus. The annulus fibrosus consists of several layers of fibrocartilage. The strong annular fibers contain the nucleus pulposus and distribute pressure evenly across the disc. The nucleus pulposus contains loose fibers suspended in a mucoprotein gel with the consistency of jelly. The nucleus of the disc acts as a shock absorber, absorbing the impact of the body's daily activities and keeping the two vertebrae separated.

When one develops a prolapsed disc the nucleus pulposus is forced out of the disc and may put pressure on the nerve located near the disc. This can give one the symptoms of sciatica.

T here is one disc between each pair of vertebrae, except for the first cervical segment, the atlas. The atlas is a ring around the roughly cone-shaped extension of the axis (second cervical segment). The axis acts as a post around which the atlas can rotate, allowing the neck to swivel. There are a total of thirty-three discs in the human spine, which are most commonly identified by specifying the particular vertebrae they separate. For example, the disc between the fifth and sixth cervical vertabrae is designated "C5-6".

http://en.wikipedia.org/wiki/Vertebral_column

http://en.wikipedia.org/wiki/Axis_(anatomy)

http://en.wikipedia.org/wiki/Atlas_(anatomy)

http://en.wikipedia.org/wiki/Sciatica

http://en.wikipedia.org/wiki/Prolapsed_disc

http://en.wikipedia.org/wiki/Jelly_(fruit_preserves)

http://en.wikipedia.org/wiki/Fibrocartilage

http://en.wikipedia.org/wiki/Nucleus_pulposus

http://en.wikipedia.org/wiki/Annulus_fibrosus_disci_intervertebralis

CAUSE OF PROLAPSED INTERVERTEBRAL DISC (SLIPPED DISC)

Trauma accounts for approximately 50% of disk herniations.

Examples of traumatic incidents include:

Lifting heavy objects while in flexed position(most common) Falling on buttocks or back Sudden jerk

The herniation syndrome can also occur with other degenerative processes such as osteoarthritis, ankylosing spondylosis. Patients with congenital anomalies such as scoliosis are at risk for disk injury because of the malalignment of the vertebral column.

PATHOPHYSIOLOGY:

A herniated disk often results from trauma, degenerative disk disease or a combination of both. The intervertebral disk consists of 3 parts:

The nucleus pulposus The annulus fibrosus The cartilaginous end plates.

The nucleus pulposus is a gelatinous mass that is surrounded by an outer laminated fibrocartilaginous structure, the annulus fibrosus. The annulus fibrosus holds the vertebral bodies together and is attached to the vertebral body, the cartilage endplates and the vertebral

ligaments. The intervertebral disk begans to lose its hydraulic and elastic properties with age as a result of decrease in collagen fibres and the water

content of the nucleus. In the normal disk, the nucleus can accommodate a wide variety of movements and high compression loads. With age and degeneration of the disk, the nucleus cannot tolerate and absorb stress. As the nucleus begins to weaken with sufficient stress, the nucleus ruptures through the annulus fibrossus.

Cervical disk: Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula,[8] shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected.[9]

Thoracic disc: Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations. Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected and cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.

http://en.wikipedia.org/wiki/Femoral_nerve

http://en.wikipedia.org/wiki/Sciatica

http://en.wikipedia.org/wiki/Sciatic_nerve

http://en.wikipedia.org/wiki/Toe

http://en.wikipedia.org/wiki/Foot

http://en.wikipedia.org/wiki/Perineal_nerve

http://en.wikipedia.org/wiki/Perineum

http://en.wikipedia.org/wiki/Thigh

http://en.wikipedia.org/wiki/Buttocks

http://en.wikipedia.org/wiki/Sacrum

http://en.wikipedia.org/wiki/Lumbar

http://en.wikipedia.org/wiki/Spinal_disc_herniation#cite_note-8

http://en.wikipedia.org/wiki/Brachial_plexus

http://en.wikipedia.org/wiki/Cervical_plexus

http://en.wikipedia.org/wiki/Spinal_disc_herniation#cite_note-7

CLINICAL MANIFESTATIONS:

Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material.

LUMBAR AREA:

Neurologic symptoms result from compression of the spinal cord or the spinal nerve roots or both. Symptoms reflect the nerves affected. Most herniated disks occur in the lumbar region.

PAIN:

Pain is the most characteristic symptom, generally in the lower back with radiation to the buttocks, thigh and leg. The pain is aggravated by lifting and twisting and may vary in intensity, causing mild to severe discomfort.

http://en.wikipedia.org/wiki/Low_back_pain

The term sciatica is used to describe a syndrome of lumbar back pain that spreads down one leg to the ankle and is intensified with coughing & sneezing.

POSTURAL DEFORMITY:

Normal lumbar lordosis may be absent and one iliac crest may be elevated. It is accompanied by scoliosis and spasms of the paravertebral muscles.

Abnormal posture may be evident as a mechanism to compensate for discomfort. In the standing position, the patient exhibits a typically flattened lumbar spine.

The gait often is stiff.

MOTOR DEFICITS:

Mild motor weakness of the foot, hamstring and quadriceps muscles may be evident. Urinary and bowel functioning and sexual functioning may be altered.

SENSORY DEFICITS:

Sensory impairements may include paresthesias and numbness of the legs and the foot.

ALTERATION OF REFLEXES:

The knee or ankle reflexes are absent or diminished.

CERVICAL DISK HERNIATION:

Usually occurs at C5-C6 and C6-C7 interspaces.

Pain and stiffness in the neck, the top of the shoulders and the scapula. Pain may also occur in the upper extremities and head accompanied by paresthesia and numbness of the upper extremities.

DIAGNOSTIC MEASURES:

Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying lesions, as well as to evaluate the efficacy of potential treatments.

Physical examination: positive straight leg raise test(lasegue’s sign):

Normally it is possible, when lying on the back, to move the straightened leg about 90` with only slight discomfort.

In a patient with a herniated disk, the stretching of the sciatic nerve during leg rising creates traction on the already inflamed or irritated nerve roots, producing severe pain. Patients with sciatica will not be able to raise their legs beyond 20`-30`.

Spinal x-rays: may reveal narrowing of disk spaces and degenerative changes. X-Ray lumbo-sacral spine:

Narrowed disc spaces. Loss of lumber lordosis. Compensatory scoliosis.

Myelography: reveals presence of herniation and level of herniation. An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. It will indicate the presence of herniation & the precise level of herniation, as well as ruling out cord neoplasms.

CSF analysis: elevated protein levels. Queckenstedt’s test: may reveal partial or complete blockage of CSF in spinal sub-arachnoid space. Electromyography: may reveal neural or muscle damage, may indicate specific nerve root affected. Discography: may reveal herniation of specific disk, use is controversial.

http://en.wikipedia.org/wiki/Lesion

http://en.wikipedia.org/wiki/Metastases

http://en.wikipedia.org/wiki/Tumor

http://en.wikipedia.org/wiki/Spondylolisthesis

http://en.wikipedia.org/wiki/Physical_examination

CT scan: reveals herniated disk Outline of soft tissue. Bulging out disc..

MRI: A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.• Intervertebral disc protrusion.• Compression of nerve root.

TREATMENT:

The majority of herniated discs will heal themselves in about six weeks and do not require surgery

Treatment follows two approaches:

Initial treatment is conservative, aimed at rest and reducing stress. If unsuccessful, surgery may be indicated. Bed rest: periods of bed rest on a firm mattress or back board in a semi fowler’s position with knee slightly flexed. This relieves

compression of nerve roots and minimizes spinal flexion. Immobilize the spine to give the soft tissues time to heal and to reduce inflammation in the surrounding tissues and the affected nerve roots.

Physical therapy: an extensive exercise program is prescribed to strengthen back and abdominal muscles. This is begun after the acute symptoms have subsided.

Traction: used to increase the intervertebral space, which relieves spasm. Pelvic traction a canvas girdle is applied to pelvis and hips. Straps are attached to girdle and weights are attached.

Cervical halter traction: a canvas string is placed under the chin and occiput. Straps attached to the sling are attached to a pulley and weight system.

Lumbar traction: patient is placed in a chest harness which is attached to a circolectric bed. The bed is elevated gradually and traction is applied by means of the patient’s own weight.

Cervical collar: supports the neck in a neutral or slightly flexed position.

Nutrition: weight loss or weight control is recommended.

Restrict jerky movements. Avoid- forward bending, lifting weight.

Hot moist compresses several times a day increases blood flow to the muscles and helps relax and reduce muscle spasm.

MEDICATION THERAPY:

Analgesics: acetaminophen and NSAID’s –aspirin, ibuprofen, naproxen ;to relieve the pain during the acute stage. Muscle relaxants: carisoprodol, metaxalone, methocarbamol, to interrupt muscle spasm and to promote comfort. Sedatives to relieve the anxity associated with the problem:

Oral steroids (e.g. prednisone or methylprednisolone)- to treat the inflammation at the nerve roots and supporting tissues.

Epidural (cortisone) injection

SURGICAL MANAGEMENT:

Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate the pain and heal the disc herniation.

The goal of the surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse neurological deficits.

Microsurgical techniques make it possible to remove only the amount of tissue that is necessary, which preserves the integrity of normal tissue better and imposes less trauma on the body.

Diskectomy: The removal of the nuclear disk material of an intervertebral disc.

http://en.wikipedia.org/wiki/Cortisone

http://en.wikipedia.org/wiki/Epidural

http://en.wikipedia.org/wiki/Methylprednisolone

http://en.wikipedia.org/wiki/Prednisone

A spinal fusion may be performed if an unstable bomy mechanism is present. The spine is stabilized by creating an ankylosis(fusion) of c ontiguous vertebrae with a bone graft from the patient’s fibula or iliac crest or from donated cadaver bone. Metal fixation with rods, plates or screws may be implanted at the time of spinal surgery to provide more stability and decrease vertebral motion.

Percutaneous laser diskectomy: The aim of percutaneous laser disc decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disc, thereby reducing the volume of a diseased disc and the pressure within it.

Laminectomy: the traditional and most common procedure. It involves removal of the lamina, part of the posterior arch of the vertebra, to gain access to part or all of the protruding disk to remove it.

Hemilaminectomy: removal of part of lamina and part of the posterior arch of the vertebra. Partial laminectomy or laminotomy: creation of a hole in the lamina of the vertebra. Foroaminotomy: removel of the intervertebral foramen to increase the space for exit of a spinal nerve, resulting in reduced pain,

compression and edema.

POTENTIAL COMPLICATIONS:

Hematoma at the surgical site, resulting in cord compression and neurologic deficits. A change in the neurologic status (motor and sensory) should be reported immediately-indicates hematoma formation

Recurrent or persistent pain after surgery. Severe pain not relieved by analgesics should be duly informed. Cervical procedures:

Monitor for respiratory difficulty- may be due to injury to laryngeal nerve which may lead to hoarseness, inability to cough and remove secretions.

Because the spinal canal may be entered during the surgery, there is potential for CSF leakage. Severe headache or leakage of CSF on the dressing should be reported immediately. CSF appears as clear or yellow drainage on the dressing, has high glucose concentration & will be positive for glucose in a dipstick test.

Frequent monitoring of peripheral neurologic signs of the extremities is a routine post operative nursing responsibility. Movement of arms and legs and assessment of sensation should be unchanged when compared preop.

Loss of bowel & bladder function indicates nerve damage and should be reported immediately.

DISCHARGE INSTRUCTIONS:

After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). As their regular use can cause constipation, drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).

If you had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing.

Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon. Avoid sitting for long periods of time. Do not lift anything heavier than 10 pounds (e.g., gallon of milk). Do not bend or twist at the waist. Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing,

and loading/unloading the dishwasher, washer, or dryer. Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise. Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.

Activity

You may need help with daily activities (e.g., dressing, bathing) for the first few days. Fatigue is common. Let pain be your guide. Gradually return to your normal activities. Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily.

A physical therapy program may be recommended.

Bathing/Incision Care

You may shower 1 to 4 days after surgery. No tub baths, hot tubs, or swimming pools until recommended. Staples or stitches, which remain in place when you go home, will need to be removed. Ask your surgeon or call the office to find out

when.

When to Call Your Doctor

If your temperature exceeds 101° F, or if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage.

Recovery and prevention

Schedule a follow-up appointment with your surgeon for 2 weeks after surgery. Physical therapy may be necessary for some people.

The recovery time varies from 1 to 4 weeks depending on the underlying disease treated and your general health. You may feel pain at the site of the incision. The original pain may not be completely relieved immediately after surgery. Aim to keep a positive attitude and diligently perform your physical therapy exercises if prescribed.

Most people can return to work in 2 to 4 weeks or less with jobs that are not physically challenging. Others may need to wait at least 8 to 12 weeks to return to work for jobs that require heavy lifting or operating heavy machinery.

Recurrences of back pain are common. The key to avoiding recurrence is prevention:

Proper lifting techniques Good posture during sitting, standing, moving, and sleeping Appropriate exercise program Healthy weight and lean body mass A positive attitude and relaxation techniques (e.g., stress management) No smoking

CONCLUSION: intervertebral disc prolapse is a significant public health disorder although its prevalence is difficult to quantify. Acute back pain lasts less than 3 months, whereas chronic or degenerative disease has duration of 3 months or longer. Most back problems are related to disc disease.

http://www.mayfieldclinic.com/PE-EXER.htm

http://www.mayfieldclinic.com/PE-POSTURE.htm

http://www.mayfieldclinic.com/PE-self.htm

COMPARISION:

BOOK PICTURE Mrs. Shabana Mrs. Pankaja Mrs. Ruckiya

INTERVERTEBRAL DISC PROLAPSE:

A herniated intervertebral disk is one in which the gelatinous substance (nucleus pulposus) has protruded through the fibrocartilaginous substance (annulus fibrosus).

CAUSE OF PROLAPSED INTERVERTEBRAL DISC (SLIPPED DISC)

Trauma accounts for approximately 50% of disk herniations.

Examples of traumatic incidents include:

Lifting heavy objects while in flexed position(most common)

Falling on buttocks or back Sudden jerk

The herniation syndrome can also occur with other degenerative processes such as osteoarthritis, ankylosing spondylosis.

Patients with congenital anomalies such as scoliosis are at risk for disk injury because of the malalignment of the vertebral column.

History of heavy work.

Overweight

History of fall 6 months before the onset of symptoms.

History of heavy work

History of LSCS under Sub Arachnoid Block 14 years back.

Overweight

History of heavy work

CLINICAL MANIFESTATIONS:

Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material.

LUMBAR AREA:

Neurologic symptoms result from compression of the spinal cord or the spinal nerve roots or both.

Symptoms reflect the nerves affected. Most herniated disks occur in the lumbar region.

PAIN: Pain is the most characteristic symptom, generally

in the lower back with radiation to the buttocks, thigh and leg.

The pain is aggravated by lifting and twisting and may vary in intensity, causing mild to severe discomfort.

The term sciatica is used to describe a syndrome of lumbar back pain that spreads down one leg to the ankle and is intensified with coughing & sneezing.

POSTURAL DEFORMITY: Normal lumbar lordosis may be absent and one

iliac crest may be elevated. It is accompanied by scoliosis and spasms of the paravertebral muscles.

Abnormal posture may be evident as a mechanism to compensate for discomfort. In the standing position, the patient exhibits a typically flattened

Low back pain

The pain is acute in nature, sever in nature, radiating to right lower limb, more during strenuous activities.

Not being able to get up and walk

Tingling and numbness of the right lower limb.

Pain in the neck radiating to left upper limb.

The neck pain was insidious in onset and gradually progressive.

Paresthesia of the left upper limb.

Low back pain since last 4 months, insidious in onset.

Radiation to right lower limb.

Paresthesia present over right leg.

Lower back pain radiating to right leg till great toe.

Pain is moderate to severe in nature, rapidly progressive, more in night, aggravated by movement and relieved by rest and analgesic.

Tingling and numbness over sole of right foot, more in the night and hence sleepless.

Aggravated during standing, walking and relieved by lying down.

Pain over buttocks while sitting.

http://en.wikipedia.org/wiki/Low_back_pain

lumbar spine. The gait often is stiff.

MOTOR DEFICITS: Mild motor weakness of the foot, hamstring and

quadriceps muscles may be evident. Urinary and bowel functioning and sexual

functioning may be altered.SENSORY DEFICITS:

Sensory impairements may include paresthesias and numbness of the legs and the foot.

ALTERATION OF REFLEXES:The knee or ankle reflexes are absent or diminished.

CERVICAL DISK HERNIATION:

Usually occurs at C5-C6 and C6-C7 interspaces. Pain and stiffness in the neck, the top of the

shoulders and the scapula. Pain may also occur in the upper extremities and

head accompanied by paresthesia and numbness of the upper extremities.

DIAGNOSTIC MEASURES:

Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying lesions, as well as to evaluate the efficacy of potential treatments.

Physical examination: positive straight leg raise test (lasegue’s sign):

Normally it is possible, when lying on the back, to move

Chest x-ray:No abnormality. Chest x-ray:

No abnormality

Chest x-ray:No osseous deformity.

http://en.wikipedia.org/wiki/Lesion

http://en.wikipedia.org/wiki/Metastases

http://en.wikipedia.org/wiki/Tumor

http://en.wikipedia.org/wiki/Spondylolisthesis

http://en.wikipedia.org/wiki/Physical_examination

the straightened leg about 90` with only slight discomfort.In a patient with a herniated disk, the stretching of the sciatic nerve during leg rising creates traction on the already inflamed or irritated nerve roots, producing severe pain. Patients with sciatica will not be able to raise their legs beyond 20`-30`.

Spinal x-rays: may reveal narrowing of disk spaces and degenerative changes. X-Ray lumbo-sacral spine:

Narrowed disc spaces. Loss of lumber lordosis. Compensatory scoliosis.

Myelography: reveals presence of herniation and level of herniation. An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. It will indicate the presence of herniation & the precise level of herniation, as well as ruling out cord neoplasms.

CSF analysis: elevated protein levels. Queckenstedt’s test: may reveal partial or

complete blockage of CSF in spinal sub-arachnoid space.

Electromyography: may reveal neural or muscle damage, may indicate specific nerve root affected.

Discography: may reveal herniation of specific disk, use is controversial.

CT scan: reveals herniated disk Outline of soft tissue. Bulging out disc..

MRI: A diagnostic test that produces three-

MRI:L5-S1 ACUTE IVDP

STRAIGHT LEG TEST:

RT 30LT 80

LASEGUES TEST: positive on right SIDE.

MRI:L4-L5 DISC PROLAPSE

STRAIGHT LEG TEST:

RT 50LT 90


MRI:L4-L5 DISC PROLAPSE.

STRAIGHT LEG TEST:

RT 40LT 80

LASEGUES TEST: positive on right SIDE.

dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.• Intervertebral disc protrusion.• Compression of nerve root.

TREATMENT:The majority of herniated discs will heal themselves in about six weeks and do not require surgery

Treatment follows two approaches: Initial treatment is conservative, aimed at rest and

reducing stress. If unsuccessful, surgery may be indicated.

Bed rest Physical therapy Traction: used to increase the intervertebral

space, which relieves spasm. Pelvic traction

Cervical halter traction Lumbar traction Cervical collar Restrict jerky movements. Avoid- forward bending, lifting weight.

Hot moist compresses several times a day

MEDICATION THERAPY: Analgesics: acetaminophen and NSAID’s –aspirin,

ibuprofen, naproxen ;to relieve the pain during the acute stage.

Bed rest

Pelvic traction with 8 lbs.

Physical therapy

Moist heat Intermittent

lumbar traction

Medications:

T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs

Bed rest

Pelvic traction with 8 lbs.

Physical therapy


lumbar traction

Medications:

T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs

Bed rest Pelvic traction

with 8 lbs. Physical therapy


lumbar traction

Medications:

T. Aceclo plus bd

T. Pan 40 mg od

T. Sirdalaud 2mg hs

Cap. Myoril 8mg

Muscle relaxants: carisoprodol, metaxalone, methocarbamol, to interrupt muscle spasm and to promote comfort.

Sedatives to relieve the anxity associated with the problem:

Oral steroids (e.g. prednisone or methylprednisolone)- to treat the inflammation at the nerve roots and supporting tissues. Epidural (cortisone) injection

SURGICAL MANAGEMENT:

Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate the pain and heal the disc herniation.

The goal of the surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse neurological deficits.Microsurgical techniques make it possible to remove only the amount of tissue that is necessary, which preserves the integrity of normal tissue better and imposes less trauma on the body.

Diskectomy Spinal fusion Percutaneous laser discectomy Laminectomy Hemilaminectomy Partial laminectomy or laminotomy Foroaminotomy


T. Meganeuron od


Epidural steroid injection 80 mg

No surgical intervention


T. Neugaba ER 75mg hs


No surgical intervention done. Planned for discectomy if conservative measures fail.

0-1-0

T. Meganeuron od


Epidural steroid injection 80

No surgical intervention done.

NURSING DIAGNOSES:

http://en.wikipedia.org/wiki/Cortisone

http://en.wikipedia.org/wiki/Epidural

http://en.wikipedia.org/wiki/Methylprednisolone

http://en.wikipedia.org/wiki/Prednisone

MRS SHABHANA BANU MRS RUCKIYA MRS PANKAJA

1. Pain related to spinal cord and or nerve compression, muscle spasm.

2. Impaired physical mobility related to pain & discomfort: muscle spasms, restrictive therapies such as traction & bed rest.

3. Deficient knowledge regarding condition, prognosis, treatment, self care & discharge needs.

4. High risk for complications related to immobility & imposed bed rest.



3. Sleep disturbance related to pain and paresthesia.







MRS SHABHANA BANU:

ASSESSMENTNURSING DIAGNOSIS

OBJECTIVE

PLAN OF ACTION IMPLEMENTATION RATIONALE EVALUATION

Subjective data:Patient says “I am having severe pain in my back”.

Objective data:Walking with limp, guarding behavior, facial expression of pain.

Pain related to spinal cord and or nerve compression, muscle spasm.

The patient will verbalize reduction in pain.

Assess pain, location, duration, precipitating factors, have patient rate pain on scale from 1-10.

Maintain patient on bed rest as prescribed; if with lumbar problem- semi-fowler’s position with knees slightly flexed, place firm back board under mattress.Limit activity during the acute phase. Provide rest periods; shorten rest intervals & duration as client improves.

Help patient to maintain traction as prescribed.

Instruct in logrolling technique for position change.

Place needed items such as phone, water within easy reach.

Consult with physical therapist. Apply & monitor use & effects of cold/moist hot packs.

Prepare the patient for epidural steroid injection.

Assessed. She is having severe pain. She rates her pain as 8.

Kept the patient on strict bed rest during the acute phase.

Put her on pelvic traction with 8 lbs.

Instructed the patient to follow the technique. Placed items within easy reach.

Consulted with physio dept. MH packs, ILT given.

Epidural steroid injection 80 mg given.

To determine the extent of pain and the effectiveness of selected interventions.

A firm bed provides support to the spine; a semi fowler’s position with knees slightly flexed reduces pain and muscle spasms.

Traction reduces discomfort associated with spinal nerve compression.

It reduces flexion, twisting & strain on back.

Easy access reduces risk of straining.Individualized program can be implemented. Cold packs relieve muscle spasms. MH packs increase circulation to the affected muscles.To relieve the inflammation & reduce pain.

The patient verbalized slight reduction in pain. She has been discharged after epidural steroid injection.

Subjective data:Patient says” I am having pain on movement & am not able to do my ADLs.Objective data:Patient needs help with her ADLs, her facial expression shows pain.

Impaired physical mobility related to pain & discomfort: muscle spasms, restrictive therapies such as traction & bed rest.

The patient will be able to maintain/ improve the strength & function of the affected body part.

Administer narcotics, analgesics, muscle relaxants and NSAIDS as prescribed.

Assess neurologic deficit and degree of impairment; evaluate motor and sensory loss and reflexes.

Maintain prescribed bed rest and traction, encourage proper body alignment.

Maintain patient’s safety and position personal items so as to minimize stressful physical movements.

Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.

Provide appropriate skin care and anti-embolic stockings; encourage deep breathing and coughing exercises.—to prevent complications of immobility.

Monitor for signs and symptoms of complications of immobility

Administered T. Aceclo plus, T. Sirdalaud, Inj. Dynapar IM SOS.

Assessed. She complains of pain radiating to right leg. Presence of tingling & paresthesia.Put her on bed rest & pelvic traction with 8 lbs.Maintained patient safety.

Encouraged adequate rest periods.

Provided appropriate skin care & taught deep breathing & coughing exercises.

Monitored for presence of DVT, skin

Muscle relaxants decreases muscle spasms, NSAIDs decreases nerve root edema, analgesics reduce pain.

To determine the degree of physical impairment & effectiveness of interventions.

Limits activities & reduces stress on spine & vertebrae.

To reduce twisting & turning movements.

Rest between activities provides time for energy conservation and recovery.

To prevent complications of immobility.

Prolonged immobility is associated with numerous complications.

She is able to get up from the bed & is able to do her activities of daily living.

Subjective data:Patient says”I don’t know much about my condition & what to do when I get discharged.Objective data:Patient asks many questions & is eager to learn about her condition.

Deficient knowledge regarding condition,prognosis, treatment, self care & discharge needs.

The patient will verbalize understanding of her condition, prognosis & treatment.

Administer pain medications on a regular schedule or 30 mins before painful procedures.

Review disease process & prognosis. Stress activity restrictions including avoiding riding in a car for long periods, refrain from aggressive sports.

Instruct in proper body mechanics & home exercises. Includes proper posture, body mechanics for standing, sitting.

Discuss regarding medications, their uses & side effects.

Recommend use of firm mattress & small flat pillow under neck. Instruct on sleeping on side with knees flexed. Avoid prone position.

Discuss dietary needs & goals.

breakdown etc.


Reviewed the disease process including the activity restrictions.

Instructed the patient in proper body mechanics.

Discussed regarding the medications.

Instructed regarding the proper positioning.

Encouraged patient to lose weight & maintain

Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort & improve motivation to increase activity.

Knowledge & understanding of the disease, prognosis, and activity limitations help the client to clarify & accept current lifestyle changes.

Proper body mechanics reduce the risk of reinjuring the back & neck area.

Increases compliance & reduces the risk of complications.

Provides structural support & prevent hyper extension of the spine. These may decrease muscle strain.Constipation is a

Explained the patient regarding the disease condition & discharge instructions. She verbalized understanding of the instructions.

Objective High risk The

Instruct the client to alternate hot & cold application.

Provide information about what symptoms need to be reported to doctor- sharp pain, loss of sensation, inability to walk & change in bowel & bladder function.

Encourage the patient to ask questions & clear the doubts.

Assess the patient’s ability to do ADLs.

a normal weight.

Instructed the patient to apply hot & cold packs alternately.

Advised the patient to report these signs & symptoms.

Encouraged the client to ask questions & cleared her doubts.

Assessed. The patient has severe back pain

complication of analgesic use & immobility. Caloric restriction promote weight control or reduction & can decrease pressure on disc when obesity is aggravating back pain.

Cold application reduces nerve pain; MH packs increases circulation to the affected area.

Timely report of signs & symptoms for further evaluation & management improves client outcomes.

Helps the client to have a clear idea & clears misunderstandings.

Assessment provides a baseline for further

The patient

data:Patient is on prolonged bed rest.

for complications related to immobility & imposed bed rest.

patient will remain free from complications & demonstrate behaviors to enable resumption of activities.

Encourage the patient to do deep breathing & coughing exercises.

Encourage the patient to do ankle & leg exercises.

Encourage the patient to perform log rolling technique while changing position.

Provide back care & provide a wrinkle free bed.

Enforce strict bed rest during the acute phase. Start resumption of activities gradually.

Encourage the patient to take fiber rich diet.


radiating to right leg. Is partially dependent for her ADLs.

Encouraged the patient to do deep breathing & coughing exercises. Provided steam inhalation q 8 hrly.

Encouraged her to perform log rolling technique.

Provided back care & inspected skin for any break down. Provided a wrinkle free bed.Enforced strict bed rest. Gradual resumption of activities done.Encouraged patient to consume fiber rich diet.

Monitored for presence of DVT, skin breakdown etc.

interventions.

Prevents build up of secretions, increases lung expansion. Decreased chest excursions and stasis of secretions are associated with immobility.Prevents further damage to the neck & back muscles.

Frequent back care improves circulation & prevents skin breakdown.


Constipation is a complication of analgesics & immobility.

Prolonged immobility is associated with numerous complications eg. DVT, pneumonia, bed sore etc.

did not develop any complications of immobility.

MRS RUCKIYA:

ASSESSMENTNURSING DIAGNOSIS

OBJECTIVE












Administer narcotics, analgesics, muscle relaxants and NSAIDS as











Easy access reduces risk of straining.

Individualized program can be implemented. Cold packs relieve muscle spasms. MH packs increase circulation to the affected muscles.

Muscle relaxants decreases

The patient verbalized slight reduction in pain.




prescribed.






Monitor for signs and symptoms of complications of immobilityAdminister pain medications on a regular schedule or 30 mins before painful procedures.

Assessed. She complains of pain radiating to right leg. Presence of tingling & paresthesia.

Put her on bed rest & pelvic traction with 8 lbs.

Maintained patient safety.



Monitored for presence of DVT, skin breakdown etc.Administered T. Aceclo plus, T. Sirdalaud, Inj. Dynapar IM SOS.

muscle spasms, NSAIDs decreases nerve root edema, analgesics reduce pain.






Prolonged immobility is associated with numerous complications.Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort &


Subjective data:Patient says”I don’t know much about my condition & what to do when I get discharged.Objective data:Patient asks many questions & is eager to learn about her condition.


The patient Will verbalize understanding of her condition, prognosis & treatment.











Encouraged patient to lose weight & maintain a normal weight.


improve motivation to increase activity.




Provides structural support & prevent hyper extension of the spine. These may decrease muscle strain.Constipation is a complication of analgesic use & immobility. Caloric restriction promote weight control or reduction & can decrease pressure on disc when obesity is aggravating back pain.



Subjective data:Patient says” I am not able to sleep at night due to pain and paresthesia.

Objective data:

Sleep disturbance related to back pain and paresthesia.

High risk for

The patient will achieve & maintain normal sleep pattern as evidenced by verbalization.

The patie



Assess the sleep pattern of the patient, pain level.

Instruct the patient not to sleep during the day. Engage in activities during the day

Maintain the patient on strict bed rest and traction.

Administer analgesics as and when required.

Provide a soothing quiet environment.



Patient says her sleep is disturbed due to pain and paresthesia. Pain-8.Instructed and advised her to read books & talk with others.

Maintained on pelvic traction.

Administered T. aceclo plus. Inj Dynapar sos.

Provided a calm & quiet environment.

Assessed. The patient has severe back pain



Assessment provides a baseline for further interventions.

Helps to improve sleep.

Traction reduces discomfort associated with spinal nerve compressionHelps to relieve pain & muscle spasm.

A calm & quiet environment promotes sleep.


The patient verbalized that her pain has reduced & she is able to sleep without much

Patient is on prolonged bed rest.

complications related to immobility & imposed bed rest.

nt will remain free from complications & demonstrate behaviors to enable resumption of activities.








Monitor for signs and symptoms of complications of immobility.

radiating to right leg. Is partially dependent for her ADLs.




Monitored for presence of DVT, skin breakdown etc





Prolonged immobility is associated with numerous complications eg. DVT, pneumonia, bed sore etc

disturbance.

The patient did not develop any complications of immobility.

MRS. PANKAJA:

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE












Prepare the patient for epidural steroid injection.






Epidural steroid injection 80 mg given.





Easy access reduces risk of straining.Individualized program can be implemented. Cold packs relieve muscle spasms. MH packs increase circulation to the affected muscles.To relieve the inflammation & reduce pain.

The patient verbalized slight reduction in pain.




Administer narcotics, analgesics, muscle relaxants and NSAIDS as prescribed.






Monitor for signs and symptoms of


Assessed. She complains of pain radiating to right leg. Presence of tingling & paresthesia.Put her on bed rest & pelvic traction with 8 lbs.Maintained patient safety.



Monitored for presence of DVT, skin breakdown

Muscle relaxants decreases muscle spasms, NSAIDs decreases nerve root edema, analgesics reduces pain.






Prolonged immobility is associated with numerous complications.


Subjective data:Patient says”I don’t know much about my condition & what to do when I get discharged.Objective data:Patient asks many questions


The patient Will verbalize understanding of her condition, prognosis & treatment.

complications of immobility

Administer pain medications on a regular schedule or 30 mins before painful procedures.






etc.






Encouraged patient to lose weight & maintain a normal weight.

Client’s anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort & improve motivation to increase activity.




Provides structural support & prevent hyper extension of the spine. These may decrease muscle strain.Constipation is a complication of analgesic use & immobility. Caloric restriction promote


& is eager to learn about her condition.

Objective data:Patient is on

High risk for complic

The patient will








Assessed. The patient has severe back pain radiating to right leg. Is

weight control or reduction & can decrease pressure on disc when obesity is aggravating back pain.





The patient did not develo

prolonged bed rest.

ations related to immobility & imposed bed rest.

remain free from complications & demonstrate behaviors to enable resumption of activities.








partially dependent for her ADLs.




Monitored for presence of DVT, skin breakdown etc.





Prolonged immobility is associated with numerous complications eg. DVT, pneumonia, bed sore etc

p any complications of immobility.

DISCHARGE PLAN & INSTRUCTIONS:

MRS SHABANA MRS PANKAJA MRS RUCKIYA

Patient was discharged after epidural steroid injection.

Discharge instructions:


Proper lifting techniques Good posture during sitting, standing,

moving, and sleeping Appropriate exercise program Healthy weight and lean body mass A positive attitude and relaxation

techniques (e.g., stress management) No smoking Hot & cold application High fiber diet Not to sit or drive for long periods of

time

Take the medicines on time

Consult doctor in case of worsening signs & symptoms

She was discharged and told to come back after 10 days for discectomy.






time



Patient was discharged after epidural steroid injection.






time



BIBLIOGRAPHY:










1. Harrison. Principle of internal Medicine. 17th ed. Vol II. Mc Graw Hill; 2008.2. Brunner and Suddarth. Textbook of Medical Surgical Nursing. 11 th ed. Lippincott Williams and Wilkins; 2008.3. Black J.M, Hawks J.H, Keene A.M. Medical Surgical Nursing: Clinical Management for positive outcomes. 6th ed. Saunders:2004.4. Davidson S .Davidson’s Principles and practice of medicine.21st ed. Churchill Livingstone Elsevier; 2010.5. Lewis S.M, Heitkemper M.M, Dirksen S.R. Medical Surgical Nursing: Assessment and Management of clinical problems. 6th ed.

Canada:Mosby;2004.6. Doenges M.E, Moorhouse M.F, Murr A.C. Nursing Care plan: Guidelines for individualizing client care across life span.8th ed.

Phildelphia:FA Davis company; 2005.p.7. en.wikipedia.org/wiki/Spinal_disc_herniation

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COMPARATIVE ANALYSIS