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A Case Presentation of : Herniated Nucleus Pulposus (HNP) Slip Disk in L3 L4:L4L5

Prepared by: BSN-IV Group B

NURSING ASSESSMENT PATIENT’S DATA

•Name: J.G.•Age: 24 years old•Nationality: Filipino •Gender: Male•Religion: Roman Catholic•Address: Calumpang, Marikina•Occupation: Factory Worker•Adm. Date & Time: June 18, 2011/ 10:20pm•Chief Complaint: Scaly Patches•Final Diagnosis: Herniated Nucleus Pulposus (HNP) Slip Disk in L3 L4:L4L5

NURSING ASSESSMENT PATIENT’S HISTORY

• Present History Illness:

• This is a case study of a 29 year old male who has Psoriasis since 2009.

• The patient has been hospitalized from June 18, 2011 to June 23, 2011 at World Citi Medical Center. Two weeks prior to admission, patient had recurrent dryness, erythematous, scaly and patches all over the trunk. Start of scaling June 22.

• According to the patient, it was his first confinement in the hospital. Before the patient has been admitted in the WCMC, he complains painful in his right foot and hip pain. After 4 days, experiencing of hip pain the patient decided to go to the nearest hospital, due to immobilization.


• Past History Illness:

• Patient has not yet been hospitalized.

• Family History Illness:

• Patients’ maternal side has a history of Hypertension (HPN), while in his paternal side none. He is the second eldest child in his family. According to the patient, he is the only one in the family who has allergy in chicken, seafood’s, and beer.


• Social History:

• Patient is a factory worker that worked in paper mill, over 12 years up until the present. Patient likes to play billiards. Sometimes he smokes. Often, patient eats pork meat, vegetables and beef.

•The patient has also an ALLERGY in chicken meat, seafood’s and beer

NURSING ASSESSMENT HEAD-TO-TOE ASSESSMENT

PATHOPYSIOLOGY Risk factors:

Lifting from a bent over positionFalls

Organ Affected:

Lumbar vertebra

Disease Process

Strong force that cause injury to the area

Vertebral misalignment and disk degeneration

Compression, inflammation and edema of the nerve roots

Muscle spasm (protective mechanism associated with trauma)

Herniation of the nucleus through the annulus - either posterior or lateral

Extreme pain

PATHOPYSIOLOGY By Book By Patient

Medical Management

NSAIDsNarcotic painkillersMuscle relaxants

Medical Management

AlevaPrevacidPrednisoneNeurofenacDolcetCalopetnial ointmentBethamethasone

ointment

Herniated Nucleus Pulposus

Diagnostic / Lab

X-rayMyelogramMRICT Scan

Diagnostic / Lab

X-rayCT ScanCBCCreatinineBUNALT and AST

DIAGNOSTIC TEST & LAB

June 19, 2011• • Specimen: Serum

Examination Result Normal Value SignificanceAST (SGOT) 44.71 35. /L An increased level of

Serum glutamic-oxaloacetic can cause Weakness, fatigue, Loss of appetite, Nausea, vomiting, Abdominal swelling and/or pain, Jaundice, Dark urine, light colored stool, Itching (pruritus)

And used to monitor people who are taking medications that are potentially toxic to the liver.

ALT (SGPT) 23.50 0.00-45 U/L


June 19, 2011•

Specimen: Blood

Examination Result Normal Value SignificanceWBC 10.4 4.00-10.00^g/L An increased production of

white blood cells to fight an infection

Neutrophils 0.75 0.50-0.80Lymphocytes 0.19 0.25-0.50 A decrease of lymphocytes can

cause leucopenia (decreased concentration of the circulating WBC’s in the blood stream) which can cause allergies

Monocytes 0.05 0.02-0.10Eosinophils 0.01 0.00-0.05Basophils 0.00 0.00-0.02

HGB 138 130.00-170.00HCT 0.41 0.40-0.54RBC 4.55 4.50-6.50MCV 80-100 flMCH 27.00-32 pg

MCHC 320-360 g/LPLT 320 150-350


June 19, 2011•

Specimen: Serum

Examination Result Normal Value SignificanceCreatinine 58.76 72-127 vmol/L Low creatinine levels can

reduced muscle mass, which can cause disease, debilitating or aging.

BUN 8.24 20.mol/L

An increase in the BUN level is known as azotemia. An elevated BUN may be caused by: Impaired renal function, Congestive heart failure as a result of poor renal perfusion, Dehydration, Shock, Hemorrhage into the gastrointestinal tract, Acute myocardial infarction, Stress, Excessive protein intake or protein catabolism.


• X-ray

• June 20, 2011• • -There is slight anterior dislocation of L5 over L1 vertebral

height and intervertebral disc spaces are maintained.• • Impression: Consider Spondylolisthesis, L5 over L1.• • -Suspicious upper lobe densities are seen.


•CT-Scan• June 21, 2011• • -There is slight anterior dislocation of L5 over L1 vertebral

height and intervertebral disc spaces are maintained.• • Impression: Consider Spondylolisthesis, L5 over L1.• • -Suspicious upper lobe densities are seen.

NURSING CARE PLAN (Pain)

Assessment Planning Intervention Evaluation

Subjective: “ masakit po ang likod ko.” as verbalized by the patient.

Objective: Facial grimace Pain scale 8/10 Protective gestures to

avoid pain Frequent sighing

Nursing Dx: Acute pain related to traumatic injury.

After 30 minutes of nursing intervention the patient should report that the pain is relieved from 8-4.

Provide quiet environment and calm activities.R: for comfort of the patient

Encourage diversion activities example: watching TV or playing music.R: to reduce precipitating factors

Provide comfort measure ( positioning, use of hot and cold compress)R: to provide non pharmacologic management

Encourage adequate rest periodsR: to prevent fatigue

Administer analgesic as prescribed by the doctor.R: to relieve pain

After 30 minutes of nursing intervention the patient reported relief from pain, scale of 5/10.

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