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8/7/2019 Spinal cord injury macas
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Capitol University
College of Nursing
Cagayan de Oro City
A
Case Study on:
Complete Spinal Cord Injury at
C4 Level Secondary to
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ACKNOWLEDGEMENT
The student nurses would like to send their warmest gratitude to those people
who had a great role in the success of the presentation of this case.
First and foremost to our Almighty God who gave us wisdom and knowledge to
get these pieces of thoughts and knowledge and put it into a meaningful output.
To God is the glory!
To our parents who supported us all through out the entire course of the study by
means of providing us our financial needs and gave everything we needed.
To our schoolmates who were always there whenever we needed penny of their
thoughts and information and who were always there to provide us there opinions
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Introduction
The spinal cord is a bundle of nerves that carries messages between the
brain and the rest of the body. Complete spinal cord injury (SCI) is due to a
traumatic injury that either results in a bruise (also called a contusion), a partial
tear, or a complete tear (called a transection) in the spinal cord. SCI is a common
cause of permanent disability and death in children and adults.
About 11,000 people a year sustain a spinal cord injury. About 243,000
people in the US are living with a spinal cord injury. Fifty-three percent of all SCIs
occur among young people between the ages of 16 and 30 years. The majority of
SCI victims (82 percent) are male. Injuries affecting the spinal cord commonly
results from trauma, gunshot wounds and motor vehicle accidents. Many cases
of SCI are caused by falls, sports-related injury and minor trauma. The principal
risk factors for SCI include age, gender, and alcohol and drug use. Males are
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TABLE OF CONTENTS
Title
Acknowledgement…………………………………………………………………
Table of Contents……………………………………………………………….....
I. Introduction………………………………………………………………………
II. Goals and Objectives
III………………………………………………………………
IV. Clients Profile……………………………………………………………………..
V Diagnostic Test and Laboratory Results
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Goals and Objectives of the Study
Goal
Student nurses will be able to apply necessary knowledge and skills to
render quality care and service to the patient.
Specific Objectives
Student nurses will be able to:
1. Understand the patient’s condition.
2. Gain sufficient knowledge about patient’s medical regimen.
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Patient can now tolerate any diet plan with a fair appetite but is noted to
have minimal difficulty of swallowing. He does not have nausea and vomiting. His
lips are dusky in color, with pinkish mucosa and gums. The tongue is in midline.
He has missing teeth. His uvula is in midline with no evident lympadenopathy,
palpable thyroid and neck engorgement. His general skin color is dusky, smooth
in texture with supple turgor.
D. Elimination Pattern
Week 1, 2and 3
Patient X has no evident defecation. There are no superficial veins noted
in the abdomen. Bowel sounds are hypoactive.
Patient X has been catheterized. His urine color is between yellow to
orange. There is no noticed bladder distention.
E. Activity and Exercise pattern
Week 1, 2 and 3
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He described himself as physically weak nowadays but according to him, he
fights for his life and for his family.
J. Role Relationship Pattern
Patient is married with no known family illness and lives with his family.
K. Value-Belief Pattern
Patient X was a Roman Catholic and says that his religion plays an important
role in his life
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In cross-section, the peripheral region of the cord contains neuronal white
matter tracts containing sensory and motor neurons. Internal to this peripheral
region is the gray, butterfly-shaped central region made up of nerve cell bodies.
This central region surrounds the central canal, which is an anatomic extension
of the spaces in the brain known as the ventricles and, like the ventricles,
contains cerebro spinal fluid.
The three meninges that cover the spinal cord—the outer dura mater , the
arachnoid mater , and the innermost pia mater —are continuous with that in the
brainstem and cerebral hemispheres. Similarly, cerebrospinal fluid is found in the
subarachnoid space. The cord is stabilized within the dura mater by the
connecting denticulate ligaments, which extend from the enveloping pia mater
laterally between the dorsal and ventral roots. The dural sac ends at the vertebrallevel of the second sacral vertebra.
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Hematology Test
September 15, 2010
TestRESULT UNIT REFERENCE
WHITE BLOOD
CELLS13.7
10^3/uL 5.0-10.0
RED BLOOD
CELLS3.69
10^6/uL 4.2-5.4
HEMOGLOBIN11.3
g/FdL 12.0-16.0
HEMATOCRIT32 6
% 37.9-47.0
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BASOPHIL0.0
% 0.0-2.0
Hematology Test
September 16, 2010
TestRESULT UNIT REFERENCE
WHITE BLOOD
CELLS11.7
10^3/uL 5.0-10.0
RED BLOOD
CELLS3.69
10^6/uL 4.2-5.4
g/FdL 12.0-16.0
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9.0
EOSINIPHIL0.7
% 1.0-3.0
BASOPHIL0.0
% 0.0-2.0
WBC
Increased:
• Infection
• Stress
• Inflammation
• Tissue necrosis
• Trauma
• Hemorrhage
M li i ( ti l l t i t ti l li b d t t i )
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Test RESULT UNIT REFERENCE
WHITE BLOOD
CELLS17.7
10^3/uL 5.0-10.0
RED BLOOD
CELLS4.66
10^6/uL 4.2-5.4
HEMOGLOBIN13.6
g/FdL 12.0-16.0
HEMATOCRIT 39.9
% 37.9-47.0
MCV85.6
fL 82.0-98.0
Pg 27.0-31.0
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WBC
Increased:
• Infection
• Stress
• Inflammation
• Tissue necrosis
• Trauma
• Hemorrhage
• Malignancies(particularly gastrointestinal, live, bone, and metastasis)
• Toxins
• Serum sickness
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Glucose: negative
SEDIMENT MICROSCOPIC EXAMINATION
Epithelial cells: few
Pus cells: 0-1
Red blood cells: plenty
Bacteria: moderate
Others: Amorphous phosphate- plenty
Triple phosphate- moderate
BLOOD CHEMISTRY RESULT FORM
September 16,2010
Creatinine: 0.44 Normal: 0.6-1.2 mgs%
September 18, 2010
Blood Sugar: 90.0 mgs% Normal: 60-110mgs%
Creatinine: 0.85 Normal: 0.6-1.2 mgs%
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EXERCISE • Implement doing of passive range of motion exercises in a cephalo-
caudal manner this promotescirculation.
Abduction-movement away fromthe midline of the body.
Adduction-movement toward themidline of the body.
Flexion-bending of a joint so thatthe angle of the joint diminishes.
Rotation-turning or movement of a part around its axis.
• Exercise the affected extremitiespassively through range of motion 4-5 times a day while on bed rest tomaintain joint mobility and enhancecirculation; encourage active ROMas able. Instruct client and family onth ll iti i
According to Bare(2000) providing full
range of motion four or five times a daymaintain joint mobility;regain motor control,and preventcontracturedevelopment, enhancecirculation and prevent
venous stasis.
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communication with the client by:
Speaking slowly, using visual
cues and gestures; be consistent,and repeat if necessary.
Speaking directly to the patientwhile facing him.
Giving plenty of time for response, and reinforce attempts
as well as correct responses.
Using alternative methods of communication other than verbal,such as written, words, gesturesor pictures.
• Discuss and instruct the family inproviding the tracheostomy care
Assess condition of stomabefore tracheostomy care( d lli h t f
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sterile water-soaked gauzesponges then dry sponges.
Change a disposable inner cannula, touching only theexternal portion, and lock itsecurely into place. If inner cannula is reusable, remove itwith your contaminated handand clean it in hydrogen
peroxide solution, using brush or pipe cleaners with your sterilehand. When clean, drop it intosterile saline solution and agitateit to rinse thoroughly with your sterile hand. Tap it gently to dryit and replace it with your sterilehand.
Change the tracheostomy tietapes:
o Cut soiled tape while
holding tube securely with other hand Use care not to cut the pilot
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OUTPATIENT • Advice the significant other/s to
attend to the scheduled follow-upcheck-up of the client with thephysicians to evaluate client’s over-all health condition.
• Instruct the family to report to thephysician for any recurrence or severity of symptoms, any adverse
effects of the medications taken, andany development of complications.
According to Bare
(2002), keeping follow-up appointments withhealth care providersfor monitoring toprevent and detectcomplications.According to Hawk(2005), the physical
and the psychologicalstatus of the patientand the ability of thefamily to cope with anyalterations in thepatient status are bestmonitored with thenurse during home
visits.
DIET •
SPIRITUALITY • Encourage family to attend massevery Sunday or anytime when theyare free This will enhance spiritual
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study, we were able to prove to ourselves that we can do it despite of the
obstacles encountered during those days.
As for us, many things have happened that are sad and happy things.
Sad! For having many mistakes and learning from those mistakes. Therefore
learning is not just in classrooms but learning is everywhere. Wherever you go,
whatever you do, and how you do things there is always a way for learning.
We would like to extend our heartfelt gratitude to those people who have
encouraged us. First and foremost, we would like to thank our almighty God for
the guidance and enlightenment he has given, that despite the obstacles
encountered during the duty, patience is always a virtue.
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http://emedecine.medscape.com/article/1148570-overview
http://www.apparelyzed.com/spinalcord.html
Drug order(genericname, brand name, Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibi
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classification, route,
dosage, frequency)
Generic name:
amikacin sulfate
Brand name:
Amikin
Classification:
Anti-infective
Route:
IVTT
Dosage: 500mg
Frequency:
Q12
.Interferes with protein
synthesis in bacterial
cells by binding to 30S
ribosomal subunit,
leading to bacterial cell
death
Severe systemic
infections
.Hypersensitivity to
aminoglycosides
CNS: dizziness, vertigo,
tremor, numbness,
depression, confusion,
lethargy, headache,
paresthesia, ataxia,
neuromuscular
blockade, seizures,
neurotoxicity
CV: hypotension,
hypertension,
palpitations
EENT: nystagmus and
other visual
disturbances,
ototoxicity, hearing loss,
tinnitus
GI: nausea, vomiting,splenomegaly,
stomatitis, increased
salivation, anorexia
GU: azotemia,
• Monitor kidney func
test results and urine
cultures, output, prote
and specific gravity.
• Monitor results of p
and trough drug bloo
levels.
• Evaluate for signs a
symptoms of ototoxic
(hearing loss, tinnitus
ataxia, and vertigo).
• Assess for seconda
superinfections,
particularly upper
respiratory tract infec
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Drug order(genericname, brand name, Mechanism of Action Indications Contraindications Adverse Effects
Nursing
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classification, route,
dosage, frequency)
g
Responsibilitie
Generic name:
levofloxacin
Brand name:
Quixin
Classification:
Anti-infective
Route:
PO
Dosage:
750mg
Frequency:
OD
Inhibits the enzyme
DNA gyrase in
susceptible gram-
negative and gram-
positive aerobic and
anaerobic bacteria,
interfering with
bacterial DNA
synthesis
Acute bacterial
exacerbation of chronic
bronchitis
Hypersensitivity to drug,
its components, or other
quinolones
CNS: dizziness,
headache, insomnia,
seizures
CV: chest pain,
palpitations,
hypotension
EENT: photophobia,
sinusitis, pharyngitis
GI: nausea, vomiting,
diarrhea, constipation,
abdominal pain,
dyspepsia, flatulence,
pseudomembranous
colitis
GU: vaginitis
Hematologic:
lymphocytopenia
Metabolic:
• Check vital signs,
especially blood pres
Too-rapid infusion ca
cause hypotension.
• Closely monitor pat
with renal insufficienc
• Monitor blood gluco
level closely in diabe
patients. Assess for
severe diarrhea, whic
may indicate
pseudomembranous
colitis. Watch for
hypersensitivity react
Discontinue drug
immediately if rash o
other signs or sympto
occur. Watch for sign
symptoms of tendinit
tendon rupture.
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Drug order(genericname, brand name,
l ifi ti t
Mechanism of Action Indications Contraindications Adverse EffectsNursing
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classification, route,
dosage, frequency)Responsibilitie
Generic name:
dexamethasone
Brand name:
Dexasone
Classification:
Anti-inflammatory
Route:
IVTT
Dosage:
500mg
Frequency:
q12
Reduces inflammation
by suppressing
polymorphonuclear
leukocyte migration,
reversing increased
capillary permeability,
and stabilizing
leukocyte lysosomal
membranes.
Allergic and inflammatory
conditions
Hypersensitivity to drug,
benzyl alcohol, bisulfites,
EDTA, creatinine,
polysorbate 80, or
methylparaben
CNS: headache,
malaise, vertigo,
psychiatric
disturbances, increased
intracranial pressure,
seizures CV:
hypotension,
thrombophlebitis,
myocardial rupture after
recent myocardial
infarction,
thromboembolism
EENT: cataracts GI:
nausea, vomiting,
abdominal distention,
dry mouth, anorexia,
peptic ulcer, bowel
perforation, pancreatitis,
ulcerative esophagitis
Metabolic: decreased
carbohydrate tolerance,
hyperglycemia,
cushingoid appearance
Monitor blood glucos
level closely in diabe
patients receiving dru
orally.
• Monitor hemoglobin
potassium levels.
• Assess for occult bl
loss. In long-term the
never discontinue dru
abruptly. Dosage mu
tapered gradually.
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