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



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



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



TABLE OF CONTENTS

Title

Acknowledgement…………………………………………………………………

Table of Contents……………………………………………………………….....

I. Introduction………………………………………………………………………

II. Goals and Objectives

III………………………………………………………………

IV. Clients Profile……………………………………………………………………..

V Diagnostic Test and Laboratory Results



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.



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



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



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.

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


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

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

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

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

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

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

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

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

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

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

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

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

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


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



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

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

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

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

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

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

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

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

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

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


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

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


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



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



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



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 )



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



WBC

Increased:

• Infection

• Stress

• Inflammation

• Tissue necrosis

• Trauma

• Hemorrhage

• Malignancies(particularly gastrointestinal, live, bone, and metastasis)

• Toxins

• Serum sickness



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%



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.



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



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



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



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.



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







28

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



30


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.



31

Drug order(genericname, brand name,

l ifi ti t

Mechanism of Action Indications Contraindications Adverse EffectsNursing



32


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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Spinal cord injury macas

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