Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite

College of Nursing
A Case Study on
ACUTE SPINAL CORDLEVEL
INJURY,
COMPLETE SENSORY C4
SECONDARY TO UNILATERAL
FACET DISLOCATION OF C5/C6
VERTEBRA SECONDARY TO DIVING
ACCIDENT IN SPINAL SHOCK
Presented by:

Baro Jenelyn L.
Braga, Rhodeva Joy T.
Cedron, Ariane Rose S.
Cubillo, Irish Jane B.
Dala, Roxanne Jade K.
Espineli, Leanna Mae S.

Lopez, Don Rafael V.

Masenas, Ayr Hershel D.
Millamena, Cirmarie Hope B.
Pastores, Flora Angeli D.
Puedan, Jenivic E.
Torrevillas, Jeth Viel A.

IV BSN 1/Group 3

Presented to:
Lenila A. De Vera RN, MPH, MAN
Evelyn M. Del Mundo RN, MAN, PhD.
Normidia A. Quion, RN, MAN
Clinical Instructor, Level IV

March 26, 2015

In Partial Fulfillment of the Requirement in NURS 95 for the Degree Bachelor of Science
in Nursing
ABSTRACT

The researcher had chosen Acute Spinal Cord Injury as the subject for detailed
study because it is new and an interesting problem, as far as researcher were
 exposed to the clinical area. In addition to that, our kind clinical instructor also
suggests having this as our case. We also wanted to gain more knowledge and
acquire more skills of excellence for the benefit of their future clients in
succeeding years of the studies.

The case is about a patient who has Acute Spinal Cord Injury. This study aims to
identify the different manifestations of signs and symptoms of the disorder, define
the illness state, trace the pathophysiology, and apply nursing care and medical
intervention during the course of exposure.

INTRODUCTION
 As many as 500 000 people suffer a spinal cord injury each year.

People with spinal cord injuries are 2 to 5 times more likely to die

prematurely, with worse survival rates in low- and middle-income

countries. The new WHO report, "International perspectives on spinal

cord injury", summarizes the best available evidence on the causes,

prevention, care and lived experience of people with spinal cord injury.

Males are most at risk of spinal cord injury between the ages of
20-29 years and 70 years and older, while females are most at
risk between the ages of 15-19 years and 60 years and older.
Studies report male to female ratios of at least 2:1 among adults.
Anyone at any age can break their neck or back which results in damage to the
spinal cord, or develop an illness that leads to damage to the spinal cord.
Spinal cord injury (SCI) is caused by damage to the spinal cord. During trauma,
for example, the spinal cord is crushed and deprived of its blood supply resulting
in loss of function, (paralysis) and loss of sensation below the point of injury.
Damage to the spinal cord can also occur through illness, (referred to as non-
traumatic SCI) such as tumours, infections or circulatory disorders such as
haemorrhage or clot formation within the spinal cord.
Current estimates are 250,000 - 400,000 individuals living with Spinal Cord
Injury or Spinal Dysfunction which is specifically classified as 82% male, 18%
female, highest per capita rate of injury occurs between ages 16-30, average age
at injury - 33.4, median age at injury 26, mode (most frequent) age at injury 19.
Several causes were also identified such as motor vehicle accidents (44%), acts of
violence (24%), falls (22%), sports (8%) (2/3 of sports injuries are from diving)
and other (2%) Therefore, falls overtake motor vehicles as leading cause of injury
after age 45, acts of violence and sports cause less injuries as age increases and
acts of violence have overtaken falls as the second most common source of spinal
cord injury in the last 4 years.

DEMOGRAPHIC DATA

A. Initials of Clients Name: M.M Date of Admission: January 17, 2013

B. Address: Mindoro City
C. Age: 21 years old
D. Birth Date: December 8, 1993
E. Birth Place: Mindoro
F. Gender: Male
G. Civil Status: Single
H. Religion: Roman Catholic
I. Highest Educational Attainment: High School - Undergraduate
J. Occupation: N/A
K. Monthly Income / Budget: N/A
Time of Admission: 7: 35 p.m.
Mode of Admission: Transfer
Date of Interview: February 9 and 11, 2015
Primary Informant: Patient M.M
Secondary informant: None
Other Data Sources: Patients Chart

REASON FOR SEEKING HEALTH CARE

Patient M.M was brought awake, conscious and coherent in a supine position with

a chief complaint of weakness of left upper extremity and inability to move right upper

and both lower extremities with no spinal support after he and his friends went to the

beach in Mindoro, dove from a ten foot high bridge, landed on shallow waters

approximately 6 feet deep with neck in flexed position that hitting his nape first.

HISTORY OF PRESENT ILLNESS

Patient M.M condition started fifteen hours prior to admission, he and his friends

went to the beach in Mindoro, dove from a ten feet high bridge, landed on shallow waters

approximately 6 feet deep with neck in flexed position, hitting his nape first. He

immediately experienced numbness on both upper and lower extremities associated with

inability to move. Patient started to ingest seawater and nearly drowned losing his

consciousness. Two of his friends rescued and brought him to the shore one carrying him

on his lower extremities, the other on his arms. They performed chest compressions for

two minutes which claimed to have brought the patient to consciousness. But still patient

complained of inability to move both upper and lower extremities.

 Patient was then brought to the nearest Local Health Center which was 30 minutes

away via tricycle in a sitting position with no spinal support. At the health center, oxygen

was administered at 2/ L per minute via nasal cannula and suctioning was done. They

were then advised to bring the patient to Pinamalaya Doctors Hospital which was two

hours away via ambulance conduction. At the emergency room of the said hospital,

venoclysis was started and soft collar was applied. Patient was then advised to be

transferred immediately to Philippine Orthopedic Hospital for further evaluation and

management due to lack of diagnostic and hospital beds.

Patient was then brought to this institution via an ambulance in a supine position with no

spinal support and was subsequently admitted.

PAST MEDICAL HISTORY

Patient has no history of gastric ulcers. Duodenal ulcers, diabetes mellitus,

hypertension, pulmonary tuberculosis, cancer and bronchial asthma and has no know

food and drug allergies. Patient has no other history of hospitalization or consultation

from medical profession. According to the patient, he had an active physical activity. He

just ignores whenever he feels ill.

HEREDO-FAMILIAL HISTORY

Legend:

Interpretation:

This genogram shows the third generation of patient M.M. According to him, their family has no
known history of heart disease, diabetes mellitus and asthma. His father died due to colon cancer
when he was 5 years old. His mother is bed ridden due to fracture secondary to fall. Patient M.M.
started to be paralyzed after his cliff diving when he was 19 years old. His other siblings are well
and alive.

GENERAL HEALTH STATUS

Patient body build is mesomorph, he stands 5 feet 9 inches and weighs 76
kilograms. The patient looks weak and has signs of distress can be seen. He also
has limited movements because he cant stand either sit alone because his lower
extremities are already loss of function. He was mostly lying on the bed in
different position such as supine position or in Fowler or semi-fowlers position.
The patient has been staying at the hospital without any proper bathing. He also
looks untidy. Since the patient was paraplegia, he cannot perform proper hygiene
independently. He has no unusual body and breath odor.

COMPREHENSIVE PHYSICAL EXAMINATION

(Date Performed: January 17-18, 2015)

Vital Signs: (10:00pm to 6:00am shift)

January 17, 2015

TIME BLOOD TEMPERATURE RESPIRATORY PULSE
PRESSURE RATE RATE
11:00pm(Initial) 90/60 mmHg 35.4 0C 15 cpm 74 bpm

12:00mn 90/60 mmHg 36 0C 16 cpm 73 bpm

04:00am 100/70 mmHg 36.50C 20 cpm 78 bpm

January 18, 2015

TIME BLOOD TEMPERATURE RESPIRATORY PULSE
PRESSURE RATE RATE
11:00pm(Initial) 100/80 mmHg 36.9 0C 18 cpm 80 bpm

12:00mn 110/70 mmHg 37.1 0C 20 cpm 76 bpm

04:00nn 120/80 mmHg 37.4 0C 20 cpm 77 bpm

Anthropometric Data:
 Height: 59 (175.26 cm)
Weight: 76 kg

Body Mass Index:

weight (kg) Conversion:
height (m2) 1ft=12 inches
1 inch=2.54 cm
1 m=100 cm

Patient __ who is a male, age of 21 years with a height of 59 and weight of

76 kg

76 kg Ht: 5 ft= 60 inches

3.07 + 08 inches
= 69 inches x 2.54
24.7557 = 175.26 cm
= 175.26 cm / 100
= 175.26
= 175.262 or 3.07
= 3.07160676

FOCUSED ASSESSMENT

Body Part Examined Actual Finding Normal Finding Clinical Significance

INTEGUMENT With skin Evenly colored Varies from light brown
Skin discoloration of skin tones without from ruddy pink; from
I: color, uniformity, lower unusual yellow over tones to oliv
edema, lesions
P: moisture, temp. extremities. discolorations.
Turgor

Lesion and Skin is intact, and Lesion and redness migh

redness at the there are no due to his condition ofte
upper and lower reddened areas. signaling a pathologica
extremities. condition, such as
inflammation, infection

Scaliness of the skin ma

Scaliness of the Smooth, without be due to poor nutrition
skin with scars lesions. Healed
at the upper and scars, freckles,
lower moles or
extremities. birthmarks are
common findings.

Skin is smooth and

 even
Skin surfaces vary
from moist to dry
depending on the
area assessed. Cold clammy of the ski
Skin is cold to Skin is normally may be due to
touch warm in Hypothermia this is due
temperature. Abnormal blood
circulation.

According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 166
171.
Heal \Hair Hair is black in Natural hair color,
I: evenness of growth colors.. as opposed to
thickness, texture, chemically colored
oiliness, infection
or infestation, body hair, varies among
hair clients from pale
P: smoothness blond to black to
gray or white.

Scalp is not Scalp is clean, and Due to poor hygiene

clean and dry dry and without
with presence of the presence of
dandruff dandruff.

Hair is dry. Hair is smooth and Hair is dry may be due t

firm, somewhat poor nutrition and poor
hygiene.
elastic. However,
as people age, hair
feels coarser and
drier. Without the
presence of lice
and pediculosis.
No sign of
infestation or
infection.

According to Health
Assessment in Nursing
3rd Edition by Webber
 and Kelley, page 172.
Nail Nails on the Nails are clean and -Dirt in nails and slightl
I: plate shape, texture, right hand are manicured. longer may indicate poo
bed color, long and dirty self caretaking skills
surrounding tissues and the nails on Nail bed is highly
P: Blanch test the left hand are vascular with a pink colo
short but dirty. in light-skinned clients
and longitudinal streaks
brown or black
Nails are pale in Pink tones should pigmentation in dark-
color. be seen. Some skinned clients.
longitudinal
ridging is normal
Angle between the
fingernail and base is
about 160 degree.
There is 160-
degree angle There is normally
between the nail 160-degree angle
and the base of between the nail Nails should be hard an
the skin. base and the skin. basically immobile.

Nails are hard When palpated, the nail

and immobile. Nails are hard and base should be firm.
basically
Nails are rough immobile.
and firm. Nails are smooth
and firm; nailplate
should be firmly
attached to
nailbed.

Pink tone returns

Blanch Test immediately to
blanched nail beds
-Delayed when pressure is There is slow (greater
capillary refill released. than 2 seconds) capillar
more than 4 nail bed refill (return o
seconds Capillary refill pink tone), this means th
returns into its there is an alteration on
normal color in 5 the blood flow of the
seconds. body.

According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 174
175.

HEAD Head is Head size and Head should be rounded

Skull and Face symmetrical, shape vary. symmetrical,
I: size, shape , round, erect, and Usually the head is normocephalic and
 symmetry midline symmetric, round, upright. Without the
: facial features erect, and in presence of lesions.
: eyes for edema midline.
and hollowness No lesions No lesions are
P: nodules, masses, Head is upright visible.
Depressions Head should be
held still and
upright.

Head is hard and The head is The head is normall

dry with normally hard and hard and having roug
dandruff. smooth without and dry scalp is due
dandruff. self care deficit.

Face is The face is

elongated and symmetric with a
symmetrical. round, oval,
elongated, or
square appearance.
No abnormal No abnormal
movements are movements must The face may be oval,
noted. be noted. round or square. It has
symmetrical features an
According to Health movement.
Assessment in Nursing
3rd Edition by Webber
and Kelley, page 200.

Eyes and Vision Upper and lower The upper and The upper and lowe
I: eyebrows for lids close easily lower lids close lids close
distribution & and meet easily and meet symmetrically.
alignment, quality & completely when completely when
movement closed. closed.
: eyelashes for
evenness of Lower eyelid is The lower eyelid is The lower eyelid is
distribution & upright with no upright with no upright with no inwa
direction of curl inward or inward or outward or outward turning
: eyelids for surface outward turning. turning.
characteristics, position
in relation to cornea,
ability to blink & Eyelashes are evenl
frequency Eyelashes are Eyelashes are distributed and curle
: bulbar & palpebral evenly evenly distributed slightly outward.
conjunctiva for color, distributed and and curve outward
texture, and lesion curved outward along the lid
I/P: lacrimal gland sac, along the lid margins.
nasolacrimal duct for margins.
edema, tenderness / Eyes and eyelid
tearing No redness in Skin on both should be free from
I: cornea for clarity, the skin on both eyelids is without inflammation,
texture & sensitivity eyelids. redness, swelling, crusting, edema or
I: pupils for color, shape, or lesions. masses.
symmetry of size, direct
and consensual reaction Eyeballs are Eyeballs are Eyeballs are
to light, & symmetrically symmetrically symmetrically aligned i
accommodation aligned without aligned in sockets sockets without
protruding without protruding protruding or sinking.
or sinking.

Bulbar Bulbar conjunctiva Bulbar conjunctiva is

conjunctiva is is clear, moist, and transparent with small
clear, moist and smooth. blood vessels visible.
smooth

Sclera is white. Sclera is white. Sclera appears white an

yellowish in dark skinne
clients.

No lesion and The lower and Palpebral conjunctiva

free of swelling. upper palpebral should be shiny, smooth
conjunctivae are and varies from pink or
clear and free of red. Free from swelling
swelling or and lesions.
lesions.

No swelling or No swelling or Lacrimal glands should

redness over the redness should not be palpable. It has n
areas if lacrimal appear over the edema or tearing.
gland. areas of lacrimal
gland.
No drainage
No drainage No drainage should b
should be noted noted from the punc
from the puncta (medial aspect of
(medial aspect of lower eyelid) when
lower eyelid) palpating the
when palpating the nasolacrimal duct.
nasolacrimal duct.

Cornea is The cornea is Cornea is transparent,

transparent. transparent with shiny and smooth; detai
Presence of no opacities. The of the iris are visible.
opacities on the oblique view
lens. shows a smooth
and overall moist
surface; the lens is
free of opacities.

Iris is round, flat The iris is Iris is transparent with n

and evenly typically round, shadows of light. It has
colored. flat, and evenly depth of about 3 mm.
colored.
 Pupil is round The pupil, round
and at the center with a regular
of the iris. border, is centered
in the iris.
Pupil is 4 mm in Pupils are
size. normally equal in
size (3 to 5 mm).
Direct papillary The normal direct
response is pupillary response
constriction is constriction.
Consensual The normal
papillary consensual
response is pupillary response
constriction. is constriction.
The normal
Pupillary pupillary response
response in is constriction of
accommodation the pupils and
and convergence convergence of the
is constriction. eyes when
focusing on a near
object.
Blurred vision The client is able
to read line of
letters at a distance
of 20 feet.
According to Health
Assessment in Nursing
3rd Edition by Webber
Nearsighted and Kelley, pages 222 higher the second numbe
231.
Ears and Hearing Ears are equal in Ears are equal in
I: auricles for color, size size bilaterally
The pupil is black in
color, equal in size,
normally 3 to 5 mm in
diameter, round and
smooth border.
Illuminated pupil
constricts (direct
response).
Non illuminated pupil
constricts (consensual
response).
Pupils constrict when
looking at near object;
pupils dilate when lookin
at far object; pupils
converge when near
object is moved toward
nose.
Normal vision, based o
the Snellen Chart, is 20/2
(at a distance of 20 fee
the normal eye can read
the chart).
Myopia(impaired far
vision) is present when
the second number in th
test result is larger than
the first (20/40). The
the poorer the vision. An
client with vision worse
than 20/30 should be
referred for further
evaluation.
Ears are symmetrical
 symmetry and position
: external canal for
cerumen, lesions, pus or
blood
P: auricles for texture,
elasticity and areas of
tenderness
* Gross Hearing Acuity
Tests: normal voice tone
and whispered voice
(normally 4 to 10
cm).
Auricle with the The auricle aligns The auricles are
corner of each with the corner of symmetrical and the col
eye within a 10- each eye and is same as facial skin. It
degree angle of within a 10-degree aligned with outer canth
the vertical angle of the of eye, about 10 degree
position. vertical position. from vertical.
Color is Color is
consistemt with consistemt with
facial color. facial color.
Earlobes are Earlobes may be Earlobes may be free,
tightly attached free, attached, or attached, or soldered
to adjacent skin soldered (tightly (tightly attached to
with no apparent attached to adjacent skin with no
lobe. adjacent skin with apparent lobe).
no apparent lobe).
Skin is scaly The skin is smooth
with no lesions, with no lesions, The skin is firm,
lumps or lumps, or nodules. smooth and free from
nodules. lesions, lumps, or
nodules.
No discharge No discharge
should be present. There is no presence of
discharge that indicates a
infection.
No tenderness Normally the
auricle, tragus, and The auricle is mobile, fir
mastoid process and not tender; pinna
are not tender. recoils after it is folded
Presence of A small amount of
moist cerumen odorless cerumen Dry cerumen; grayish ta
Yellow, moist (ear wax) is the color; or sticky wet
cerumen only discharge cerumen in various shad
normally present. of brown and this is due
poor hygiene.
Cerumen maybe
yellow, orange,
red, brown, gray,
or black and soft,
moist, dry, flaky,
or even hard.
Canal walls are The canal walls
pink and smooth should be pink and Ear cannal is pinkish in

Nose and Sinuses
I: nose deviation in shape
size, color, flaring,
discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness, masses,
displacements;
: nasal patency
: maxillary and frontal
sinuses for tenderness
Pe: the above sinuses for
tenderness
without nodules. smooth without color and dry.
nodules.
Tympanic The tympanic
membrane is membrane should The tympanic membran
pearly, gray, be pearly, gray, is intact, translucent and
shiny and shiny, and pearly gray in color.
translucent. translucent with no
There is no bulging or
bulging or retraction. It is
retraction. slightly concave,
Concave, smooth and intact.
smooth and
intact. According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 260
263.
The color of the Color of the nose is the The nose is symmetric
nose is same as same as the rest of the and straight. There is no
the color of the face; the nasal structure is discharge and flaring an
rest of the face. smooth and symmetric; it is uniform in color.
the client reports no
tenderness.
Able to sniff
through each Client is able to Air moves freely as the
nostril while sniff through each client breathes through t
other is nostril while other nares.
occluded. is occluded.
Dark pink, moist The nasal mucosa Mucosa is pink in colo
and free of is dark, pink, with clear, watery
exudates. moist, and free of discharge and has no
exudate. lesions.
Nasal septum is The nasal septum The nasal septum is inta
intact and free of is intact and free and should be in the
ulcers or of ulcers or midline.
perforations. perforations.
No tenderness Frontal and It is usually not tender,
on frontal and maxillary sinuses without swelling,
maxillary are nontender to bleeding, lesions or
sinuses. palpation, and no masses.
crepitus is evident.
No tenderness The sinuses are not The sinuses are not tend
on percussion. tender on when palpated.

Mouth / Oropharynx
I: lips for symmetry of
contour, color, texture,
moisture, lesion
: teeth for alignment,
loss, dental filings and
caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
movement, as well as
the base of the tongue,
mouth floor and
frenulum
: salivary gland ducts for
swelling, redness
: palates for color,
shape, texture, presence
of bony prominences
: uvula for position &
mobility
: oropharynx for color &
texture
: tonsils for color,
discharge, and size
percussion.
Lips are smooth Lips are smooth Lips and mucosa should
and moist and moist without be pink, firm, and mois
without lesions lesions or without inflammation o
or swelling. swelling. lesions.
Without Thirty-two pearly Loose or missing teeth
dentures whitish teeth with are common because bon
Presence of smooth surfaces resorption increases. An
cavities on upper and edges. older adults teeth often
and lower teeth feel rough when tooth
and Tooth decay, enamel calcifies. Yellow
located at the and darkened teeth are
first and second also common in the olde
molar. adult because of genera
wear and tear that expos
Gums are pale in the darker underlying
color, moist and dentin.
firm.
Gums are pink, Gums is pale may be du
No lesions or moist, and firm to less of production of
masses with tight margin red blood cells.
to the tooth. No
lesions or masses
should be present.
Tongue is in
central in
position and The tongue is placed in
Tongue should be the central position, pin
pink in color. pink, moist, a in color (some brown
moderate size with pigmentation on tongue
papillae present. borders in dark skinned
Smooth, shiny, clients).
slightly pale
with no lesions Moist, slightly rough, ha
thin whitish coating, wit
The tongues smooth lateral margins
ventral surface is and has no lesions.
smooth, shiny,
pink, or slightly
pale with visible
veins and no
lesions.
The frenulum is The frenulum is midline
midline. The client The client has no
Frenulum is has no swelling, swelling, redness, or pai
 positioned redness, or pain.
midline.
No swelling,
redness, or pain.
No lesions, ulcers, No lesions, ulcers, or
or nodules are nodules are present on th
No lesions, present on the side side of the tongue.
ulcers, nodules, of the tongue.
on the side of
the tongue. There is a strong
The tongue offers resistance of the tongue
strong resistance.
Tongue offers
strong
resistance. The client can The client has normal
distinguish taste buds by determinin
between sweet and sweet from salty.
salty.

The hard palate is lighte

Client can pink and more irregular
distinguish texture.
between sweet
and salty.
The hard palate is
pale or whitish
Hard palate is with firm,
pale with firm transverse rugae.
transverse rugae.

No Breath odor Breath should smell fres

No unusual or foul Breath odor indicates po
odor is noted. hygiene.

Positioned in midline o
The uvula is a soft palate and rise
Uvula hangs fleshy, solid symmetrically with no
structure that lesions.
freely on the hangs freely on the
midline. midline. No
No redness or redness or
exudates. exudates from
uvula or soft
palate. Midline
elevation of uvula
and symmetric
elevation of the
soft palate.
 Tonsils may be prese
Tonsils may be or absent. They are
Tonsils are present or absent. normally pink and
They are normally symmetric and may b
slightly pink in pink and enlarged to 1+ in
color and symmetric and healthy clients. No
symmetrical. may be enlarged to exudates, swelling, o
No exudates, 1+ in healthy lesions should be
swellings, or clients. No present.
lesions. exudates, swelling,
or lesions should
be present.
Throat is normally
Throat is normally pink without exudate
Throat is pink pink without or lesions.
without lesions or exudates or
exudates. lesions.

According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 281
286.

NECK Neck is Neck is symmetric Muscles are symmetrica

Neck Muscles symmetrical with head centered with head in central
I: abnormal swelling or and without position.
masses, head with head bulging masses.
movement, and muscle centered and
strength without bulging
Lymph Nodes masses.
P: enlargement
Trachea Thyroid The thyroid Coordinated, smooth
P: lateral deviation cartilage, cartilage, cricoid movements with no
Thyroid Gland cartilage, and the discomfort. Gland ascen
I: symmetry and visible cricoids thyroid gland during swallowing but i
masses, rise during cartilages and move upward not visible.
swallowing the thyroid gland symmetrically as
P: smoothness moves upward the client
A: bruit symmetrically swallows.
when the client
swallows.

Neck movement Normally neck Movement through ful

is smooth and movement should range of motion withou
controlled with be smooth and complaint of discomfor
45-degree controlled with 45- or limitation.
flexion, 55- degree flexion, 55-
degree extension,
degree 40-degree lateral
 extension, 40- abduction, and 70-
degree lateral degree rotation.
abduction and
70-degree
rotation.

No swelling of There is no Lymph nodes should no

lymph nodes, swelling of lymph be palpable. Small,
enlargement and nodes or movable nodes are
tenderness. enlargement and
no tenderness significant.

According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 202 -
205.

THORAX & LUNGS

Posterior Thorax Scapulae are Scapulae are Scapulae are
I: shape & symmetry symmetric and symmetric and symmetric and non
from posterior-lateral non-protruding. protruding.
views; spinal alignment non-protruding
for deformities
Pa: temperature, bulges, The ratio of The ratio of Anteroposterior to
tenderness, abnormal anteroposterior anteroposterior to transverse diameter in
movements, respiratory to transverse transverse ratio of 1:2.
excursion, vocal diameter is 1:2. diameter is 1:2.
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds

Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
The client does The client does not Trapezius, or shoulder
not use use accessory muscles are used to
accessory muscles to assist facilitate inspiration in
muscles to assist breathing. Client cases of acute and chron
breathing. Client should be sitting airway obstruction or
should be sitting up and relaxed, atelectasis.
up and relaxed, breathing easily
breathing easily with arms at sides
with arms at or in lap.
sides or in lap.

Client has no Client reports no Muscle soreness from

tenderness, pain, or tenderness, pain, exercise or the excessiv
or unusual work of breathing (as in
unusual sensations sensations. copd) may be palpated a
 tenderness.

The examiner The examiner finds no

No crepitus finds no palpable palpable crepitus
crepitus.

No lesions and Skin and

masses subcutaneous Skin and subcutaneous
tissue are free of tissue are free of lesions
lesions and and masses.
masses.
No fremitus Fremitus is Fremitus is normally
symmetric and decreased over heart an
easily identified in breast tissue.
the upper regions
of the lungs.

.
Thumbs When the client Excursion is 3 cm to 5 c
separates 3 cm takes a deep bilaterally in women an
when breathing breath, the 5 to 6 cm in
examiners thumbs Percussion notes resonat
should move 3 to 5 except over scapula.
cm bilaterally in Lowest point of resonan
women.
is at the diaphragm
Resonance is the
Present resonant percussion tone
sound elicited over
normal lung tissue.
Percussion elicits
flat tones over the
scapula.

No adventitious
Normal breath sounds, such as
sounds Normal breath Sounds
crackles (discrete
and discontinuous
Negaive sounds) or
Crackles wheezes (musical
Negative and continuous),
Wheezes are auscultated.
Respiratory rate:
18 20 bpm
According to Health
Assessment in Nursing
3rd Edition by Webber

ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements associated
w/ respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
deviations
and Kelley.
Abdominal skin Abdominal skin Abdominal skin may be
paler than the may be paler than paler than the general sk
the general skin tone because this skin i
general skin tone because this so seldom exposed to th
tone. skin is so seldom natural elements.
exposed to the
natural elements.
No scars Pale, smooth, Pale, smooth,
minimally raised minimally raised ol
old scars may be scars may be seen.
seen.
Abdomen is free Unblemished skin and
Without lesions of lesions or uniform in color.
and masses rashes. Flat or
raised brown
moles, however,
are normal and
may be apparent.
Umbilical skin Umbilical skin
tones are similar tones are similar to Umbilical skin tones ar
surrounding similar to surrounding
to abdominal abdominal skin abdominal skin tones o
skin tones or even even pinkish
pinkish.
Umbilicus is Umbilicus is
midline at lateral midline at lateral Umbilicus is depressed
line line. and beneath the
abdominal surface.
Abdomen is Abdomen is flat,
evenly rounded. rounded, or Flat, rounded (convex),
scaphoid (usually scaphoid (concave) and
seen in thin not distended.
adults). Abdomen
should be evenly
rounded.
Abdomen is Abdomen is Contour is flat or rounde
symmetrical. symmetric. and bilaterally
symmetrical.
No bulging of Abdomen does not Pain may indicate post
the abdomen

MUSCULOSKELETAL
Muscles
I: size, contractures,
fasciculations, tremors
P: tonicity, flaccidity,
spasticity, smoothness
of movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness, smoothness
of movement, swelling,
crepitation, nodules
Range of motion:
when the client bulge when client abdominal surgery.
raises head raises head.
Abdominal Abdominal Abdomen rises with
respirations noted respiratory inspirations and falls wi
Presence of bowel movement may be expirations, free from
sounds. seen, especially in respiratory retractions.
male clients.
Abdomen is non Abdomen is soft and
tender and soft. tenderness should not b
No tenderness noted because it indicate
inflammation.
No palpable Masses may be due to
masses are present. tumors, feces, o enlarge
No palpable organs.
masses
According to Health
Assessment in Nursing
3rd Edition by Webber
and Kelley, pages 438-
448.
Gait Gait is natural, with arm
Evenly distributed swinging freely at sides
Asymmetric weight. Client able and head leading the bod
structure and to stand on heels
development of and toes. Toes Spine has a cervical
upper extremities point straight concavity, thoracic
muscles. ahead. Equal on convexity, and lumbar
both sides. Posture concavity.
Dry skin erect, movements
coordinated and Limited ROM is due to
Limited ROM:
rhythmic, arms lack of muscle strength
flexion,
swing in
extension,
opposition, stride Muscle grading is low
abduction,
length appropriate. because of loss of
rotation (internal
Client does not fall function of some body
and external) of backward.
the upper parts due to affection o
extremities cervical spine (C5).
This is due to tendency
be less active because h
already has a paraplegia
Cervical, Thoracic, and
 Lumbar Spine
Cervical and
lumbar spines are
concave; thoracic
Presence of spine is convex.
flabby muscle Spine is straight
on the upper (When observed
extremities. from behind).

Muscle strength Nontender spinous

(Grading): processes, well-
developed, firm
Upper Extremities: and smooth, non-
tender
R 2 over 5 paravertebral
muscles. No
L 2 over 5 muscle spasm.
Flexion of the
Lower Extremities cervical spine is 45
degrees. Extension
R 0 over 5 of the cervical
L 0 over 5 spine is 45
degrees.
About 70 degrees
of rotation is
No swelling normal.
Client has full
Absence of ROM against
redness and resistance.
nodules Flexion of 75
degrees to 90
degrees, smooth
movement, and
Cervical and lumbar concavity
flattens out and the
lumbar spines spine remains
are concave straight.
Lateral bending
capacity of the
thoracic and
Spine is straight lumbar should be
about 35 degrees;
hyperextension
about 30 degrees;
and rotation about
30 degrees.
Presence of
muscle spasm. Back and Leg
Pain not
reproduced.
Patient is able to
Non tender raise left to 90
spinous process
 degree angle. Mild
pain of the
harmstring is a Paraplegia is due
common finding to the damaging
and does not the (c5) cervical
indicate sciatic
pain. nerve that causes
Measurements are the malfunction o
equal or within 1 the spinal.
cm. If the legss
still look unequal, His condition wa
assess the apparent slowly damage th
leg length by spinal cord, they
measuring from a can cause paralys
nonfixed point (the with increased
umbilicus) to a
fixed point (medial muscle tone and
malleolous) on muscle spasms
each leg.
Spasms can occu
because signals
Shoulders, Arms, and from the brain
Lower Extremities Elbows cannot pass
Right leg 14 inches Elbows through the
Left leg 14 inches Elbows are damaged area to
symmetric without
deformities, help control som
redness, or reflexes. As a
Paraplegia
swelling. result, the reflexe
Muscle Spasm on Nontender; become more
without nodules. pronounced over
both lower
Normal ranges of days to weeks.
extremities. motion are 160
degrees of flexion; Then, the muscle
180 degrees of controlled by the
extension. 90 reflex may tighte
degrees of feel hard, and
pronation. 90 twitch
degrees of uncontrollably
supination. Some from time to time
clients may lack 5
to 10 degrees or
have
hyperextension.
The client should
have full ROM
against resistance.

Wrists
Wrists are
symmetric without
redness, or
swelling. They are
 nontender and free
of nodules.
No tenderness
palpated in
anatomic snuffbox.
Normal ranges of
motion are 90
degrees, flexion;
70 degrees,
hyperextension; 55
degrees, ulnar
deviation; and 20
degrees, radial
deviaton. Client
should have full
ROM against
resistance.
No tingling,
numbeness, or
pain result from
Presence of Phalens test or Shoulders are equal in
keloids on left from Tinels test. height, and movements
elbow. should be done with ease
Hands and Fingers Without the presence of
Hands and fingers
are symmetric, swelling or redness and i
nontender and not tender that indicates
Elbows are at
without nodules. inflammation.
the same height
Fingers lie in
and symmetrical straight line. No Elbows are at the same
in appearance. swelling or height and symmetrical
deformities. appearance. Movement
Rounded should be done with eas
protuberance noted
next to the thumb
over the thenar
Do not have prominence.
equal strength Smaller
on each body protuberance seen
side which is the adjacent to the
left upper small finger.
extremities was
more strength
that the right
side of upper
extremities.

Wrist are asymmetric ma

be due to Acute Spinal
cord injury, spinal leve
C5.
 Wrists are
straight and
asymmetric.
Knees

Knees symmetric,
hollows present on
both sides of the
patella, no
swelling or
deformities. Lower
leg in alignment
with upper leg.
Nontender and
cool. Muscles
firm. No nodules.
No bulge of fluid
appears on medial
side of knee.
No movement of
patella noted. Fingers, hands, and wris
Patella rests firmly are straight and
over femur. asymmetric. However,
There is no pain dominant hand is bigge
on examination.
Crepitus may be because it is used often
present. Joints are smooth,
Normal ranges: movement is difficult, an
120 degrees to 130 theres weakness on bot
degrees of flexion; arms.
Hands and 0 degrees of
fingers are extension to 15 No tenderness noted an
symmetric. degrees of has limited ROM agains
hyperextension. resistance.
Dominant hand Client should have
full ROM against Fingers have no longer
is somewhat resistance.
bigger. No pain or sensation due to
clicking noted. paraplegia.
Fingers lie in No pain, heat,
straight line. swelling, or
nodules are noted.
Fingers have no
longer sensation.
Knees are in alignment
Upper Extremities with each other and do n
Right arm 9 inches protrude medially or
Left arm 10 inches laterally. Presence of
 Movements are paraplegia due to ASCI
done with ease.
Do not have full
resistance
against ROM.

No tenderness
noted.
To tingling
numbness, or
pain.
Movement is
easy.
Strength is felt
on grasp.

Knees are
symmetric.
No nodules
Muscles are
firm
Presence of
keloids on left
lower
extremities.
 DEVELOPMENTAL HISTORY

We chose Erikson's theory because it describes the impact of social

experience across the whole lifespan of a person. Erik Erikson explains

eight stages through which a healthily developing human should pass

from infancy to late adulthood. Each stage builds upon the successful completion

of earlier stages. The challenges of stages not successfully completed may be

expected to reappear as problems in the future. Erik Erikson's theory of

psychosocial development is one of the best-known theories of personality in

psychology.

Erikson's Psychosocial Stages of Development

First stage is the Trust vs. Mistrust, it is between birth to 18 months. In

this stage the infant should develop a sense of trust when caregivers provide

reliability, care, and affection. A lack of this will lead to mistrust. According to the

patient he does not remember anything about this stage because he is still an

infant, but he thinks that he developed trust because he said that he has a sense of

trust to his parents ..

Second stage is the Autonomy vs. Shame and Doubt, it is from 2 to 3

years old. In this stage the child need to develop a sense of personal control over

physical skills and a sense of independence. Success leads to feelings of

autonomy, failure results in feelings of shame and doubt. According to the patient,

he thinks that he developed autonomy than shame and doubt because he thinks

that his parents taught him to do things with assistance to help him learn. As a

toddler he begin to feed himself, wash and dress himself, and use the bathroom.
 The third stage is Initiative vs. Guilt 3-5 years old. In this stage, children

need to begin asserting control and power over the environment. Success in this

stage leads to a sense of purpose. Children who try to exert too much power

experience disapproval, resulting in a sense of guilt. According to him, he

developed initiative because he begin to plan activities and initiate activities with

others. According to him he always go outside to play with his playmates and

mostly with his cousins. If given this opportunity, children develop a sense of

initiative, and feel secure in their ability to lead others and make decisions.

Forth stage is Industry vs. Inferiority 6 to 11 years old. Children need to

cope with new social and academic demands. Success leads to a sense of

competence, while failure results in feelings of inferiority. He developed industry

than inferiority because he achieved the recognition of teachers, parents and peers

by producing things- drawing pictures and so on because he stated that he was a

very studious child when he was on elementary. If children are encouraged to

make and do things and are then praised for their accomplishments, they begin to

demonstrate industry by being diligent, persevering at tasks until completed, and

putting work before pleasure.

Fifth stage is Identity vs. Role Confusion, it is from 12-18 years old. Teens

need to develop a sense of self and personal identity. Success leads to an ability to

stay true to yourself, while failure leads to role confusion and a weak sense of

self. This is a major stage in development where the child has to learn the roles he

will occupy as an adult. It is during this stage that the adolescent will re-examine

his identity and try to find out exactly who he or she is. Erikson suggests that two

identities are involved: the sexual and the occupational. During this period, they

explore possibilities and begin to form their own identity based upon the outcome

of their explorations. According to Patient PA mahilig akong magexplore noong

 kabataan ko, mapusok ika nga. Kaya nakilala ko kaagad sarili ko..he developed

identity and it leads to an ability to stay true to yourself

In this stage the person should achieve Intimacy vs. Isolation, it is ccurring in

Young adulthood, we begin to share ourselves more intimately with others. We

explore relationships leading toward longer term commitments with someone

other than a family member. Successful completion can lead to comfortable

relationships and a sense of commitment, safety, and care within a relationship.

Avoiding intimacy, fearing commitment and relationships can lead to isolation,

loneliness, and sometimes depression.

Patient MM was able to achieve intimacy. Before hospitalization,he stayed in

his Aunties house with his cousins. He also had four girlfriends and a lot of

friends in Mindoro. Now he was able to establish friendship with the other

patients in the Spinal ward he stated that lahat kami magkakaibigan dito.

Parang magkakapatid na rin. thats why Patient MM established a good

relationship and a sense of commitment with his cousins and friends.

GORDONS 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception Health Management Pattern

Prior to hospitalization, patient perceived himself as a healthy person. He does a

lot of activities to keep himself healthy such as playing sports like swimming, diving and

basketball since he was at his younger age. He has no known allergies. He doesnt get

sick often, but when he does he takes over the counter drugs. He doesnt consider any

herbal medicine when he gets sick. The patient only gets a cold twice year. In addition,

M.M doesnt remember if he is fully immunized or not. The patient also mentioned that
he drinks alcohol and smokes marijuana with his friends during his fare time. He

consumes 2 -3 stick of cigarettes per day.

When patient was hospitalized, he perceived himself that he is not a healthy

person. Patient verbalized Syempre ngayon hindi na ako makakilos, kasi kahit nga upo

di ko na magawa. The patient said he became dependent to the medications and

management.

B. Nutritional Metabolic Pattern

Before hospitalization, patient M.M had a big appetite. He mentioned that one

time he ate 15 cup of rice in Mang Inasal. In daily basis, he used to eat 1-3 cups of rice a

day and drink 3 liters of water a day since he was very active. Also he is fond of drinking

1-2 battles of soft drinks every day. Patient also used to eat vegetables and with only

little meat.

During hospitalization he was put on NPO prior to surgery. After the operation, he

is now eating hospital meal given to them particularly DAT. During breakfast, he only

consumes 1-2 bread with a cup of water. At lunch time, he eats pork chop, fried chicken

and mostly fish with a 1 cup of rice. Lastly at dinner, sometimes he eats chicken adobo or

vegetables viand.

C. Elimination Pattern

Before hospitalization patient M.M .defecates once a day on a regular without

experiencing any discomfort. The patient did not experienced any problem regarding

controlling his bowel. His urinary elimination pattern is normal and urinates about 5-6

times a day. According to patient M.M, he doesnt have any trouble holding his urine

until getting to the bathroom

During hospitalization, he mentioned that he did not have bowel elimination for
11 days. He was given laxatives and digital stimulation to eliminate his bowel. The

patient was inserted indwelling foley catheterization prior to surgery. He urinate 400

cc/day with yellowish color.

D. Activity Exercise Pattern

Prior to hospitalization according to patient M. M he was very active person. He

used to play sports such as Sepak Takraw, basketball and diving. He is one of a player in

Sepak Takraw in his elementary days. He was independent in his Activity Daily Living

and used to work at a furniture and construction when he was 18 years old. Patient said
that he considered his job as form of an exercise since he is a furniture and construction

worker. M.M said he had sufficient energy for desired activity around work and home. He

spends his time by having an extreme activity with his friends like playing basketball and

diving.

During hospitalization patient M.M can no longer do daily activity living such as

feeding himself, grooming, bathing and dressing without the help of nurse. He usually

chats with his friends most of the time.

E. Sleep Rest Pattern

Before hospitalization patient M. M usually sleeps at least 8 hours to 10 hours a

day. He had no problem with sleeping and did not use any sleeping aids. He doesnt

snores and does not experience headache when awakening. He sleeps around 10 oclock

in the evening and usually wakes up at 9 A.M in the morning. The patient also mentioned

that he always pray before he sleeps.

In his hospitalization the patient doesnt encounter any kind of problem in

sleeping. He sleeps 12 oclock A.M and wakes up 7 oclock in the morning. Patient M.M
does not used sleeping aids and has nighttime routines. He also takes naps in the hospital

during daytime.

F. Cognitive Perceptual Pattern

Patient M.M can answer questions quickly and does not had any difficulty

understanding questions being asked. He experienced pain in the scale of 7/ 10 after

surgery for insertion of Crutchfield tong. According to patient M.M he does not have

difficulty in reading; he didnt use any kind of reading glasses or contact lenses to read.

He can also hear normally and doesnt use any hearing aid. He has no history of
glaucoma. There are no changes in his sense of smell or taste.

G. Self-Perception Self Concept Pattern

Patient M.M feels positive most of the time. He accepted the situation and

describes himself as a good person and a loving friend. According to him he makes sure

that he had time to chat with his friends inside the hospital.

H. Role-Relationship Pattern

Prior to Admission, patient M.M came from a broken family. He lives with his

auntie since he was 10 years old. He named himself as a black sheep of the family. He

drinks alcohol, smokes and steals electric wire with his friends at a young age. He took 1st

year high school four times. The patient also supports himself in studying.

During hospitalization, he mentioned that in 2 years of stay in the hospital, he

built a strong bond to the people around him especially to his close friends which are Jr

and Joseph. Even though he didnt get any visitation from his parents and relatives he

verbalized that Naiintindihan ko naman sila kung bakit minsan lang sila nadalaw sa

akin. Wala naman akong galit o hinanakit sa kanila.

Sexuality-Reproductive Pattern
 Patient M.M stated that he is sexually active having 3 to 4 times a week with his

girlfriends but then during hospitalization his sexually activity was deprived due to his

condition.

J. Coping-Stress Tolerance Pattern

Prior to hospitalization M.M was usually relaxed most of the time together with

his friends. He uses drugs sometimes and alcohol to cope with his stress. For him, his

friends were his family because they were always there to help him whenever he has

problems. In addition, mentioned that whenever he is bored, he paints to relieve his stress
and to relax his mind. Praying also kept him strong and helped him to cope with his

stress.

K. Value-Belief Pattern

The patient said that even though he is not capable of going to church every

Sunday, he always prays before he sleeps. He stated that Walang taong malas, at ang

lahat ay pagsubok lamang. Patient M.M perceived that life is a full of challenges but he

mentioned that you have to be positive to overcome it. The important thing in his life is

his faith in God and his motto in life is everything happens for a reason.

ANATOMYAND PHYSIOLOGY

The spinal column is one of the most vital parts of the human body, supporting
our trunks and making all of our movements possible. Its anatomy is extremely
well designed, and serves many functions.

All of the elements of the spinal column and vertebrae serve the purpose of
protecting the spinal cord, which provides communication to the brain and
mobility and sensation in the body through the complex interaction of bones,
ligaments and muscle structures of the back and the nerves that surround it.
The normal adult spine is balanced over the pelvis, requiring minimal workload
on the muscles to maintain an upright posture.
Loss of spinal balance can result in strain to the spinal muscles and spinal
deformity. When the spine is injured and its function impaired, the consequences
may be painful and even disabling.

Regions of the Spine

Humans are born with 33 separate vertebrae. By adulthood, we typically have 24

due to the fusion of the vertebrae in the sacrum.
The top 7 vertebrae that form the neck are called the cervical spine and are
labeled C1-C7. The seven vertebrae of the cervical spine are responsible for
the normal function and mobility of the neck. They also protect the spinal
cord, nerves and arteries that extend from the brain to the rest of the body.
The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12.
The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar
spine bears the most weight relative to other regions of the spine, which
makes it a common source of back pain.
The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are
fused together to form a solid, bony unit.

Spinal Curvature
When viewed from the front or back, the normal spine is in a straight line, with
each vertebra sitting directly on top of the other. Curvature to one side or the other
indicates a condition called scoliosis.
When viewed from the side, the normal spine has three gradual curves:
The neck has a lordotic curve, meaning that it curves inward.
The thoracic spine has a kyphotic curve, meaning it curves outward.
The lumbar spine also has a lordotic curve.
These curves help the spine to support the load of the head and upper body, and
maintain balance in the upright position. Excessive curvature, however, may
result in spinal imbalance.

Elements of the Spine

The elements of the spine are designed to protect the spinal cord, support the body
and facilitate movement.

A. Vertebrae
The vertebrae support the majority of the
weight imposed on the spine. The body of each vertebra is attached to a bony ring
consisting of several parts. A bony projection on either side of the vertebral body
called the pedicle supports the arch that protects the spinal canal. The laminae are
the parts of the vertebrae that form the back of the bony arch that surrounds and
covers the spinal canal. There is a transverse process on either side of the arch
where some of the muscles of the spinal column attach to the vertebrae. The
spinous process is the bony portion of the vertebral body that can be felt as a
series of bumps in the center of a persons neck and back.

B. Intervertebral Disc
Between the spinal vertebrae are discs, which function as shock absorbers and
joints. They are designed to absorb the stresses carried by the spine while
allowing the vertebral bodies to move with respect to each other. Each disc
consists of a strong outer ring of fibers called the annulus fibrosis, and a soft
center called the nucleus pulposus. The outer layer (annulus) helps keep the discs
inner core (nucleus) intact. The annulus is made up of very strong fibers that
connect each vertebra together. The nucleus of the disc has a very high water
content, which helps maintain its flexibility and shock-absorbing properties.

C. Facet Joint
The facet joints connect the bony arches of each of the vertebral bodies. There are
two facet joints between each pair of vertebrae, one on each side. Facet joints
connect each vertebra with those directly above and below it, and are designed to
allow the vertebral bodies to rotate with respect to each other.

D. Neural Foramen
The neural foramen is the opening through which the nerve roots exit the spine
and travel to the rest of the body. There are two neural foramen located between
each pair of vertebrae, one on each side. The foramen creates a protective
passageway for the nerves that carry signals between the spinal cord and the rest
of the body.

E. Spinal Cord and Nerves

The spinal cord extends from the base of the brain to the area between the bottom
of the first lumbar vertebra and the top of the second lumbar vertebra. The spinal
cord ends by diverging into individual nerves that travel out to the lower body and
the legs. Because of its appearance, this group of nerves is called the cauda equina
the Latin name for horses tail. The nerve groups travel through the spinal
canal for a short distance before they exit the neural foramen.
The spinal cord is covered by a protective membrane called the dura mater, which
forms a watertight sac around the spinal cord and nerves. Inside this sac is spinal
fluid, which surrounds the spinal cord.
The nerves in each area of the spinal cord are connected to specific parts of the
body. Those in the cervical spine, for example, extend to the upper chest and
arms; those in the lumbar spine the hips, buttocks and legs. The nerves also carry
electrical signals back to the brain, creating sensations. Damage to the nerves,
nerve roots or spinal cord may result in symptoms such as pain, tingling,
numbness and weakness, both in and around the damaged area and in the
extremities.
 Spinal Muscles
Many muscle groups that move the trunk and the limbs also attach to the spinal
column. The muscles that closely surround the bones of the spine are important
for maintaining posture and helping the spine to carry the loads created during
normal activity, work and play. Strengthening these muscles can be an important
part of physical therapy and rehabilitation.

Nervous System
All of the elements of the spinal column and vertebrae serve the purpose of
protecting the spinal cord, which provides communication to the brain, mobility
and sensation in the body through the complex interaction of bones, ligaments and
muscle structures of the back and the nerves that surround it.
The true spinal cord ends at approximately the L1 level, where it divides into the
many different nerve roots that travel to the lower body and legs. This collection
of nerve roots is called the cauda equina, which means horses tail, and
describes the continuation of the nerve roots at the end of the spinal cord.

PATHOPHYSIOLOGY
Interpretation:

The illustration above shows the pathophysiology of Acute Spinal Cord Injury
and other complications that occurred to patient M.M. Acute spinal cord injury
(SCI) is due to a traumatic injury. There are predispose and precipitating factors
that affect the occurrence and development of the patients condition.
Precipitating factor is age 19 years old considered as young adults (16-30) years
old and men because they become more common as they engage in active sports
and increase participation in risky physical activity. Predisposing factor as a habit
 or an environmental condition predispose an individual to develop a particular
disease such as having an active sports, participation in risky physical activity
alcohol drinker, and prone to diving accident. These factors caused the trauma to
the cervical spine.

Landing on the head from a great height can lead to tearing in the annulus (outer
ring/ring like figure, part, or structure of vertebrae; shock absorber) and fracture
dislocation of unilateral articular process because of too much pressure. Tearing in
the annulus causes the fluid content of nucleus pulposus to leak through some of
annular fibers. It may produce inter-vertebral disc bulging on cervical spine (C5).
Bulging puts pressure on surrounding ligaments that causes the intrusion into the
cervical spine. This condition damage the cervical nerve and affecting the spinal
function.

The manifestation that the patient has impaired/loss of physical function below
the level of injury like hemiparesis, paraplegia, loss of voluntary movement in the
chest (immobility), spasticity. Only full inervation of sternocleidomastoid,
trapezius another muscles: therefore neck, scapula and shoulder movement is
retained. The patient is independent with assistance in daily activities like eating
and dressing. The patient has impaired/loss of renal control leading to U.T.I
because of prolonged catheterization. The patient has maximal assistance with his
bladder and bowel control. The patient has loss his sensation such as light touch,
numbness, pain, temperature.

DIAGNOSTIC TEST

Invasive

HEMATOLOGY REPORT
Date: January 28, 2015
Time: 08:57 AM
TEST NORMAL ACTUAL ANALYSIS
FINDINGS FINDINGS
White Blood 4.8-10.8 x 10.49 Normal
 Cells 10^3u/L 10^3u/L
Red Blood M: 4.7-6.1 x 3.93 10^6u/L Decreased level may indicate:
Cells 10^6u/L Thalassemia
F:4.0-5.51 x Anemia
10^6u/L Bone marrow suppression
Lead poisoning
Trauma
Nutritional Deficiency

Hemoglobin M: 135-160 G/L 111.0 G/L Decreased level may indicate:

F: 120-160 G/L Blood loss
Anemia
Bone marrow suppression

Hematocrit M:0.37-0.57 0.33 Decreased level may indicate:

Blood loss
Over hydration
Dietary deficiency
MCV M: 82- 92 83 Normal
femtoliters
F:81-99
femtoliters
MCH 28-32 pitogram 28.0 Normal
MCHC 32- 38% 34 % Normal
PLATELET 150-450 10^3/uL 177 10^3/uL Normal
Lymphocytes 0.19-0.48 0.10 Decreased level may indicate:
Severe malnutrition
Autoimmune disease
Monocyte 0.03-0.09 0.05 Normal
Eosinophils 0.00-0.07 0.00 Normal
Basophils 0.00-0.02 0 Normal

HEMATOLOGY REPORT
Date: January 20, 2015
Time: 11:29 AM
TEST NORMAL ACTUAL ANALYSIS
FINDINGS FINDINGS
White Blood 4.8-10.8 x 9.48 Normal
Cells 10^3u/L 10^3u/L
Red Blood M: 4.7-6.1 x 4.24 x 10^6u/L Decreased level may indicate:
Cells 10^6u/L Thalassemia
F:4.0-5.51 x Anemia
10^6u/L Bone marrow suppression
Lead poisoning
Trauma
Nutritional Deficiency
.
Hemoglobin M: 135-160 G/L 119.0 G/L Decreased level may indicate:
F: 120-160 G/L Blood loss
Anemia
Bone marrow suppression

Hematocrit M:0.37-0.57 0.36 Decreased level may indicate:

Blood loss
Over hydration
Dietary deficiency
MCV M: 82- 92 85 Normal
femtoliters
F:81-99
femtoliters
MCH 28-32 pitogram 29.0 Normal
MCHC 32- 38% 34 % Normal
PLATELET 150-450 10^3/uL 210 10^3/uL Normal
Lymphocytes 0.19-0.48 0.16 Decreased level may indicate:
Severe malnutrition
Autoimmune disease
Monocyte 0.03-0.09 0.05 Normal
Eosinophils 0.00-0.07 0.01 Normal
Basophils 0.00-0.02 0 Normal

PHARMACOLOGICAL MANAGEMENT

List of Medications

Acetylcysteine

Ceftazidime

Ceftriaxone

Cefuroxime Sodium
 Celecoxib

Paracetamol

Pregabalin

Tramadol hydrochloride

Multivitamins

Nitrofurantoin

Albuterol

Bisacodyl
 DRUG STUDY

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21y/o Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: Male

DRUG MECHANISM OF INDICATION CONTRAINDICATION EFFECTS

ACTION
Generic Name Exerts mucolytic Treatment of Treatment of respiratory Adverse Reacti
Acetylcysteine action through its respiratory affections characterized by Hypersensit
free sulfhydryl affections thick and viscous bronchospas
Brand Name fluimicil group which opens characterized by hypersecretions: acute angioedema
up the disulfide thick and viscous bronchitis, chronic rashes and
Classification bonds in the hypersecretions: bronchitis and its pruritus, ma
Mucolytic agent mucoproteins thus acute bronchitis, exacerbations; pulmonary occur.
lowering mucous chronic bronchitis emphysema, Other adver
Dosage viscosity. The exact and its mucoviscidosis and effects repo
600 mg dissolve in mechanism of exacerbations; bronchiectasis. include naus
glass of water action in pulmonary and vomitin
acetaminophen emphysema, fever, synco
Route toxicity is unknown. mucoviscidosis and sweating,
PO It is thought to act bronchiectasis. arthralgia, b
by providing vision,
Frequency substrate for disturbances
OD conjugation with liver functio
the toxic metabolite. Side Effects
Form -nausea
tablet -vomiting

Color
White

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM OF INDICATION CONTRAINDICATION EFFECTS

ACTION
Generic Name Bactericidal: Treatment of the Contraindicated with Side Effects
Ceftazidime inhibits synthesis of following infections allergy to Diarrhea, sto
bacterial cell wall, caused by cephalosporins or upset
Brand Name causing cell death. susceptible penicillins Difficulty o
Tazicef organisms: Skin breathing
and skin structure, Anusual tire
Classification Urinary and or fatigue
Antibiotic, gynecologic Pain at injec
Cephalosporin (second infections, or , site
generation) Respiratory tract Adverse Effect
infections. CNS: heada
Dosage dizziness,
1 gm lethargy,
paresthesias
Route GI: nausea,
IV vomiting,
diarrhea,
Frequency anorexia,
q8 ANST (-) abdominal p
flatulence,
Form pseudomenb
injectable se colitis,
hepatotoxici
Color: GU:
clear Nephrotoxic
Hematologi
Bone marro
depression
Hypersensit
ranging from
to fever to
anaphylaxis
serum sickn
reaction
Local: pain,
abcess at inj
site, phlebiti
inflammatio
IV site
Others:
superinfecti
disulfram- l
reaction wit
alcohol
Initials of patient: M.M Date of Admission:
January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM OF INDICATION CONTRAINDICATION ADVERSE/SI

ACTION EFFECTS
Generic Name: Works by inhibiting UTI; lower Contraindicated in Side effects:
Ceftriaxone the mucopeptide respiratory patients hypertensive
synthesis in the tract, bone or to drug or other GI: diarrh
bacterial cell wall. joint, intra- cephalosporins Hematolo
Brand Name: The beta-lactam abdominal,
Rocephin eosinophil
moiety of skin, or skin thrombocy
Ceftriaxone binds to structure Skin: pain
Classification: carboxypeptidases, infection; induration
Antibiotic endopeptidases, and septicaemia tenderness
transpeptidases in the injection s
bacterial cytoplasmic rash
Dosage:
membrane. These Other:
1 gm enzymes are hypersens
involved in cell-wall reactions,
Route: synthesis and cell sickness
IV division. By binding
to these enzymes,
Ceftriaxone results in Adverse effec
Frequency: GI:
the formation of of
Q12 ANST (-) psuedome
defective cell walls
and cell death ous colitis
Form: Hematolo
Injectable Leukopen
Other:
anaphylax
Color:
Clear

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M
DRUG MECHANISM INDICATION CONTRAINDICATIONS EFFECTS
OF ACTION
Generic Name Bactericidal: Lower Contraindicated with Side Effects
Cefuroxime inhibits synthesis respiratory allergy to Diarrhea, stomach
Sodium of bacterial cell infections cephalosporins or upset
wall, causing cell caused by S. penicillins Difficulty of
Brand Name death. pneumonia, S. breathing
aureus, E. coli, Anusual tiredness
Classification Klebsiella or fatigue
Antibiotic, pneumonia, H. Pain at injection
Cephalosporin influenza, S. site
(second pyogenes Adverse Effect
generation) Dermatologic CNS: headache,
Dosage infections dizziness,
700mg caused by S. lethargy,
Route aureus, S. paresthesias
IV pyogenes, E. GI: nausea,
Frequency coli, K. vomiting,
q8 ANST (-) pneumonia, diarrhea, anorexia,
Form Enterobacter abdominal pain,
injectable UTIs caused by flatulence,
Color: E. coli, K. pseudomenbranou
Clear pneumonia se colitis,
Uncomplicated hepatotoxicity
and GU:
disseminated Nephrotoxicity
gonorrhea Hematologic:
caused by N. Bone marrow
gonorrhoeae depression
Septicimia Hypersensitivity:
caused by S. ranging from rash
pneumonia, S. to fever to
aureus, E. coli, anaphylaxis;
K pneumonia, serum sickness
H. influenza reaction
Local: pain,
Meningitis abcess at injection
caused by S. site, phlebitis,
pneumoniae, H. inflammation of
influenza, S. IV site
aureus, N. Others:
meningitides superinfection,
Bone and joint disulfram- like
infections due reaction with
to S. aureus alcohol
Perioperative
prophylaxis
Treatment of
acute bacterial
maxillary
 sinusitis in
patients 3-mo
12yr

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM OF INDICATION CONTRAINDICATION EFFECTS

ACTION
Generic Name Inhibits the enzyme Relief of signs and Contraindicated in: Adverse
Celecoxib COX-2. This symptoms of Hypersensitivity Reactions:
enzyme is required osteoarthritis, Cross-sensitivity may
Brand Name for the synthesis of rheumatoid arthritis, exist with other NSAIDs, GI: GI Bleedi
Celebrex prostaglandins, thus ankylosing including aspirin
has an analgesic spondylitis and History of allergic-type Derm: Exfolia
Classification effect. juvenile rheumatoid reactions to sulfonamides dermatitis, stev
antirheumatics, arthritis. History of asthma, johnson syndr
nonsteroidal anti- urticaria, or allergic-type toxic epiderma
inflammatory agents, reactions to aspirin or other necrolysis
COX-2 inhibitors NSAIDs, including the
aspirin triad (asthma, nasal Side Effects:
Dosage polyps, and severe
200 mg hypersensitivity reactions CNS: dizzines
to aspirin) headache,
Route Advanced renal disease insomnia.
PO Peri-operative pain from
 coronary artery bypass CV: edema.
Frequency graft (CABG) surgery
PRN for Pain GI: abdomina
pain, diarrhea,
Form dyspepsia,
Capsule flatulence, nau

Color: Derm: rash

White and yellow

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM OF INDICATION CONTRAINDICATIONS ADVERSE

ACTION EFFECTS A
SIDE EFFE
Generic Name -Decreases fever by a -Control of pain Contraindicated in: Side Effects
Paracetamol hypothalamic effect due to headache, Previous -Minimal GI
leading to sweating earache, hypersensitivity methemoglo
Brand Name and vasodilation dysmenorrhea, Products containing , hemolytic a
Biogesic -Inhibits pyrogen arthralgia, alcohol, aspartame, neutropenia,
effect on the myalgia, saccharin, sugar, or thrombocyto
Classification hypothalamic-heat- musculoskeletal should be avoided in pancytopenia
Non- narcotic analgesic, regulating centers pain, patients who have leucopenia,u
Antipyretic arthritis, immuniz hypersensitivity or CNS stimula
-Inhibits ations, teething, intolerance to these hypoglycem
CNS prostaglandin sy tonsillectomy compounds. jaundice, gli
Dosage nthesis with minimal drowsiness,
effects on -Reduce fever in
500 mg viral damage
peripheral prostaglan
din synthesis and bacterial infec Adverse Eff
Route tions -Allergic ski
P.O -Does not cause reactions & G
ulceration of the GI disturbances
Frequency tract and causes no
q4 PRN anticoagulant action
Form
Tablet

Color
Orange
Initials of patient: M.M Date of Admission:
January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM INDICATION CONTRAINDICATION EFFECTS

OF ACTION
Generic Name Binds to calcium Pain due to: Contraindicated in: Side Effects
Pregabalin channels in CNS diabetic Myopathy Dizziness
tissues which peripheral (known/suspected) Drowsiness
Brand Name regulate neuropathy, OB: Lactation. edema
Lyrica neurotransmitter postherpetic dry mouth
release. Does not neuralgia, Adverse Effect
Classification bind to opioid fibromyalgia. CNS: impaired
Therapeutic: receptors. Adjunctive attention/concentrat
analgesics, therapy of king GI: nausea, vom
anticonvulsants partial-onset diarrhea, anorexia,
Pharmacologic: seizures in abdominal pain, flat
gamma aminobutyric adults. pseudomenbranouse
acid (GABA) hepatotoxicity
analogues, nonopioid EENT: blurred visio
analgesics GI:, abdominal pain
constipation, appe
Dosage vomiting.
75 mg Hemat: platelet c
Metab: weight gain
Route Misc: allergic reacti
PO fever.

Frequency
HS

Form
capsule

Color:
red
Initials of patient: M.M Date of Admission:
January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M

DRUG MECHANISM OF INDICATION CONTRAINDICATION EFFECT

ACTION
Generic Name: Binds to mu-opioid - Contraindicated with Adverse Effec
Tramadol hydrochloride receptors and -Relief of moderate allergy to tramadol or CNS: seizures
inhibits the reuptake to moderately opioids or acute CV: sy
BrandName: of norepinephrine severe pain intoxication with alcohol, orthostatic
and serotonin; opioids, or psychoactive hypotension
 causes many effects -Relief of moderate drugs. Others:
Classification: similar to the to severe chronic Potential for
Analgesic opioids----dizziness, pains in adults who anaphylactoid
Opioid analgesic somnolence, nausea, need around-the-
constipationbut clock treatment for Side Effects:
Dosage: does not have the extended periods CNS:
50 mg respiratory (ER tablets) Sedation, dizzi
depressant effects. vertigo, he
Route: confusion,drea
Tab sweating, a
seizures.
Frequency:
Q12 CV:
Hypotension,
Form: tachycardia,
oral bradycardia,
vasodilation,
Color:
white GI:
Nausea, vo
dry
constipation,
flatulence.

Dermatologic
Sweating, p
rash, pallor, ur
Initials of patient: M.M Date of Admission:
January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M
DRUG MECHANISM INDICATION CONTRAINDICATIONS EFFECTS
OF ACTION
Generic Name An Use the In case of overdose Adverse Effect
Multivitamins amalgamation of Multivitamin as of the medication, Constipation
a variety of directed by the take professional and Diarrhea,
Brand Name vitamins and physician or follow help immediately.
minerals that are the instruction on Vomiting,
Classification regularly found the label. Avoid Over dose of
in our daily food taking more than Vitamin, A, D,E Serious
Dosage and other normal the prescribed and K can cause stomach pain
500mg sources. dosage of serious and life and abdominal
Multivitamin are multivitamin threatening cramp,
Route prescribed for tablets. Dont use problems.
oral treating the medication for Abnormal hair
deficiency of more than the loss,
Frequency vitamins caused recommended time
OD by illness like period. Unless Unusual
pregnancy, prescribed, avoid headache,
Form unhealthy using more than
tablet nutrition, one multivitamin Extreme
unsteady product at the same muscle and
Color: digestion and time. Taking more back pain
other similar than one Excessive
conditions. multivitamin bleeding,
product can result
in vitamin overdose Problem in
which can be life urination
threatening. (blood traces),
It contains minerals Dry mouth,
like potassium,
Zinc, iron, calcium Skin
and magnesium. An problems,
over dose of the
multivitamin can Yellowish and
cause serious side pale skin
effects like
urination problem,
uneven heartbeats,
 anxiety, confusion,
weakness, tiredness
and stomach
bleeding.

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M
DRUG MECHANISM INDICATION CONTRAINDICATIONS EFFECTS
OF ACTION
Generic Name Bacteriostatic in Treatment of Contraindicated Adverse Effect
Nitrofurantoin low UTIs, including with allergy to CNS:
concentrations, acute cystitis, nitrofurantoin, peripheral
Brand Name possibly by caused by renal impairment, neuropathy,
interfering with susceptible pregnancy, headache,
Classification bacterial strains of lactation dizziness,
Antibacterial, carbohydrate Escherichia Use cautiously in nystagmus,
Urinary tract anti- metabolism; coli, patients with G6PD drowsiness,
infective bactericidal in Staphylococcus deficiency, anemia vertigo
high aureus, and diabetes
Dosage concentrations, Klebsiella Dermatologic:
100mg possibly by Enterobacter, exfoliative
disrupting Proteus dermatitis
Route bacterial cell wall Prophylaxis or Stevens-
oral formation, long term Johnson
 causing cell suppression of syndrome,
Frequency death. UTIs alopecia,
QID pruritus,
urticarial,
Form angioderma
capsule
GI: nausea,
Color: abdominal
cramps,
vomiting,
diarrhea,
anorexia,
parotitis,
pancreatitis,
hepatotoxicity

Hematologic:
hematologic
anemia in
G6PD
deficiency,
granulocytope
nia,agranulocy
tosis,
leukopenia,
thrombocytop
enia,
eosinophilia,
megaloblastic
anemia

Respiratory:
pulmonary
hypersensitivit
y

Others:
superinfection
of the GU
tract;
hypotension;
muscular
aches; brown
rush- urine

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M
DRUG MECHANISM INDICATION CONTRAINDICATIONS EFFECTS
 OF ACTION
Generic Name It relieves nasal To control Hypersensitivity to Adverse Effect
Albuterol congestion and and prevent adrenergic amines Nervousness
reversible reversible Hypersensitivity to Restlessness
Brand Name bronchospasm by airway fluorocarbons Tremor
relaxing the obstruction Headache
Classification smooth muscles caused by Insomnia
Bronchodilator of the asthma or Chest pain
(therapeutic); bronchioles. The chronic Palpitations
adrenergics relief from nasal obstructive Angina
congestion and pulmonary Arrhythmias
Dosage bronchospasm is disorder Hypertension
700mg made possible by (COPD) Nausea and
the following Quick relie vomiting
Route mechanism that f Hyperglycemi
inhalation takes place when for broncho a
Salbutamol is spasm Hypokalemia
Frequency administered. For the
q8 prevention
First, it of exercise-
Form binds to the induced
liquid beta2- bronchospa
adrenergic sm
Color: receptors in Long-term
the airway control
of the agent for
smooth patients
muscle with
which then chronic or
leads to the persistent
activation of bronchospa
the adenyl sm
cyclase and
increased
levels of
cyclic- 35-
adenosine
monophosph
ate (cAMP).
When cAMP
increases,
kinases are
activated.
Kinases
inhibit the
phosphorylat
ion of
myosin and
decrease
intracellular
calcium.
Decreased in
 intracellular
calcium will
result to the
relaxation of
the smooth
muscle
airways.

Initials of patient: M.M Date of Admission:

January 17, 2013
Age: 21 Diagnosis: ASCI C5 TO
UFD C5 2 TO FALL IN SPINAL SHOCK
Sex: M
DRUG MECHANISM INDICATION CONTRAINDICATIONS EFFECTS
OF ACTION
Generic Name Stimulates Hypersensitivity Adverse Effect
Bisacodyl peristalsis and Evacuation of the Abdominal pain GI:
alters fluid and bowel before Obstruction abdominal
Brand Name electrolyte radiologic studies Nausea or vomiting cramps,
transport, or surgery. (especially with nausea,
Classification producing fluid Part of a bowel fever or other signs diarrhea,
laxatives accumulation in regimen in spinal of an acute rectal burning.
the colon. cord injury abdomen).
Dosage patients. F and E:
1 tab Use Cautiously in: hypokalemia
(with chronic
Route Severe use).
oral cardiovascular
disease MS: muscle
Frequency Anal or rectal weakness
fissures (with chronic
Form Excess or use).
tablet prolonged use (may
result in
Color: dependence) Misc: protein-
Products losing
containing tannic enteropathy,
acid (Clysodrast) tetany (with
should not be used chronic use).
as multiple enemas
(increased risk of
hepatotoxicity)
May be used
during pregnancy
and lactation.
 LIST OF NURSNG PROBLEMS

List of Actual Nursing Nursing Diagnosis Date Identified Date Resolved

Problems

Constipation Altered elimination pattern February 9, 2015 Unresolved

Paralysis Activity Intolerance February 9, 2015 Unresolved

Edema Ineffective Peripheral Tissue February 9, 2015 Unresolved

Pressure Ulcer Impaired Skin Integrity February 9, 2015 Unresolved

Potential Problem

Altered mobility Risk for Injury February 9, 2015 Unresolved

NURSING CARE PLAN

Patients Initials: M. M. Diagnosis: Acute Spinal Cord Injury Sensory Level C5

secondary to UFD C5 secondary to fall spinal shock
Age & Gender: 21 y/o; Male

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RA

DIAGNOSIS

Subjective Data: Constipation Sudden After 1 day of nursing Independent: Reasses

related to impingement on intervention with the conditio
Naranasan ko immobility and the spinal cord help of medical Reassessed clients baseline
mga 11 days effects of due to due to cliff management, patients condition. effectiv
akong hindi injury at the 5th diving altered elimination interven
nakadumi. As cervical spine pattern will be
verbalized by the secondary to cliff improved as evidenced Encouraged client to Fiber cr
client diving by absence of increase intake of which i
5th cervical food with bowel consiste
 spine injury abdominal tenderness stimulating facilitat
and distension, change properties. through
Objective Data: from hard formed stool
to soft stool and Encouraged Increase
Immobility Impaired sufficient fluid intake keeps st
verbalization of
physical at least 2 to 3 liters specific
Abdominal Medyo lumambt na
mobility daily. intestine
tenderness ang dumi ko.
absorpti
Distended
abdomen Decreased Advised client for To stim
peristaltic activity and exercise contract
Hard formed stool movement within limits of peristals
clients ability. intestine
Decreased fiber
intake Dependent Reduce
Constipation of the o
Tramadol q12 Gave Bisacodyl 1 interfac
suppository as per resultin
Bisacodyl HS doctors order incorpo
and fat
stool so

Performed digital Mechan

stimulation should b
patients
who hav
motor fu
sensatio
injuries
segmen
cord, su
quadrip
parapleg
brain-in
Patients Initials: M. M. Diagnosis: Acute Spinal Cord Injury Sensory Level C5
secondary to UFD C5 secondary to fall spinal shock
Age & Gender: 21 y/o; Male

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIO

DIAGNOSIS

Subjective Data: Activity Sudden After 1 day of Independent: Reasse

Intolerance impingement on the nursing patient
Hindi ko na related to spinal cord due to intervention, the Reassessed clients conditi
naigagalaw tong paraplegia due cliff diving client will be able condition. as base
dalawa kong paa. to spinal cord to improve muscle for furt
As verbalized by injury secondary strength from poor effectiv
the client to cliff diving ROM to average interve
5th cervical spine
weakness, and
injury Helped perform To rega
participate with
daily activities and passive ROM of the strengt
Objective Data:
verbalization of lower extremities
Injury on 5th Alteration of the
cervical spine nerve impulse in the Naigagalaw ko na Encouraged clients To enh
deltoid muscle of kahit paunti-onti participation in self- concep
Paralysis on both shoulder, triceps and ang mga paa ko. care. of inde
wrist and legs extensor muscles of Dependent: Electric
the forearm and stimula
Asymmetric arm
flexor muscles of Performed electrical impuls
length
forearm and some shock on both upper
(L:10in; R:9.5in) muscles of hand extremities twice a
week by a Physical
Decreased muscle Therapist
strength: 2Passive
Paralysis and
ROM (gravity Assisted in To enh
atrophy of the
removed and performing range of muscle
deltoid muscle, wrist
assisted by motion and exercise and to
drop and inability to
examiner) of both extremities. muscle
pick up small
Poor range of objects
motion of the
upper and lower
extremities Activity Intolerance

Constipation

Functional Level
Classification: 4
(dependent; does
not participate in
activity)

Requires complete
assistance in
activities of daily
living

Patients Initials: M. M. Diagnosis: Acute Spinal Cord Injury Sensory Level C5

secondary to UFD C5 secondary to fall spinal shock
Age & Gender: 21 y/o; Male

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RAT

DIAGNOSIS

Subjective Data: Ineffective Sudden After 1day of nursing Independent: Reasse

Peripheral Tissue impingement on intervention with the patient
Mula dito sa Perfusion related the spinal cord help of medical Reassessed clients conditi
may dibdib to immobility due to cliff management, patients condition. as base
pababa wala ng due to spinal diving peripheral tissue for furt
pakiramdam. As cord injury perfusion will be effectiv
verbalized by the secondary to cliff improved as evidenced interve
client
 diving 5th cervical by non-edematous legs Assessed presence, this is u
spine injury from non-pitting location, and degree identify
Objective Data: edema, moisten skin of swelling or edema quantif
from dry and scaly skin formation. edema
Injury on 5th
and temperature of extrem
cervical spine Numbness from
hands is same with the
chest to lower Performed turning To prom
Pallor rest of the body parts.
extremities every 2 hours. circula
Paralysis on both
wrist and legs
Impaired
Chest has very physical Encouraged patient to Dehydr
minimal sensation mobility increased fluid intake reduces
unless volume
Non pitting edema contraindicated compro
on both legs periphe
Decreased circula
Dry and scaly skin peripheral tissue
on both lower perfusion Assisted in Perform
extremities performing passive of moti
range of motion and promot
Cold clammy
exercise of both circula
hands
lower extremities.
Capillary refill: 4
seconds Dependent: To max
system
Administered circula
intravenous fluid as organ p
per doctors order
Patients Initials: M. M. Diagnosis: Acute Spinal Cord Injury Sensory Level C5
secondary to UFD C5 secondary to fall spinal shock
Age & Gender: 21 y/o; Male

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION

DIAGNOSIS
Subjective Data: Impaired skin Sudden After 3 hours of Independent: Re
Matagal nang integrity related to impingement on nursing intervention Reassessed clients con
ganito ang balat immobility due to the spinal cord with the help of condition. bas
ko. Ung napunta spinal cord injury due to cliff diving pharmacologic fur
ako dito As secondary to cliff management, nur
verbalized by the diving 5th cervical spine patients impaired Performed turning To
client injury skin integrity will every 2 hours. circ
not worsen as
Objective Data: Impaired physical evidenced by
Paralysis on mobility moisten skin from
both wrist and dry and scaly skin,
legs Decreased capillary refill of <3, Keep bedclothes dry Re
Scaliness of peripheral tissue and the skin is cold and free of wrinkles, irri
the skin with perfusion to touch. crumbs
scars at the
upper and Dry Skn,
lower
extremities. Bed Sores Wash and dry skin, Cle
Lesion and especially in high pro
redness at the Impaired Skin moisture areas suchas exc
upper and Integrity perineum. Take care n
lower to avoid wetting lining
extremities. of brace/halo vest.
Skin is cold to Encouraged patient to Pro
touch increased fluid intake circ
Delayed at least 2000 to 3000
capillary refill mL per day.
more than 4
seconds Noted clients Pro
nutritional and fluid ma
status. we
isc
pro
Dependent: To
Assisted in stre
performing range of mu
motion and exercise
of both extremities.
Patients Initials: M. M. Diagnosis: Acute Spinal Cord Injury Sensory Level C5
secondary to UFD C5 secondary to fall spinal shock
Age & Gender: 21 y/o; Male

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION

DIAGNOSIS
Subjective Data: Risk for Upper Sudden After hours of Independent: Fa
Nakahiga lang Respiratory Tract impingement on nursing Assess patients ass
ako palagi. As Infection or the spinal cord intervention with safety thoroughly. or
verbalized by the inflammation of due to cliff the help of can
client lung parenchyma diving pharmacologic at
related to management, cre
Objective Data: confinement to 5th cervical spine patient will be able iss
Confined to bed due to injury to practice several pra
bed immobilization preventive Note clients age, Af
Numbness f Impaired meeasures as gender, abi
trunk and physical evidenced by developmental and
paraplegia mobility demonstration of stage, level of inf
Paralysis on methods. competence. int
both wrist and Confinement to tea
legs bed

Risk for
inflammation of Frequent changing To
lung of position acc
parenchyma flu
reg

Encourage regular To
deep breathing and exp
coughing exercises

Instruct about To
respiratory therapy exp
such as using of
incentive spirometry