Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right

Sided I. INTRODUCTION Spondylolisthesis is a condition in which one of the bones of the spine (vertebrae) slips out of place onto the vertebra below it. If it slips too much, the bone might press on a nerve, causing pain. Usually, the bones of the lower back are affected. The word spondylolisthesis comes from the Greek words spondylos, which means "spine" or "vertebra," and listhesis, which means "to slip or slide." Spondylolisthesis is the most common cause of back pain in teens. Symptoms of spondylolisthesis often begin during the teen-age growth spurt. Degenerative spondylolisthesis occurs most often after age 40. Types of spondylolisthesis There are different types of spondylolisthesis. The more common types include.

Congenital

spondylolisthesis

Congenital

means

"present

at

birth."

Congenital spondylolisthesis is the result of abnormal bone formation. In this case, the abnormal arrangement of the vertebrae puts them at greater risk for slipping.

Isthmic spondylolisthesis this type occurs as the result of spondylolysis, a condition that leads to small stress fractures (breaks) in the vertebrae. In some cases, the fractures weaken the bone so much that it slips out of place.

Degenerative spondylolisthesis this is the most common form of the disorder. With aging, the discs the cushions between the vertebral bones lose water, becoming less spongy and less able to resist movement by the vertebrae.

Less common forms of spondylolisthesis include:

Traumatic spondylolisthesis, in which an injury leads to a spinal fracture or slippage Pathological spondylolisthesis, which results when the spine is weakened by disease such as osteoporosis an infection, or tumor Post-surgical spondylolisthesis, which refers to slippage that occurs or becomes worse after spinal surgery A radiologist determines the degree of slippage upon reviewing spinal X-rays.

Slippage is graded I through IV: Grade I 1 percent to 25 percent slip Grade II 26 percent to 50 percent slip Grade III 51 percent to 75 percent slip
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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Grade IV 76 percent to 100 percent slip Generally, Grade I and Grade II slips do not require surgical treatment and are treated medically. Grade III and Grade IV slips might require surgery if persistent, painful, slips are present. http://my.clevelandclinic.org/disorders/back_pain/hic_spondylolisthesis.aspx This condition might lead to spinal stenosis causes narrowing of the spine. The narrowing can occur at the center of the spine, in the canals branching off the spine and/or between the vertebrae, the bones of the spine. The narrowing puts pressure on your nerves and spinal cord and can cause pain. Spinal stenosis occurs mostly in people older than 50. Younger people with a spine injury or a narrow spinal canal are also at risk. Diseases such as arthritis and scoliosis can cause spinal stenosis, too. (http://www.nlm.nih.gov/medlineplus/spinalstenosis.html) Spinal stenosis occurs when the space around the spinal cord narrows. This puts pressure on the spinal cord and the spinal nerve roots, and may cause pain, numbness, or weakness in the legs. As we age, the bone in our spines may harden and become overgrown. This can lead to a narrowing of the spinal canal, called stenosis. When stenosis occurs in the lower back, it is called lumbar spinal stenosis. It often results from the normal aging process. As people age, the soft tissues and bones in the spine may harden or become overgrown. These degenerative changes may narrow the space around the spinal cord and result in spinal stenosis. Degenerative changes of the spine are seen in up to 95% of people by the age of 50. Spinal stenosis most often occurs in adults over 60 years old. Pressure on the spinal cord is equally common in men and women, although women are more likely to have symptoms that require treatment. A small number of people are born with back problems that develop into lumbar spinal stenosis. This is known as congenital spinal

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided

stenosis. It occurs most often in men. People usually first notice symptoms between the ages of 30 and 50. (http://orthoinfo.aaos.org/topic.cfm?topic=a00329) On the other hand, hypertrophy of the ligaments in the vertebral canal of the spinal column can increase their mass enough that they narrow the canal (stenosis) sometimes to the point that the spinal cord and/or nerve roots running through the canal are compressed further worsening then the spinal stenosis which may cause the condition called Radiculopathy. It is usually a result of nerve root compression, which occurs when something puts pressure on the nerve root. Most of the time the pressure comes from a herniated disc. Above conditions will then result to myelopathy which is described as the gradual loss of nerve function caused by disorders of the spine. Myelopathy can be directly caused by spinal injury resulting in either reduced sensation or paralysis. Degenerative disease may also cause this condition, with varied degrees of loss in sensation and movement. (http://backandneck.about.com/od/conditions/f/radiculopathy.htm; http://www.wisegeek.com/what-is-myelopathy.htm) Spinal stenosis complications vary, depending on which nerves are compressed. One of the most common is incontinence, you may lose the ability to control your bowels or bladder or it can even reach Cauda equina syndrome is a rare but serious complication, in which the bundle of nerve roots at the lower end of the spinal cord is compressed. This can cause numbness and paralysis, and emergency surgery may be necessary to relieve the pressure. (http://www.mayoclinic.com/health/spinalstenosis/DS00515/DSECTION=complications)

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided II. SCOPE AND LIMITATIONS OF THE STUDY This case study tackles about Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided and the operation performed to improve the condition specifically on the case of the patient. It includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of the above said diagnosis with its associated factors. The Medical and Nursing Management along with the discharge plans and other relevant data are also being covered. The scope of the plan encompasses during the course of duty and date of operation last August ____, 2011 with the assigned students who have assessed the client with cumulative interaction postoperatively and established good rapport to the patient and significant other. Nursing Management covers the above mentioned dates which encompasses the clients Recovery Phase. Data gathering about the Laboratory results covers from August __ 2011 to August __ 2011 and other previous laboratory results, the date and time of operation is also included and how it was performed. The areas of concerns are limited to the discussions of Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided and the quality of nursing care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records. OBJECTIVES OF THE STUDY The study aims to explore the concepts about the condition and the quality of nursing care being rendered to our client. Primarily, the primordial reason why we have chosen this as our case study because it is our first time to encounter such health condition and we want to further brush up our knowledge conditions associated with the indispensable anatomical structure of our body. Secondly, in order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically, the main goal of this study in relation to knowledge is to identify the nursing interventions after the patient undergone an operation.

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate patients condition. The presentors also intend to compare and contrast the ideal management for Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study. SIGNIFICANCE OF THE STUDY The study is significant to the following people: the client, the clients family, and nursing students. The study is significant to the client, because it enlightens the clients queries and doubts regarding his condition. Allowing him to understand the situation of his present state, this would allow him to be more aware of the importance of following the treatment regimen. Clients family must also be aware of the condition of the client. With the study, the clients family will be able to participate in the clients continuous treatment, and they will be able to realize the importance of the support system in participating in the clients care. The study is also important to the nursing students, since it allows them to explore the clients condition, giving them firsthand experience in observing the manifestations of the disease condition and allowing them to apply theoretical knowledge regarding nursing managements for the manifested signs and symptoms.

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided III. CLIENTS PROFILE A. Socio-demographic Date Patient AL is a 64-year old male, Roman Catholic, married to his 60-year old wife and is currently residing at #270 Demetrio Velez St. Pinikitan, Cagayan de Oro City, was admitted last August 17, 2011 due to tingling sensation felt at gluteal area and numbness to the right leg since the year 2008 and lower extremity weakness. B. Vital Signs Upon assessment, the patients vital signs were: BP: 120/80 mmHg, Temperature: 36.9 degree Celsius, PR: 76 beats per minute, and RR: 20 cycles per minute and 22 cycles per minute upon exertion. The patient weighs 73.6 kilograms and is 170 centimeters tall. C. Health Pattern Assessment Aside from the current condition, patient has also persistent problem in voiding. Generally, he looks normal, neat, conscious and coherent but irritable, mildly anxious and unable to ambulate and change positions without careful assistance from the healthcare provider or significant other. Patient used to smoke 10 sticks per day but had stopped since the year 1996 as well as alcohol consumption of 1-2 cups thrice a week. Hes taking a cupful of coffee every morning. No allergies were reported. 1. Past Medical History Client AL has never been hospitalized until the date of admission (August 17, 2011) but only seeks and visits the doctor for follow-up check up. He was diagnosed at this institution-CUMC to have Spinal Stenosis L4, L5 secondary to spondylolisthesis L4, L5 Grade II with hypertrophized ligamentum and radiculopathy with myelopathy right sided. He has family history of hypertension but doesnt have any home medication to control elevated blood pressure. He was also diagnosed to have Benign Prostatic Hyperplasia (BPH) and was given (Xatral) alfuzosin 10 mg, 1 tab @ Hours of sleep, 8pm and (Uriflow) Bethanicol, 1 tab TID at the specific time of 8 am, 1 pm, and 6 pm. 2. History of Present Illness

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Fifteen years ago patient had sudden onset of tingling sensation on his right gluteal area; CT-Scan was made, result showed: spine Disc herniation, L4-L5 Mild spondylolisthesis, L4-L5 Compression deformity of L1 due to degenerative Hypertrophic degenerative osteoarthropathy, lumbar

changes Five years ago before the admission, patient noticed urine voiding changes consulted a urologist, diagnosed to have BPH recalled meds given, 4 years ago, there is persistence of voiding problem, 3 weeks ago patient had MRI result herniated slip disc L4-L5, L1-2 x L5-S1. 3. Physical Assessment Before operation, patient AL was hooked with an IVF infusion of D5NM 1L @ 10 gtts/min and D5LR @ 20 gtts/min on NPO. After operation, patient AL was hooked with an IV infusion pump of PLR 1L regulated @ 30 gtts/min. and PNSS 1L regulated @ 30 gtts/min side drip infusing well at the right arm. It was terminated before the duty on August 25, 2011. HEENT: Head, hair and scalp Eyes: sclera, pupils Normocephalic with fine dry hair and clean scalp. Sclerae are anicteric, pupils are equal in size and reaction to light. Periorbital region is not sunken or edematous. Cornea and lens are not opaque Ears and tympanic membrane Nose and conjunctiva is pink. Equal in size with no discharges and has equal auditory function. Intact tympanic membrane. No nasal flaring noted. Septum is medial. Mucosa is pink in color. Gross smell is normal and symmetrical. Mouth, lips, tongue, teeth and Lips and oral mucosa are pale. No lesions noted oral mucosa Throat and neck Facial movements in the mouth. Tongue is midline. With dentures. Gums are pallor. Trachea and uvula are midline. Thyroids are non palpable. Tonsils are not inflamed. Symmetrical.

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided 4. Cognitive/ Neurological Assessment Conscious, coherent and responsive Oriented to time, place and person Irritable, and mildly anxious but can answer short simple questions answerable by yes or no Visayan AB Graduate

Level of consciousness Orientation Emotional state Primary language Educational attainment

5.

Nutritional and Metabolic Pattern At home, Client AL usually eats three times a day with red meat

which sometimes combined with vegetables and rice with good appetite. He drinks water and other fluids at most 6 glasses a day. He takes Fern-C and Centrum as his supplement. Upon hospital stay, he was on soft diet, with fair appetite and still drinks fluid at most 6 glasses a day. ACTIVITIES OF DAILY LIVING Feeding Bathing DRESSING Grooming Meal preparation Cleaning Laundry Toileting Bed mobility Chair/toilet transfer Ambulation R.O.M 2 Assist with person 3 Assist with device and person 2 Assist with person 2 Assist with person 4 - Total dependence 4 - Total dependence 4 - Total dependence 3 Assist with device and person 3 - Assist with device and person 3 - Assist with device and person 3 - Assist with device and person 2 Assist with persons

6.

Elimination Pattern

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Patient ALs defecation is usually not consistent; he used to defecate once a day and sometimes defecates every other day. His stool appears soft in consistency, greenish to brown in color and in minimal amount with no discomforts upon defecating. He urinates at about 5-6 times a day with amber to yellow colored urine in minimal amount. He has an enlarged prostate and had difficulty urinating. Abdominal configuration Bowel sounds Symmetrical, no superficial veins, with no lesions and scars Hypoactive upon auscultation, 4 bowel sounds per minute Percussion Tympanic and dullness noted on right upper quadrant

7.

Activity-Exercise Pattern He used to jog and walk around twice a week. His leisure activities

include watching TV, sleeping, bonding with his family and reading news paper. CARDIOVASCULAR STATUS Chest pain, radiation No chest pain or radiation Point of maximal impulse, 5th intercostal space, midclavicular line Precordial area Heart sounds Peripheral pulses Capillary refill time RESPIRATORY STATUS Breathing pattern Lung expansion Vocal/tactile fremitus Percussion Breath sounds Cough Regular Symmetrical Symmetrical Resonant Vesicular None Flat Distinct and regular, no murmurs noted Regular and symmetrical 2 seconds, no clubbing noted

8.

Sleep and Rest Pattern Client AL usually sleeps about 6-8hours a day with naps during day

time, he sleeps early at night and wakes up early morning. He said this number of hours is adequate enough for his activities the following day.
9

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided He does not have any history of sleep disturbances, by just merely closing his eyes for a moment can make him easily fall asleep, he prays and meditates before sleeping to promote a good and sound sleep. 9. Role and Relationship Pattern Client AL is married to his 60- year old healthy wife and a father to four healthy children- two females and two male ages 30, 29, 23, and 20 years old. He lives with his family. He has a sound and good relationship to his family; he is very close to them. 10. Value and Belief Pattern Client X is a Roman Catholic; He usually goes to church every Sunday together with his family. He said that he needs God the most especially that hes hospitalized. He gets his strength in facing his condition from his faith that gives him hope. He believes his hospitalization will not interfere with his religious rites but he finds ways to communicate with God through prayers as an alternative, he knows that he can go to church when he will get well because he believes that God will answer his prayer. He considers his family as his support group and thinks they can help him the most.

10

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided

REVIEW OF SYSTEMS (ANTERIOR)

Irritable and mildly anxious

Pale oral mucosa, gums and lips

Hypoactive, 4 bowel sounds per minute

Prostate Enlargement Lower extremity weakness Difficulty in urination 3/5

Uncoordinat ed gait 11

Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided POSTERIOR

Pain scale: 8/10 L4,L5

Tingling sensation (right gluteal area)

Right leg numbness

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided IV. ANATOMY AND PHYSIOLOGY

The spinal cord begins below the medulla and ends just above the small of the back at the conus medularis. The area within the vertebral column beyond the end of the spinal cord is called the cauda equina. Meninges

Dorsal (sensory) and ventral (motor) horn cells

The spinal cord is protected by the vertebrae and the meninges. The dura mater, arachnoid mater and pia mater of the spinal cord are continuous with those of the brain.

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Cerebrospinal fluid is in the subarachnoid space that lies between the arachnoid and pia mater and in the central canal, a space in the middle of the gray matter of the cord. It provides a hydraulic cushion for the spinal cord. When the cord is viewed in a cross-section, its gray matter is "H" shaped or, as described by Bhatnagar, 2002, butterfly shaped. It has two ventral and two dorsal horns. The white matter surrounding the cell bodies of the cord is made up of ascending and descending fibers. Motor tracts are found on the ventral and lateral aspects of the cord while sensory tracts run along its dorsal area. Neuronal types

Motor neurons These lower motor neurons are located on the ventral aspect of the cord. They are either alpha or gamma cells. Alpha cells are the principle lower motor neurons of the spinal cord and form the main portion of the final common pathway. They conduct rapid motor impulses, with each alpha cell innervating approximately 200 muscle fibers. Gamma neurons are also part of the final common pathway according to some sources but they are only half as numerous as alpha cells. Gamma cells conduct slow motor impulses. Their major function is to stretch muscle spindles. Association neurons Interneurons connect the anterior and posterior horns of the gray matter and are involved in the reflex arc. They work within the same segment of the spinal cord, with a

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided segment being defined as the horizontal section of the cord that gives rise to one pair of spinal nerves.

Internuncial Neurons travel between segments, sending projections up to the brain stem and cerebellum. They project in an ascending, not descending manner. These association neurons are found throughout the central nervous system. They are much more numerous than motor neurons; the ratio between the two types of cells is 30:1. The main function of the association neurons in the spinal cord is that of inhibitory control. They also interconnect other cells with one another. Some sources, including Bhatnager and Andy, (1995), do not distinguish between interneurons and internuncial neurons. Even if these two types of association neurons are grouped together, they should definitely be distinguished from the spinal nerves which are lower motor neurons, forming a final common pathway for information descending from the brain. The Spinal Nerves There are thirty-one pairs of spinal nerves. These nerves are mixed, having both a sensory and a motor aspect. Their motor fibers begin on the ventral part of the spinal cord at the anterior horns of the gray matter. The roots of their sensory fibers are located on the dorsal side of the spinal cord in the posterior root ganglia. When the motor and sensory fibers exit the spinal column through the intervertebral foramina and pass through the meninges, they join together to form the spinal nerves. Spinal nerves receive only contralateral innervation from first order neurons: Eight pairs of spinal nerves are located in the uppermost, cervical region of the cord Twelve pairs are found in the thoracic region. Five pairs are in the lumbar area. Five pairs are in the sacral area. One pair is found in the most inferior, coccygeal region.

These second order lower motor neurons, the spinal nerves, form part of the final common pathway for information traveling from the central nervous system to the INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided periphery. The spinal nerves provide innervation to body areas below the neck while cranial nerves (also second order neurons) carry impulses only to the head and neck, except for the vagus. (You will understand shortly that cranial nerves can be sensory, motor or both). Reflex arc Also, the sensory and motor fibers of the spinal nerves form a reflex arc. This type of reflexive behavior occurs when a message from afferent fibers causes a motor reaction before going to the brain. For example, if you touch a hot burner on the stove, sensory information about the temperature of the burner travels along spinal nerves to your spinal cord and are carried directly to their motor nuclei by interneurons; the motor command goes out along the axons of the lower motor neuron causing you to move your hand away from the stove. As messages do not have to travel up to the brain to be processed, reactions mediated by this reflex arc can occur very rapidly. Of course you will feel pain shortly thereafter (milliseconds) as the information gets to the parietal lobe via the thalamus The Autonomic (self regulating) Nervous System The autonomic nervous system is involved in the control of the heart, glands and smooth muscles of the body and plays a major role in regulating unconscious, vegetative functions. It works together with the endocrine system to control the secretion of hormones and is itself controlled by the hypothalamus. Because motor fibers make up the bulk of the autonomic system, some anatomists consider it to be purely motoric although it does include some afferent axons that carry information from the viscera. Although the autonomic nervous system is considered to be one of the three main divisions of the human nervous system in its own right, parts of both the central nervous systems and the peripheral nervous systems play a role in its functions. The autonomic nervous system has two components,

the sympathetic system and the parasympathetic system. These two aspects have antagonistic functions. Sympathetic System The sympathetic system prepares the body for fight or flight reactions. Action of this system results in accelerated heart rate, increased blood pressure and blood flow INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided

away from the periphery and digestive system toward the brain, heart and skeletal muscles. It also causes adrenaline to be released, temporarily increasing physical strength. Parasympathetic System The parasympathetic system brings the body back to a state of equilibrium. It slows heart rate and decreases the release of hormones into the blood stream. The activity of the parasympathetic system causes more localized reactions than does the sympathetic system as much of its output is to specific organs. The autonomic nervous system consists of four chains of nuclei or ganglia, two of which are located on either side of the spinal cord. The outer chains of nuclei form the parasympatheticdivision of the system while those closest to the spinal cord make up its sympathetic element. Rami communicantes The rami of the autonomic nervous system are the axons of pre-ganglionic and ganglionic fibers. Most of the axons of pre-ganglionic fibers are myelinated. Their cell bodies are found in the gray matter of the brain stem and spinal cord. Their axons synapse with neurons within the two ganglionic chains. Pre-ganglionic cells of the autonomic nervous system are neurons located in some of the cranial nerves of the brain stem and in some of the spinal nerves that project to the ganglionic chains of the autonomic nervous system. The autonomic nervous system is closely connected with the central and peripheral nervous systems. Ganglionic cells originate within the ganglia. They project to post-ganglionic neurons. Post-ganglionic cells are neurons that are located in the target organs and muscles of the autonomic nervous system. It can be said that the motor pathways of the autonomic nervous system are made up of its pre-ganglionic and ganglionic cells. The fibers of the ganglionic chain of the parasympathetic system are not as welldefined as those of the sympathetic chain. All pre-ganglionic neurons of the sympathetic

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided

system synapse with the sympathetic chain. This is not true of the parasympathetic preganglionic cells, however. Some of them synapse with the chain, but others go directly to end organs or muscles.

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided V. PATHOPHYSIOLOGY Predisposing Factors: Age: 64 years old Gender: Male Precipitating Factors: Frequent rotational forces LEGEND: Predisposing Factors Precipitating Factors Disease Process Treatment (either through medication or surgery) Decrease androgen secretion and other male hormones Diagnostic Examination dessication between the cushion of vertebral bones Surgery effects Signs and symptoms Decrease the spongy feature of the vertebral bones Administration of alfuzocin (Xatral) 10 mg P.O@ HS Male catheterization done Administration of bethanecol (Uriflow) 1 tab PO T.I.D

Increase the number of cells as well as to its size

Compression of male urethral meatus

Less resistance to vertebral locomotion

Partial resistance of pars interarticularis

Inability to urinate adequate amount of urine

Degeneration of L4 and L5 spinal discs

Formation of fibrous nonunion

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Microfractures of the involved vertebral bones

Annulus fibrosis degeneration occurs

Radial tears take place

XRAY (08/17 and 24/11) show Mild to moderate osteodegenerativ e changes) and Disk Disease

Elongation of pars

Progressive shearing of articular facets Intersegmental instability XRAY (08/ 24/11) shows Grade 1 Spondylolithesis Facets incompetence will occur

posteriorly migrated nucleus pulposus ligaments hypertrophy

Inevitable spinal subluxation Herniates other important spinal components

Slippage of lumbar vertebrae ( L4 and L5)

Back pain of 8/10

(+) Stork Test

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Walker provided Uncoordinated gait Tingling sensation on the right gluteal area XRAY (08/24/11) shows Mild compression deformity

Compression of indispensable nerve roots Progressive narrowing of the spine

Hypoactive bowel dounds of 4 clicks/minutes

Laminectomy + Foraminotomy L4L5 Posterior Instrumentation Pedicular Screw Fixation L4L5 + Post-spinal Fusion

Gradual significant loss of nerve sensation Right leg numbness Pain at the incision site Administration of the following: Hydrocortisone (Solu-cortef)weakness of 12 hours Muscle 100mg every both lower Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D extremities 3/5 Referred to Physical Therapist for Rehabilitation. TENS given

Destruction of NPO temporarily (preoperatively and primary defenses postoperatively Administration of the following: 1. ranitidine (Zantac) 150 mg 1 tab PO @ HS 2. esomeprazole (Nexium) 40 mg IVTT OD

Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---PO PRN ----- TID

( INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided VI. OPERATION PERFORMED

Esophagogastroduodenoscopy (EGD) Esophagogastroduodenoscopy, or EGD for short, is a procedure used by your

doctor to gain more information about your esophagus, stomach, and small intestine. Your doctor can look at the insides of these structures by placing an endoscope (a small, bendable tube that acts like a video camera) into your throat. If any unusual growths or foreign bodies are found by your doctor, the endoscope may also be used to treat them. Preoperative: When you are ready, medication may be given through your IV to make you sleepy and relaxed. In order to make this examination more comfortable, your healthcare provider may spray a numbing medication into the back of your throat, or you may gargle with it. This may taste slightly bitter and will make your mouth and throat numb for approximately 30 minutes. Then you will be positioned on your left side. Intraoperative: The use of a long, soft, bendable tube endoscope is utilized. This instrument acts as a camera and allows your doctor to view the inside of your digestive system on a video screen. It can also take pictures and videotape the procedure. A small plastic mouthpiece or guard will be put into your mouth to protect your teeth when the tube is slowly placed into your esophagus (or food pipe), and to keep you from accidentally biting the tube. In order to help relax the muscles in the back of your throat and help open the passageway, you will need to take slow, deep breaths. You will then be instructed to put your chin to your chest and open your mouth. As the doctor begins to push the tube in, you will be asked to swallow. Swallowing makes the tube go down more easily. You may experience some gagging or nausea during the tube placement into your esophagus -- this is normal. Once the endoscope is inside, your doctor will examine your esophagus, stomach, and the first part of the small intestine. To better see this area, these structures may be gently filled with a small quantity of air through the endoscope. While this air may cause you to feel full, it should not be painful. Your saliva may be suctioned from your mouth using a small plastic tube similar to the ones used by dentists. Depending on what is found during the endoscopy, your doctor may perform several procedures through the endoscope. A photograph, biopsy, or cytology may be taken. A biopsy involves taking a small sample of tissue, and cytology is a brushing of INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided cells. Other procedures that may be performed include stretching narrowed areas of the esophagus, stomach, or duodenum; removing polyps and swallowed objects; or treating bleeding vessels and ulcers. When the examination is finished, the doctor will slowly pull the endoscope out through your mouth. You'll be asked to clear your throat and spit out any saliva or phlegm. This procedure usually takes about 20 to 30 minutes. Postoperative: After the upper endoscopy (also known as an EDG), you will either be closely monitored in the recovery room or return to your hospital room. If this was done as an outpatient procedure, you will remain in the clinic area for about one hour. If a procedure was done that requires more observation, you may stay in the hospital overnight. During this time, you may feel slightly bloated from the air that was placed in your stomach during the examination. Your throat may also feel numb and slightly sore. You should expect this to last two to four hours. You will stay in the recovery room long enough for the drugs that make you sleepy to wear off and to be sure that you are recovering normally. Remember that your healthcare provider wants you to recover without any problems, so be sure to report anything that does not feel normal or "right."

Laminectomy + Foraminotomy L4L5 Posterior Instrumentation Pedicular Screw Fixation L4L5 + Post-spinal Fusion For an open laminectomy and foraminotomy procedure, the patient is placed under

general anesthesia. The surgeon makes an incision in the back over the area of the spine more the spinal compression is located. The surgeon uses small instruments to scrape away or remove portions of the lamina in the disc or discs causing the problem. He then shaves or cuts away small portions of the foramen, or the space where nerve roots branch off from the spinal cord in the cervical, thoracic or lumbar area to make more room for these nerves. The surgeon may need to use a surgical microscope to see this area more clearly. At this time, the surgeon will also determine the overall health and condition of the vertebra and vertebral discs adjacent to the problem area. In some cases, other procedures made at this time, such as removal of a herniated or bulging disc, called a discectomy, or spinal fusion if vertebra has slipped out of position. For a laparoscopic laminectomy or foraminotomy, a small incision is made over the affected spine area. A very small camera attached to the end of a long tube is inserted into the incision, which allows the surgeon to view the operating field on a video monitor in the surgical suite. Very small surgical instruments are inserted into one or more small INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided incisions around the affected disc area and the operation proceeds in much the same way and open laminectomy procedure is performed. However, if the surgeon feels you may have a herniated or bulging disc or any spine instability, the patient may not be considered a good candidate for this approach. Following the procedure, the surgeon will use stitches or staples to close the incision area. In most cases, you will stay in the hospital for 1 to 3 days, depending on your overall health and wellness, your physical condition and your response to the surgery. A physical therapist may be offered to help you ambulate and perform daily functions, depending on the area where the laminectomy occurred. The Spinal Fusion Operation Spinal fusion is performed under general anesthesia. During the procedure, the target vertebrae are exposed. Protective tissue layers next to the bone are removed, and small chips of bone are placed next to the vertebrae. These bone chips can either be from the patient's hip or from a bone bank. The chips increase the rate of fusion. Using bone from the patient's hip (an autograft) is more successful than banked bone (an allograft), but it increases the stresses of surgery and loss of blood. Fusion of the lumbar and thoracic vertebrae is done by approaching from the rear, with the patient lying face down. Cervical fusion is typically performed from the front, with the patient lying on his or her back. Many spinal fusion patients also receive spinal instrumentation . During the fusion operation, a set of rods, wires, or screws will be attached to the spine. This instrumentation allows the spine to be held in place while the bones fuse. The alternative is an external brace applied after the operation. An experimental treatment, called human recombinant bone morphogenetic protein2, has shown promise for its ability to accelerate fusion rates without bone chips and instrumentation. This technique is only available through clinical trials at a few medical centers. Spinal fusion surgery takes approximately four hours. The patient is intubated (tube placed in the trachea), and has an IV line and Foley (urinary) catheter in place. At the end of the operation, a drain is placed in the incision site to help withdraw fluids over the next several days. The fusion process is gradual and may not be completed for months after the operation.

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided VII. LABORATORY RESULTS Hematology Report (August 18, 2011) TEST WBC RBC Hgb Hct MCV MCH MCHC Differential Count Lymphocytes Monocytes Platelet count 30.0 2.0 200,000 18-45% 4-8% 144,000-372,000 cell/mm3 Within Normal Range Below Normal Range Within the normal range which connotes the clotting factor is good. RESULTS 7,700 4.78 14.6 44.0 95.2 31.0 33.5 REFERENCE VALUES 5,000-10,000 cell/mm3 4.7-6.1 10^6/uL 13.7-16.7 g/dL 37.0- 47.0 gm% 80.0-96.0 fL 27.0-31.0 pg 32.0-36.0% INTERPRETATION Within Normal Range Within Normal Range Within Normal Range Within Normal Range Within Normal Range Within Normal Range Within Normal Range

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Hematology Report (August 22, 2011)

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided X-ray Report (August 17, 2011) TEST Examination: Chest AP RESUL REFERENCE INTERPRETATION TS WBC 15,300 VALUES 5,000-10,000 cell/mm3 An increase in the WBC level indicates that there is an infection.

RBC Hgb

4.78 12.7

4.7-6.1 10^6/uL Within Normal Range 13.7-16.7 g/Dl Low hemoglobin levels indicate the oxygen carrying capacity of the blood is decreased. Low hemoglobin levels may also indicate anemia.

Hct MCH

38.0 23.3

37.0- 47.0 gm% Within Normal Range 27.0-31.0 pg A low MCH number might indicate the presence of anemia. The Mean Corpuscular Hemoglobin indicates the weight of hemoglobin in each cell. Below Normal Range

MCHC

24.3

32.0-36.0%

Differential Count Segme nters Lymph ocytes Monoc ytes 93.0 5.0 2.0 45-70% 18-45% 4-8% 144,000372,000 cell/mm3 Above Normal Range Below Normal Range Below Normal Range Within the normal range which connotes the clotting factor is good.

Platelet 333,000 count

No active parenchymal infiltrates. The heart is not enlarged. The aortic knob is calcified.

INTRODUCTION

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Spinal Stenosis L4, L5 secondary to Spondylolisthesis L4, L5 Grade II with Hypertrophized Ligamentum and Radiculopathy with Myelopathy Right Sided Both costophernic sulci and hemidiaphragm are intact. Degenerative changes are seen in the visualized osseous structures. Impression: Atherosclerotic Aorta Osteodegenerative changes. (August 24, 2011) Examination: Lumbo Sacral Spine APL No old film available for comparison. Spurformations are seen in the antero-lateral aspects of the lumbar spine. (Mild to moderate osteodegenerative changes) Mild anterior wedging of L1 is noted. (Mild compression deformity) L1-L2 and L5-S1 intervertebral disc spaces are narrowed with intra-disctal gas formation. (Disk Disease) L4 is slightly displaced anteriorly in relation to L5 with metallic brackets and screws at these levels as well as vertebral foraminal narrowing. (Grade 1 Spondylolithesis) No lytic or blastic lesion seen. Mild lumbar straightening noted probably secondary to muscle spasm and or fixators. Alignment is sustained. Midline surgical staples seen in site. Drainage tube in site.

INTRODUCTION

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CT SCAN OF THE LUMBAR (September 24, 1996) Findings: Multiple axial tomographic sections of the lumbar spine without contrast were obtained. Plain axial images revealed the ff: Osteophytic spurs seen along the margins of lumbar spine. Disc hernation noted at the level of L4-L5, centrally located and with some extension into the intervertebral foramina. Ligamentum flavum are hypertrophied, (L2-4) Compression changes of L1 seen as well mild spondylolisthesis of L4 over L5 by scanogram. Rest of findings are unremarkable. Impression: Hypertrophic degenerative osteoarthropathy, lumbar spine disc hernation, L4 over 5 Mild spondylolisthesis, L4 over 5 Compression deformity of L1 due to degenerative changes.

ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER (August 18,2011) Dimension LV (ed) LV (es) IVS (ed) IVS (es) LVPW (ed) LVPW (es) Aorta LA (AP diameter) MPA LVET Measurement 4.3 2.6 1.1 1.6 1.5 1.7 2.2 3.6 1.9 0.2 (3.0 3.5) (0.8 1.1) (0.8 1.1) Normal (4.5- 5.0)

EPSS LVOT RV RA MV Annalus TV Annalus LVEDV LVES SV CO EF FS VCF LV Mass

0.6 1.9 2.7 2.7 2.2 1.7 77.35 24.24 53.11 3.6 69 % 38% (55.0 77.0) (29.0 - 42.0) (0.5 - 1.5) (2.2 4.0) (3.5 4.5)

Diastolic Function Parameter Decel. Time IVRT Patient 265 71 Normal

SPECTRAL and Color Flow Doppler Valve Maximum Velocity Peak Gradient Orifice Area Regurgitation Ratio T Jet Area cm GRADIENT 42.42

Aorta Mitral Tricuspid Pulmonic RA Pressure

0.91 1.08 0.42 0.56 0.67 0.80 0.82 PAt: 134.6

3.29 4.66 0.72 2.58 1.81 2.58 2.96 PRJ:

Notes:

 Study done in normal sinus rhythm Normal left ventricular cavity with hypertrophied walls with adequate wall motion contractility and systolic function Normal left atrium, right atrium, right ventricle, main pulmonary artery and aortic root dimension. Thickened none coronary cusp and left coronary cusp of the aortic valve but without restriction of motion Thickened mitral valve leaflet but without restriction of motion Structurally normal tricuspid valve and pulmonic valve No pericardial effusion nor intracardiac thrombus noted Doppler: Mosaic color flow display noted across the aortic valve during diastole Reverse mitral valve E/A velocity ratio at prolonged deceleration time Normal pulmonary atrial pressure Conclusion: Concentric left ventricular hypertrophy with adequate contractility and systolic function but with Doppler evidence of impaired left ventricular relaxation Aortic sclerosis with aortic regurgitation +/ Mitral sclerosis Normal pulmonary arterial pressure Urinalysis (August 17, 2011) Test Color Reaction Transparency Specific Gravity Sugar Protein Pus Cells RBC 0-2 cells/HPF 0-2 cells/HPF Result Light yellow Clear 7.0 1.005 Negative Negative Normal Value Yellow Clear

Epithelial Cells Bacteria Amorphous phosphate Few Moderate

Clotting Time and Bleeding Time (August 18, 2011) Result Clotting Time Bleeding Time 4 minutes 1 minute 00 seconds 00 seconds Normal Value 2-6 minutes 1-3 minutes Interpretation Within Normal Range Within Normal Range

Hematology (August 19, 2011) Cardiac NT-proBNP Result: 156 pg/mL Normal Value: less than 125 pg/mL Interpretation: Levels above 125 pg/ml may indicate the presence or development of cardiac dysfunction and are associated with an increased risk of cardiac events. Fecalysis (August 18, 2011) Consistency: Soft Color: Greenish Brown RBC: -Pus Cells: -NO PARASITES SEEN

VIII. DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: ranitidine Brand Name: Zantac Classification: Histamine antagonist Dosage: 150 mg 1 tab Route: PO Frequency: HS Timing: 8pm DRUG ORDER

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Competitively inhibit the actions of histamine at the H2 receptors of the parietal cell of the stomach, inhibiting 2 basal gastric acid secretion and gastric acid secretion that is stimulated by food

Short term treatment With allergy to CNS: headache, of active duodenal ranitidine malaise, dizziness, ulcer somnolence, insomnia, Use cautiously with vertigo Short term treatment impaired renal or of GERD hepatic function CV: tachycardia, bradycardia,

1. Administer oral drug with meals and HS. 2. Decrease doses in renal and liver failure.

3. Provide concurrent antacid therapy to DERMATOLOGIC: rash, relieve pain. alopecia, 4. Arrange for regular GI: constipation, follow-up, including diarrhea, nausea, blood test, to evaluate vomiting, abdominal effects. pain

(Generic name, brand name, classification, dosage, route, frequency) Generic Name: cefuroxime Brand Name: Zinacef Classification: Antimicrobila agent Dosage: 1.5 g ----- 500 mg 1 tab Route: IVTT ---- PO Frequency: PRN ----- TID Timing: 8pm-1pm-6pm

MECHANISM OF ACTION

INDICATON

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

A second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usuallu bacterial

Skin and skin structure infections, bone and joint infection

Contraindicated in CNS: headache, 1. With large doses or patient with malaise, paresthesia, prolonged therapy hypersensitivity to dizziness monitor for cefuroxime or other superinfection, GI:pseudomemebranous especially in high risk cephalosporin colitis, nausea, anorexia, patient Use cautiously in vomiting, diarrhea, patient with history to glossitis, dyspepsia 2. Give oral drug with sensitivity to penicillin food to decrease GI GU: genital pruritus upset and enhanced absorption HEMATOLOGIC: hemolytic anemia, 3. Have vit. K available decrease in hemoglobin in case of hypoprothrombinemia occurs

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: bethanecol Brand Name: Uriflow Classification: Cholinergic (parasympathomimetic) Dosage: 1 tab Route: PO Frequency: T.I.D Timing: 8pm-1pm-6pm

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Binds to cholinergic (muscarinic) receptors, mimic the action of acetylcholine

Acute postoperative nonobstructive (functional) urine retention

Contraindicated with unusual sensitivity to bethanicol, hyperthyroidism, peptic ulcer, latent or active asthma, bradycardia, vasomotor instability, CAD.

CV: Transient heart 1. Give on empty block, cardiac arrest, stomach, otherwise arthostatic hypotension may cause nausea and vomiting GI: abdominal discomfort, salivation, 2. Monitor vital signs nausea, vomiting, frequently, especially abdominal cramps, respirations diarrhea 3. Never give IM or IV GU: Urinary urgency it could cause circulatory collapse, RESPIRATORY: hypotension, severe Dyspnea abdominal cramping, bloody diarrhea, shock Other: Malaise, or cardiac arrest headache, sweating, flushing

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: metoprolol Brand Name: Neobloc Classification: Antihypertensive Dosage: 50 mg tab Route: PO Frequency: T.I.D Timing: 8pm-1pm-6pm

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

A beta1-selective Hypertension blocking agent that decreases myocardial contractility, heart rate and cardiac output; lower blood pressure and reduce myocardial oxygen consumption. Also depresses renin secretion

Contraindicated in patient with hypersensitivity to the drugs or other beta blockers and in patient with bradycardia, and cardiogenic shock

CNS: fatigue, lethargy, 1. Always check the dizziness, patient apical pulse rate before giving CV:bradycardia. drugs. If it is slower Hypotension, CHF, than 60 bpm withhold peripheral vascular drug and call the disease doctor immediately. 2. Monitor BP frequently and watch out for hypotension. 3. Food may increase absorption of metoprolol. Give consistently with meals

Metoprolol masks GI: nausea, vomiting, common signs of diarrhea shock and RESPIRATORY: hypoglycemia dyspnea, bronchospasm SKIN: rash Other: fever arthralgia and

DRUG ORDER

(Generic name, brand name, classification, dosage, route, frequency) Generic Name: ipratropium salbutamol Brand Name: Combivent Classification: Bronchodilators Dosage: 1 neb Route: Inhalation Frequency: Every 8 hours Timing: 10am-6pm-2am &

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Salbutamol: Relaxes bronchial and uterine smooth muscle by actine on beta2adrenergic receptors Ipratropium: Inhibits vagally mediated reflexes by antagonizing acetylcholine, an anticholinergic

Bronchospasm viscous sputum

and Contraincated patient hypesensitivity drugs or component of formulation

in with to any the

Use cautiously in patient with cardiovascular disorders, including any insufficiencies and hypertension; in GI: heartburn, nausea, 4. Do chest tapping patient with vomiting after every treatment in hyperthyroidism or DM not contraindicated. RESPIRATORY: bronchospasm

CNS: tremor, 1. Monitor closely the nervousness, patient for toxicity insomnia, headache 2. Teach the patient to CV: tachycardia, perform oral inhalation palpitation, correctly hypertension 3. Aeresol form may EENT: drying and be prescribed for use irritation of nose and 15 minutes before throat( with inhaled exercise. induced form) bronchospasm

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: esomeprazole Brand Name: Nexium Classification: Proton pump inhibitor Dosage: 40 mg Route: IVTT Frequency: OD Timing: 6am

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Gastric acid-pump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the first step of acid production

Reduction in Patient occurrence of gastric hypersensitivity ulcer drugs

with CNS: headache, 1. Ensure that the to dizziness, vertigo, patient swallow whole insomnia, anxiety capsule; do not crush or chew. Treatment of duodenal Use cautiously with DERMATOLOGIC: ulcer hepatic dysfunction rash, inflammation, 2. Provide additional pruritus, alopecia, dry comfort measures to skin alleviate discomfort from GI effects and GI: diarrhea, headache. abdominal pain, nausea, vomiting, 3. Establish safety constipation, dry precaution if dizziness mouth, or other CNS effects occur

DRUG ORDER

(Generic name, brand name, classification, dosage, route, frequency) Generic Name: hydrocortisone Brand Name: Solu-cortef Classification: corticosteroids Dosage: 100 mg Route: IVTT Frequency: Every 12h Timing: 8am-8pm

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Decrease Severe inflammation inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses the immune response; stimulate bone marrow, and influences protein, fat and carbohydrate metabolism

Contraindicated in patient allergy to any component of the formulation, and in those with systemic fungal infections. Certain injectable forms contain sulfites which can cause allergy

CNS: euphoria, insomnia, psychotic behavior, pseudomotorcerebri

1. Elderly patients may be more susceptible to oesteoporosis. Advise patients receiving long term therapy to CV: CHF, consider exercise or hypertension, edema physical therapy. EENT: glaucoma

cataract, 2. Gradually reduce drug dosage after long term therapy. GI: peptic ulceration, Use cautiously in GI irritation increased 3. Do not give IM patient with GI appetite, pancreatitis injections if patient has ulceration or renal thrombocytopenic disease, and purpura hypertension

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: metronidazole Brand Name: Dazomet Classification: Antimicrobial Dosage: 5oo mg Route: PO Frequency: B.I.D for 1 week Timing: 8am-6pm

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

A direct acting trichomonocide and amebicide that works at both intestinal and extra intestinal site

Bacterial infections This drug has shown caused by anaerobic to be carcinogenic in microorganisms, mice and possibly in rats. Unnecessary use Prevention of post should be avoided. operative infection in contaminated or Use cautiously in potentially patient with a history of contaminated surgery CNS disorder and in patient with retinal or visual field changes.

CNS: vertigo, headache, ataxia, incoordination, confusion, irritability, depression, restless

1. Tell the patient to avoid alcohol or alcohol-containing medications during therapy or at least 48hrs after therapy is GI: unpleasant metallic completed. taste, anorexia, nausea, vomiting, 2. Tell the patient that diarrhea, GI upset, the metallic taste and cramps dark or red-brown urine may occur. GU: dysuria, incontinence, 3. Give with meals to darkening of the urine minimize GI distress

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: amoxicillin Brand Name: Amoxil Classification: Antibiotic Dosage: 500 mg 1 tab Route: PO Frequency: B.I.D Timing: 8am-6pm

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE EFFECT OF THE DRUG

NURSING RESPONSIBILTIES/ PRECAUTION

Bactericidal: inhibits Helicobacter synthesis of cell wall of infection sensitive organism, causing cell death

pyloric Contraindicated with CNS: lethargy, allergy to penicillin, hallucination, seizures cephalosporin, other GI: stomatitis, sore allergen mouth Use cautiously with GU: nephritis renal disorders HEMATOLOGIC: anemia, thrombocytopenia HYPERSENSITI-VITY Rash, fever, wheezing, anaphylaxis

1. Culture infected area prior to treatment 2. Give in oral preparation only; amoxicillin is not affected by blood 3. Use corticosteroids or antihistamines for skin reaction. 4. Take this drug around the clock

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: alfuzocin MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT OF THE DRUG NURSING RESPONSIBILTIES/ PRECAUTION

Blocks alpha receptors Relieving the urinary in the muscle of the symptoms of enlarged prostate gland, which prostate gland Brand Name: causes the muscle in Xatral the prostate to relax. This allow urine to flow Classification: Alpha adrenergic freely past the prostate and relieve th urinary blocker symptoms Dosage: 10 mg Route: P.O Frequency: HS Timing: 8pm

Contraindicated in elderly patient, history of decreased liver function, allergy to alpha blocker, CAD and angina pectoris

CNS: headache

dizziness, 1. Taken after meal, the tablet should swallowed whole, not CV: orthostatic chew or crushed. hypotension, syncope, tachycardia, chest pain 2. Do not stop taking the tablet gradually by GI: abdominal pain, reducing the dose over dyspepsia, a number of days constipation 3. Tell the patient not GU: impotence, to take alcohol, bronchitis, URI because effects of alcohol could made worse while taking xatral

IX. NURSING CARE PLAN: (Pre-operative)

ASSESSMENT SUBJECTIVE:
Sakit kaayo akong

NURSING DIAGNOSIS ACUTE (BACK) PAIN RELATED TO SLIPPAGE OF L4 AND L5 VERTEBRAE SECONDARY TO SPONDYLOLISTHESI S

GOALS AND OBJECTIVES Short-Term Within 10 - 15 minutes of nursing care and interventions, the patent will: 1. Report controlled pain as evidenced by a decreased pain scale from 8/10 to 0/10. 2. Demonstrate use of relaxation skills. Long-Term

NURSING INTERVENTION /RATIONALE INDEPENDENT: 1. Monitor V/S which is usually altered when patient is in acute pain. R - Changes in vital signs may indicate acute pain and discomfort.

EVALUATION

likod, dili nako alihok sa kasakit as verbalized by the patient. OBJECTIVE: Pain Scale :8/10 Restless Guarding on the left side of the body

After 8 hours of thorough effectively. nursing intervention, the client will be able to report 4. Teach patient deep-breathing relief of pain. exercise to help refocus attention and enhance coping abilities. R - This reduces muscle tension

Short- Term Goals: Goals met. After 15 minutes of Nursing interventions, the patient reported pain was relieved as evidenced by a pain scale of 0/10 and demonstrated relaxation techniques such as deep 2. Provide comfort measures to the breathing exercise and patient such as providing reduction in stimulating appropriate ventilation. activities. R - To promote relaxation. Long-Term Goals: 3. Assist patient to find position of Goal partially met. After the 8-hour shift, the patient comfort. R - Position affects the patients reported relieved pain with a ability to relax and rest/sleep pain scale of 0/10.

which reduces the intensity of the pain. 5. Provide quiet environment and calm activities. R - Decreases external stimuli, which may aggravate anxiety and cardiac strain, limits coping abilities and adjustment to current situation. 6. Limit activities of the patient and refrain from stimulating procedures R- Movement and activities trigger stimulation of pain nerve endings that may aggregate pain sensation. DEPENDENT: 1. Administer hydrocortisone 100 mg every 12 hours R Decreases inflammation and results to relief of pain.

ASSESSMENT DATA (Subjective & Objective) SUBJECTIVE:

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVE

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

ACTIVITY INTOLERANCE RELATED TO SLIPPAGE dli kayo nako malihok OF L4 AND L5 akong right side sah ako VERTEBRAE lawas, as verbalized by SECONDARY TO the patient. SPONDYLOLITHESIS

INDEPENDENT: 1. Assist and demonstrate At the end of 8 hrs. of passive and active rangenursing interventions, the of-motion. patient will be able to: R - To strengthen muscle. Short-Term Goals: 1. Perform and improve ADL such as performing self-care gradually.

Short-Term Goals: Goals Met. At the end of 8 hrs. of nursing interventions, the patient was able to perform and improve ADL such as performing self-care gradually, Participated and demonstrate exercises such as range-of-motion and reported.

OBJECTIVE:
Muscle

strength of 3/5 (lower extremities)

Uncoordinated gait Back pain of 8/10

2. Instruct patient to do selfcare such as combing his hair using the unaffected arm to assist the affected arm. 2. Participate and R - To prevent misuse demonstrate syndrome. exercises such as Long- Term Goals: range-of-motion Goals Partially met. At the 4. Provide rest between end of 2 days of nursing activities. Long- Term Goals: interventions, the patient R - To prevent fatigability. was able to continue to At the end of 2 days of demonstrate modified nursing interventions, the 5. Turn patient to side at activities to promote activity intervals. patient will be able to: tolerance but still has the R - To prevent skin muscle strength of 3/5. 1. Improve muscle breakdown. strength from 3/5 to

5/5. 2. Continue to demonstrate modified activities to promote activity tolerance. COLLABORATIVE: 1. Referred to to PT for regular physical therapy. R To rehabilitate muscles.

ASSESSMENT SUBJECTIVE CUES:

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE

EVALUATION

IMPAIRED BED MOBILITY RELATED TO Maglisod kog lihok kay INSUFFICIENT MUSCLE sakit akong likod. as STRENGTH SECONDARY verbalized by the patient TO PAIN.

OBJECTIVE CUES: Inability to reposition self in bed at any desired position

Functional

After 8 hours of nursing INDEPENDENT care, patient will be able 1. Determine diagnoses that to: contribute to immobility. R - To identify causative factors 1. Maintain position of function and skin integrity 2. Determine functional level as evidenced by absence classification. of decubitus ulcer and R - To assess functional ability footdrop.

level: Level 2 (requires help from another person)

Goals met. After 8 hours of nursing care, patient was able to maintain position of function and skin integrity as evidenced by absence of decubitus ulcer and foot drop and verbalized partici0pation in repositioning program as 2. Verbalize to participate 3. Reposition patient n good body well as physical movement alignment using appropriate program. in repositioning program supports like utilizing bed linens . and asking assistance from the SO. R - To promote optimal level of function and prevent injuries. 4. Observe skin for reddened areas and for presence of shearing. Provide pressure relief by the use of pillows or rolled linens on high risk areas e.g. sacral/bony areas. R - To reduce friction, maintain safe skin pressure, and to

prevent moisture. 5. Assist with activities of hygiene, and toileting. R To avoid injury 6. Provide extremity protection like padding on the foot and on elbows. R - To prevent growth and spread of microorganism. 7. Assist patient in passive ROM to enhance gains in strength and muscle control. R - To prevent disused syndrome and promote blood circulation

DEPENDENT: 1. Administer hydrocortisone 100 mg every 12 hours R Decreases inflammation and results to relief of pain.

ASSESSMENT

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE INDEPENDENT:

EVALUATION

SUBJECTIVE: Nahadlok jud ko labi na adtong paigon nako sa operating room, as verbalized by the patient. OBJECTIVES: Irritability Facial flushing Restlessness

ANXIETY, MILD RELATED After 30 minutes of TO FEAR OF THE nursing interventions, the UNKNOWN SECONDARY patient will be able to: TO SURGERY 1. Appear relaxed and report anxiety is reduced to a manageable level

Goals met. After 3 hours of nursing interventions, the 1. Monitor vital signs patient was able to appear R: To identify physical relaxed and reported responses associated with both anxiety was reduced to a medical and emotional manageable level and conditions identified ways to deal with and expressed anxiety 2. Identify ways to deal 2. Establish therapeutic with and express anxiety relationship, conveying empathy as evidenced by and unconditional positive regard. verbalization of feelings. R: To avoid the contagious effect/transmission of anxiety 3. Be available to client for listening and talking. R Encourage verbalization of feelings 4. Provide accurate information about the situation. R: Helps client to identify what is reality based 5. Provide comfort measures such as back rub, calm environment.

R To help the patient to be at ease.

Post-operative:

ASSESSMENT SUBJECTIVE: Sakit jud sa akong likod, sa ubos dapit as verbalized by the patient.

NURSING DIAGNOSIS ACUTE PAIN AT SPINAL COLUMN RELATED TO DESTRUCTION OF LUMBAR TISSUE SECONDARY TO SURGICAL INCISION AS EVIDENCED BY THE OPERATION SITE AT L4, L5

GOALS AND OBJECTIVES Short term Within 1hour of nursing interventions the patient will be able to: 1. Report no pain as evidenced by absence of pain scale from 8/10 to 0/10. 2. Demonstrate methods that will provide relief.

NURSING INTERVENTION /RATIONALE INDEPENDENT: 1. Monitor V/S which is usually altered when patient is in acute pain. R - Changes in vital signs may indicate acute pain and discomfort.

EVALUATION

OBJECTIVES: Pain scale of 8/10 Moaning Facial grimace Protective behavior Operation site at L4, L5 spinal column

Short term GOALS PARTIALLY MET. After 1 hour of Nursing interventions, the patient demonstrated methods that relieved pain but reported pain partialyl relieved as evidenced by a pain scale of 2. Provide comfort measures such 4/10. as touch, repositioning, use of heat or cold packs and nurses Long term Long term presence, quiet environment and GOALS MET. After the 8After 8 hours of thorough calm activities hour shift, the patient nursing intervention, the R To promote

client will be able to permanent relieve of pain and demonstrate use of relaxation skills and diversional activities

nonpharmacological management.

pain reported relieved pain with a pain scale of 0/10. Patient was able to demonstrate use 3. Encourage adequate rest of relaxation skills and periods. diversional activities. R - To prevent fatigue 4. Assist patient to find position of comfort. R - Position affects the patients ability to relax and rest/sleep effectively. 5. Teach patient deep-breathing exercise to help refocus attention and enhance coping abilities. R - This reduces muscle tension which reduces the intensity of the pain. 6. Instruct and encourage use of relaxation techniques, such as listening to music and/or watching television. R: To distract attention and reduce tension. DEPENDENT: 1. Administer

hydrocortisone

100mg every 12 hours, as ordered R: To decrease level of pain. Notify physician if regimen is inadequate to meet pain control goal.

ASSESSMENT

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE

EVALUATION

SUBJECTIVE: IMPAIRED SKIN Sakit kayo diri dapit sa INTEGRITY RELATED akong operasyon, as TO SURGICAL verbalized by the patient. INCISION AT THE LUMBAR AREA OBJECTIVE: Pain scale of 8/10 Disruption of skin surface (epidermis) Disruption of layers (dermis) skin

Short term goal: INDEPENDENT: After 8 hours of nursing interventions, the patient 1. Inspect skin on a daily basis and will be able to: describe changes. R To note changes on the Verbalize feelings surgical incision. of increased ability to manage 2. Keep the area clean and dry, carefully dress wounds and prevent situation. Display wound free infection R: To assist bodys natural from infection. process of repair Long term goal: After 4 days of nursing 3. Use appropriate wound dressing interventions, the patient R: To protect the wound and will be able to display surrounding tissues timely healing of operative

Short term goal: Goals met. After 8 hours of nursing interventions, the patient was able to verbalized feelings of increased ability to manage situation and displayed wound free from infection. Long term goal: Goals met. After 4 days of nursing interventions, the patient was able to display timely healing of operative wound without complications.

wound complications

without 4. Encourage early ambulation R: Promotes circulation and reduces risk associated with immobility.

ASSESSMENT SUBJECTIVE: Dili pa kayo ko makalihok ug makatindog basta bast anga ako ra tungod sa akong opera as verbalized

NURSING DIAGNOSIS IMPAIRED PHYSICAL MOBILITY RELATED TO POSTOPERATIVE INCISION SITE AT L4,L5 OF SPINAL COLUMN AS EVIDENCED BY LIMITED RANGE OF MOTION AND SLOWED MOVEMENT

GOALS AND OBJECTIVES Short term:

NURSING INTERVENTION /RATIONALE INDEPENDENT:

EVALUATION Short term:

1. Note situations such as surgery At the end of 30-45 that may restrict movement. minutes of continuous R To identify causative/ health teachings, patient contributing factors will be able to : 1. Verbalize willingness to and demonstrate participation in activities 2. Verbalize understanding of situation and individual treatment regimen and safety measures such as raising the side rails

OBJECTIVE: Limited motion range of

Slowed movement Operation site at L4 ,L5 of spinal column

Goals met. At the end of 3045 minutes of continuous heath teachings the patient was able to verbalize willingness to and demonstrated participation in 2. Determine degree of immobility activities, verbalized in relation to previously suggested understanding of situation scale. and individual treatment R - To assess functional ability regimen and safety measures such as raising the 3. Observe movement when client side rails. is unaware of observation. Long term: R - To note any incongruences Goals met At the end of 16 with reports of abilities hours of nursing intervention,

 Functional level classification:3 requires help from another person and equipment device

Long term:

4. Assist or have client reposition self on a regular schedule as At the end of 16 hours of dictated by individual situation nursing intervention, R - To promote optimal level of patient will be able to: function and prevent 1. Demonstrate complications techniques that enable 5. Instruct in use of side rails, roller resumption of activities pads for position changes/transfers 2. Maintain position of R To secure safety for the function and skin integrity client. as evidenced by absence of contractures, decubitus 6. Support affected body part using pillows and so forth R - To maintain position of 3. Maintain or increase function and reduce risk f strength and function of pressure ulcers. affected or compensatory body part. 7. Schedule activities with adequate rest periods during the day to reduce fatigue. Provide client with ample time. R - To perform mobility related tasks 8. Encouraged participation in selfcare,diversional/ recreational activities

the patient was able to demonstrate techniques that enable resumption of activities, maintained position of function and skin integrity as evidenced by absence of contractures and maintained or increased strength and function of affected or compensatory body part.

R - To enhance self-concept and sense of independence 9. Demonstrate use of adjunctive devices (walker). R - To promote independence and enhances safety.

ASSESSMENT RISK FACTOR

NURSING DIAGNOSIS

GOALS AND OBJECTIVES Short term:

NURSING INTERVENTIONS/ RATIONALE

EVALUATION

RISK FOR INFECTION RELATED TO 1. Post operative wound at DESTRUCTION OF SKIN L4,L5 of spinal column. INTEGRITY SECONDARY TO POST OPERATIVE WOUND AT L4,L5 OF SPINAL COLUMN

INDEPENDENT 1. Note risk factors for occurrence At the end of 30-45 of infection such as break in skin minutes of continuous integrity health teachings patient R To assess will be able to: causative/contributing factors. 1. Verbalize understanding of individual causative/ factor 2. Identify interventions to prevent/reduce risk of infection Long term: At the end of 16 hours of

Short term: Goals met . At the end of 30-45 minutes of continuous health teachings the patient was able to verbalize understanding of individual causative/ factor, 2. Observe for localized signs of and identified interventions infection at surgical to prevent/reduce risk of incisions/wounds. infection. R To give prompt action to avoid further complications. Long term: Goals met. At the end of 3. Cover dressings with plastic 16 hours of nursing the when using bedpan patient was able to R - To prevent contamination demonstrate techniques ,lifestyle changes to 4. Stressed proper hand washing promote safe environment

techniques by all care givers and achieved timely wound nursing interventions between therapies/clients. healing; purulent drainage patient will be able to: R - A first line defense against or erythema; afebrile nosocomial 1. Demonstrate infection/contamination techniques, lifestyle changes to promote safe 5. Instruct client/significant others environment. in techniques to protect the 2. Achieve timely wound integrity of skin, care of lesions healing; be free of and prevention of spread of purulent drainage or infection R - To promote wellness. erythema; be afebrile DEPENDENT 1. Administer Hydrocortisone (Solu-cortef) 100mg every 12 hours; Amoxicillin (Amoxil) 500 mg 1 tab PO B.I.D; Metronidazole (Dazomet) 5oo mg PO B.I.D for 1 week; Cefuroxime (Zinacef) 1.5 g ----- 500 mg 1 tab IVTT ---- PO PRN ----- TID, as ordered. R To act as Prophylaxis against bacterial invasion.

ASSESSMENT SUBJECTIVE:

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS/ RATIONALE

EVALUATION Goals met. At the end of 30mins. of nursing interventions, the patient was able to report understanding of the disease condition and its management, Knew the importance of rehabilitation and Reported understanding on the prevention of further complications.

READINESS FOR mo-uli najud ko karon, ENHANCED as verbalized by the THERAPEUTIC REGIMEN patient. RELATED TO IMPROVED CONDITION. OBJECTIVE: Stable vital signs: BP:130/70mmhg PR:67bpm RR:17cpm Temp:36.3C

At the end of 30mins. of INDEPENDENT: nursing interventions, the 1. Instruct patient about the home patient will be able to: medications and its proper timing, 1. Report understanding mechanism of action and dosage. of the disease condition R To guide the patient accordingly with the discharge and its management. instructions. 2. Know the importance of rehabilitation. 2. Encourage patient to continue physical therapy. 3. Report understanding R - To improve condition. on the prevention of further complications. 3. Instruct patient to eat foods rich in carbohydrate and protein. R - To provide energy and facilitate muscle growth. 4. Instruct patient to perform

range-of-motion every day. R - To strengthen muscle. Healing wound 5. Instruct patient to have adequate rest between activities. R - To prevent fatigability. Dependent: 1. Home medications (Xatral), (Uriflow),(Mecobalamin) as ordered. R To continuously provide relief of the recent condition of the patient.

X. DISCHARGE PLANNING MEDICATIONS Explain to the patient and family members the importance of taking medications. Take the entire course of medication. Discuss to the patient and family the dosage, frequency and adverse effects of the drugs. Anti-inflammatory medications can help reduce pain by decreasing the inflammation of the muscles and nerves. ECONOMIC STATUS Explain to significant others that the patient may undergo physical therapy in order for the family to prepare for any financial needs. Inform the patient to avail to some government health insurance programs such as Philhealth that may help ease their financial burden for hospitalization. TREATMENT Patient must take a short period of rest or avoiding activities such as lifting and bending. Patient may undergo physical therapy that can help increase range of motion of the lumbar spine and hamstrings as well as strengthen the core abdominal muscles. Control weight to prevent increased pressure on the lumbar vertebrae. Use assistive and supportive devices as ordered like a lumbar corset. HEATLH TEACHINGS Advised patient to avoid prolonged sitting, walking and standing because it can add pressure on the lumbar vertebrae. Advised patient to consult the doctor before taking any medications, to prevent any drug-drug interactions with the prescribed drugs. Advised patient to balance work with rest. Advised significant others to follow safety measures to prevent falls and injury. Advised patient to follow proper body mechanics. Advised patient to inform health care provider if complications may occur such as chronic pain in the lower back or legs, as well as numbness, tingling or weakness in the legs.

OUT-PATIENT
Keep all of follow-up appointments even though the patient feels better. Advised

to seek consultation from a physician whenever there will be recurrence of the signs and symptoms. This is to prevent the occurrence of a far more serious complication. DIET Eat protein rich foods to help repair the damage tissues and to provide muscle strength. Sources of protein include meat and eggs. Eat a well-balanced diet high in calcium and Vitamin D. Foods high in calcium include milk, yogurt, cheese, salmon and dark green vegetables. Sources of Vitamin D include fortified milk, liver, butter, eggs and sunlight. Eat Vitamin C rich fruits like orange to help boost immune system.

SPIRITUALITY
Encouraged patient and Family members to go to church every Sunday and to

continue to seek Gods guidance and enlightenment.

Emphasized the importance of prayers in healing Encouraged

to

ask

for

divine

assistance

in

everything

and

to

encouragecontinuing to pray to God.

Encouraged to continue to have a positive outlook in life. Encouraged to keep faith in God and not to give up easily when hard times come

XI. RELATED LEARNING EXPERIENCE This rotation was never the easiest task, neither the hardest of all that we had been through in our two years exposure to the clinical area. Thus, we were anxious that we may not be able to live up to what is expected of us since we are now fourth year. However, one thing has been sure, this rotation made us take a closer leap to what it is like when we will finally be wearing our all white uniform someday. The staffing rotation has inflicted upon us some values that we are to hold on as we go through this profession, namely: humility, compassion, discipline and empathy. These were taught to us few years back but we may have forgotten their essence, yet, with this duty, we unconsciously regained them. Our duty for the staffing rotation in Station 4 of Capitol University Medical City is probably one of the best experiences we will ever have since we are meeting different kinds of personalities of patients and watchers as well. Some might have accepted us warmly as their nurses others may have rejected us at some points. In spite of that, we have taken it as a challenge to prove ourselves worthy of their trust and take it as an opportunity to learn in handling distrustful watchers, and agitated patients---to whom we consider bumps on our road to success. Basically our duty fell on the same pattern as with the other medical rotations we had but this had taught on two new concepts: carrying out doctors orders and leadership and management following the chain of command, in line of authority. We have all experienced being a staff nurse, a head nurse and the nurse supervisor as well. We exploited this rotation to the maximum in terms of carrying out doctors order since we fell on an afternoon shift where fewer doctors make their orders after their rounds. Nevertheless, we saw to it that everyone can try carrying out doctors orders and nobody is left behind. We enjoyed this rotation so much while we were learning at the same time. The entire process of making this case study may have not been easy for all of us but fortunately, weve manage to deal with the problems properly and thus, we were able to finish this case study in the best way we could. Whether the outcome of this case study is good or bad, we must take it as a lesson and a parameter to continue seeking knowledge and improving our skills for we never stop learning.

This case study enabled the group to identify nursing intervention which are appropriate to promote the well-being of the patient and as well as the medical management for the case.

We would like to thank Mrs. Syvel Jane M. Caharian, for being the best teacher we could ever ask for in the task of staffing, in teaching and molding us to be good and competent nurses in the future. Furthermore, this rotation would have not been successful without the guidance of our almighty God!

XII. REFERENCE

BOOKS:
Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care

Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurses pocket

Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.). Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).

Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippincotts Nursing Drug Guide, 8th edition. Lippincott

Williams & Wilkins. Nurses Pocket Guide, 10th edition F.A. Davis. Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr. Patients Chart
Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for

Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005 Malseed, Roger T. ; Springhouse Nurses Drug Guide 2004, 5th edition.
Davis drug handbook, 10th edition

Drug handbook by Saunders

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th

edition By: Joyce Black and Jane Hokanson Hawks Nursing Care of Infants and Children by Wong

INTERNET:

http://cpmcnet.columbia.edu/dept/gi/.html http://www.drstandley.com/labvalues http://ocw.tufts.edu/Content/14/lecturenotes/266736

http://www.medterms.com/script/main/art.asp?articlekey=16051
http://my.clevelandclinic.org/disorders/back_pain/hic_spondylolisthesis.aspx

http://www.nlm.nih.gov/medlineplus/spinalstenosis.html http://orthoinfo.aaos.org/topic.cfm?topic=a00329 http://backandneck.about.com/od/conditions/f/radiculopathy.htm; http://www.wisegeek.com/what-is-myelopathy.htm