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UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE COLLEGE OF NURSING

TOPIC: Lumbar Radiculopathy GENERAL OBJECTIVE: Within 2 hours of lecture-discussion, the BSN IV-B students will be able to enhance knowledge, improve skills and develop positive attitude towards the topic- Lumbar Radiculopathy. SPECIFIC OBJECTIVES Specifically, the Level IV-B students will be able to: 1. discuss the overview of lumbar radiculopathy. CONTENTS Prayer Preconditioning Activity A. Human Resources: - Student s - CIs B.Books: Lecturediscussion 15 minutes Black and Hawks. (2008). Medical Surgical Nursing: Clinical Management for Positive Outcomes. Mosbys medical Dictionary Post test METHODOLO GY TIME RESOURCES ALLOTMENT EVALUATION

2. define related terms 3. state the petients demographic data II. DEMOGRAPHIC DATA: Name Age Gender Civil Status Religion Occupation : Mrs. T.A.B : 74 years old : female : married : Roman Catholic : housewife

Lecturediscussion Lecturediscussion

10 minutes

Post test

10 minutes

Post test

4. delineate on patients Gordons Functional Pattern;

Height : 51 Weight : 50 kg Date of Admission : February 12, 2012 Time of Admission : 05:09 PM Hospital : Chong Hua Hospital Patient # : 0000289413 Room # : C-317 Residence : 233 M.D. Jakosalem St. Cebu City Physician : Dr. Virginia Espaol Chief Complaints : loss of appetite, weakness, gluteal pain Final Diagnosis : Lumbar radiculopathy GORDONS FUNCTIONAL PATTERN 1. Health Perception Health Management Pattern 2. Nutritional Metabolic Pattern 3. Elimination Pattern 4. Activity Exercise Pattern 5. Sleep Rest Pattern

Lecturediscussion

20 minutes

Post test

6. Cognitive Perceptual Pattern 7. Sexuality Reproductive Pattern . 8. Self Perception Self Concept Pattern

9. Role Relationship Pattern 10. Coping Stress Tolerance Pattern

11. Value Belief Pattern

Physical Appearance

General Measurement: Height: 51 Weight: 50 kg

General Appearance:

Date of Assessment: February 15,2012 Time: 11:00 pm

Seen patient lying on bed, conscious, awake, coherent and responsive with an IVF of #5 PNSS 1L regulated at 15 gtts/min with a remaining level of 800, well infused on the left arm. Limited range of motion and slowed movement noted. Vital signs are as follows: T: 36.5 C PR: 80 bpm RR: 20cpm BP: 130/80 mmHg

Physical Assessment

SKIN: brown complexion, old wrinkled skin, good skin turgor, no masses, tenderness, warm to touch

HEAD AND HAIR: normocephalic, equally distributed grey and black hair, no lice

infestations, no flaking, no swelling or tenderness, no masses palpated.

EARS: symmetrical, pinna is in line with outer canthus of the eye, minimal cerumen seen in the ear canal, no discharges, and no tenderness upon palpation

NOSE AND SINUSES: nasal septum in midline, no deformities, no discharges, no swelling, no masses and tenderness upon palpation.

MOUTH AND THROAT: moist lips, moist buccal mucousa, pinkish and moist gums, tongue at midline and rest at the floor of the mouth, uvula at midline, (+) gag reflex, no halitosis, no pain upon swallowing, tonsils are not inflamed.

NECK: centrally located, supple, no lesions, no lymphadenopathy, undistended jugular vein, trachea at midline, smooth and firm, no tenderness, non-palpable lymph nodes, no masses.

THORAX AND LUNGS: equal chest expansion, (-) adventitious sounds, RR= 20 cpm

CARDIOVASCULAR: distinct S1 and S2, no chest pain, no palpitations, no murmurs, heart rate= 80 bpm

ABDOMEN: no lesions, umbilicus at midline, round fatty abdomen, symmetrical, bowel sounds of 5 clicks/minute, no masses, (-) kidney punch left flank.

GENITALIA AND ANUS: grossly female, no discharges.

EXTREMITIES: short clean fingernails and toenails, pinkish nail beds, (-) nail clubbing, CRT= <2 secs, full active range of motion for upper extremities, weak lower extremities

CRANIAL NERVES

CN 1: identified smell of perfume and alcohol CN 2: identified color of student nurses uniform (stripe white and red), unable to read at 2 feet distance CN 3: (+) PERRLA, (+) extra ocular movements CN 4 and 6: (+) cardinal gaze CN 5: felt wisp of tissue on her cheeks, able to chew upon eating food CN 7: active and symmetrical facial muscles movement upon smiling and frowning CN 8: able to repeat hello as whispered by the student nurse at 2 feet distance CN 9 and 10: able to swallow, identified sweet taste of banana, (+) gag reflex CN 11: good strength of sternocleidomastoid and trapezius muscles as indicated through instructing the patient to rotate head and elevate shoulders while student nurse applies resistance on the shoulder

CN 12: able to protrude, elevate and depress the tongue

5. review the anatomy and physiology of the nervous system.

(See Appendix A for the genogram.) Anatomy and Physiology of Pancreas, Cerebral Cortex and Hippocampus

Lecturediscussion

20 minutes

Seeley. Anatomy & Physiology.pp. 145-148

Post test

6. trace the pathophysiolog y of lumbar radiculopathy.

LectureDiscussion See Appendix B for the conceptual framework.

15 minutes

Black & Hawks. MedicalSurgical Nursing. pp.1067-1070 patients data

Post test

7. identify the ideal and actual management;

MEDICAL AND SURGICAL MANAGEMENT A. LABORATORY EXAMINATIONS

Lecturediscussion

10 minutes

Post test

IDEAL

ACTUAL

B. DIAGNOSTIC EXAMS IDEAL Chest X-ray -this is done to find out any abnormalities on the patient's chest ECG -a recorded of electrical activity of the heart, shows certain waves called P,Q,R,S,T and U waves Magnetic resonance imaging (MRI) -is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. Computerized axial tomography scan (CT Scan) - is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the ACTUAL - chest x-ray

ECG

MRI

- CT scan

body. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.

See Appendix C for the laboratory results.

C. MEDICATIONS AND TREATMENT IDEAL

ACTUAL

D. SURGICAL MANAGEMENT IDEAL ACTUAL

E. DIET

IDEAL

ACTUAL

8. discuss the ideal and actual nursing management;

IDEAL

ACTUAL Actual Nursing Management Assessed patients condition. Regulated IVF to 15 gtts/min. Bedside care done. Vital signs taken and monitored every hour. 5. Neuro vital signs taken and monitored every hour. 6. Intake and output taken and recorded. 7. Assisted patient on repositioning self. 8. Provided safety measures by raising side rails up. 9. Assisted with activities of toileting. 10. Changed diaper. 11. Gave health teachings. 12. Encouraged deep breathing exercises. 13. Placed patient on seizure precaution. 14. Attended patients needs. 15. Provided adequate rest. 1. 2. 3. 4.

Lecture discussion

5 minutes

Smeltzer, Suzanne C. et al.(2008). Brunner and Suddharths Textbook of MedicalSurgical Nursing. 11th edition. Lippincott Williams and Wilkins

Post test

9. enumerate the different drugs and intravenous fluids administered to the patient; 10. appreciate the nursing care plans;

Lecturediscussion (See Appendix D for Drug & IVF Study)

10 minutes

Spratto, George R. et al.(2007). PDR Nurses Drug Handbook. 2007th edition Doenges, Marilynn E. et.al.( 2008).Nurses Pocket guide: Diagnosis, Prioritized Interventions, Rationales. 11th edition. Philadelphia Doenges, Marilynn E. et.al.( 2008).Nurses Pocket guide: Diagnosis, Prioritized Interventions, Rationales. 11th edition. Philadelphia

Post test

(See Appendix E)

Lecturediscussion

10 minutes

Post test

11. formulate a discharge plan;

(See Appendix F)

Lecturediscussion

5 minutes

Post test

12. identify the prognosis;

Lecturediscussion

3 minutes

Post test

APPENDIX A

(Genogram)

APPENDIX B

(Pathophysiology)

APPENDIX C
(LABORATORY RESULTS)

LABORATORY AND DIAGNOSTIC TEST RESULTS

02/14/12 Sodium test

TEST Sodium (serum)

RESULT 1110.0

REFERENCE 134.0-148.0

UNIT Mmol/l

IMPLICATION hyponatremia

02/12/12 Electrocardiographic report -sinus rhythm with non-specific ST-T wave changes

02/12/12 Complete blood count TEST WBC Platelet PDW 13.50 522 8.3 RESULT 4.8-10.8 130-400 9.0-14.0 REFERENCE 10^3/uL 10^3/uL % UNIT IMPLICATION infection thromboembolism Myeloproliferative neoplasms Bacterial infection Viral infection Bone marrow injury

Neutrophil Lymphocyte Monocyte

81.4 15.3 2.0

40-74 19-48 2.4-9.0

% % %

02/12/12 Lumbosacral Spine X-ray- APL, Cone down

Conclusions: 1. 2. 3. 4. 5. straightening of the lumbar lordosis due to muscular spasm mild hypertrophic degenerative changes of the lumbar spine and lateral aspect of both iliac bones generalized osteopenia/osteoporosis atherosclerosis of the abdominal aorta fecal stasis in some of the colonic segments

02/12/12 Chest X-ray- PA or AP

Conclusions: 1. 2. 3. 4. 5. clear lung fields magnified cardiac silhouette with slightly accentuated upper pulmonary vascular markings due to positioning tortuous and atheromatous aorta hypertrophic degenerative changes of the thoracic spine generalized osteopenia/ osteoporosis

02/15/12 Ultrasound report Whole abdomen Conclusions: 1. 2. 3. 4. unremarkable GB, CBD and biliary radicles normal sized liver with mild fatty infiltration and structural changes compatible with aging liver, and/or non specific, hepatic, parenchymal disease essentially normal pancreas and spleen bilateral fullness of the pelvo-calyceal structures, which may relate to any of the following: a. distal, partially obstructing processes, proximal to UVS at present b. decreased ureteral peristalsis as seen in recent passage of a stone and/or UTI 5. normal sized uterus with physiologic endometrium. 6. Ovaries not seen, most likely atrophic 7. structurally unremarkable urinary bladder

8. atherosclerotic abdominal aorta

02/12/12 Clinical Neurophysiology Laboratory Interpretation: The nerve conduction study of both upper and both lower limbs is abnormal due to the: 1. 2. 3. 4. 5. 6. 7. absent of the action potential of both median sensory senses absence of the action potential of both median motor nerves severely decreased amplitude of the action potentials of the right peroneal motor nerve decreased conduction velocities of both peroneal and both tibial motor nerves absence of the F waves of the right peroneal motor nerve prolonged F wave latencies of the left peroneal and both tibial nerves absence of the H reflexes of both tibial nerves.

The needle (muscle) study is abnormal due to the: 1. 2. 3. 4. presence of spontaneous potentials on certain limb muscles and certain paracervical muscles tested difficulty in attaining relaxation of the paralumbosacral muscles presence of the serrated muaps on certain limb muscles tested decreased insertional activities on certain limb muscles tested.

The EMG-IVCV studies suggest the following conditions: 1. Pathology proximal to the dorsal root ganglia of both L4-S1 nerve roots. This is most likely bilateral L4-S1 radiculopathy with signs of acute and chronic denervation changes. 2. Pathology proximal to the dorsal root ganglia of right C5-C6 nerve roots. This is most likely right C5-C6 radiculopathy with signs of chronic denervation changes and signs of muscle reinnervation. 3. Bilateral distal median neuropathy, sensory and motor, demyelinating and axonopathic at the level between the mid-palms and the distal creases of the wrists. This is most likely bilateral carpal tunnel syndrome, severe.

02/14/12

CT-Scan report Brain Plain-CT16

Conclusion: Brain atrophy with suspicious areas of ischemia in the subcortical white matter of the left posterior frontal lobe.

02/14/12

Magnetic Resonance Imaging Report

Conclusion: 1. 2. 3. 4. Mild bilateral neural foramen stenosis of L2/L3, L3/L4 & L5/S1. Severe central canal and moderate bilateral neural foramen stenosis at L4/L5. Mild cervical kyphosis. This may be due to muscle spasm. Markedly dilated urinary bladder.

APPENDIX E
(NURSING CARE PLAN)

EVALUATION 1. Goal met Patient maintained free from signs of impaired skin breakdown as evidenced by no redness over the bony prominences and capillary refill of less than 6 seconds over the areas

APPENDIX D
(DRUG &IVF STUDY)
Drug Name Dosage and Frequency Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilities

Generic Name: Lactulose

Brand Name: Lilac

Classification: laxative

A. Patients dose Produces osmotic and Frequency: effect in colon. Resulting distention -20 ml OD promotes peristalsis. Decreases blood ammonia build-up that causes hepatic B. Minimum encephalopathy, Dose and probably as a Frequency: result of bacterial degredation which - 2.5 ml OD lowers pH of colon

Constipation

Containdicated in patients on low galactose diet. Use cautiously in patients with diabetes mellitus because drug contains lactose, galactose and other sugars.

GI: Abdominal cramps and distention, belching, diarrhea, flatulence, nausea & vomiting

Important patient teachings:

Replace fluid loss. Diarrhea may indicate overdose. To minimize sweet taste, dilute with water or fruit juice or give with food. Advice patient to dilute drug with food to improve taste. Inform patient of adverse reactions and tell him to notify prescriber.

contents. C. Maximum dose and Frequency: - 300 ml OD

How supplied:

A. Patients supply: - syrup

Spratto, George R. et al.(2007). PDR Nurses Drug Handbook. 2007th edition

B. Other forms: - crystals for reinsitution

Drug Name

Dosage and Frequency A. Patients dose and Frequency: - 500 mg tablet

Mechanism of Action Birds to 50S Subunit of bacterial ribosome, blocking protein synthesis; bacteriostatic or bactericidal, depending on

Indication

Contraindication

Side Effects

Nursing Responsibilities

Generic Name: Azithromycin

Brand Name: Zithromax

Acute bacterial exacerbation, community acquired pneumonia, bacterial sinusitis, nongonococcal urethritis, prevention of

Contraindicated in patient hypersensitive to erythromycin or other macrolides.

CNS: anxiety, dizziness, headache CV: Torsades de pointes, prolonged QT interval

Important nursing responsibilities: Dont give drug I.M or by I.V bolus injection. If patient vomits within 5 minutes of drinking extended-release solution, consider additional antibiotic treatment. Dont give with antacids. Tell patient that tablets or oral suspension may be taken with or

concentration. Classification: Antibiotic How supplied: - 10 mg/ P.O daily A. Patients supply: - Tablet B. Minimum Dose and Frequency:

Spratto, George R. et al.(2007). PDR Nurses Drug Handbook. 2007th edition

C. Maximum dose and Frequency: - 600 mg P.O daily

disseminated mycobacterium avium complex, pelvic inflammatory disease, genital ulcer disease, acute otitis media, chlamydial ophthalmia neonatorum.

EENT: Hearing loss, tinnitus, dyspepsia GI: Abdominal pain, diarrhea nausea GU: candiasis, nephritis, vaginitis

without food, but that taking with food may decrease risk of nausea.

B. Other forms: - Injection - Powder for oral suspension

Type of IVF 0.9% Sodium Chloride

Content Each 100ml contains 900mg of Sodium Chloride Electrolytes in 1000ml: Soduim..154mmol Chloride.154mmol

Classification Isotonic

Indication For replacement or maintenance of fluid and electrolytes

Contraindication Renal/Circulatory impairment, older adults, sodium retention.

How Supplied 1000ml in plastic bottle

Nursing Interventions Before Administration: 1.Do handwashing 2.Check the IVF sheet 3.Check the Doctors order 4.Read the label of the bottle. Ensure solution is the one ordered. 5.Inspect the container for

leaks. During Administration: 1.Close the clamp 2.Administer the IV solution. 3.Hang the IVf bottle slowly. 4.Regulate the drops per minute as prescribed. After Administration: 1.Do after care 2.Document the name of the Iv bottle, hooked, date and time started. 3.Assess for any redness or any allergic reactions. Monitor IVF and IV site. 4.Refer to health care provider if allergic reactions occur.

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

Mosby.PDQ Nurses for Today.p.9

APPENDIX F
(INTERDISCIPLINARY DISCHARGE PLAN)

BIBLIOGRAPHY: BOOKS:
Black, Joyce M. et al.(2008).Medical-Surgical Nursing.8th edition. C&E Publishing, Inc. Metro Manila, Philippines Deglin, Judith H. et.al (2007) Daviss Drug Guide for Nurses.10th edition. Philadelphia, Pennsylvania: E.A. Davis Company. Doenges, Marilynn E. et.al.( 2006).Nursing Care Plans. 7th edition. Philadelphia

Doenges, Marilynn E. et.al.( 2008).Nurses Pocket guide: Diagnosis, Prioritized Interventions, Rationales. 11th edition. Philadelphia Kee, Joyce Lefever.et al.(2009).Pharmacology: A Nursing Process Approach. 6th edition.Elsevier (Singapore) Winsland House I Singapore Mosby, Elsevier.(2006). Mosbys Pocket Dictionary. 5th edition. Singapore Seeley, Stephens Tate.et al.(2007).Essentials of Anatomy and Physiology. 6th edition. Mc- Graw Hills International Smeltzer, Suzanne C. et al.(2008). Brunner and Suddharths Textbook of Medical- Surgical Nursing. 11th edition. Lippincott Williams and Wilkins Spratto, George R. et al.(2007). PDR Nurses Drug Handbook. 2007th edition

Electronics:
http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/ http://diabetes.webmd.com/guide/oral-medicine-pills-treat-diabetes

UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE A.C. CORTES AVENUE, LOOC, MANDAUE CITY

COLLEGE OF NURSING

A RESOURCE UNIT

LUMBAR RADICULOPATHY
SUBMITTED BY:
Abubakar, Mirkhadz Ampo, Nheil Christopher Dignos, Edelyn Engasca, Paramae Fuentes, Roselyn Gasta, Jan Anthony Inoc, Creselda Lazaga, Maria Melfa Mae Lemosnero, Erika Charisse A. Lubas, Laarni Mariveles, Mark Mondigo, Cathy Lou Rubi, Sergs Domique Soquillo, Junafe Vanesa, Napala

SUBMITTED TO:
Ms. Regina M. Omana, RN Clinical Instructor