c



  

m 
 c


As a part of my Medical surgical posting I was posted in OF1(K2) ward from 28/2/11 to 5/3/11. I took 3 patients for my comparative analysis
assignment. They were Mrs. Shabhana Banu, Mrs Pankaja and Mrs Ruckiya. All of them were diagnosed to have intervertebral disc prolapse and
were managed conservatively with medications and traction.

£m 
  

 
 

 

 c

’m
 Mrs Shabhana Banu Mrs. Pankaja Mrs. Ruckiya

’m  01612973 02097215 02124693
!£"

’m #$ % 36 yrs/ F 40 yrs 40 yrs

’m &&" KM Manzil, Kodavoor, Udupi Chennagiri TQ, Davangere. Thupnalu village, chaltur post.
Davengere
’m # Muslim Hindu
Muslim
’m
" Married Married
! Married

’m  '  19/2/2011 24/2/2011
( & 22/2/2011
Cervical disc disease with
’m #  L5-S1 Acute IVDP radiculopathy. IVDP L4-L5 with right L4-L5 IVDP with right sided
lower limb radiculopathy. radiculopathy




Patient came with complaints of
)m c neck pain radiating to left upper
c

 Patient came with complaints of: limb since 1 year.
* Low back pain since 2 days, radiating Low back pain radiating to right Patient came with complaints of low

 to right lower limb. lower limb since 3 months. back pain with right sided radiation.







Patient came with complaints of low Patient was apparently normal 1 yr Patient came with complaints of lower
&m     back pain since 2 days. The pain is back when she started noticing pain back pain radiating to right leg till
 
 acute in nature, sever in nature, in the neck which was radiating to great toe.

  radiating to right lower limb, more left upper limb. Pain is moderate to severe in nature,
during strenuous activities. The neck pain was insidious in onset rapidly progressive, more in night,
She also gives history of not being able and gradually progressive. She also aggravated by movement and relieved
to get up and walk gives history of Paresthesia of the by rest and analgesic.
History of tingling and numbness of left upper limb. She also complains of tingling and
the right lower limb. Patient gives history of fall 6 months numbness over sole of right foot, more
back. Was asymptomatic for 2 in the night and hence sleepless.
months but started noticing low Aggravated during standing, walking
back pain since last 4 months, which and relieved by lying down.
was insidious in onset. History of Also complains of pain over buttocks
radiation to right lower limb. while sitting.
Paresthesia present over right leg.



 She is a known case of B/L
m     endometrial cyst, left cystectomy with
  adhesiolysis done on 22/12/2004. She

  was on Inj. Depo-Provera till 2007. No past history of any illness like No past history of any illness like DM,
She is also a known case of DM, HTN etc. HTN etc.
hypothyroidism on T.Thyronorm 75mg
od.
No family history of DM, HTN or any No family history of DM, HTN or any
No family history of DM, HTN or any other illness. She is married with other illness.
(m 
 other illness. four children. She lives with her joint She is married with two children and
   She is married with one child and lives family. lives in a nuclear family.
in a nuclear family.

.m ) ) .m ) ) .m ) )
Her husband makes decision on health Her husband makes decision on Her husband makes decision on health
#m c + matters. Has good support system & health matters. Has good support matters. Has good support system &
c

c neighborhood relations. system & neighborhood relations. neighborhood relations.
  .m ) ) ! .m ) ) ! .m ) ) !
Vducation- B.A Vducation- V th std Vducation- Xth std
Occupation- housewife Occupation- housewife Occupation- housewife
Type of house- own house Type of house- own house Type of house- own house
Toilet & water facility available. Toilet & water facility available. Toilet & water facility available.

Kasturba Hospital, Sonia clinic. Bapuji hospital, various small clinics. Bapuji hospital, various small clinics
,m
"
,, )" ! / ,"-: immunized ! / ,"-: immunized ! / ,"-: immunized
()- "- ,"- "- ,"- "- ,"-
Non-vegetarian Vegetarian Non-vegetarian
3 meals / day 3 meals / day 3 meals / day
m "  Prefers Indian home made food Prefers Indian home made food Prefers Indian home made food
,"- Fluid intake- 8-10 glasses/day Fluid intake- 8-10 glasses/day Fluid intake- 8-10 glasses/day

"  ,-#  "  ,-#  "  ,-# 
Oral- once/day Oral- once/day Oral- once/day
 Bath- once/day Bath- once/day Bath- once/day
 ' "  ' "  ' "
Uninterrupted Uninterrupted Uninterrupted
No drugs used for sleeping No drugs used for sleeping No drugs used for sleeping
Day time naps: 1-2 hrs/day Day time naps: 1-2 hrs/day Day time naps: 1-2 hrs/day
)1- ' %") )1- ' %") )1- ' %")
Daily walks No exercise No exercise
Moderate worker Moderate worker Moderate worker
£$ ,££ £$ ,££ £$ ,££
No use of alcohol/ any drugs. No use of alcohol/ any drugs. No use of alcohol/ any drugs.
        
Bowel: once/ day Bowel: once/ day Bowel: once/ day
Regular bowel movements Regular bowel movements Regular bowel movements

0m
"$ Married Married
%! Spouse general health: good Spouse general health: good Married
,"- Spouse job status: working Spouse job status: working Spouse general health: good
Staying together: yes Staying together: yes Spouse job status: working
Relationship with spouse: satisfactory. Relationship with spouse: Staying together: yes
satisfactory. Relationship with spouse: satisfactory.
Female:
Menstrual history:
She was diagnosed with B/L
endometrial cyst, Left cystectomy with Menstrual history: Nil significant Menstrual history: Nil significant
adhesiolysis done in 2004. Regular periods Regular periods
She was on Inj. Depo provera once a Normal pregnancy & delivery Normal pregnancy & delivery
month till 2007.
Her periods were highly irregular.
She underwent IVF in 2007.
Ô


  

 
 

 

 c

2

  #   #   # 
0 0

c ´m Temperature : 98.6 F ´m Temperature : 98.6 F ´m Temperature : 98.6 0F
´m Pulse : 88 beats/min ´m Pulse : 72beats/min ´m Pulse :80 beats/min
´m Respiration :22 breaths/ min ´m Respiration :20 breaths/ min ´m Respiration :18 breaths/ min
´m Blood pressure : 120/80 mmhg ´m Blood pressure : 110/70 mmhg ´m Blood pressure : 110/80 mmhg
’m Height : 156 cm ’m Height : 160cm ’m Height : 155 cm
’m Weight : 80 kg ’m Weight : 60 kg ’m Weight : 68 kg
’m BMI : 33( obese) ’m BMI : 23(normal) ’m BMI : 28(overweight)
’m Body built : heavily built ’m Body built : moderately built ’m Body built : heavily built
’m Nourishment: well nourished ’m Nourishment: well nourished ’m Nourishment: well nourished
’m Dependency status : partially ’m Dependency status : partially ’m Dependency status : partially
dependent dependent dependent
’m Sensorium : alert & conscious ’m Sensorium : alert & conscious ’m Sensorium : alert & conscious



The skin is warm to touch. Periphery is The skin is warm to touch. Periphery is The skin is warm to touch. Periphery is
warm There is no lesion or masses. The warm There is no lesion or masses. The warm There is no lesion or masses. The
skin texture is normal. No hyper or hypo skin texture is normal. No hyper or hypo skin texture is normal. No hyper or
pigmentation. pigmentation. hypo pigmentation.
Temperature: 98.6 0 F. Temperature: 98.6 0 F. Temperature: 98.6 0 F.

The hair is black in color and equally The hair is black in color and equally The hair is black in color and equally
. distributed. No hair loss or pediculosis. distributed. No hair loss or pediculosis. distributed. No hair loss or pediculosis.
c3 No lesions or masses over the scalp. No No lesions or masses over the scalp. No No lesions or masses over the scalp. No
c asymmetry and involuntary movements asymmetry and involuntary movements asymmetry and involuntary movements
of faces. of faces. of faces.

Vyelids are healthy without drooping or Vyelids are healthy without drooping or Vyelids are healthy without drooping or
edema. Conjunctiva is pink in color and edema. Conjunctiva is pink in color and edema. Conjunctiva is pink in color and
sclera is white in color. Visible blood sclera is white in color. Visible blood sclera is white in color. Visible blood
 vessels are present over the conjunctiva. vessels are present over the conjunctiva. vessels are present over the
Pupils are equally responding to light. Pupils are equally responding to light. conjunctiva. Pupils are equally
Visual acuity is normal. Visual acuity is normal. responding to light. Visual acuity is
normal.

No hearing aids are used. Both the ears No hearing aids are used. Both the ears No hearing aids are used. Both the ears
 are placed symmetrically. Pinna is in are placed symmetrically. Pinna is in are placed symmetrically. Pinna is in
alignment. No ear discharge, foreign alignment. No ear discharge, foreign alignment. No ear discharge, foreign
bodies are present. Some wax collection bodies are present. Some wax collection bodies are present. Some wax
is present in the ear canal. is present in the ear canal. collection is present in the ear canal.
Weber͛s Test and Rinne͛s Test are Weber͛s Test and Rinne͛s Test are Weber͛s Test and Rinne͛s Test are
normal. normal. normal.


No nasal discharge is present. Both the No nasal discharge is present. Both the No nasal discharge is present. Both the

 
 nares are symmetrically placed. There is nares are symmetrically placed. There is nares are symmetrically placed. There is

  no deviation of septum, masses or no deviation of septum, masses or no deviation of septum, masses or
lesions. Sinuses are palpated and there lesions. Sinuses are palpated and there is lesions. Sinuses are palpated and there
is no tenderness or pain. no tenderness or pain. is no tenderness or pain.


No signs of dehydration are present. No signs of dehydration are present. Oral No signs of dehydration are present.

 Oral hygiene is adequate. Lips are moist. hygiene is adequate. Lips are moist. Oral hygiene is adequate. Lips are
Tongue is not coated. Teeth are in Tongue is not coated. Teeth are in moist. Tongue is not coated. Teeth are
alignment. No ulcers are present. Tonsils alignment. No ulcers are present. Tonsils in alignment. No ulcers are present.
are not enlarged. are not enlarged. Tonsils are not enlarged.



c Trachea is in position and there is no Trachea is in position and there is no Trachea is in position and there is no
enlargement of lymph nodes or thyroid enlargement of lymph nodes or thyroid enlargement of lymph nodes or thyroid
 gland. No bruits are heard over the gland. No bruits are heard over the gland. No bruits are heard over the
thyroid gland. thyroid gland. thyroid gland.


 )   )   ) 
RR-22/min. No congenital deformities RR-22/min. No congenital deformities are RR-22/min. No congenital deformities
 4 are present. AP diameter is half the present. AP diameter is half the lateral are present. AP diameter is half the
lateral diameter. Normal shape & diameter. Normal shape & symmetry. lateral diameter. Normal shape &
symmetry.  symmetry.
 No tenderness or masses are present. 
No tenderness or masses are present. ")! No tenderness or masses are present.
")! Resonance sound is heard all over the ")!
Resonance sound is heard all over the lungs except over the heart. Resonance sound is heard all over the
lungs except over the heart. !)! lungs except over the heart.
!)! Bronchial, broncho-vesicular and !)!
Bronchial, broncho-vesicular and vesicular sounds are heard. No Bronchial, broncho-vesicular and
vesicular sounds are heard. No adventititious sound. vesicular sounds are heard. No
adventititious sound. adventititious sound.



 )   )   ) 
No visible apex pulsations, no JVP No visible apex pulsations, no JVP No visible apex pulsations, no JVP
 
 pulsations. Normal capillary refill. No pulsations. Normal capillary refill. No pulsations. Normal capillary refill. No
 c varicose veins, cyanosis. varicose veins, cyanosis. varicose veins, cyanosis.
   
Peripheral pulses well felt. No thrills or Peripheral pulses well felt. No thrills or Peripheral pulses well felt. No thrills or
vibrations. vibrations. vibrations.
!)! !)! !)!
S1 and s2 is heard at the apex and base S1 and s2 is heard at the apex and base S1 and s2 is heard at the apex and base
of the heart respectively. No murmurs of the heart respectively. No murmurs of the heart respectively. No murmurs
are heard. are heard. are heard.



Abdominal contour is round. Abdominal Abdominal contour is round. Abdominal Abdominal contour is round.


pulsations are not felt. Bowel pulsations are not felt. Bowel elimination Abdominal pulsations are not felt.
elimination pattern is normal. pattern is normal. Bowel elimination pattern is normal.
No Pain or tenderness while palpating. No Pain or tenderness while palpating. No Pain or tenderness while palpating.
Normal bowel sounds. Normal bowel sounds. Normal bowel sounds.




 )   )   ) 
c 
 Back: no abnormal curvature. Back: no abnormal curvature. Back: no abnormal curvature.
4
 altered gait present altered gait present altered gait present
stiff posture, loss of lumbar lordosis stiff posture, loss of lumbar lordosis stiff posture, loss of lumbar lordosis
present. present. present.
Vxtremities: normal length, no Vxtremities: normal length, no Vxtremities: normal length, no
deformities. deformities. deformities.
Normal ROM in the upper extremities. Normal ROM in the upper extremities. Normal ROM in the upper extremities.
Restricted ROM in the lower limbs. Restricted ROM in the lower limbs. Restricted ROM in the lower limbs.
Unable to bend forward. Unable to bend forward. Unable to bend forward.
Decreased muscle strength in the right Decreased muscle strength in the right Decreased muscle strength in the right
leg. leg. leg.
No cyanosis or clubbing. Normal No cyanosis or clubbing. Normal capillary No cyanosis or clubbing. Normal
capillary refill. refill. capillary refill.
     
No swelling or masses. No swelling or masses. No swelling or masses.
Tenderness present over L4-L5. Tenderness present over L3-L5. Tenderness present over L4-L5.
Normal muscle tone. Normal muscle tone. Normal muscle tone.
"#, #  "#, #  "#, # 
RTV 30 RTV 40 RTV 40
LTV 80 LTV 90 LTV 80
#! : POSITIVV ON RT SIDV #! : POSITIVV ON RT SIDV #! : POSITIVV ON RT SIDV

!"#) %  
!"#) %  
!"#) %  
Motor weakness: nil Motor weakness: nil Motor weakness: nil
 Loss of reflexes: nil Loss of reflexes: nil Loss of reflexes: nil
Sensory loss: Tingling and numbness of Sensory loss: Paresthesia present over Sensory loss: Tingling and numbness
the right lower limb. right leg. over sole of right foot



 c
Oriented to time, place and person.
 c  c Memory is intact. Pattern and content

  2c Oriented to time, place and person. Oriented to time, place and person. of speech is normal.
 
Memory is intact. Pattern and content of Memory is intact. Pattern and content of Sensation & motor functioning
speech is normal. speech is normal. Adequate sensation to pain, touch, heat
Sensation & motor functioning Sensation & motor functioning and cold. No abnormal movements.
Adequate sensation to pain, touch, heat Adequate sensation to pain, touch, heat Muscle tone and muscle strength has
and cold. No abnormal movements. and cold. No abnormal movements. decreased.
Muscle tone and muscle strength has Muscle tone and muscle strength has Cerebellar functioning
decreased. decreased. Fine coordination of hands.
Cerebellar functioning Cerebellar functioning Reflexes
Fine coordination of hands. Fine coordination of hands. All the reflexes are normal like corneal,
Reflexes Reflexes deep and superficial reflexes
All the reflexes are normal like corneal, All the reflexes are normal like corneal,
deep and superficial reflexes. deep and superficial reflexes

 2


". ,£, 
"  50
". !)5-


 

Hb 12-15 gm/dl 12.4 gm/dl 13.1 gm/dl 12.2 gm/dl

Hct 36-46% 37.4% 36.6% 35.4%
RBC count 3.80-4.80 million/cumm 4.22 million/ cumm 4.03 million/cumm 8600 cells/cumm
Total WBC 4000-10,000 cells/cumm 6300 cells/cummm 9900 cells/cumm 2,47,000 cells/cumm
Platelet 1.5-4 lakh cells/cumm 3,05,000 cells/cummm 2,91,000 cells/cumm 16 mm/hr
VSR 0-20 mm/hr 33 mm/hr 07 mm/hr

PP glucose 90-140 mg/dl 97 mg/dl 85 mg/dl 120 mg/dl

Urea 8-35 mg/dl 17 mg/dl 13 mg/dl 30 mg/dl
Creatinine 0.6-1.6 mg/dl 0.7 mg/dl 0.7 mg/dl 0.6 mg/dl
Sodium 130-143 mVq/L 136 mVq/L 139 mVq/L 138 mVq/L
Potassium 3.5-5 mVq/L 4.4 mVq/L 4.1 mVq/L 3.6 mVq/L

THROID PROFILV:
T3 0.8-2 ng/ml 1.33 ng/ml
T4 4.5-12 ug/dl 11.64 ug/dl
TSH 0.3-5 UIU/ML 0.035 UIU/ML
LIVVR FUNCTION TVST:
Total Bilirubin 0.2-1.3 mg/dl 0.2 mg/dl 0.3 mg/dl
Direct Bilirubin 0.0-0.4 mg/dl 0.1 mg/dl 0.1 mg/dl
Total protein 6-8 g/dl 6.4 g/dl 7.3 g/dl
Albumin 3.5-5 g/dl 3.8 g/dl 4.7 g/dl
Globulin 1.8-3.4 g/dl 2.60 g/dl 2.6 g/dl
AST 5-40 U/L 22 U/L 32 U/L
ALT 5-40 U/L 12 U/L 40 U/L
ALK Phosphatase 40-140 U/L 36 U/L 35 U/L

CHVST X-RAY No abnormality. No abnormality No osseous deformity.

MRI L5-S1 ACUTV IVDP L4-L5 DISC PROLAPSV L4-L5 DISC PROLAPSV.

STRAIGHT LVG TVST RTV 30 RTV 40 RTV 40

LTV 80 LTV 90 LTV 80

LASVGUVS TVST Positive on right side Positive on right side Positive on right side.



 

S.No Mrs. Shabhana Mrs. Pankaja Mrs. Ruckiya Action of Medicines

1. T. Aceclo plus bd T. Aceclo plus bd T. Aceclo plus bd Analgesic & anti pyretic

2. T. Pan 40 mg od T. Pan 40 mg od T. Pan 40 mg od Proton pump inhibitor

3. T. Sirdalaud 2mg hs T. Sirdalaud 2mg hs T. Sirdalaud 2mg hs Muscle relaxant

4. Cap. Myoril 8mg 0-1-0 Cap. Myoril 8mg 0-1-0 Cap. Myoril 8mg 0-1-0 Muscle relaxant

5. T. Meganeuron od T. Neugaba VR 75mg hs T. Meganeuron od Multi-vitamin

6. Inj Dynapar 75 mg IM sos Inj Dynapar 75 mg IM sos Inj Dynapar 75 mg IM sos Analgesic




  

 





 

INTRODUCTION:
A herniated intervertebral disk is one in which the gelatinous substance (nucleus pulposus) has protruded through the fibrocartilaginous
substance (annulus fibrosus).

The herniation of the intervertebral disk is a major cause of chronic back pain. Intervertebral disk disease is most common in the lumbar region,
followed by the cervical region. These two regions are the most flexible areas of the spine and the most susceptible to injury.

Most lumbar disk disorders develop at L4-L5 to S1. The C6-C7 and C5-C6 levels are the most commonly affected cervical regions. Thoracic
herniations are rare.

 - ( ,   )!  The spinal column, also called the vertebral column or backbone, is made up of 33 vertebrae that are separated
by spongy disks and classified into four distinct areas. The cervical area consists of seven vertebrae in the neck; the thoracic spine consists of 12
vertebrae in the back area; the lumbar spine consists of five vertebrae in the lower back area; five sacral bones (fused into one bone, the
sacrum); and four coccygeal bones (fused into one bone, the coccyx).

’m Lamina - the bony arch on the posterior part of the vertebrae that is over the spinal column.
’m Disks - soft pads between the bones of the vertebrae that allow the back to bend and act as shock absorbers.
’m Spinal Cord - the bundle of nerves that connects the brain to the rest of the body. The spinal cord passes through the center of the
vertebrae.
’m Spinal Nerves - nerves that connect the spinal cord to the rest of the body.
’m Muscles And Ligaments - support the spinal column, providing both strength and movement


c   
  

Discs consist of an outer annulus fibrosus, which surrounds the inner nucleus pulposus. The annulus fibrosus consists of several layers of
fibrocartilage. The strong annular fibers contain the nucleus pulposus and distribute pressure evenly across the disc. The nucleus pulposus
contains loose fibers suspended in a mucoprotein gel with the consistency of jelly. The nucleus of the disc acts as a shock absorber, absorbing
the impact of the body's daily activities and keeping the two vertebrae separated.

When one develops a prolapsed disc the nucleus pulposus is forced out of the disc and may put pressure on the nerve located near the disc.
This can give one the symptoms of sciatica.

T here is one disc between each pair of vertebrae, except for the first cervical segment, the atlas. The atlas is a ring around the roughly cone-
shaped extension of the axis (second cervical segment). The axis acts as a post around which the atlas can rotate, allowing the neck to swivel.
There are a total of thirty-three discs in the human spine, which are most commonly identified by specifying the particular vertebrae they
separate. For example, the disc between the fifth and sixth cervical vertabrae is designated "C5-6".
c      
  c 6   c

wm Trauma accounts for approximately 50% of disk herniations.

Vxamples of traumatic incidents include:

’m Lifting heavy objects while in flexed position(most common)

’m Falling on buttocks or back
’m Sudden jerk

wm The herniation syndrome can also occur with other degenerative processes such as osteoarthritis, ankylosing spondylosis.
wm Patients with congenital anomalies such as scoliosis are at risk for disk injury because of the malalignment of the vertebral column.
Ê
Ê

’m A herniated disk often results from trauma, degenerative disk disease or a combination of both.
’m The intervertebral disk consists of 3 parts:
´m The nucleus pulposus
´m The annulus fibrosus
´m The cartilaginous end plates.
’m The nucleus pulposus is a gelatinous mass that is surrounded by an outer laminated fibrocartilaginous structure, the annulus fibrosus.
’m The annulus fibrosus holds the vertebral bodies together and is attached to the vertebral body, the cartilage endplates and the vertebral
ligaments.
’m The intervertebral disk begans to lose its hydraulic and elastic properties with age as a result of decrease in collagen fibres and the water
content of the nucleus.
’m In the normal disk, the nucleus can accommodate a wide variety of movements and high compression loads.
’m With age and degeneration of the disk, the nucleus cannot tolerate and absorb stress.
’m As the nucleus begins to weaken with sufficient stress, the nucleus ruptures through the annulus fibrossus.

c"1) &5 Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical
vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula,[8] shoulder, arm, and hand. The nerves of the
cervical plexus and brachial plexus can be affected.[9]

,")) &) Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic
cervical disc herniations, while herniation of the other discs can mimic lumbar herniations. Lumbar disc herniations occur in the lower back, most
often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks,
thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected
nerve, causing symptoms of sciatica. The femoral nerve can also be affected and cause the patient to experience a numb, tingling feeling
throughout one or both legs and even feet or even a burning feeling in the hips and legs.
c

c 
 



Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can
range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions
served by affected nerve roots that are irritated or impinged by the herniated material.


 

’m Neurologic symptoms result from compression of the spinal cord or the spinal nerve roots or both.
’m Symptoms reflect the nerves affected.
’m Most herniated disks occur in the lumbar region.




´m Pain is the most characteristic symptom, generally in the lower back with radiation to the buttocks, thigh and leg.
´m The pain is aggravated by lifting and twisting and may vary in intensity, causing mild to severe discomfort.
 ´m The term sciatica is used to describe a syndrome of lumbar back pain that spreads down one leg to the ankle and is intensified with
coughing & sneezing.

   


´m Normal lumbar lordosis may be absent and one iliac crest may be elevated. It is accompanied by scoliosis and spasms of the
paravertebral muscles.
´m Abnormal posture may be evident as a mechanism to compensate for discomfort. In the standing position, the patient exhibits a
typically flattened lumbar spine.
´m The gait often is stiff.

  c 

´m Mild motor weakness of the foot, hamstring and quadriceps muscles may be evident.
´m Urinary and bowel functioning and sexual functioning may be altered.


 c 

´m Sensory impairements may include paresthesias and numbness of the legs and the foot.


 4 

The knee or ankle reflexes are absent or diminished.

cc   



Usually occurs at C5-C6 and C6-C7 interspaces.

´m Pain and stiffness in the neck, the top of the shoulders and the scapula.
´m Pain may also occur in the upper extremities and head accompanied by paresthesia and numbness of the upper extremities.


2
c
  

Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be
performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastases and space-occupying
lesions, as well as to evaluate the efficacy of potential treatments.

’m Physical examination: positive straight leg raise test(lasegue͛s sign):

Normally it is possible, when lying on the back, to move the straightened leg about 90` with only slight discomfort.

In a patient with a herniated disk, the stretching of the sciatic nerve during leg rising creates traction on the already inflamed or irritated nerve
roots, producing severe pain. Patients with sciatica will not be able to raise their legs beyond 20`-30`.

’m Spinal x-rays: may reveal narrowing of disk spaces and degenerative changes. X-Ray lumbo-sacral spine:

´m Narrowed disc spaces.

´m Loss of lumber lordosis.
´m Compensatory scoliosis.

’m Myelography: reveals presence of herniation and level of herniation. An x-ray of the spinal canal following injection of a contrast
material into the surrounding cerebrospinal fluid spaces. It will indicate the presence of herniation & the precise level of herniation, as
well as ruling out cord neoplasms.
’m CSF analysis: elevated protein levels.
’m Queckenstedt͛s test: may reveal partial or complete blockage of CSF in spinal sub-arachnoid space.
’m Vlectromyography: may reveal neural or muscle damage, may indicate specific nerve root affected.
’m Discography: may reveal herniation of specific disk, use is controversial.
’m CT scan: reveals herniated disk
´m Outline of soft tissue.
´m Bulging out disc..
’m MRI: A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It
can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues
even better than CAT scans.
ͻ Intervertebral disc protrusion.
ͻ Compression of nerve root.



The majority of herniated discs will heal themselves in about six weeks and do not require surgery

Treatment follows two approaches:

wm Initial treatment is conservative, aimed at rest and reducing stress.

wm If unsuccessful, surgery may be indicated.
’m & ": periods of bed rest on a firm mattress or back board in a semi fowler͛s position with knee slightly flexed. This relieves
compression of nerve roots and minimizes spinal flexion. Immobilize the spine to give the soft tissues time to heal and to reduce
inflammation in the surrounding tissues and the affected nerve roots.
’m ,-) ,"-: an extensive exercise program is prescribed to strengthen back and abdominal muscles. This is begun after the acute
symptoms have subsided.
’m ")  used to increase the intervertebral space, which relieves spasm.
´m Pelvic tractionV a canvas girdle is applied to pelvis and hips. Straps are attached to girdle and weights are attached.
´m Cervical halter traction: a canvas string is placed under the chin and occiput. Straps attached to the sling are attached to a pulley
and weight system.
 ´m Lumbar traction: patient is placed in a chest harness which is attached to a circolectric bed. The bed is elevated gradually and
traction is applied by means of the patient͛s own weight.
´m Cervical collar: supports the neck in a neutral or slightly flexed position.

!" : weight loss or weight control is recommended.

’m Restrict jerky movements.

´m Avoid- forward bending, lifting weight.
’m Hot moist compresses several times a day increases blood flow to the muscles and helps relax and reduce muscle spasm.

c


’m  #): acetaminophen and NSAID͛s ʹaspirin, ibuprofen, naproxen ;to relieve the pain during the acute stage.
’m
!) "% : carisoprodol, metaxalone, methocarbamol, to interrupt muscle spasm and to promote comfort.
’m &1 to relieve the anxity associated with the problem:

’ " "& (e.g. prednisone or methylprednisolone)- to treat the inflammation at the nerve roots and supporting tissues.

’ &!" 6)"   0)

2c

2



Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate
the pain and heal the disc herniation.

The goal of the surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse neurological deficits.

Microsurgical techniques make it possible to remove only the amount of tissue that is necessary, which preserves the integrity of normal tissue
better and imposes less trauma on the body.

’m 5)- The removal of the nuclear disk material of an intervertebral disc.

 ’m A spinal fusion may be performed if an unstable bomy mechanism is present. The spine is stabilized by creating an ankylosis(fusion) of c
ontiguous vertebrae with a bone graft from the patient͛s fibula or iliac crest or from donated cadaver bone. Metal fixation with rods,
plates or screws may be implanted at the time of spinal surgery to provide more stability and decrease vertebral motion.
’m ")! ! " &5)- The aim of percutaneous laser disc decompression (PLDD) is to vaporize a small portion of the nucleus
pulposus of an intervertebral disc, thereby reducing the volume of a diseased disc and the pressure within it.
’m  )- the traditional and most common procedure. It involves removal of the lamina, part of the posterior arch of the vertebra,
to gain access to part or all of the protruding disk to remove it.
’m  )- removal of part of lamina and part of the posterior arch of the vertebra.
’m "  )- "  - creation of a hole in the lamina of the vertebra.
’m " - removel of the intervertebral foramen to increase the space for exit of a spinal nerve, resulting in reduced pain,
compression and edema.

 
 c
c


’m Hematoma at the surgical site, resulting in cord compression and neurologic deficits. A change in the neurologic status (motor and
sensory) should be reported immediately-indicates hematoma formation
’m Recurrent or persistent pain after surgery. Severe pain not relieved by analgesics should be duly informed.
’m Cervical procedures:
Monitor for respiratory difficulty- may be due to injury to laryngeal nerve which may lead to hoarseness, inability to cough and remove
secretions.
’m Because the spinal canal may be entered during the surgery, there is potential for CSF leakage. Severe headache or leakage of CSF on the
dressing should be reported immediately. CSF appears as clear or yellow drainage on the dressing, has high glucose concentration & will
be positive for glucose in a dipstick test.
’m Frequent monitoring of peripheral neurologic signs of the extremities is a routine post operative nursing responsibility. Movement of
arms and legs and assessment of sensation should be unchanged when compared preop.
’m Loss of bowel & bladder function indicates nerve damage and should be reported immediately.
 DISCHARGV INSTRUCTIONS:

’m After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (2 to
4 weeks). As their regular use can cause constipation, drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk
of Magnesia) can be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).

’m If you had a fusion, do  use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen
sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing.
’m Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
’m Avoid sitting for long periods of time.
’m Do not lift anything heavier than 10 pounds (e.g., gallon of milk). Do not bend or twist at the waist.
’m Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing,
and loading/unloading the dishwasher, washer, or dryer.
’m Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise.
’m Do  smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.

)1-

’m You may need help with daily activities (e.g., dressing, bathing) for the first few days. Fatigue is common. Let pain be your guide.
’m Gradually return to your normal activities. Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily.
A physical therapy program may be recommended.

, #$ ) c"

’m You may shower 1 to 4 days after surgery. No tub baths, hot tubs, or swimming pools until recommended.
’m Staples or stitches, which remain in place when you go home, will need to be removed. Ask your surgeon or call the office to find out
when.

*,  c !" )"

 ’m If your temperature exceeds 101° F, or if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or
drainage.

)1"-  & "1 

Schedule a follow-up appointment with your surgeon for 2 weeks after surgery. Physical therapy may be necessary for some people.

The recovery time varies from 1 to 4 weeks depending on the underlying disease treated and your general health. You may feel pain at the site
of the incision. The original pain may not be completely relieved immediately after surgery. Aim to keep a positive attitude and diligently
perform your physical therapy exercises if prescribed.

Most people can return to work in 2 to 4 weeks or less with jobs that are not physically challenging. Others may need to wait at least 8 to 12
weeks to return to work for jobs that require heavy lifting or operating heavy machinery.

Recurrences of back pain are common. The key to avoiding recurrence is prevention:

’m Proper lifting techniques

’m Good posture during sitting, standing, moving, and sleeping
’m Appropriate exercise program
’m Healthy weight and lean body mass
’m A positive attitude and relaxation techniques (e.g., stress management)
’m No smoking

c
c 
 intervertebral disc prolapse is a significant public health disorder although its prevalence is difficult to quantify. Acute back pain
lasts less than 3 months, whereas chronic or degenerative disease has duration of 3 months or longer. Most back problems are related to disc
disease.

c





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". ,£ 
".  50
". !)5-


  c   

A herniated intervertebral disk is one in which the

gelatinous substance (nucleus pulposus) has protruded
through the fibrocartilaginous substance (annulus
fibrosus).

c      
  c
6   c

wm Trauma accounts for approximately 50% of disk

herniations.

Vxamples of traumatic incidents include:

’m Lifting heavy objects while in flexed position(most History of LSCS under Sub
common) History of heavy work. History of fall 6 months Arachnoid Block 14 years
’m Falling on buttocks or back before the onset of back.
’m Sudden jerk Overweight symptoms.
Overweight
wm The herniation syndrome can also occur with other History of heavy work
degenerative processes such as osteoarthritis, History of heavy work
ankylosing spondylosis.
wm Patients with congenital anomalies such as
scoliosis are at risk for disk injury because of the
 malalignment of the vertebral column.

c
c

 

´m Low back pain ´m Pain in the neck
Symptoms of a herniated disc can vary depending on the radiating to left ´m Lower back pain
location of the herniation and the types of soft tissue that ´m The pain is acute upper limb. radiating to right
become involved. They can range from little or no pain if in nature, sever ´m The neck pain leg till great toe.
the disc is the only tissue injured, to severe and in nature, was insidious in ´m Pain is moderate
unrelenting neck or low back pain that will radiate into the radiating to right onset and to severe in
regions served by affected nerve roots that are irritated or lower limb, more gradually nature, rapidly
impinged by the herniated material. during strenuous progressive. progressive, more
activities. ´m Paresthesia of in night,

  ´m Not being able to the left upper aggravated by
get up and walk limb. movement and
’m Neurologic symptoms result from compression of ´m Low back pain relieved by rest
the spinal cord or the spinal nerve roots or both. ´m Tingling and since last 4 and analgesic.
’m Symptoms reflect the nerves affected. numbness of the months, insidious ´m Tingling and
’m Most herniated disks occur in the lumbar region. right lower limb. in onset. numbness over

 ´m Radiation to sole of right foot,
´m Pain is the most characteristic symptom, generally right lower limb. more in the night
in the lower back with radiation to the buttocks, ´m Paresthesia and hence
thigh and leg. present over sleepless.
´m The pain is aggravated by lifting and twisting and right leg. ´m Aggravated during
may vary in intensity, causing mild to severe standing, walking
discomfort. and relieved by
´m The term sciatica is used to describe a syndrome of lying down.
lumbar back pain that spreads down one leg to the ´m Pain over buttocks
ankle and is intensified with coughing & sneezing. while sitting.
   

´m Normal lumbar lordosis may be absent and one
iliac crest may be elevated. It is accompanied by
scoliosis and spasms of the paravertebral muscles.
´m Abnormal posture may be evident as a mechanism
 to compensate for discomfort. In the standing
position, the patient exhibits a typically flattened
lumbar spine.
´m The gait often is stiff.

  c 
´m Mild motor weakness of the foot, hamstring and
quadriceps muscles may be evident.
´m Urinary and bowel functioning and sexual
functioning may be altered.

 c 
´m Sensory impairements may include paresthesias
and numbness of the legs and the foot.

 4 
The knee or ankle reflexes are absent or diminished.

cc   



Usually occurs at C5-C6 and C6-C7 interspaces.
´m Pain and stiffness in the neck, the top of the
shoulders and the scapula.
´m Pain may also occur in the upper extremities and
head accompanied by paresthesia and numbness
of the upper extremities.

2
c
  

Diagnosis is made by a practitioner based on the history,

symptoms, and physical examination. At some point in the
evaluation, tests may be performed to confirm or rule out
other causes of symptoms such as spondylolisthesis,
degeneration, tumors, metastases and space-occupying ´m Chest x-ray: ´m Chest x-ray:
lesions, as well as to evaluate the efficacy of potential No abnormality. ´m Chest x-ray: No osseous deformity.
treatments. No abnormality
’m ,-) %   positive straight leg raise
 test (lasegue͛s sign): ´m MRI:
Normally it is possible, when lying on the back, to move ´m MRI: L4-L5 DISC PROLAPSV.
the straightened leg about 90` with only slight discomfort. L5-S1 ACUTV IVDP ´m MRI:
In a patient with a herniated disk, the stretching of the L4-L5 DISC PROLAPSV ´m STRAIGHT LVG
sciatic nerve during leg rising creates traction on the ´m STRAIGHT LVG TVST:
already inflamed or irritated nerve roots, producing severe TVST: ´m STRAIGHT LVG
pain. Patients with sciatica will not be able to raise their TVST: RTV 40
legs beyond 20`-30`. RTV 30 LTV 80
LTV 80 RTV 50
’m 
   m
m
m

mm
m LTV 90 LASVGUVS TVST: positive

m
 m 

m
m
m LASVGUVS TVST: positive on right SIDV.
 

m
mm on right SIDV. Positive on right side

´m „
  m
m
m
´m mmmm m 
m
´m m 
m

m

’m
-#",-: reveals presence of herniation and

level of herniation. An x-ray of the spinal canal
following injection of a contrast material into the
surrounding cerebrospinal fluid spaces. It will
indicate the presence of herniation & the precise
level of herniation, as well as ruling out cord
neoplasms.
’m c   - elevated protein levels.
’m *!)5 &7 : may reveal partial or
complete blockage of CSF in spinal sub-arachnoid
space.
’m )"-#",- may reveal neural or muscle
damage, may indicate specific nerve root affected.
’m )#",- may reveal herniation of specific
disk, use is controversial.
’m c )  reveals herniated disk
´m Outline of soft tissue.
 ´m Bulging out disc..
’m
 A diagnostic test that produces three-
dimensional images of body structures using
powerful magnets and computer technology. It
can show the spinal cord, nerve roots, and
surrounding areas, as well as enlargement,
degeneration, and tumors. It shows soft tissues
even better than CAT scans.
ͻ Intervertebral disc protrusion.
ͻ Compression of nerve root.




The majority of herniated discs will heal themselves in ´m Bed rest
about six weeks and do not require surgery ´m Bed rest ´m Bed rest ´m Pelvic traction
with 8 lbs.
"  (8 8 "), ´m Pelvic traction ´m Pelvic traction ´m Physical therapy
wm Initial treatment is conservative, aimed at rest and with 8 lbs. with 8 lbs.
reducing stress. ’m Moist heat
wm If unsuccessful, surgery may be indicated. ´m Physical therapy ´m Physical therapy ’m Intermittent
lumbar traction
’m Bed rest ’m Moist heat ’m Moist heat
’m Physical therapy ’m Intermittent ’m Intermittent
’m Traction: used to increase the intervertebral lumbar traction lumbar traction
space, which relieves spasm. Medications:
´m Pelvic traction Medications: Medications:
´m Cervical halter traction
´m Lumbar traction ´m T. Aceclo plus ´m T. Aceclo plus bd
´m Cervical collar bd ´m T. Aceclo plus
´m Restrict jerky movements. bd ´m T. Pan 40 mg od
´m Avoid- forward bending, lifting weight. ´m T. Pan 40 mg od
’m Hot moist compresses several times a day ´m T. Pan 40 mg od ´m T. Sirdalaud 2mg
´m T. Sirdalaud 2mg hs

c
 hs ´m T. Sirdalaud 2mg
’m Analgesics: acetaminophen and NSAID͛s ʹaspirin, hs ´m Cap. Myoril 8mg
 ibuprofen, naproxen ;to relieve the pain during ´m Cap. Myoril 8mg 0-1-0
the acute stage. 0-1-0 ´m Cap. Myoril 8mg
’m Muscle relaxants: carisoprodol, metaxalone, 0-1-0 ´m T. Meganeuron od
methocarbamol, to interrupt muscle spasm and to ´m T. Meganeuron
promote comfort. od ´m T. Neugaba VR ´m Inj Dynapar 75 mg
’m Sedatives to relieve the anxity associated with the 75mg hs IM sos
problem: ´m Inj Dynapar 75
’ Oral steroids (e.g. prednisone or mg IM sos ´m Inj Dynapar 75 ´m Vpidural steroid
methylprednisolone)- to treat the inflammation at the mg IM sos injection 80
nerve roots and supporting tissues. ´m Vpidural steroid
’ Vpidural (cortisone) injection injection 80 mg

2c

2



Surgery should only be considered as a last resort after all

conservative treatments (non-surgical therapy) have been
 !"#)  "1 
tried, that did not alleviate the pain and heal the disc & .
herniation.

 !"#)  "1 
 !"#)  "1 
The goal of the surgical treatment is to reduce the & .
pressure on the nerve root to relieve pain and reverse Planned for discectomy if
neurological deficits. conservative measures
Microsurgical techniques make it possible to remove only fail.
the amount of tissue that is necessary, which preserves
the integrity of normal tissue better and imposes less
trauma on the body.
’m 5)-
’m   (!
’m ")! ! " &))-
’m  )-
’m  )-
’m "  )- "  -
’m " -

 
2 2
 

 
 

 c
 


1.m Pain related to spinal cord and 1.m Pain related to spinal cord and 1.m Pain related to spinal cord and
or nerve compression, muscle or nerve compression, muscle or nerve compression, muscle
spasm. spasm. spasm.

2.m Impaired physical mobility 2.m Impaired physical mobility 2.m Impaired physical mobility
related to pain & discomfort: related to pain & discomfort: related to pain & discomfort:
muscle spasms, restrictive muscle spasms, restrictive muscle spasms, restrictive
therapies such as traction & therapies such as traction & therapies such as traction &
bed rest. bed rest. bed rest.
3.m Deficient knowledge
3.m Sleep disturbance related to regarding condition,
3.m Deficient knowledge pain and paresthesia. prognosis, treatment, self
regarding condition, care & discharge needs.
prognosis, treatment, self 4.m Deficient knowledge
care & discharge needs. regarding condition, 4.m High risk for complications
prognosis, treatment, self related to immobility &
4.m High risk for complications care & discharge needs. imposed bed rest.
related to immobility &
imposed bed rest. 5.m High risk for complications
related to immobility &
imposed bed rest.


 
 


 
c 
 c





 
 

 2  

2


Subjective Pain The Assess pain, location, duration, Assessed. She is having To determine the extent of
data: related patient precipitating factors, have patient severe pain. She rates pain and the effectiveness of
Patient says to spinal will rate pain on scale from 1-10. her pain as 8. selected interventions.
͞I am having cord verbali The
severe pain and or ze Maintain patient on bed rest as Kept the patient on A firm bed provides support patient
in my back͟. nerve reducti prescribed; if with lumbar problem- strict bed rest during to the spine; a semi fowler͛s verbalize
compres on in semi-fowler͛s position with knees the acute phase. position with knees slightly d slight
Objective sion, pain. slightly flexed, place firm back board flexed reduces pain and reduction
data: muscle under mattress. muscle spasms. in pain.
Walking with spasm. Limit activity during the acute She has
limp, phase. Provide rest periods; shorten been
guarding rest intervals & duration as client discharge
behavior, improves. d after
facial Traction reduces discomfort epidural
expression of Help patient to maintain traction as Put her on pelvic associated with spinal nerve steroid
pain. prescribed. traction with 8 lbs. compression. injection.

Instruct in logrolling technique for Instructed the patient It reduces flexion, twisting &
position change. to follow the strain on back.
technique.
Place needed items such as phone, Placed items within Vasy access reduces risk of
water within easy reach. easy reach. straining.
Individualized program can
Consult with physical therapist. Consulted with physio be implemented. Cold packs
Apply & monitor use & effects of dept. MH packs, ILT relieve muscle spasms. MH
cold/moist hot packs. given. packs increase circulation to
the affected muscles.
To relieve the inflammation
 Prepare the patient for epidural Vpidural steroid & reduce pain.
steroid injection. injection 80 mg given.
Muscle relaxants decreases
Administer narcotics, analgesics, Administered muscle spasms, NSAIDs
muscle relaxants and NSAIDS as T. Aceclo plus, T. decreases nerve root edema,
prescribed. Sirdalaud, Inj. Dynapar analgesics reduce pain.
IM SOS.

Subjective Impaire The Assess neurologic deficit and degree Assessed. She To determine the degree of
data: d patient of impairment; evaluate motor and complains of pain physical impairment &
Patient says͟ physical will be sensory loss and reflexes. radiating to right leg. effectiveness of She is
I am having mobility able to Presence of tingling & interventions. able to
pain on related maintai Maintain prescribed bed rest and paresthesia. get up
movement & to pain n/ traction, encourage proper body Put her on bed rest & Limits activities & reduces from the
am not able & improv alignment. pelvic traction with 8 stress on spine & vertebrae. bed & is
to do my discomf e the lbs. able to
ADLs. ort: strengt Maintain patient͛s safety and Maintained patient To reduce twisting & turning do her
Objective muscle h& position personal items so as to safety. movements. activities
data: spasms, functio minimize stressful physical of daily
Patient needs restricti n of movements. living.
help with her ve the Rest between activities
ADLs, her therapie affecte Vncourage adequate rest periods, Vncouraged adequate provides time for energy
facial s such d body especially before meals, other ADLs, rest periods. conservation and recovery.
expression as part. exercise sessions, and ambulationG
shows pain. traction
& bed Provide appropriate skin care and Provided appropriate To prevent complications of
rest. anti-embolic stockings; encourage skin care & taught deep immobility.
deep breathing and coughing breathing & coughing
exercises.Ͷto prevent exercises.
complications of immobility.
Prolonged immobility is
 Monitor for signs and symptoms of Monitored for associated with numerous
complications of immobility presence of DVT, skin complications.
breakdown etc.
Administer pain medications on a Client͛s anticipation of pain
regular schedule or 30 mins before can increase muscle tension.
painful procedures. Administered Medications can help relax
T. Aceclo plus, T. the client, enhance comfort
Sirdalaud, Inj. Dynapar & improve motivation to
IM SOS. increase activity.

Subjective
data: Deficien The Review disease process & prognosis. Reviewed the disease Knowledge & understanding Vxplained
Patient says͟I t patient Stress activity restrictions including process including the of the disease, prognosis, and the
don͛t know knowled will avoiding riding in a car for long activity restrictions. activity limitations help the patient
much about ge verbali periods, refrain from aggressive client to clarify & accept regarding
my condition regardin ze sports. current lifestyle changes. the
& what to do g unders disease
when I get conditio tanding Instruct in proper body mechanics & Instructed the patient condition
discharged. n,progn of her home exercises. Includes proper in proper body Proper body mechanics &
Objective osis, conditi posture, body mechanics for mechanics. reduce the risk of reinjuring discharge
data: treatme on, standing, sitting. the back & neck area. instructio
Patient asks nt, self progno ns. She
many care & sis & Discuss regarding medications, their Discussed regarding verbalize
questions & discharg treatm uses & side effects. the medications. Increases compliance & d
is eager to e needs. ent. reduces the risk of understa
learn about Recommend use of firm mattress & Instructed regarding complications. nding of
her small flat pillow under neck. Instruct the proper positioning. the
condition. on sleeping on side with knees Provides structural support & instructio
flexed. Avoid prone position. prevent hyper extension of ns.
the spine. These may
Discuss dietary needs & goals. Vncouraged patient to decrease muscle strain.
lose weight & maintain Constipation is a
a normal weight. complication of analgesic use
& immobility. Caloric
restriction promote weight
control or reduction & can
decrease pressure on disc
when obesity is aggravating
back pain.

Instruct the client to alternate hot & Instructed the patient Cold application reduces
cold application. to apply hot & cold nerve pain; MH packs
packs alternately. increases circulation to the
affected area.
Provide information about what Advised the patient to
symptoms need to be reported to report these signs & Timely report of signs &
doctor- sharp pain, loss of sensation, symptoms. symptoms for further
inability to walk & change in bowel evaluation & management
& bladder function. improves client outcomes.

Vncouraged the client

Vncourage the patient to ask to ask questions & Helps the client to have a
questions & clear the doubts. cleared her doubts. clear idea & clears
misunderstandings.
 Assess the patient͛s ability to do Assessed. The patient Assessment provides a The
Objective High risk The ADLs. has severe back pain baseline for further patient
data: for patient radiating to right leg. Is interventions. did not
Patient is on complic will partially dependent for develop
prolonged ations remain Vncourage the patient to do deep her ADLs. any
bed rest. related free breathing & coughing exercises. Prevents build up of complicat
to from Vncouraged the patient secretions, increases lung ions of
immobil compli Vncourage the patient to do ankle & to do deep breathing & expansion. Decreased chest immobilit
ity & cations leg exercises. coughing exercises. excursions and stasis of y.
imposed & Provided steam secretions are associated
bed demon Vncourage the patient to perform inhalation q 8 hrly. with immobility.
rest. strate log rolling technique while changing Prevents further damage to
behavi position. Vncouraged her to the neck & back muscles.
ors to perform log rolling
enable Provide back care & provide a technique.
resump wrinkle free bed. Frequent back care improves
tion of Provided back care & circulation & prevents skin
activiti inspected skin for any breakdown.
es. Vnforce strict bed rest during the break down. Provided a
acute phase. Start resumption of wrinkle free bed. Limits activities & reduces
activities gradually. Vnforced strict bed stress on spine & vertebrae.
rest. Gradual
Vncourage the patient to take fiber resumption of activities
rich diet. done. Constipation is a
Vncouraged patient to complication of analgesics &
consume fiber rich diet. immobility.
Monitor for signs and symptoms of
complications of immobility Prolonged immobility is
Monitored for associated with numerous
presence of DVT, skin complications eg. DVT,
breakdown etc. pneumonia, bed sore etc.


 c

 
 
 c





 
 

 2 c 

2


Subjective Pain The Assess pain, location, duration, Assessed. She is having To determine the extent of pain The
data: related patie precipitating factors, have patient severe pain. She rates and the effectiveness of patient
Patient says to spinal nt rate pain on scale from 1-10. her pain as 7. selected interventions. verbaliz
͞I am having cord and will ed
severe pain or nerve verb Maintain patient on bed rest as Kept the patient on A firm bed provides support to slight
in my back͟. compres alize prescribed; if with lumbar problem- strict bed rest during the spine; a semi fowler͛s reducti
sion, redu semi-fowler͛s position with knees the acute phase. position with knees slightly on in
Objective muscle ction slightly flexed, place firm back board flexed reduces pain and muscle pain.
data: spasm. in under mattress. spasms.
Walking with pain. Limit activity during the acute
limp, phase. Provide rest periods; shorten
guarding rest intervals & duration as client
behavior, improves. Put her on pelvic
facial traction with 8 lbs. Traction reduces discomfort
expression of Help patient to maintain traction as associated with spinal nerve
pain. prescribed. Instructed the patient to compression.
follow the technique.
Instruct in logrolling technique for Placed items within easy It reduces flexion, twisting &
position change. reach. strain on back.

Place needed items such as phone, Consulted with physio Vasy access reduces risk of
water within easy reach. dept. MH packs, ILT straining.
given.
Consult with physical therapist. Individualized program can be
Apply & monitor use & effects of implemented. Cold packs
cold/moist hot packs. Administered relieve muscle spasms. MH
T. Aceclo plus, T. packs increase circulation to the
Sirdalaud, Inj. Dynapar affected muscles.
 Administer narcotics, analgesics, IM SOS.
muscle relaxants and NSAIDS as Muscle relaxants decreases
prescribed. muscle spasms, NSAIDs
decreases nerve root edema,
analgesics reduce pain.

Subjective Impaire The Assess neurologic deficit and degree Assessed. She complains
data: d patie of impairment; evaluate motor and of pain radiating to right To determine the degree of
Patient says͟ physical nt sensory loss and reflexes. leg. Presence of tingling physical impairment &
I am having mobility will & paresthesia. effectiveness of interventions.
pain on related be
movement & to pain able Maintain prescribed bed rest and Put her on bed rest & She is
am not able & to traction, encourage proper body pelvic traction with 8 Limits activities & reduces stress able to
to do my discomf main alignment. lbs. on spine & vertebrae. get up
ADLs. ort: tain/ from
Objective muscle impr Maintain patient͛s safety and Maintained patient the bed
data: spasms, ove position personal items so as to safety. To reduce twisting & turning & is
Patient restrictiv the minimize stressful physical movements. able to
needs help e stren movements. do her
with her therapie gth & activiti
ADLs, her s such as funct Vncourage adequate rest periods, Vncouraged adequate Rest between activities provides es of
facial traction ion especially before meals, other ADLs, rest periods. time for energy conservation daily
expression & bed of exercise sessions, and ambulationG and recovery. living.
shows pain. rest. the
affec Provide appropriate skin care and Provided appropriate
ted anti-embolic stockings; encourage skin care & taught deep To prevent complications of
body deep breathing and coughing breathing & coughing immobility.
part. exercises.Ͷto prevent exercises.
complications of immobility.
Monitored for presence Prolonged immobility is
Monitor for signs and symptoms of of DVT, skin breakdown associated with numerous
complications of immobility etc. complications.
Administer pain medications on a Administered Client͛s anticipation of pain can
regular schedule or 30 mins before T. Aceclo plus, T. increase muscle tension.
 painful procedures. Sirdalaud, Inj. Dynapar Medications can help relax the
IM SOS. client, enhance comfort &
improve motivation to increase
activity.

Subjective Deficien Review disease process & prognosis.

data: t The Stress activity restrictions including Reviewed the disease Knowledge & understanding of
Patient says͟I knowled patie avoiding riding in a car for long process including the the disease, prognosis, and
don͛t know ge nt periods, refrain from aggressive activity restrictions. activity limitations help the
much about regardin Will sports. client to clarify & accept current
my condition g verb lifestyle changes.
& what to do conditio alize Instruct in proper body mechanics &
when I get n,progn unde home exercises. Includes proper Instructed the patient in
discharged. osis, rstan posture, body mechanics for proper body mechanics. Proper body mechanics reduce
Objective treatme ding standing, sitting. the risk of reinjuring the back &
data: nt, self of neck area. Vxplain
Patient asks care & her Discuss regarding medications, their ed the
many discharg condi uses & side effects. Discussed regarding the patient
questions & e needs. tion, medications. Increases compliance & reduces regardi
is eager to prog Recommend use of firm mattress & the risk of complications. ng the
learn about nosis small flat pillow under neck. Instruct Instructed regarding the disease
her & on sleeping on side with knees proper positioning. Provides structural support & conditi
condition. treat flexed. Avoid prone position. prevent hyper extension of the on &
ment spine. These may decrease dischar
. Discuss dietary needs & goals. Vncouraged patient to muscle strain. ge
lose weight & maintain Constipation is a complication of instruct
a normal weight. analgesic use & immobility. ions.
Caloric restriction promote She
weight control or reduction & verbaliz
can decrease pressure on disc ed
when obesity is aggravating underst
back pain. anding
Instruct the client to alternate hot & of the
cold application. Instructed the patient to Cold application reduces nerve instruct
 apply hot & cold packs pain; MH packs increases ions.
alternately. circulation to the affected area.
Provide information about what
symptoms need to be reported to Advised the patient to Timely report of signs &
doctor- sharp pain, loss of sensation, report these signs & symptoms for further evaluation
inability to walk & change in bowel symptoms. & management improves client
& bladder function. outcomes.

Vncourage the patient to ask

questions & clear the doubts. Vncouraged the client to Helps the client to have a clear
ask questions & cleared idea & clears
The her doubts. misunderstandings.
Subjective Sleep patie
data: disturba nt Assess the sleep pattern of the
Patient says͟ nce will patient, pain level. Patient says her sleep is Assessment provides a baseline
I am not able related achie disturbed due to pain for further interventions.
to sleep at to back ve & Instruct the patient not to sleep and paresthesia. Pain-8.
night due to pain and main during the day. Vngage in activities Instructed and advised Helps to improve sleep.
pain and paresthe tain during the day her to read books & talk
paresthesia. sia. norm with others.
al Maintain the patient on strict bed
sleep rest and traction. Maintained on pelvic Traction reduces discomfort
patte traction. associated with spinal nerve The
rn as Administer analgesics as and when compression patient
evide required. Administered T. aceclo Helps to relieve pain & muscle verbaliz
nced plus. Inj Dynapar sos. spasm. ed that
by Provide a soothing quiet her
verb environment. Provided a calm & quiet A calm & quiet environment pain
alizat environment. promotes sleep. has
ion. reduce
d & she
is able
to
sleep
Objective High risk The Assessed. The patient Assessment provides a baseline withou
data: for patie has severe back pain for further interventions. t much
Patient is on complic nt radiating to right leg. Is disturb
prolonged ations will partially dependent for ance.
bed rest. related rema Assess the patient͛s ability to do her ADLs. Prevents build up of secretions,
to in ADLs. increases lung expansion.
immobili free Vncouraged the patient Decreased chest excursions and
ty & from to do deep breathing & stasis of secretions are
imposed comp Vncourage the patient to do deep coughing exercises. associated with immobility.
bed rest. licati breathing & coughing exercises. Provided steam Prevents further damage to the
ons inhalation q 8 hrly. neck & back muscles.
& Vncourage the patient to do ankle &
dem leg exercises. Vncouraged her to
onstr perform log rolling Frequent back care improves
ate Vncourage the patient to perform technique. circulation & prevents skin
beha log rolling technique while changing breakdown.
viors position. Provided back care &
to inspected skin for any Limits activities & reduces stress The
enabl Provide back care & provide a break down. Provided a on spine & vertebrae. patient
e wrinkle free bed. wrinkle free bed. did not
resu Vnforced strict bed rest. develo
mpti Gradual resumption of Constipation is a complication of p any
on of Vnforce strict bed rest during the activities done. analgesics & immobility. complic
activi acute phase. Start resumption of Vncouraged patient to ations
ties. activities gradually. consume fiber rich diet. Prolonged immobility is of
associated with numerous immobi
Vncourage the patient to take fiber complications eg. DVT, lity.
rich diet. Monitored for presence pneumonia, bed sore etc
of DVT, skin breakdown
etc
Monitor for signs and symptoms of
complications of immobility.


 . 


 
c 
 c





 
 
 2  

 2


Subjective Pain The Assess pain, location, duration, Assessed. She is having To determine the extent of The
data: related patient precipitating factors, have patient severe pain. She rates pain and the effectiveness of patient
Patient to spinal will rate pain on scale from 1-10. her pain as 8. selected interventions. verbaliz
says ͞I am cord verbali ed
having and or ze Maintain patient on bed rest as Kept the patient on strict A firm bed provides support to slight
severe nerve reducti prescribed; if with lumbar problem- bed rest during the acute the spine; a semi fowler͛s reducti
pain in my compres on in semi-fowler͛s position with knees phase. position with knees slightly on in
back͟. sion, pain. slightly flexed, place firm back board flexed reduces pain and muscle pain.
muscle under mattress. spasms.
Objective spasm. Limit activity during the acute phase.
data: Provide rest periods; shorten rest
Walking intervals & duration as client
with limp, improves.
guarding Traction reduces discomfort
behavior, Help patient to maintain traction as Put her on pelvic traction associated with spinal nerve
facial prescribed. with 8 lbs. compression.
expression
of pain. Instruct in logrolling technique for Instructed the patient to It reduces flexion, twisting &
position change. follow the technique. strain on back.
Placed items within easy
Place needed items such as phone, reach. Vasy access reduces risk of
water within easy reach. straining.
Consulted with physio Individualized program can be
Consult with physical therapist. Apply dept. MH packs, ILT implemented. Cold packs
& monitor use & effects of given. relieve muscle spasms. MH
cold/moist hot packs. packs increase circulation to
the affected muscles.
Prepare the patient for epidural Vpidural steroid injection To relieve the inflammation &
 steroid injection. 80 mg given. reduce pain.

Administer narcotics, analgesics, Administered Muscle relaxants decreases

muscle relaxants and NSAIDS as T. Aceclo plus, T. muscle spasms, NSAIDs
prescribed. Sirdalaud, Inj. Dynapar decreases nerve root edema,
IM SOS. analgesics reduces pain.

Subjective Impaire Assess neurologic deficit and degree Assessed. She complains To determine the degree of
data: d The of impairment; evaluate motor and of pain radiating to right physical impairment &
Patient physical patient sensory loss and reflexes. leg. Presence of tingling effectiveness of interventions. She is
says͟ I am mobility will be & paresthesia. able to
having related able to Maintain prescribed bed rest and Put her on bed rest & Limits activities & reduces get up
pain on to pain maintai traction, encourage proper body pelvic traction with 8 lbs. stress on spine & vertebrae. from
movemen & n/ alignment. Maintained patient the bed
t & am not discomf improv safety. To reduce twisting & turning & is
able to do ort: e the Maintain patient͛s safety and movements. able to
my ADLs. muscle strengt position personal items so as to do her
Objective spasms, h& minimize stressful physical activiti
data: restricti functio movements. Vncouraged adequate Rest between activities es of
Patient ve n of rest periods. provides time for energy daily
needs therapie the Vncourage adequate rest periods, conservation and recovery. living.
help with s such affecte especially before meals, other ADLs,
her ADLs, as d body exercise sessions, and ambulationG Provided appropriate
her facial traction part. skin care & taught deep To prevent complications of
expression & bed Provide appropriate skin care and breathing & coughing immobility.
shows rest. anti-embolic stockings; encourage exercises.
pain. deep breathing and coughing
exercises.Ͷto prevent complications
of immobility. Prolonged immobility is
 Monitored for presence associated with numerous
Monitor for signs and symptoms of of DVT, skin breakdown complications.
complications of immobility etc.
Client͛s anticipation of pain can
Administer pain medications on a Administered increase muscle tension.
regular schedule or 30 mins before T. Aceclo plus, T. Medications can help relax the
painful procedures. Sirdalaud, Inj. Dynapar client, enhance comfort &
IM SOS. improve motivation to increase
activity.

Review disease process & prognosis. Reviewed the disease Knowledge & understanding of
Deficien The Stress activity restrictions including process including the the disease, prognosis, and Vxplain
t patient avoiding riding in a car for long activity restrictions. activity limitations help the ed the
Subjective knowled Will periods, refrain from aggressive client to clarify & accept patient
data: ge verbali sports. current lifestyle changes. regardi
Patient regardin ze ng the
says͟I g unders Instruct in proper body mechanics & Instructed the patient in disease
don͛t conditio tanding home exercises. Includes proper proper body mechanics. Proper body mechanics reduce conditi
know n,progn of her posture, body mechanics for the risk of reinjuring the back & on &
much osis, conditi standing, sitting. neck area. dischar
about my treatme on, ge
condition nt, self progno Discuss regarding medications, their Discussed regarding the Increases compliance & instruct
& what to care & sis & uses & side effects. medications. reduces the risk of ions.
do when I discharg treatm complications. She
get e needs. ent. Recommend use of firm mattress & Instructed regarding the verbaliz
discharged small flat pillow under neck. Instruct proper positioning. Provides structural support & ed
. on sleeping on side with knees prevent hyper extension of the underst
Objective flexed. Avoid prone position. spine. These may decrease anding
data: muscle strain. of the
Patient Discuss dietary needs & goals. Vncouraged patient to Constipation is a complication instruct
asks many lose weight & maintain a of analgesic use & immobility. ions.
questions normal weight. Caloric restriction promote
& is eager weight control or reduction &
to learn can decrease pressure on disc
about her when obesity is aggravating
condition. back pain.

Instruct the client to alternate hot & Instructed the patient to Cold application reduces nerve
cold application. apply hot & cold packs pain; MH packs increases
alternately. circulation to the affected area.

Provide information about what Advised the patient to Timely report of signs &
symptoms need to be reported to report these signs & symptoms for further
doctor- sharp pain, loss of sensation, symptoms. evaluation & management
inability to walk & change in bowel & improves client outcomes.
bladder function.

Vncouraged the client to Helps the client to have a clear

Vncourage the patient to ask ask questions & cleared idea & clears
questions & clear the doubts. her doubts. misunderstandings.

Objective Assess the patient͛s ability to do Assessment provides a baseline The

data: High risk The ADLs. Assessed. The patient has for further interventions. patient
Patient is for patient severe back pain did not
on complic will radiating to right leg. Is develo
prolonged ations remain Vncourage the patient to do deep partially dependent for Prevents build up of secretions, p any
bed rest. related free breathing & coughing exercises. her ADLs. increases lung expansion. complic
to from Decreased chest excursions ations
immobil compli Vncourage the patient to do ankle & Vncouraged the patient and stasis of secretions are of
ity & cations leg exercises. to do deep breathing & associated with immobility. immobi
imposed & coughing exercises. Prevents further damage to the lity.
bed demon Vncourage the patient to perform log Provided steam neck & back muscles.
rest. strate rolling technique while changing inhalation q 8 hrly.
behavi position.
ors to Vncouraged her to Frequent back care improves
enable Provide back care & provide a wrinkle perform log rolling circulation & prevents skin
resump free bed. technique. breakdown.
tion of
activiti Provided back care & Limits activities & reduces
es. Vnforce strict bed rest during the inspected skin for any stress on spine & vertebrae.
acute phase. Start resumption of break down. Provided a
activities gradually. wrinkle free bed.
Vnforced strict bed rest. Constipation is a complication
Vncourage the patient to take fiber Gradual resumption of of analgesics & immobility.
rich diet. activities done.
Vncouraged patient to Prolonged immobility is
consume fiber rich diet. associated with numerous
Monitor for signs and symptoms of complications eg. DVT,
complications of immobility pneumonia, bed sore etc
Monitored for presence
of DVT, skin breakdown
etc.

 c2 
' 
c


MRS SHABANA MRS PANKAJA MRS RUCKIYA

Patient was discharged after epidural steroid She was discharged and told to come back Patient was discharged after epidural steroid
injection. after 10 days for discectomy. injection.

Discharge instructions: Discharge instructions: Discharge instructions:

Recurrences of back pain are common. The Recurrences of back pain are common. The Recurrences of back pain are common. The
key to avoiding recurrence is prevention: key to avoiding recurrence is prevention: key to avoiding recurrence is prevention:

’m Proper lifting techniques ’m Proper lifting techniques ’m Proper lifting techniques

’m Good posture during sitting, standing, ’m Good posture during sitting, standing, ’m Good posture during sitting, standing,
moving, and sleeping moving, and sleeping moving, and sleeping
’m Appropriate exercise program ’m Appropriate exercise program ’m Appropriate exercise program
’m Healthy weight and lean body mass ’m Healthy weight and lean body mass ’m Healthy weight and lean body mass
’m A positive attitude and relaxation ’m A positive attitude and relaxation ’m A positive attitude and relaxation
techniques (e.g., stress management) techniques (e.g., stress management) techniques (e.g., stress management)
’m No smoking ’m No smoking ’m No smoking
’m Hot & cold application ’m Hot & cold application ’m Hot & cold application
’m High fiber diet ’m High fiber diet ’m High fiber diet
’m Not to sit or drive for long periods of ’m Not to sit or drive for long periods of ’m Not to sit or drive for long periods of
time time time

Take the medicines on time Take the medicines on time Take the medicines on time

Consult doctor in case of worsening signs & Consult doctor in case of worsening signs & Consult doctor in case of worsening signs &
symptoms symptoms symptoms
 2

1.m Harrison. Principle of internal Medicine. 17th ed. Vol II. Mc Graw Hill; 2008.
2.m Brunner and Suddarth. Textbook of Medical Surgical Nursing. 11 th ed. Lippincott Williams and Wilkins; 2008.
3.m Black J.M, Hawks J.H, Keene A.M. Medical Surgical Nursing: Clinical Management for positive outcomes. 6th ed. Saunders:2004.
4.m Davidson S .Davidson͛s Principles and practice of medicine.21st ed. Churchill Livingstone Vlsevier; 2010.
5.m Lewis S.M, Heitkemper M.M, Dirksen S.R. Medical Surgical Nursing: Assessment and Management of clinical problems. 6th ed.
Canada:Mosby;2004.
6.m Doenges M.V, Moorhouse M.F, Murr A.C. Nursing Care plan: Guidelines for individualizing client care across life span.8th ed.
Phildelphia:FA Davis company; 2005.p.
7.m en.wikipedia.org/wiki/Spinal_&)_herniation