Spinal Cord Injury, Complete, Motor Level C4 secondary to

Intradural Intramedullary Mass of T10, AIS-A

________________________

A Case Study
Presented to the Faculty of the
COLLEGE OF NURSING
________________________

In Partial Fulfillment
of the Requirements for the Subject
RELATED LEARNING EXPERIENCE
ORTHOPEDIC NURSING
________________________

Presented by:
Aberin, John Winston P.
Bernarno, Miyuki P.
Bonus, Charlotte Yvonne A.
Camua, Martin Louise
De Leon, Jasmine Joy
Gapasen, Ma. Sophia T.
Llavore, Alyner
Macalinao, Hanna Yumi B.
Marquez, Frinzes Allyn
Mendiola, Pauline Marinella I.

Presented to:
Prof. Phoebe P. Caisip, MAN, RN
Prof. Erlina Cruz, MAN, RN
Prof. John Paulo Calma,PhD, MAN, RN, LPT
Prof. Kimjay Rivera, PhD, MAN, RN, LPT
 CHAPTER I. THE PROBLEM AND ITS SETTINGS
OBJECTIVES OF THE CASE
A. General Objectives
The objective of this case presentation is to provide
comprehensive, evidence-based care for a patient with multiple
comorbidities, focusing on effective management of sepsis,
pressure injuries, infections, and impaired mobility to
improve patient outcomes and quality of life.

B. Specific Objectives
1. To assess the progression and healing of the sacral
pressure injury through regular wound evaluations.
2. To monitor for signs of infection and ensure optimal
infection control practices, especially in relation to TB
and urinary tract infections.
3. To manage the patient’s hypotension and tachycardia,
aiming for stable hemodynamic status.
4. To evaluate urinary output and manage neurogenic bladder
symptoms with appropriate catheter care.
5. To support bowel regularity and neurogenic bowel
function with scheduled bowel care interventions.
6. To facilitate functional mobility and muscle stimulation
in the upper and lower extremities to prevent muscle
atrophy and enhance patient comfort.

1
 INTRODUCTION
A. What is a Case Study?
A case study is a comprehensive examination of a specific
patient or a group of patients that focuses on their health
condition, the treatments they received, and the outcomes of
those treatments. This process includes collecting detailed
information through various methods, such as interviews,
observations, physical assessments, and reviewing medical
records. The goal is to gain a deeper understanding of the
disease process, the patients' responses to treatment, and the
effectiveness of the interventions used.

For future Registered Nurses (RNs), case studies serve as

essential learning tools. They allow students to apply
theoretical knowledge to real-world scenarios, enhancing
critical thinking, clinical reasoning, and decision-making
skills. By analyzing case studies, nursing students gain
insight into the complexities of patient care, learn to
develop and implement effective care plans, and improve their
ability to provide patient-centered care. This hands-on
experience is vital for preparing nursing students for the
challenges they will face in clinical practice, ensuring that
they can deliver high-quality care throughout their nursing
careers. Case studies not only enrich the educational
experience but also help cultivate the skills necessary for
successful nursing practice in diverse healthcare settings.

B. Introduction about the Case

This case study focuses on a patient with multiple
complex health issues, including a sacral pressure injury,
sepsis, and tuberculosis (TB) orchitis. The patient’s medical
history reveals significant challenges, including a Stage IV
sacral pressure injury that has shown partial healing to Stage
III, indicating progress but still requiring careful
management. The patient has experienced complications such as
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a urinary tract infection and a fistula between the bladder
and scrotum, leading to ongoing concerns about infection and
urinary function.

Currently, the patient is being monitored for vital

signs, including blood pressure and heart rate, which have
shown fluctuations during the course of treatment. This case
provides an opportunity to explore the intricacies of patient
care, including wound management, infection control, and
supportive therapies. It highlights the importance of a
multidisciplinary approach in addressing the various aspects
of the patient’s health.

Through this case study, nursing students and

professionals can gain insights into the application of
theoretical knowledge in clinical settings. It serves as a
platform for developing critical thinking and decision-making
skills while emphasizing the importance of patient-centered
care in managing complex health conditions. By examining this
case, we aim to understand the challenges faced in nursing
practice and identify strategies for delivering effective care
to patients with similar profiles.

C. Incidence (International-WHO; Local-DOH)

In 2024, spinal cord injuries (SCI) remain a significant
global health issue, with the World Health Organization
estimating 250,000 to 500,000 new cases each year (World
Health Organization, 2024). In the Philippines, the Department
of Health reports approximately 11,000 new cases annually,
primarily due to road traffic accidents, falls, and violence
(Philippine Department of Health, 2024). The average age of
injury has increased to 43 years, predominantly affecting
males, highlighting the need for targeted interventions and
public awareness to improve outcomes for those affected
(Spinal Cord Injury Association, 2024).
3
D. Theoretical Framework
For this nursing case study, the Orem's Self-Care Deficit
Theory serves as the guiding theoretical framework. Orem's
theory emphasizes the importance of patient self-care and the
role of nurses in supporting individuals who cannot fully care
for themselves due to health conditions. In the context of our
patient with spinal cord injury and associated complications,
this theory is particularly relevant as it highlights the
challenges faced in self-care activities, such as mobility,
hygiene, and managing urinary and bowel functions. The
patient’s inability to move both upper and lower extremities
necessitates a comprehensive nursing approach that focuses on
assessing self-care deficits, providing necessary
interventions, and educating both the patient and caregivers
about adaptive strategies to promote independence as much as
possible.

Orem's theory encourages nurses to evaluate the patient's

environment and the influence it has on their ability to
perform self-care. This case involves complex issues such as
sepsis secondary to a sacral pressure injury, neurogenic
bladder, and urinary tract infections, which further
complicate the patient's self-care capabilities. By applying
Orem's framework, nursing interventions can be tailored to
address these specific needs, emphasizing the importance of
preventing complications and promoting healing. Through
careful assessment, planning, and implementation of
personalized care strategies, nurses can empower the patient
to regain control over their health and improve their quality
of life, ultimately working towards restoring their self-care
abilities.

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E. Review of Related Literature and Studies
Recent research has highlighted the role of
neuroinflammation in both worsening and potentially aiding
recovery after SCI. A study by David et al. (2022) underscores
that controlling inflammation in the spinal cord post-injury
can enhance neural repair. Anti-inflammatory interventions
during the early stages of SCI were shown to reduce secondary
injuries, which may prevent further neuronal loss and improve
outcomes. However, the exact timing and type of intervention
remain crucial for effective treatment (David, S., & Kroner,
A., 2022).

Advances in regenerative medicine, especially stem cell

therapy, offer promise for SCI recovery. A systematic review
by Lee et al. (2021) highlights that mesenchymal stem cells,
when transplanted into the injured spinal cord, could promote
axonal regrowth and improve functional outcomes. However, the
study notes challenges such as immune rejection and
inconsistent results across cases, suggesting that more
research is needed to optimize stem cell therapy protocols for
SCI (Lee, B., et al., 2021).

Rehabilitation efforts have a profound impact on the

quality of life in SCI patients. A study by Zhang and Chen
(2023) discusses how tailored physical therapy, combined with
psychological support, can significantly improve motor skills,
reduce depression, and increase social integration among SCI
patients. The authors argue that an integrated rehabilitation
approach involving both physical and mental support is
essential for long-term recovery and overall well-being in SCI
cases (Zhang, T., & Chen, L., 2023).

Anderson et al. (2020) conducted a controlled trial

assessing the effectiveness of neuroprotective agents in
reducing damage post-SCI. They tested agents like riluzole and

5
methylprednisolone on SCI patients and found a measurable
improvement in functional outcomes within the first six months
post-injury. The study provides insights into pharmacological
approaches to limit secondary damage following SCI (Anderson,
M., et al., 2020).

A comparative study by Patel and Reddy (2021) examined

different spinal cord stimulation techniques to alleviate
chronic pain and enhance mobility post-SCI. They concluded
that newer, high-frequency stimulation techniques offered
better pain relief and reduced spasticity compared to
traditional methods. These findings support SCS as a viable
adjunct to improve life quality in SCI patients (Patel, S., &
Reddy, K., 2021).

Psychological support plays a critical role in SCI

recovery. A 2022 study by Miller et al. evaluated the effects
of cognitive-behavioral therapy (CBT) in managing the mental
health of SCI patients. Results showed significant reductions
in depression, anxiety, and improved coping mechanisms.
Miller’s study stresses the importance of mental health as
part of SCI rehabilitation, highlighting that CBT and similar
therapies can greatly enhance patient resilience and
adaptation post-injury (Miller, J., et al., 2022).

6
 CLIENT’S PROFILE
A. Name : Patient ESR
B. Address : Quezon City
C. Age : 53 years old
D. Gender : Male
E. Religion : Roman Catholic
F. Occupation : None
G. Marital Status : Single
H. Number of Children : 0
I. Reason for Seeking Care : Decreased urine output
J. Date of Admission : July 18,2024
K. Ethnicity : Filipino
L. Educational Attainment : College Level
M. Admitting History : SCI Incomplete NL T12 to
Pott’s Disease
N. Admitting Diagnosis : Spinal Cord Injury, Complete,
Motor Lever C4 secondary to
Intradural Extramedullary Mass
of T10, AIS-A
O. Final Diagnosis : Sepsis secondary to Sacral
Pressure Injury, Urinary Tract
Infection, Scrotal Swelling
Secondary to TB orchitis,
Hypotension and Desaturation,
Neurogenic Bladder, Neurogenic
Bowel, Inability to move both
upper and lower extremities.

7
 SUBJECTIVE DATA COLLECTION
A. COMPREHENSIVE NURSING HEALTH HISTORY
A. History of Present Illness
The patient is a known case of Spinal Cord Injury,
Complete, Neurologic Level C4 secondary to Intradural
Extramedullary Mass of T10, AIS-A. He had also undergone an
Open Laminectomy and Excision Biopsy of Intramedullary Spinal
cord lesion T10 and Rapid Frozen Section last June 20, 2023,
and Pressure Injury Stage 2 Sacral Area-Healing; Debridement
of Sacral Ulcer last March 24, 2023, and Cerebrovascular
Disease Infarct, Left Cerebellar Peduncle (2018).

B. History of Past Illness

The patient mentioned had a known history of
Cerebrovascular Disease Infarct, Left Cerebellar Peduncle
(2018), Gout (2019), Acute Gastritis (2019), Tuberculous
Arthritis, Right- (March 2023), Hypertension Stage 1-
Controlled- 2019) and Hemorrhagic Cystitis with Right
Hydronephrosis (2019).

C. Family History

8
 B. GORDON’S FUNCTIONAL HEALTH PATTERNS
A. Health Preception-Health Management Pattern
The patient, a 53-year-old male with a history of gout
since 2019, perceives his health as relatively stable but has
required multiple hospitalizations, including two admissions
in 2023. He suffered a fall on an overpass staircase, which
led to injuries and subsequent complications. His first
admission in March 2023 lasted 7 months due to Pott’s disease,
treated with surgery to remove a non-cancerous 2.5 cm mass.
His second admission addressed bed sores and tuberculosis
orchitis. Currently, he has a sacral pressure injury healing
from stage IV to stage III, managed without antibiotics as he
awaits further TB-related guidance. The patient shows
compliance with medical management but has limited mobility
and requires support for daily activities.

B. Cognitive-Perceptual Pattern
The patient has a Glasgow Coma Scale (GCS) score of 11
(E4V1M6), indicating some cognitive impairment. He
demonstrates an awareness of his surroundings and can interact
to a degree, but his responses may be limited. There are no
other reports of sensory deficits, though the patient may
experience pain due to his injuries and pressure sores.

C. Self-Perception-Self-Concept Pattern
The patient may experience a compromised self-image due
to his health issues, particularly the visible sacral pressure
injury, dependence on a suprapubic catheter, and limited
mobility. These physical limitations and reliance on
caregivers for basic functions likely affect his comfort and
self-esteem. His prolonged hospital stays may also influence
his emotional well-being, leading to possible feelings of
isolation or frustration.

9
D. Role-Relationship Pattern
The patient, who has worked as a hotel front desk staff
for 36 years, likely had a strong role in the hospitality
industry. His long-standing position implies dedication and a
stable work history. However, he appears to lack family
support, which may impact his psychological and social health,
particularly given his need for assistance with mobility and
self-care.

E. Sexuality-Reproductive Pattern
At 53, the patient is likely concerned with changes in
his sexuality, especially given his diagnosis of TB orchitis
and resulting scrotal swelling, along with urine leakage due
to a fistula between the bladder and scrotum. These health
issues may contribute to dissatisfaction in his sexual health,
impacting his self-image and emotional state.

F. Value-Belief Pattern
The patient’s spiritual and moral beliefs are not
documented, but his longevity in a service role may suggest
values of dedication and resilience. His values may guide him
in coping with his current health challenges, though his lack
of family may influence his social or spiritual support
network

G. Nutritional-Metabolic Pattern
No specific dietary patterns are noted, though his
metabolic needs are likely higher due to wound healing and
infections. A 24-hour food recall and fluid intake record
would be beneficial to assess whether his nutritional intake
aligns with his needs for recovery and infection management.

10
H. Elimination Pattern
The patient uses a suprapubic catheter for urine drainage
due to a neurogenic bladder and fistula between the bladder
and scrotum. Urine output is stable at 1000-1500 ml daily,
though he experiences urine leakage. His bowel movements occur
every 1-2 days with aid, aligning with a neurogenic bowel
pattern.

I. Activity-Exercise Pattern
The patient’s physical activity is highly restricted due
to inability to move both upper and lower extremities. He
receives electrical stimulation (ES) therapy on various muscle
groups, and passive range of motion exercises are conducted on
his lower extremities. He likely relies on caregivers for all
mobility and does not engage in recreational activities due to
physical limitations.

J. Sleep-Rest Pattern
The patient may have trouble sleeping, especially if pain
from arthritis or bed sores keeps him awake. Checking how he
sleeps can help improve his rest, which is important for his
recovery.

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 C. ACTIVITIES OF DAILY LIVING
Activity Independent Dependent Patient’s
(1 Point) (0 Points) Status
Bathing Can wash Needs help 0 Points – The
themselves with washing patient likely
fully or only most or all of needs
needs help the body. assistance due
with hard-to- to limited
reach areas mobility and
inability to
move upper and
lower
extremities.
Dressing Can get Needs help 0 Points – Due
dressed getting to paralysis
independently, dressed or and limited
including fastening movement, the
putting on clothes. patient needs
shoes. assistance
with dressing.
Toileting Can use the Needs help 0 Points –
toilet using the Patient has
independently. toilet or neurogenic
cleaning up. bladder, is on
a suprapubic
catheter, and
needs
assistance.
Transferring Can move from Needs help 0 Points – Due
bed to chair moving from to inability
independently. bed to chair. to move upper
and lower
extremities,
the patient
requires
12
 assistance for
transferring.
Continence Has full May be 0 Points –
control over incontinent of Patient has
bladder and bowel or neurogenic
bowel. bladder. bladder and
bowel, with
catheter use
and assisted
bowel
movements.
Feeding Can feed Needs help 0 Points – The
themselves with feeding patient cannot
without help. or special feed himself
assistance. and requires
assistance.
Table 1.1 Activities of Daily Living

Scoring:
 6 Points = High independence
 0 Points = Very dependent
Total Score: 0 Points

This patient has 0 points, indicating that they are fully

dependent on assistance for daily activities.

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 OBJECTIVE DATA COLLECTION
GENERAL SURVEY
A. PHYSICAL APPEARANCE
The client is conscious throughout the assessment. Their
skin exhibits a light brown tone, though it appears notably
dry, with several visible skin ulcers indicating potential
areas of concern. Facial symmetry is compromised; the features
are asymmetrical, with noticeable drooping of the
mouth.Additionally, the client's physical condition is marked
by a thin frame, with protruding ribs that further emphasize a
lack of body mass and presents impaired mobility. These
observations collectively suggest significant challenges in
the client’s overall health and well-being, particularly in
relation to mobility and skin integrity.

B. BEHAVIOR
The patient exhibits an irritable mood, evident through a
consistent frown on their face. Their speech is impaired
requiring help through a relative. Despite these challenges,
the patient is appropriately dressed in a gown and is well-
groomed. There are no indications of poor hygiene and
neglect.Throughout the assessment, the patient maintains eye
contact, indicating engagement and a willingness to connect,
even amidst their discomfort. This combination of behaviors
paints a complex picture of a person grappling with mood
disturbances while still managing personal presentation
effectively.

14
 C. BODY MEASUREMENTS
 Height: 5’5 ft (165.10 cm)
 Weight: 50 kg
 BMI: 18.3 kg/m2
The BMI falls below normal range. (18.5-24.9). The BMI is
classified as underweight.

Date Blood Temperature Pulse Respiratory Oxygen

Pressure Rate Rate Saturation
10/28/ 90/60 36.9O C 96 BPM 22 BPM 97%
2024

15
 D. PHYSICAL EXAMINATION
Date Body Part Method Normal Actual Interpretation
Assessed Findings Findings
10/2 Hair and Inspection Hair is Hair is Normal. The
8/ Scalp evenly thinly hair is
2024 distribut distribu thinly
ed, no ted, no distributed,
presence presence but there is
of lice. of no indication
Scalp is infestat of
intact ion. infestation,
without Scalp suggesting
lesions, is. good scalp
scaling, Intact health. The
or without scalp itself
infestati lesions, is intact,
on or free from
scaling. lesions or
scaling,
which is a
positive
sign.
Head Inspection Head is Head is The head is
Palpation proportio proporti proportionate
nate, onate to and
symmetric the symmetrical,
al body, showing no
without symmetri lumps or
abnormali cal deformities,
ties, without which
lumps, or lumps or indicates
deformiti deformit normal
es ies cranial
development.
The facial
features are

16
 also
symmetrical
Eyes Inspection Symmetric Symmetri The
al w/o cal conjunctiva
drooping, without are pink and
conjuncti drooping moist, while
va is , the sclera
pink and conjunct are clear and
moist, iva. Is white,
sclera is pink and suggesting
white. moist, healthy eye
Smooth sclera function. The
and is patient
coordinat white. demonstrates
ed Smooth smooth and
movement. and coordinated
coordina movements,
ted indicating
movement intact motor
. function.

Ear and Inspection Ear is Ear is The ears are

nose Palpation symmetric symmetri symmetrical,
al cal with no
without without lesions or
lesions lesions discharge,
or or and the nose
discharge discharg is midline
, nose is e, nose without
midline is tenderness,
w/o midline indicating
tendernes without normal
s. tenderne structural
ss. integrity.
Mouth Inspection symmetric Asymmetr The lips show
al, Lips ical, some

17
 are lips are asymmetry due
moist, moist to the
without without patient’s
lesions lesions current
condition but
are moist and
free from
lesions
Neck Inspection Neck is Neck is The neck is
symmetric symmetri symmetrical
al cal and clear of
without without masses or
masses or masses swelling,
swelling or further
swelling indicating
normal
anatomy.
Abdomen Inspection Soft, Abdomen The abdomen
Palpation non- is soft, is soft, with
tender skin is intact skin,
intact, and the
umbilicu umbilicus is
s is in midline and
midline concave,
and suggesting no
concave abnormalities
in this area.
Extremitie Inspection Warm Extremit The
s Palpation extremiti ies have extremities
es with even exhibit an
brisk skin even skin
capillary tone and tone and are
refill, are warm warm to the
strong to touch, though
periphera touch, slightly dry,
l pulses. with which could

18
 Even skin slightly indicate a
tone. dry need for
skin. hydration. A
Strong strong
peripher peripheral
al pulse is
pulse. present,
There indicating
are good
presence circulation.
of
ulcers
in the
lower
extremit
ies.
Eyes Inspection Symmetric Symmetri The
al w/o cal conjunctiva
drooping, without are pink and
conjuncti drooping moist, while
va is , the sclera
pink and conjunct are clear and
moist, iva. Is white,
sclera is pink and suggesting
white. moist, healthy eye
Smooth sclera function. The
and is patient
coordinat white. demonstrates
ed Smooth smooth and
movement. and coordinated
coordina movements,
ted indicating
movement intact motor
. function.

19
20
 CHAPTER II. CASE DISCUSSION AND PRESENTATIONS
CASE DISCUSSION
The case involves a 53-year-old male patient presenting
with multiple complex medical issues, including sepsis
secondary to a stage III sacral pressure injury, urinary tract
infection, and scrotal swelling due to TB orchitis. The
patient's sacral wound measures 10x9 cm with a pinkish wound
bed and rolled edges, showing signs of healing without
discharge or eschar. His white blood cell count is stable at
9.84, and he recently completed a course of meropenem on
9/14/24. The clinical team is currently awaiting a referral
response from TB Dots for antibiotic guidance, which is
crucial due to the potential interplay between his infections
and TB. The patient is neurologically assessed with a Glasgow
Coma Scale (GCS) of 11 and has required support for urinary
management, indicated by a suprapubic catheter. Additionally,
he demonstrates neurogenic bowel function with bowel movements
occurring every 1-2 days.

The patient also presents with hypotension, having

experienced blood pressure as low as 90/60 mmHg, necessitating
the initiation of a titrated norepinephrine drip to stabilize
his condition. While his heart rate has improved to 90-98 bpm,
ongoing monitoring for signs of desaturation is essential. He
remains completely dependent on caregivers for mobility, with
passive range of motion exercises being implemented to
maintain muscle integrity and circulation. The complexity of
this case highlights the importance of a multidisciplinary
approach to manage the patient's infections, wound care, and
neurological impairments effectively. Continuous assessment
and tailored interventions will be vital to optimize the
patient's recovery and overall quality of life.

21
 REVIEW OF ANATOMY AND PHYSIOLOGY

A. ANATOMY
The spinal cord is a vital part of the central nervous
system (CNS) that runs within the vertebral column, extending
from the medulla oblongata at the base of the brain to the
lumbar region, typically ending at the conus medullaris around
L1-L2 in adults.

The spinal cord is divided into 31 segments, each giving

rise to a pair of spinal nerves. These segments are
categorized as follows:
Cervical (C1-C8): 8 pairs
Thoracic (T1-T12): 12 pairs
Lumbar (L1-L5): 5 pairs
Sacral (S1-S5): 5 pairs
Coccygeal (Co1): 1 pair

22
 The spinal cord is divided into 4 regions,
 Cervical Region: Contains the first eight segments (C1-C8)
and innervates the upper limbs and neck.
 Thoracic Region: Comprises segments T1-T12, primarily
involved in innervating the torso and abdomen.
 Lumbar Region: Includes segments L1-L5, responsible for
innervating the lower limbs.
 Sacral Region: Contains S1-S5, responsible for innervating
pelvic organs and parts of the lower limbs.

For the spinal cord segments, the T1 segment is located

at the upper thoracic region of the spinal cord. It is
significant for the following reasons:
 Innervation: T1 primarily innervates the intercostal
muscles, contributing to respiration. It also provides
sensory innervation to the skin over the upper chest and
the medial aspect of the arm (via the medial cutaneous
nerve of the arm).
 Clinical Relevance: Damage to the T1 segment can affect the
upper limb and trunk, leading to weakness or loss of
function in the muscles supplied by this segment.

In a cross-section of the spinal cord,

 Gray Matter
 Composed of neuronal cell bodies, dendrites, and
unmyelinated axons, and is divided into:
 Anterior (Ventral) Horns: Contain motor neurons that
send signals to skeletal muscles.
 Posterior (Dorsal) Horns: Contain sensory neurons
that receive signals from the body.
 Lateral Horns: Present in thoracic and upper lumbar
regions, involved in autonomic functions.
 White Matter
 Composed if myelinated axons, organized into ascending
and descending tracts
23
  Ascending Tracts: Carry sensory information to the
brain (e.g., dorsal columns, spinothalamic tract).
 Descending Tracts: Carry motor commands from the
brain to the body (e.g., corticospinal tract,
extrapyramidal tracts).
 Meninges
 The spinal cord is protected by three layers of
membranes,
 Dura Mater: Tough, outer layer.
 Arachnoid Mater: Middle layer with a web-like
structure.
 Pia Mater: Innermost layer, closely adhering to the
spinal cord.
 Cerebrospinal Fluid (CSF)
 Located in the subarachnoid space, providing cushioning
and nutrients to the spinal cord

B. PHYSIOLOGY
The spinal cord is essential for transmitting sensory and
motor information between the brain and the peripheral nervous
system. It also plays a key role in reflex actions.

 Reflex Arcs
 The spinal cord mediates reflexes through reflex arcs,
which include:
 Receptor: Detects the stimulus.
 Sensory Neuron: Transmits the impulse to the spinal
cord.
 Integration Center: Processes the information in the
spinal cord.
 Motor Neuron: Carries the response from the spinal
cord to the effector.
 Effector: Muscle or gland that executes the response.
 Sensory Pathways
 Ascending tracts carry sensory information to the brain
24
  Dorsal Column-Medial Lemniscal Pathway: Transmits
fine touch, vibration, and proprioception.
 Spinothalamic Tract: Carries pain and temperature
sensations.
 Motor Pathways
 Descending tracts transmit motor commands from the brain
 Corticospinal Tract: Controls voluntary motor
movements, particularly in the limbs.
 Extrapyramidal Tracts: Involved in involuntary
movements and reflexes.
 Autonomic Functions
 The spinal cord manages autonomic functions,
particularly through sympathetic and parasympathetic
pathways in the thoracic and sacral regions. This
includes regulation of heart rate, blood pressure, and
digestive functions.

C. CLINICAL RELEVANCE
Spinal Cord Injuries can result in varying degrees of
motor and sensory deficits below the injury level, affecting
functions related to specific spinal cord segments. Specific
conditions are:
 Herniated Discs: Can compress spinal nerves, leading to
pain and weakness.
 Spinal Stenosis: Narrowing of the spinal canal can affect
spinal cord and nerve function.
 Syringomyelia: A cyst forms within the spinal cord,
potentially damaging nerve fibers.

PATHOPHYSIOLOGY
(BOOK BASED)
25
Image 2.1. Spinal Infections and Trauma by Sengupta Dilip K
and Pawar Uday M, 2021

26
 PATHOPHYSIOLOGY
(PATIENT-BASED)

Image 2.2 Spinal Cord Injury Pathophysiology

27
 CLINICAL MANIFESTATIONS
1. Motor and Sensory Disability
A. Paralysis or Weakness: The complete loss of all
motor functions below the point of injury happens in a
case of a complete injury, while an incomplete injury
leads to a partial motor loss.
B. Loss of Sensation: Depending upon the level at
which the injury has occurred, the patient might
become touchless, painless, temperatureless, and also
lose the sense that the body has regarding
positioning, known as proprioception.
C. Quadriplegia (Tetraplegia): Spinal cord injuries at
the level of cervical spine (C1–C8) lead to paralysis
of all four limbs, and higher cervical injuries may
also impact the muscles of respiration.
D. Paraplegia: Injuries at the levels of thoracic,
lumbar, or sacral lead to loss of function in the
lower limbs and, to a lesser degree, trunk muscles (if
thoracic).
2. Autonomic Dysregulation
A. Neurogenic Shock: Patients are likely to
experience hypotension, bradycardia, and vasodilation
at or above the level of injury due to loss of
sympathetic tone.
B. Autonomic Dysreflexia: Patients at a level of
injury above T6 may experience sudden and severe
hypertension with accompanying reflex bradycardia due
to stimuli at a level below the level of injury, such
as distension of the bladder or bowel.
C. Temperature Regulation: Patients are likely to be
unable to sweat or shiver below the level of injury
and will therefore be poor at controlling body
temperature.

28
 D. Cardiovascular Impairment: Hypotension,
orthostatic hypotension, and bradycardia are common
due to impaired autonomic function.
3. Respiratory Impairment
A. Cervical Spinal Injuries (C1–C4): These can result
in paralytic respiratory failure because of the
phrenic nerve (C3-C5) that controls the diaphragm.
Respiratory support may be needed.
B. Lower Cervical and Thoracic Spinal Injuries: These
will compromise intercostal and abdominal muscles,
leading to a weak cough and their inability to clear
secretions effectively, thus predisposing to
respiratory infections.
4. Bowel and Bladder Impairment
A. Neurogenic Bladder: The patient may not be able to
control the bladder and loses control resulting in
urinary retention, incontinence or recurrent UTIs.
B. Neurogenic Bowel: The patient may not control
bowel functions voluntarily resulting in
constipation, incontinence or impaction
5. Spasticity and Changes in Muscle Tonicity
A. Neuropathic Pain: This is a form of pain resulting
from the insult to the spinal cord or nerve roots.
The neuropathic pain is typically burning, tingling,
or shooting.
B. Musculoskeletal Pain: This type of pain often
results from overuse in certain muscles. Most
individuals with assistive devices tend to develop
it.
6. Pressure Injuries
Due to impaired sensation and immobility,
pressure ulcers are more common among SCI patients,
especially on bony prominences like the sacrum and
heels.

29
7. Psychosocial Effects
The psyche is immensely influenced as the patient
feels discomfort of independence and the sense of self-
image through isolation threats that may cause danger
from feelings of depression, anxiety, and adjustment
disorder.

30
 RISK FACTORS
SCI is highly common in the age bracket of 16 to 30 years
due to the increased participation in risk-prone activities.
Nevertheless, older adults aged 65 years and above also face a
higher risk from falls. The male gender faces a far greater
risk compared to the female gender since they represent
approximately 80% of SCIs, mainly due to the higher
involvement in risk-prone activities.

Seat belt failure, drunkenness, excessive speeding, and

distraction can increase the risk of encountering an MVA. Most
of these are SCI's common causes. Contact sports can be
dangerous. Other activities that have a higher potential for
injury include football, rugby, wrestling, gymnastics or horse
riding. Even in equipment use. Alcohol and drug abuse often
accompanies an SCI because they impair judgment and
coordination, leading to falls, accidents, and other injuries.

Construction, heavy machinery use, and other jobs

involving labor involve dangers because of a risk for falling,
machinery accidents, or a blow from a heavy object. Their
personnel is under exposure due to injuries resulting from
their combat, falling, blasting, and accidental incidents.

The weak safety rules at their respective places of work

and unorganized use of safety kits or protective gears which
tend to contribute accidental injuries. Spinal injuries
primarily resulted due to winter sport performances that
involve skiing as well as snowboarding and, in general,
through dives into shallow water together with off-roading
practices.

A leading condition in the elderly characterized by bone

weakening, predisposing to spinal fractures and consequent
SCI. In the elderly, severe spinal arthritis or degenerative
spinal disease leads to compression or injury of the spinal

31
cord. Spinal tuberculosis, abscesses, or tumors lead to
weakening of the spine with a high probability of injury to
the spinal cord on minor trauma.

Past history of injuries to the neck or the back has

predisposed one to a risk of injury to the spine, more so to
activities that create stress in the spine

32
 PREVENTIONS
Always seatbelt when you are a driver or an occupant in a
car. Strapped seatbelts minimize the chances of SCIs because
they decrease the opportunity to be flung off from the car. Do
not attempt to drive drunk or with any other controlled
substance or illegal drug; do not try to send texts and use
other such distractions as well. Use appropriate car seats and
boosters for children. Install them correctly.

Installing handrails, grab bars, and non-slip mats in

bathrooms and stairways may prevent falls. Strength and
balance training in physical exercise greatly reduces the risk
of fall in older persons. The passage ways should be kept
clear of objects, and the floor should be dry and brightly lit
to prevent falls

Use helmets, padding, and other protection equipments for

sports like cycling, football, hockey, skiing, and
skateboarding. The water should be at a depth of 12 ft. or
more and no diving into an unknown shallowness of water area.
Conduct proper training and supervision when engaging in
sports, especially contact sports, to limit the risk of
injury.

Adhere to all safety measures at work, especially in jobs

that involve lifting heavy loads, operating heavy machinery,
or working in elevated areas. Lifting heavy objects should
always be done using your legs and not your back; avoid
twisting your spine to lift heavy objects. Wear hard hats and
harnesses, etc where in the workplace falls or impacting
injuries are likely.

Play under playgrounds with shock absorbing materials

such as mulch, sand, or rubber mats that will absorb and
cushion falls. Modify the environment; for instance, removing
33
possible tripping obstacles, improving stairways and flooring
layouts to be safer.

Advocate and participate in public safety programs on

injury prevention. Educate high-risk groups (athletes,
hazardous job workers) about the risk of SCI and preventive
measures. Provide training on SCI prevention and emergency
response in sports and hazardous jobs.

Provide adequate calcium and vitamin D supplementation,

especially for older patients, to limit the likelihood of
osteoporosis weakening bones. Inspect for diseases such as
arthritis, osteoporosis, or spinal degeneration among older
patients to identify potential risk factors early.

34
 COMPLICATIONS
The paralysis of diaphragms results due to injuries to
spinal levels C4 and up; the patient will become ventilator
dependent. The respiration muscles are weak due to the injury,
therefore causing difficulties in clearing up the secretions,
enhancing the possibility of pneumonia among many other
respiratory infections. The poor coughing mechanism and
secretion accretion may lead to recurring lung infections.

There is hypotension, bradycardia, and vasodilation

because of sympathetic nervous system control disruption in
injuries above T6. This is common in injuries above T6. It
represents a sudden, severe elevation in blood pressure
precipitated by noxious stimuli below the level of the injury,
such as bladder or bowel distension. The loss of sympathetic
tone leads to a dramatic drop in blood pressure after a
patient stands or sits, and the patient can develop dizziness
and syncope.

Lack of control of bladder muscles leads to retention,

incontinence, recurrent infections, and greater chances of
kidney damage. Patients can develop constipation, fecal
impaction, or incontinence due to the loss of bowel control
and often need bowel management programs. Patients are at a
higher risk for developing kidney stones due to immobility,
dehydration, and chronic UTIs.

Inability to move and diminished sensation increases the

risk for pressure ulcers on bony prominences such as the
sacrum, heels, and hips. Diminished blood flow also places a
risk for pressure ulcers that can lead to potentially life-
threatening infection and sepsis if not treated.

At the level of injury below, increased muscle tone will

cause spasms, which increases pain, interfere with
35
functioning, and produces contractures (permanent muscle
shortening). Bone density loss due to less weight-bearing
activity, including muscle use. Stiffening of joints due to
lack of movement can lead to an eventual limitation of
mobility.

Chronic pain as a result of lesions to nerve pathways in

the spinal cord, often with sensations of burning, tingling,
or shooting pains. There might be musculoskeletal pain due to
the overuse of the joints, shoulders, or upper extremities of
a patient because of misuse of wheelchairs or assistive
devices due to poor posture.

Weight gain, that is, a common complication due to low

physical activity, affects health outcomes badly and poses a
risk to cardiovascular diseases and diabetes. Lower muscle
activity is associated with disturbed glucose and lipid
metabolism and poses a risk to the development of type 2
diabetes and cardiovascular complications. Long immobility
results in depletion of the mineral density of bone tissue;
therefore, leading to the development of the problem known as
osteoporosis

Loss of autonomy, social isolation brought on by SCI

leads depression and anxiety disorders. Solutions like chronic
pain with severe body restriction cause the emotional
disturbances like frustration or irascibility, that have some
behavioral disturbances at present.

Neurogenic bladder and catheterization increase the risk

of recurrent UTIs, which if left untreated, can result in
renal damage. The patient is at risk for pneumonia and other
lung infections due to poor cough and inability to clear
secretions. Pressure ulcers and recurrent infections put the

36
patient at risk for sepsis, a systemic infection that can be
potentially life-threatening.
SCI can be associated with sexual dysfunction in males
resulting in impotence, retrograde ejaculation, and reduced
sperms count, while on the female side, a decrease in
lubrication could be present with issues that may be seen with
the arousal. While a female SCI patient is usually fertile but
the risk with the conceptus during pregnancy is higher that
too through complications like the autonomic dysreflexia.

37
 LABORATORY FINDINGS
Dat Laboratory Normal Actual Clinical Nursing
e Examinatio Finding Result Interpretation Responsibilitie
n s s
Complete Blood Count
10/ Hemoglobin 110 - 114 Normal
18/ 165 g/L
24
Hematocrit 0.35 - 0.34 Low. Low 1. Nurses
0.50 hematocrit should
levels reflect a regularly check
reduced vital signs and
percentage of pulse oximetry
red blood cells to assess for
in the blood, signs of
which can lead hypoxia (low
to anemia oxygen levels)
symptoms. This and circulatory
decline in strain, such as
hematocrit increased heart
indicates that rate and low
the patient's blood pressure.
ability to carry 2. Give iron
oxygen may be supplements or
diminished, blood
often resulting transfusions if
from factors ordered, and
such as blood monitor for any
loss, side effects or
nutritional complications.
deficits, or
chronic health
issues.
Red Blood 3.8 - 3.73 Low. A reduced 1. Regularly
Cells 5.8 x number of check for signs
10/L circulating red of oxygen
blood cells can deficiency,
impair oxygen such as

38
 transport to increased heart
tissues, rate, fatigue,
resulting in and shortness
anemia symptoms. of breath, and
This low RBC report
count may result significant
from nutritional changes.
deficiencies, 2. Educate the
ongoing health patient on
issues, or following
suppression of dietary
bone marrow recommendations
function. and adhering to
treatment and
follow-up
testing.

MCV 80 - 99 92 Normal
fL
MCH 28 - 32 31 Normal
pg
MCHC 32-38 33 Normal
g/l
White 4.8 - 9.90 Normal
Blood 10.8 x
Cells 10 g/L
Differential Count
Neutrophil 0.40 - 0.77 High. An 1. Regularly
0.74 increased number assess for
of neutrophils symptoms of
indicate that infection
the body might (fever,
be reacting to redness,
an infection, swelling) and
inflammation, or report findings
stress. This promptly to the
rise in healthcare
neutrophils can provider.

39
 result from 2. Monitor
bacterial temperature,
infections, heart rate, and
physical stress, other vital
or inflammatory signs to detect
issues that any signs of
trigger the systemic
immune system's infection or
reaction. fever.
3. Advise the
patient to rest
and maintain
hydration to
support immune
function and
recovery.
Lymphocyte 0.19 - 0.10 Low. A low 1. Regularly
s 0.48 lymphocyte count assess the
indicates patient for
lymphopenia, signs of
which points to infection, such
a weakened as fever,
immune response fatigue, or any
to infections. unusual
This condition symptoms, and
can arise from report any
several factors, concerning
such as viral findings to the
infections, healthcare
specific provider.
medications, or 2. Monitor
immunodeficiency vital signs,
disorders. A particularly
decrease in temperature, to
lymphocytes can quickly
heighten the identify any
risk of febrile
infections and responses that

40
 may necessitate may indicate an
additional infection.
investigation to 3. Promote a
determine the well-balanced
underlying diet to support
causes. overall health
and immune
function, and
consult with a
dietitian if
necessary
Monocyte 0.03 - 0.06 Normal
0.09
Eosinophil 0.00 - 0.06 Normal
0.07
Basophil 0.00 - 0.01 Normal
0.02
Platelet 150 - 399 Normal
Count 450
CRP < 10 27.2 High. A CRP 1. Assess for
mg/L level that signs and
exceeds the symptoms of
normal range inflammation or
signifies infection, such
considerable as fever, pain,
inflammation in and redness,
the body, and report any
commonly linked significant
to acute findings.
infections, 2. Regularly
ongoing monitor vital
inflammatory signs,
conditions, or especially
tissue damage. temperature and
Increased CRP heart rate, to
levels indicate detect any
an inflammatory signs of
process is systemic

41
 occurring, and infection or
additional worsening
examination inflammation
might be 3. Educate the
necessary to patient about
determine the inflammation,
root cause. its possible
causes, and the
importance of
adhering to
prescribed
treatments and
follow-up
appointments
ESR <20mm/ 91 High. A high ESR 1. Regularly
hr indicates assess for
increased signs of
inflammation, inflammation,
which may result such as fever,
from infections, pain, and
autoimmune swelling, and
conditions, or report any
chronic concerning
illnesses. changes
Elevated ESR 2. Monitor
suggests the vital signs
body is like
undergoing an temperature,
inflammatory heart rate, and
response, and blood pressure
additional to detect any
investigation is systemic
typically responses to
necessary to inflammation or
identify the infection
underlying 3. Provide
cause. anti-
inflammatory

42
 medications if
prescribed and
monitor for any
side effects.
Blood Chemistry
10/ Magnesium 0.73 - 0.85 Normal
12/ 1.06
24 mmol/L
Arterial Blood Gas
10/ pH 7.35 - 7.49 High. A high pH 1. Regularly
05/ 7.45 level indicates check blood
24 mild alkalosis, pressure,
which is above pulse,
the normal respiratory
range. This rate, and
condition may temperature to
suggest primary identify any
respiratory or related changes
metabolic in the
alkalosis, patient's
possibly caused condition.
by 2. Monitor lab
hyperventilation values for
, vomiting, or possible
certain imbalances
medications. (especially
potassium and
chloride) and
fluid status,
as alkalosis
can disrupt
electrolyte
levels and lead
to dehydration.
3. Give
medications to
correct
underlying

43
 causes, such as
antiemetics for
vomiting or
electrolytes,
as ordered by
the physician.
4. Observe for
signs of
confusion,
irritability,
or muscle
twitching,
which can occur
with alkalosis.
pCO2 35-45 45 Normal
mmHg
p02 80 - 154 High. A pO₂ 1. Check if the
100 level of 154 patient is
mmHg mmHg signifies receiving
hyperoxia, supplemental
indicating an oxygen and
unusually high verify that the
amount of oxygen prescribed
in the blood. oxygen flow
This condition rate and mode
can arise from are
excessive oxygen appropriate.
therapy or being 2. Watch for
in a hyperbaric signs such as
setting. confusion,
Although a vision changes,
raised pO₂ level respiratory
doesn't always distress, or
need treatment, dry cough,
extended periods which may
of hyperoxia can indicate oxygen
result in oxygen toxicity.
toxicity and 3. Collaborate

44
 oxidative with the
stress. healthcare
provider to
decrease the
oxygen
concentration
if high levels
are
unnecessary,
helping to
prevent
hyperoxia-
related
complications.
4. Accurately
record the
patient’s
oxygen levels,
any symptoms of
oxygen
toxicity, and
adjustments
made to oxygen
therapy, and
report
significant
findings to the
healthcare team

HCO3 22-26 34.3 High. A high 1. Review the

mEq/L level of patient’s
bicarbonate history for
(HCO₃) suggests factors like
metabolic vomiting,
alkalosis. This diuretic use,
increase in or bicarbonate
bicarbonate can intake that may
be due to be contributing

45
 factors such as to the
prolonged alkalosis.
vomiting, the 2. Frequently
use of check
diuretics, or potassium,
the chloride, and
administration calcium levels,
of bicarbonate, as metabolic
which may cause alkalosis often
a significant leads to
reduction in electrolyte
hydrogen ions or imbalances.
a rise in 3. Give
bicarbonate potassium
levels. supplements or
other
medications as
ordered to
correct
electrolyte
imbalances.
B.E. +/-2 9.7 High. A high 1. Assess for
mEq/L base excess signs such as
level indicates confusion,
a marked state muscle
of metabolic twitching, or
alkalosis, weakness, which
exceeding the are common with
normal limits. metabolic
This elevated alkalosis.
base excess 2. Monitor
points to an intake and
abundance of output closely
bicarbonate in to detect fluid
the bloodstream, shifts or
potentially dehydration
arising from that could
factors such as worsen

46
vomiting, the alkalosis.
use of 3. Observe for
diuretics, or compensatory
excessive hypoventilation
administration as the body
of bicarbonate. tries to
balance pH by
retaining CO₂.

47
 DIAGNOSTIC/RADIOLOGY FINDINGS
Dat Diagnosti Normal Actual Clinical Nursing
e c/ Values Results Interpretat Responsibili
Radiology ion ties
Exam
10/ Chest X- - Clear lung Interstitia Interstitia 1. Assess
04/ ray fields l lung l lung respiratory
24 - Normal disease, disease status
heart size - both lungs indicates 2. Monitor
No masses or lung vital signs
lesion, - scarring, and oxygen
Normal potentially saturation
diaphragm from 3. Educate
position various on disease
causes such management
as 4. Administe
autoimmune r
conditions medications
or as
environment prescribed
al factors. 5. Provide
Further supportive
evaluation care (oxygen
with CT and therapy,
pulmonary breathing
function exercises)
tests is 6. Coordinat
recommended e care with
. the
healthcare
team

08/ Computed No No Bilateral 1. Monitor

29/ Tomograph hydronephros hydronephro hydronephro Vital Signs:
24 y Scan is sis sis Check for
- Normal - Normal indicates signs of
renal size renal size significant infection
and shape and shape swelling of (fever,

48
 - No - No the kidneys chills) and
urinary urinary due to assess blood
obstruction obstruction urine pressure.
- Normal - Normal buildup, 2. 2.
bladder bladder often from Assess Urine
volume and volume and obstruction Output:
wall wall (in this Monitor for
thickness thickness case, changes in
- No spinal - No likely due urine
lesions or spinal to the output;
infections lesions or displaced watch for
- Normal infections Foley signs of
sacroiliac - Normal catheter). urinary
joints sacroiliac This can retention or
- No soft joints lead to obstruction.
tissue - No soft renal 3. 3.
masses or tissue impairment Manage
abscesses in masses or if not Catheterizat
surrounding abscesses addressed. ion: Ensure
areas in Urgent proper
surrounding interventio placement of
areas n is the Foley
required to catheter;
relieve the consult with
obstruction a physician
and prevent for
complicatio repositionin
ns such as g if
renal necessary.
failure. 4. 4. Pain
- Pott’s Management:
disease Administer
indicates a pain relief
spinal as
infection prescribed
due to and assess
tuberculosi effectivenes
s, which s.

49
can lead to 5. 5.
vertebral Patient
destruction Education:
and Inform the
associated patient
soft tissue about the
abscesses. conditions,
The treatment
involvement options, and
of the the
sacroiliac importance
joints and of
iliopsoas compliance
muscle with follow-
suggests a up care.
more 6. Coordinat
extensive e Care:
infection Collaborate
requiring with the
immediate healthcare
medical team for
interventio potential
n. surgical
intervention
s and manage
referrals to
specialists
(urologist,
infectious
disease
specialist).
7. 7.
Document
Findings:
Accurately
document all
assessments,
intervention

50
 s, and
patient
responses in
the medical
record.
07/ Ultrasoun LIVER: LIVER: The 1. Monitor
31/ d of the Normal size, NORMAL ultrasound Vital Signs:
24 Whole shape, and indicates Check for
Abdomen echogenicity GALLBLADDER that the signs of
- No : liver is infection or
masses, NORMAL normal, fluid
lesions, or with no overload.
cysts in the PANCREAS evidence of 2. Assess
liver AND SPLEEN: structural Symptoms:
- Normal NORMAL abnormaliti Monitor for
liver es, any urinary
borders KIDNEYS: lesions, or symptoms
- No signs - diseases such as
of cirrhosis Left renal such as dysuria,
or fatty cyst and cirrhosis urgency, or
liver calcificati or frequency;
changes on hepatomegal assess for
- y. This is abdominal
GALLBLADDER: NORMAL a positive pain related
Normal size RIGHT finding, to ascites.
and shape KIDNEY suggesting 3. Patient
- No - the absence Education:
gallstones Incidental of liver Explain the
or sludge note of disease. significance
- No ascites in of findings,
thickening the The particularly
of the hepatorenal ultrasound cystitis and
gallbladder and indicates the renal
wall perisplenic that the cyst, and
- No region gallbladder the need for
pericholecys is normal, hydration
tic fluid URINARY with no and
- Normal BLADDER: evidence of adherence to

51
bile duct - stones, treatment.
measurement Underfilled inflammatio 4. Medicatio
urinary n, or other n
PANCREAS AND bladder. pathologica Administrati
SPLEEN: Cnsidered l on:
- Pancreas: cystitis conditions. Administer
Normal size, This prescribed
shape, and suggests a medications
echogenicity healthy (e.g.,
; no masses, biliary antibiotics
cysts, or system. for
ductal cystitis)
dilation. The and assess
- Spleen: ultrasound their
Normal size findings effectivenes
and contour; indicate s.
no lesions that both 5. 5.
or signs of the Document
splenomegaly pancreas Findings:
and spleen Accurately
KIDNEYS: are normal, record all
Normal size with no ultrasound
and shape; evidence of results and
no cysts, structural patient
masses, or abnormaliti symptoms in
significant es or the medical
calcificatio disease. record.
ns. This 6. 6.
- Renal suggests Coordinate
Cortex: proper Follow-Up:
Uniform function of Facilitate
echogenicity these referrals or
. organs and further
- Urinary absence of testing as
Tract: No conditions needed,
hydronephros such as particularly
is or pancreatiti for the
obstruction. s, tumors, ascites and

52
 - No or splenic renal cyst
ascites enlargement management.
noted. .

The
ultrasound
findings
indicate a
left renal
cyst and
calcificati
on, which
are often
benign but
require
monitoring.
The normal
appearance
of the
right
kidney is
reassuring.
The
incidental
note of
ascites may
suggest
underlying
pathology,
such as
liver
disease or
heart
failure,
and should
be
evaluated
further.

53
 The
ultrasound
findings
indicate an
underfilled
urinary
bladder,
which may
suggest
incomplete
bladder
filling or
potential
urinary
retention.
The mention
of cystitis
indicates
inflammatio
n of the
bladder,
likely due
to
infection
or
irritation,
requiring
further
evaluation
and
management.
Table

The ultrasound examination of the whole abdomen revealed

normal findings for the liver, gallbladder, pancreas, and
spleen, indicating no immediate concerns in these organs. The
54
liver showed normal size and echogenicity without any lesions,
while the gallbladder was healthy, free of stones or wall
thickening. Both the pancreas and spleen appeared normal,
suggesting they are functioning well. However, notable
abnormalities included a left renal cyst and calcification,
with the right kidney assessed as normal. Additionally,
incidental ascites in the hepatorenal and perisplenic regions
raises concerns about potential underlying issues, such as
liver dysfunction or heart failure, which require further
investigation.
The urinary bladder was underfilled and classified as
cystitis, indicating inflammation likely due to infection.
These findings necessitate careful monitoring and possible
follow-up evaluations. Nursing responsibilities are critical
in this context; nurses must monitor vital signs, assess
urinary and abdominal symptoms, and provide patient education
about the conditions. Furthermore, they are responsible for
administering prescribed medications, accurately documenting
all findings, and coordinating necessary follow-up care.
Through these actions, nurses play an essential role in
ensuring comprehensive management and addressing any potential
complications related to the patient's health status.

55
 MEDICAL MANAGEMENT
DRUG STUDY
Name of the Signs and Mechanism of Side Nursing
Date Indication Contraindication
Drug Symptoms Action Effects Responsibility
A. Generic Nerve Supports Neuropathies, Hypersensitivity GI 1. Observed
Name: damage, nerve neurogenic to mecobalamin discomfort, Rights of
Mecobalamin decreased regeneratio support headache, Medication
sensation n Administration.
B. Brand Name from and DNA 2. Monitor
Neurobion immobilit Neurological
y and
synthesis, Status:
C. Dose/Route neurogeni promoting 3. Assess for
500 mcg c issues. neurogenic improvements or
Every 8 hours health, changes in
ORAL helpful in nerve function,
compensatin especially as
g the patient has
for difficulty
limited moving and
mobility lacks sensation
in extremities.
and
Document any
promoting improvements in
nerve muscle strength
health. or reductions
in neuropathic
pain.
4. so monitor
for subtle
improvements in
movement,

56
 sensation, or
reflexes in
affected limbs.
Coordinate with
rehabilitation
to assess any
changes in
response to
therapy.
5. Support
Nutritional
Needs:
6. Ensure the
patient’s diet
includes
sources of
folate and
other B
vitamins, as
these can
enhance
Mecobalamin’s
efficacy in
supporting
nerve health.
7. Encourage
Caregivers to
Report Symptom
Changes:
8. Educate
caregivers to
observe for any

57
 changes in the
patient’s
sensation,
pain, or
movement, as
early signs of
improvement may
be subtle and
are essential
for ongoing
assessment.
9. Document
Neurological
Observations
and Side
Effects:
10. Record
neurological
assessments,
noting any
changes in
symptoms like
numbness,
tingling, or
muscle
weakness, to
help track the
effectiveness
of Mecobalamin
in managing
neuropathy.

58
 DRUG STUDY
Dat Name of the Signs and Mechanism Contraindicatio Side Nursing
Indication
e Drug Symptoms of Action n Effects Responsibility
D. Generic Hypotension Calcium Hypertension Severe Dizziness, 1. Observed
Name: , history channel , hypotension, fatigue, Rights of
Amlodipine of blocker to hypotension amlodipine mild Medication
fluctuating dilate management allergy palpitation Administration.
E. Brand BP during blood s 2. Monitor Blood
Name infection vessels, Pressure and
Norvasc recovery. reduce Heart Rate:
blood 3. Regularly
F. Dose/ pressure, assess blood
Route and pressure and
5 mg OD stabilize heart rate, as
ORAL circulation Amlodipine is
, essential used to control
in hypertension.
maintaining Record pre- and
stable BP post-
for a administration
bedridden vitals to
patient. monitor
effectiveness
and prevent
hypotension or
bradycardia.
4. Observe for
Signs of
Hypotension:
Given the
patient's
history of
59
 hypotension,
closely watch
for symptoms
such as
dizziness,
lightheadedness,
or fainting, and
report
significant
drops in blood
pressure
promptly.
5. Assess for
Edema: Monitor
for peripheral
edema, a common
side effect of
Amlodipine,
especially in
the legs and
ankles. Record
any swelling and
assess for
associated
symptoms like
discomfort or
skin changes.
6. Evaluate for
Signs of
Worsening Heart
Failure: Be
vigilant for

60
 symptoms such as
shortness of
breath, chest
discomfort, or
weight gain, as
these could
indicate
worsening heart
function. Report
these
immediately to
prevent
complications.
7. Monitor for
Drug
Interactions
Amlodipine can
interact with
other
antihypertensive
s or
cardiovascular
medications, so
check for
potential
interactions if
the patient is
on other heart-
related
treatments, such
as
norepinephrine.

61
 8. Educate
Caregivers on
Positional
Changes: Advise
caregivers to
help the patient
change positions
slowly,
especially when
moving from
lying down to
sitting or
standing, to
prevent
dizziness due to
possible
postural
hypotension.
9. Document
Vital Signs and
Side Effects:
Record blood
pressure, heart
rate, and any
observed side
effects, like
edema or
dizziness.
Consistent
documentation is
essential to
ensure safe

62
 dosing and
monitor
therapeutic
effects.

63
 DRUG STUDY
Name of the Signs and Mechanism of Side Nursing
Date Indication Contraindication
Drug Symptoms Action Effects Responsibility
G. Generic Immobility Enhances General Allergy to B GI upset, 1. Observed
Name: and lack of energy wellness, vitamins mild rash Rights of
Vitamin Benergy, production nerve Medication
Complex general and nerve health Administration.
wellness health, maintenance 2. Monitor for
H. Brand Name needs. supporting Allergy to Signs of
Berocca overall B vitamins Deficiency
wellness and Improvement:
I. Dose/Route nerve Assess for
1 tab OD regeneration improvements in
ORAL in immobile energy levels,
patients. mental clarity,
and muscle
function, as
Vitamin B
Complex aids in
nerve and muscle
health. For
bedridden
patients,
observe for any
subtle signs of
improved
strength or
reduced
neuropathic
symptoms.
3. Observe for
64
 Gastrointestinal
Side Effects:
Some patients
may experience
nausea,
diarrhea, or
mild GI
discomfort.
Administer with
food to reduce
the risk of
stomach upset
and observe for
any adverse
reactions.
4. Evaluate Skin
Integrity and
Wound Healing:
Monitor the
sacral pressure
injury, as
Vitamin B
Complex supports
skin health and
healing. Assess
for any positive
changes in wound
size, color, and
granulation.
5. Monitor for

65
 Allergic
Reactions:
Vitamin B
Complex can
occasionally
cause allergic
reactions. Watch
for itching,
rash, or
swelling, and
report any
symptoms of
hypersensitivity
immediately.
Educate
Caregivers on
Importance of
Consistency:
6. Instruct
caregivers on
the importance
of consistent
Vitamin B
Complex
administration
to maintain
levels needed
for nerve and
metabolic
health.
Encourage
66
 reporting any
changes in the
patient’s energy
or mood.
Coordinate with
Nutritional
Intake:
7. Encourage a
balanced diet
that complements
the benefits of
Vitamin B
Complex,
especially foods
rich in B
vitamins, like
whole grains and
lean proteins,
to maximize
nutritional
support.
8. Document
Patient’s
Response and
Side Effects:
Record any
changes in
energy, skin
health, and GI
symptoms, as
well as any
67
 reported
improvements in
the patient’s
general well-
being, to
evaluate the
effectiveness of
the supplement.

68
 DRUG STUDY
Name of Signs and Mechanism of Side Nursing
Date Indication Contraindication
the Drug Symptoms Action Effects Responsibility
J. Generic Urinary tract Natural UTI symptom Pregnancy, Nausea, 1. Observed
Name infection (UTI) diuretic to management, kidney disease dizziness Rights of
Sambong symptoms, kidney aid urine mild Medication
health needs due flow and diuresis Administration.
K. Brand to support 2. Monitor Urine
Name catheterization. kidney Output and
Re-leaf function, Kidney Function:
Forte reducing Measure and
fluid record urine
L. accumulation output
Dose/Route in an regularly, given
500mg OD immobile the patient’s
ORAL patient. suprapubic
catheter.
Sambong may
increase urine
production, so
monitor output
to prevent
dehydration and
detect any
unusual changes
in urine
characteristics.
3. Observe for
Electrolyte
Imbalance:

69
 Since Sambong
can act as a
diuretic,
monitor for
signs of
electrolyte
imbalance, such
as muscle
weakness,
irregular
heartbeat, or
confusion.
Arrange for
regular
electrolyte
testing if
prescribed.
4. Monitor for
GI Effects:
Assess the
patient for
possible
gastrointestinal
side effects
such as nausea,
abdominal
discomfort, or
diarrhea, which
can sometimes
occur with
herbal
70
 medications.
5. Evaluate for
Allergic
Reactions:
As with all
herbal
medications,
observe for any
signs of an
allergic
reaction,
including rash,
itching, or
swelling.
Immediately
report any
adverse effects.
6. Ensure
Adequate
Hydration:
Encourage
hydration to
prevent
dehydration,
especially if
Sambong’s
diuretic effect
significantly
increases urine
output.

71
 Hydration is
also essential
to support
kidney function
and prevent
stone formation.
7. Educate
Caregivers on
Herbal Use:
Inform
caregivers about
the purpose of
Sambong and its
possible effects
on kidney
function and
urinary output.
Emphasize the
importance of
reporting any
unusual symptoms
to the
healthcare team.
8. Document
Urine Output and
Symptom Changes:
Record changes
in urine output,
kidney-related
symptoms, or any
reported

72
 discomfort,
ensuring an
ongoing record
of the patient’s
response to
Sambong.

73
 DRUG STUDY
Name of the Signs and Mechanism Side Nursing
Date Indication Contraindication
Drug Symptoms of Action Effects Responsibility
M. Generic Muscle Muscle Muscle Hypersensitivity, Drowsiness, 1. Observed
Name spasticity, relaxant spasticity, active peptic fatigue Rights of
Baclofen limited acting on neurogenic ulcer Medication
mobility CNS to support Administration.
N. Brand due to decrease 2. Monitor for
Name stroke- spasticity, Sedation and
Lioresal related aiding in CNS Effects:
paralysis. muscle Regularly
O. relaxation assess the
Dose/Route for patient’s level
10mg BID neurogenic of
Oral support in consciousness,
immobile given their GCS
patients. status (11 -
E4V1M6).
Observe for
increased
drowsiness,
confusion, or
CNS depression,
documenting any
changes.
3. Evaluate
Muscle Tone and
Spasticity:
Assess muscle
tone in the
extremities
74
 where
electrical
stimulation
(ES) and
passive range
of motion
(PROM) are
being used,
noting any
reduction in
spasticity or
change in
muscle function
that may
indicate
Baclofen’s
effectiveness.
4. Observe for
Respiratory
Depression:
Monitor
respiratory
rate and oxygen
saturation
closely,
especially as
the patient has
a tracheostomy
and a history
of
desaturation.
75
 Immediately
report any
signs of
respiratory
depression.
5. Check for
Hypotension:
Regularly
measure blood
pressure, as
Baclofen can
cause
hypotension,
which may
complicate the
patient’s
stable but
sensitive
cardiovascular
status. Adjust
monitoring
frequency if
the patient’s
BP decreases.
6. Monitor
Bowel Function:
Observe for
constipation, a
known side
effect of

76
 Baclofen, which
could worsen
the patient’s
neurogenic
bowel
condition.
Administer
bowel aids as
prescribed and
encourage
hydration to
support regular
bowel
movements.
7. Coordinate
with
Rehabilitation
Therapy:
Ensure that
Baclofen dosing
aligns with the
timing of ES
and PROM
sessions to
maximize muscle
relaxation and
support the
patient’s
rehabilitation.
8. Document
Observations
77
 and Effects:
Accurately
record any side
effects,
changes in
muscle tone,
CNS effects,
respiratory
status, and
blood pressure.
Regular
documentation
ensures a
clear, ongoing
record for the
healthcare team
to support
patient safety
and effective
dosing.

78
 DRUG STUDY
Name of Signs and Mechanism Side Nursing
Date Indication Contraindication
the Drug Symptoms of Action Effects Responsibility
P. Generic Liver Enhances Liver Allergy to bile GI 1. Observed
Name function liver function salts discomfort, Rights of
UDCA support due health by support mild Medication
to extended reducing headache Administration.
Q. Brand immobility, bile 2. Evaluate Liver
Name medication toxicity, Function
Ursofalk use. beneficial Consistently:
for
R. patients on Given the
Dose/Route prolonged patient’s complex
250mg OD medications condition,
Oral or with regularly assess
metabolic liver function
stress. tests (ALT, AST,
ALP, bilirubin)
to monitor
potential liver
complications and
assess UDCA
efficacy.
3. Assess for GI
Tolerance and
Bowel Patterns:
Observe the
patient for signs
of
gastrointestinal
distress,
79
 including
diarrhea or
discomfort,
especially due to
neurogenic bowel
challenges and
the need for
bowel aids.
Document any
changes or
discomfort.
4. Monitor for
Adverse Effects
of UDCA:
Watch for signs
of potential
adverse reactions
like abdominal
pain, worsening
jaundice, or bile
reflux that may
complicate the
patient’s
condition.
5. Collaborate
with Dietary
Needs:
Ensure the
medication is
given with or

80
 after tube
feedings through
the NGT to
optimize
absorption and
prevent
gastrointestinal
discomfort.
6. Promote Skin
Integrity and
Positioning:
Due to the
patient’s
immobility and
pressure
injuries,
implement regular
repositioning to
prevent pressure
ulcers, as
prolonged bed
rest can increase
the risk of
additional
complications.
7. Facilitate
Multidisciplinary
Coordination:
Collaborate with
healthcare

81
 providers for
continued
monitoring,
especially as the
patient awaits
TB-related
antibiotic
guidance, which
could interact
with UDCA.
Document
Comprehensive
Observations:
Record all
findings related
to liver
function, GI
symptoms, skin
integrity, and
respiratory
stability,
ensuring clear
notes for team
communication and
ongoing patient
safety.

82
 DRUG STUDY
Name of the Signs and Mechanism Side Nursing
Date Indication Contraindication
Drug Symptoms of Action Effects Responsibility
S. Generic Thin Promotes Immune Copper Mild GI
Name physique, immune support, deficiency upset, Observed Rights
Zinc poor wound function, wound metallic of Medication
healing due cellular healing taste Administration.
T. Brand to health, and Monitor Wound
Name immobility wound Healing
Conzace and limited healing, Progress:
nutrient supporting
U. intake. recovery in Given the
Dose/Route a bedridden patient’s sacral
10mg OD patient. pressure injury,
ORAL regularly assess
the wound for
signs of
healing, such as
reduction in
size, pinkish
granulation
tissue, and
absence of
discharge. Zinc
supports tissue
repair, so
tracking wound
healing can
indicate the
effectiveness of
supplementation.
Observe for GI
83
 Disturbances:
Zinc may cause
gastrointestinal
side effects
like nausea or
upset stomach,
especially if
taken on an
empty stomach.
Ensure Zinc is
administered
with meals if
tolerated to
reduce GI
discomfort.
Monitor for
Signs of Zinc
Toxicity:
High doses of
Zinc can lead to
toxicity, so
observe for
symptoms such as
fatigue,
dizziness, or
gastrointestinal
symptoms like
vomiting.
Immediately
report any
suspected
84
 toxicity.
Check for Copper
Deficiency
Signs:
Long-term Zinc
use may cause
copper
deficiency.
Watch for signs
such as anemia,
neuropathy, or
unusual fatigue,
and ensure
regular
monitoring of
copper levels if
the patient is
on prolonged
Zinc therapy.
Coordinate with
Nutrition
Therapy:
Collaborate with
dietitians to
ensure Zinc
supplementation
aligns with the
patient’s
overall
nutritional

85
 needs,
especially for
wound healing
and immune
support.
Document Wound
Status and GI
Tolerance:
Record wound
assessment
findings and
note any
gastrointestinal
symptoms. Clear
documentation
will help in
evaluating the
response to Zinc
supplementation
and ensuring
continuity of
care.

86
 DRUG STUDY
Name of the Signs and Mechanism Side Nursing
Date Indication Contraindication
Drug Symptoms of Action Effects Responsibility
V. Generic Thin Supports Immune Allergy to GI upset, Observed Rights
Name physique immune support, ascorbic acid mild rash of Medication
Vitamin C and wound health and wound Administration.
W. Brand healing wound healing
Name support, healing, Monitor Wound
Ceelin immune essential Healing and Skin
boost to for Integrity:
X. prevent bedridden Assess the
Dose/Route infection. patients sacral pressure
500mg OD needing injury
Oral additional regularly, as
immunity Vitamin C
and healing supports
support. collagen
formation and
tissue repair.
Document wound
size, color, and
other indicators
of healing, such
as decreased
wound depth and
improved skin
integrity.
Observe for
Gastrointestinal
Side Effects:
87
 High doses of
Vitamin C can
lead to
gastrointestinal
symptoms like
stomach cramps
or diarrhea.
Administer with
meals to reduce
GI discomfort,
and monitor for
any signs of
intolerance.
Check for Signs
of Oxalate
Buildup:
High doses of
Vitamin C can
increase urinary
oxalate,
potentially
leading to
kidney stones.
Monitor urine
output and
characteristics,
especially given
the patient’s
suprapubic
catheter, and
report any signs
88
 of cloudy or
discolored
urine.
Evaluate
Hydration
Status:
Ensure the
patient remains
well-hydrated to
support Vitamin
C metabolism and
reduce the risk
of kidney stone
formation.
Regularly
monitor fluid
intake and
output to
prevent
dehydration.
Support Immune
Function:
Since Vitamin C
helps boost
immunity,
observe for
signs of
infection or
inflammation,
especially

89
 around wounds or
the urinary
tract, and
report any
unusual
findings.
Document Wound
Assessment and
Side Effects:
Record
observations
related to wound
healing, GI
symptoms, and
hydration.
Detailed
documentation
supports
evaluating the
effectiveness of
Vitamin C and
adjusting the
care plan as
needed.

90
 DRUG STUDY
Nursing
Dat Name of the Signs and Mechanism Contraindicatio Side
Indication Responsibilit
e Drug Symptoms of Action n Effects
y
11. Monitor
wound healing
Vascular
regularly
Protector/
12. Assist
Phlebotoni
with frequent
c
repositioning
Contains
J. Generic to prevent
micronized
Name: further
purified
Diosmin + pressure
flavonoid
Hesperidin injuries
fraction,
13. Monitor
Venous primarily Chronic
K. Brand GI NGT
insufficienc diosmin venous Hypersensitivit
Name discomfort tolerance, as
y symptoms, and insufficiency y to Daflon,
Daflon , GI discomfort
support in hesperidin , peptic ulcer
headache, may occur
wound , which hemorrhoids, disease
L. Dose/ dizziness 14. Educate
healing work by edema
Route caregiver on
increasing
500 mg the
venous
PO importance of
tone and
leg elevation
protecting
and keeping
blood
limbs frree
vessels to
from
improve
obstructions
circulatio
that may
n
impede blood
flow

91
 DRUG STUDY
Nursing
Dat Name of the Signs and Mechanism of Contraindicatio
Indication Side Effects Responsibilit
e Drug Symptoms Action n
y
A. Generic Irregular Electrolyte Hypokalemia Hyperkalemia, GI upset, 1. Monitor
Name heartbeat Supplement , sever renal hyperkalemia serum
KCL , fatigue Provides electrolyte impairment, , abdominal potassium
potassium, management Addison’s discomfort before
B. Brand which is a disease administratio
Name critical n
Kalium intracellula 2. Observe
r cation for for signs of
C. Dose/ conducting hyperkalemia,
Route nerve given limited
1 tab impulses, movement and
BID muscle risk of
PO (NGT) contraction, muscle
and atrophy
maintaining 3. Educate
normal the caregiver
cellular on compliance
function with blood
92
 tests to
monitor
electrolytes,
given renal
consideration
s

93
 DRUG STUDY
Nursing
Dat Name of the Signs and Mechanism Contraindicatio Side
Indication Responsibilit
e Drug Symptoms of Action n Effects
y
A. Generic Fluid Loop Edema, Anuria, severe Hypokalemia 1. Monitor
Name retention, Diuretic hypertension electrolyte , BP, urine
Furosemide possible Inhibits . Fluid imbalance, dehydration output, and
electrolyt sodium and overload sulfa allergy , electrolytes,
B. Brand e chloride dizziness, adjusting
Name imbalance reabsorptio hypotension fluid intake
Fusedex n in the carefully due
kidneys, to Foley
C. Dose/ specificall catheter
Route y the 2. Monitor
20 mg ascending signs of
PO (NGT) loop of dehydration
Henle, 3. Perform
leading to skin checks
increased to monitor
urine pressure
output and areas
removal of
94
 4. Educate on
slow
excess positional
fluid changes to
avoid
hypotension

95
 DRUG STUDY
Name of the Signs and Mechanism of Side Nursing
Date Indication Contraindication
Drug Symptoms Action Effects Responsibility
A. Generic Pain, Analgesic/ Mild to Severe liver Liver 1. Monitor
Name fever Antipyretic moderate disease, toxicity, temperature
Paracetamol management Inhibits pain, hypersensitivity skin and pain level
cyclooxygenase, fever to acetaminophen reactions, regularly
B. Brand Name primarily COX- management hypotension 2. Ensure slow
Tamin 2, in the administration
central nervous to avoid
C. Dose/Route system, hypotension
600 mg reducing the 3. Use
IV production of alternative
prostaglandins comfort
involved in measures
pain and fever 4. Educate
caregiver on
signs of pain
or fever that
may indicate
infection
recurrence,
96
 prompting
timely
reporting

97
 DRUG STUDY
Name of the Signs and Mechanism of Side Nursing
Date Indication Contraindication
Drug Symptoms Action Effects Responsibility
A. Generic Pain, Local Hemorrhoids Hypersensitivity Local 1. Apply
Name swelling at Anesthetic/ and to policresulen irritation, ointment using
Faktu hemorrhoidal Anti- fissures and cinchocaine burning, aseptic
Ointment area inflammatory itching technique to
Contains prevent
B. Brand Name policresulen infection
Faktu and 2. Educate
cinchocaine, caregiver on
C. Dose/Route which act correct
Treatment together to application
TID reduce after bowel
inflammation movements to
and provide reduce
local contamination
anesthesia risk
to relieve 3. Encourage
pain and good hygiene
discomfort in the
in
98
 perineal area
4. Monitor for
any signs of
local
irritation or
any adverse
reactions
hemorrhoidal 5. Assist with
tissue patient
positioning to
reduce
pressure in
the perineal
area and
promote
comfort

99
 DRUG STUDY
Nursing
Dat Name of the Signs and Mechanism of Indicatio Contraindicatio
Side Effects Responsibilit
e Drug Symptoms Action n n
y
A. Generic GI Gastroprotectiv Gastric Hypersensitivit Constipation 1. Administer
Name discomfor e Agent ulcers y to Rebamipide , nausea, GI via NGT with
Rebamipide t Stimulates upset flushes to
mucus secretion ensure
B. Brand in the patency
Name gastrointestina 2. Position
Mucopid l tract and the patient
enhances the at 30-45° to
C. Dose/ production of prevent
Route prostaglandins, aspiration
10 mg promoting 3. Monitor GI
PO (NGT) mucosal function, as
protection and constipation
healing of can worsen
ulcers neurogenic
bowel
symptoms and

100
 discomfort
4. Educate on
the
importance of
avoiding
NSAIDs to
prevent GI
irritation

101
 DRUG STUDY
Dat Name of the Signs and Mechanism of Contraindicatio Side Nursing
Indication
e Drug Symptoms Action n Effects Responsibility
A. Generic Respirator Mucolytic/ Chronic GI ulcer Nausea, 1. Monitor
Name y mucus Antioxidant respiratory history, asthma vomiting respiratory
N- buildup Breaks down issues with (caution), , GI rate, breath
Acetylcystein disulfide mucus hypersensitivit upset, sounds, and
e bonds in buildup, y rash sputum
mucus, acetaminophe characteristic
B. Brand Name reducing its n toxicity s
Exflem viscosity and 2. Ensure
facilitating adequate
C. Dose/Route expectoration hydration to
600 mg ; also help thin
PO (NGT) replenishes mucus
TID glutathione, 3. Administer
aiding in via NGT with
detoxificatio water flush to
n and keep the tube
antioxidant patent
effects 4. Position
the patient at
102
 30-45° to
reduce
aspiration
risk

103
 DRUG STUDY
Signs
Nursing
Dat Name of the and Mechanism of Contraindicatio Side
Indication Responsibilit
e Drug Symptom Action n Effects
y
s
A. Generic Wheezin Bronchodilator COPD, Hypersensitivit Tremors, 1. Monitor
Name g (β2-Agonist and bronchospasm y to either dry mouth, respiratory
Salbutamol + Anticholinergic , medication, tachycardia rate, depth,
Ipratropium ) respiratory tachyarrhythmia , and oxygen
Salbutamol: β2- distress s palpitation saturation
B. Brand adrenergic s pre- and
Name agonist that post-
Ipravent causes nebulization
bronchodilation to assess
C. Dose/ by relaxing effectiveness
Route airway muscles; 2. Observe
Nebulization Ipratropium: for
Every 8 anticholinergic tachycardia
hours that blocks or
acetylcholine palpitations,
receptors, 3. Inform
reducing mucus provider if
104
 symptoms
worsen.
4. Ensure
tracheostomy
care is
provided
regularly to
prevent
infection

105
 DRUG STUDY
Nursing
Dat Name of the Signs and Mechanism of Contraindicati Side
Indication Responsibili
e Drug Symptoms Action on Effects
ty
M. Generic Nausea Omeprazole is a Gastroesophage Hypersensitivi Headache, Assess for
al reflux ty to symptoms of
Name: proton pump nausea,
Vomiting disease (GERD) omeprazole or GERD or
Omeprazole inhibitor that any components vomiting, peptic
Diarrhea Peptic ulcers of the ulcers.
irreversibly diarrhea,
(gastric and formulation
Constipati blocks the duodenal) constipatio Monitor for
on Concurrent use side effects
N. Brand hydrogen/potass n,
Zollinger- such as
with certain
Name: Abdominal ium ATPase Ellison abdominal abdominal
pain syndrome medications pain,
Omepron enzyme in pain,
diarrhea, or
that require
Headache stomach cells, Erosive flatulence. headaches.
esophagitis gastric
O. Dose/ leading to
Dizziness due to acid Evaluate
acidity for
Route: decreased reflux liver
Flatulence absorp function
40mg IV gastric acid
Prevention of tests in
production and long-term
gastric ulcers
users.
a higher pH in
in patients
the stomach and Educate
taking NSAIDs
patients on
duodenum.
the
importance
of taking

106
 the
medication
before
meals.

Monitor for
signs of
vitamin B12
deficiency
with
prolonged
use.

Always refer
to the
physician
for concerns
regarding
side effects
or treatment
effectivenes
s.

107
 DRUG STUDY
Name of Signs and Mechanism of Nursing
Dat Drug Symptoms Action Indication Contraindicati Side Responsibilit
e on Effects y
A.Generic Drowsiness Diazepam is a Anxiety Hypersensitivi Drowsiness Assess the
name: benzodiazepine disorders ty to diazepam , patient's
Diazepam Dizziness that acts as a or other dizziness, level of
central nervous Muscle benzodiazepine fatigue, sedation and
Fatigue system spasms s muscle mental status
B.Brand depressant. It weakness, before and
name: Muscle enhances the Seizure Severe confusion, after
Valium weakness effects of disorders respiratory blurred administratio
GABA, a (as insufficiency vision. n.
C.Dose/ Ataxia neurotransmitte adjunctive
Route: 5mg (lack of r, by therapy) Sleep apnea Monitor for
Q15 IV muscle increasing the syndrome signs of
(for active control) frequency of Alcohol respiratory
seizure max chloride ion withdrawal Acute narrow- depression,
60mg) Confusion channel symptoms angle glaucoma especially in
openings at the elderly or
Memory GABA-A Preoperati Myasthenia high-risk
problems receptor, ve gravis patients.
resulting in sedation
Blurred calming Educate
vision effects, muscle patients
about the
Nausea potential for
dependence
Constipati and
on withdrawal
symptoms.
Dry mouth
108
 Evaluate for
Slurred interactions
speech with other
CNS
Hypotensio depressants
n (e.g.,
alcohol,
opioids).

Ensure safety
measures for
patients at
risk of
falls.

Always refer
to the
physician for
any
significant
changes in
the patient's
condition or
medication
adjustments.

109
 DRUG STUDY
Name of Drug Signs and Mechanism of Nursing
Dat Symptoms Action Indication Contraindicati Side Effects Responsibili
e on ty
A.Generic Drowsiness Levetiracetam Partial- Hypersensitivi Drowsiness, Monitor
name: works by onset ty to dizziness, seizure
Levetiraceta Dizziness binding to the seizures levetiracetam fatigue, frequency
m synaptic in adults or any headache, and severity
Fatigue vesicle and components of irritability to evaluate
B.Brand protein SV2A, children the , mood treatment
name: Weakness which formulation changes. effectivenes
Keppra modulates Myoclonic s.
Headache neurotransmitt seizures Caution in
C.Dose/ er release and in patients with Assess for
Route: Irritabilit helps prevent patients a history of side effects
500mg TID y excessive with psychiatric like
oral neuronal juvenile disorders drowsiness,
Mood firing, thus myoclonic (risk of mood dizziness,
changes aiding in epilepsy changes) or mood
seizure changes.
Anxiety management. Primary
generalize Educate
Depression d tonic- patients
clonic about the
Coordinatio seizures importance
n problems of adherence
to therapy.
Loss of
appetite Evaluate for
signs of
Nasal allergic
congestion reactions or
110
 unusual
Cough behavioral
changes.

Check renal
function
periodically
, as dosing
may need
adjustment
in renal
impairment.

Always refer
to the
physician if
the patient
experiences
increased
seizure
activity or
adverse
effects.

111
 DRUG STUDY

Name of Signs and Mechanism of Nursing

Dat Drug Symptoms Action Indication Contraindicati Side Responsibili
e on Effects ty
A.Generic Nausea Vitamin D Prevention Hypercalcemia Nausea, Assess
name: enhances the and (high calcium vomiting, dietary
Vit D+ Ca Vomiting absorption of treatment of levels) constipatio intake of
calcium and osteoporosis n, stomach calcium and
B.Brand Constipati phosphate in Hypervitaminos pain, vitamin D.
name: on the Calcium and is D increased
Caltrate intestines, vitamin D (excessive thirst. Monitor for
Plus Stomach which are deficiency vitamin D) signs of
pain essential for hypercalcemi
C.Dose/ bone health. Support for Severe kidney a (e.g.,
Route: Increased Calcium bone health impairment nausea,
OD oral thirst supports in vomiting,
various postmenopaus confusion).
Frequent bodily al women
urination functions, Educate
including patients
Muscle muscle about the
weakness movement and importance
nerve of adherence
Bone pain signaling, and dietary
while sources of
Confusion promoting calcium and
bone strength vitamin D.
Fatigue and
mineralizatio Evaluate
n. renal
function in

112
 patients on
long-term
therapy.

Always refer
to the
physician
for any
concerns
about side
effects or
the need for
dosage
adjustments.

113
 DRUG STUDY

Name of Drug Signs and Mechanism of Nursing

Dat Symptoms Action Indication Contraindicati Side Responsibili
e on Effects ty
A.Generic Drowsiness Baclofen is Muscle Hypersensitivi Drowsiness Monitor
name: similar to GABA spasticity ty to baclofen , muscle tone
Baclofen Dizziness and acts as an due to dizziness, and
agonist at GABA- multiple History of weakness, spasticity
B.Brand Weakness B receptors in sclerosis peptic ulcers nausea, before and
name: the central or spinal (caution) confusion, after
Lioresal Fatigue nervous system. cord injury headache. dosing.
This action Caution in
C.Dose/ Nausea decreases the Muscle patients with Assess for
Route: release of spasms renal side
10mg TID Vomiting excitatory related to impairment effects,
oral neurotransmitter neurologica especially
Constipatio s, leading to l sedation and
n muscle conditions dizziness.
relaxation and
Confusion reduced Educate
spasticity. patients
Headache about the
importance
Insomnia of gradual
withdrawal
Muscle to prevent
hypotonia withdrawal
symptoms.

Ensure
safety

114
 precautions
for patients
at risk of
falls.

Always refer
to the
physician if
the patient
experiences
significant
side effects
or if muscle
spasticity
does not
improve

115
 DRUG STUDY
Signs and Mechanism Nursing
Dat Name of Symptoms of Action Indication Contraindicat Side Responsibili
e Drug ion Effects ty
A.Generic Dizziness Spironolact Edema Hypersensitiv Dizziness, Monitor
name: one is a associated with ity to fatigue, blood
Aldactone Drowsiness potassium- heart failure, spironolacton nausea, pressure and
sparing liver e vomiting, assess for
Fatigue diuretic cirrhosis, or gynecomasti signs of
B.Brand that blocks nephrotic Anuria a. fluid
name: Nausea the effects syndrome (failure of overload
Spironolact of the kidneys (e.g.,
one Vomiting aldosterone Hypertension to produce edema).
in the urine)
C.Dose/ Diarrhea kidneys. Primary Check serum
Route: This hyperaldosteron Hyperkalemia potassium
50mg oral Abdominal results in ism (high levels
cramping increased potassium regularly to
excretion Treatment of levels) prevent
Gynecomasti of sodium certain cases hyperkalemia
a and water of heart Severe renal .
while failure impairment
Menstrual preserving Assess for
irregularit potassium signs of
ies levels in gynecomastia
hyperkalemi the body. or menstrual
a irregulariti
es.
Dehydration
Educate
Rash patients
about the
116
Headache need to
report any
Dry mouth signs of
hyperkalemia
(e.g.,
muscle
weakness).

Always refer
to the
physician
for any
abnormal lab
results or
concerns
regarding
treatment.

117
 DRUG STUDY
Name of Drug Signs and Mechanism of Nursing
Dat Symptoms Action Indication Contraindicatio Side Responsibilit
e n Effects y
A.Generic Localized Mupirocin is Treatment of Hypersensitivit Localized Assess the
name: burning an skin y to mupirocin burning, affected area
Mupirocin sensation antibiotic infections or any stinging, for infection
that caused by components of itching, before and
Brand name: Stinging inhibits specific the formulation redness, after
Bactroban at the bacterial bacteria irritation treatment.
applicatio protein (e.g., Avoid use in .
C.Dose/ n site synthesis by impetigo, deep puncture Educate
Route: binding to folliculitis) wounds or patients on
TID Itching isoleucyl- serious burns proper
treatment tRNA Nasal application
Redness or synthetase, colonization techniques to
irritation preventing of avoid
of the the Staphylococcu contamination
skin incorporatio s aureus .
n of
Dryness or isoleucine Monitor for
peeling of into local side
the skin proteins, effects
which (e.g.,
Rash inhibits irritation,
(rare) bacterial burning).
growth and
Allergic replication. Ensure the
reaction patient
(rare, may understands
include to complete
swelling, the full
118
severe course of
itching, treatment.
or
difficulty Always refer
breathing) to the
physician if
the infection
does not
improve or
worsens.

119
 SURGICAL MANAGEMENT
Book Based
In the "Handbook of Spinal Cord Injuries and Related
Injuries," the surgical approach for a patient with a complete
spinal cord injury (SCI) at the C4 motor level, caused by an
intradural intramedullary tumor located at T10, aims to
stabilize the injury, remove the tumor, and enhance the
patient's quality of life. Surgery for such a tumor requires
careful planning to decompress the spinal cord while
minimizing any further damage to the already affected neural
tissues. This procedure typically involves techniques like
laminectomy or laminoplasty to excise the tumor and relieve
spinal pressure that could exacerbate neurological issues.
Given the tumor's delicate position, precise surgical skills
are needed to avoid additional impairment, considering the
spinal cord's fragile structure and its closeness to vital
nerves.

After tumor removal, further measures are often taken to

stabilize the spine and reduce the risk of complications post-
surgery. Techniques for spinal stabilization, such as the use
of rods, screws, or bone grafts, are frequently employed to
preserve the spinal column’s integrity, particularly when
parts of the vertebrae are taken out. For injuries at the C4
level, maintaining respiratory support and immobilization
during and after the operation is crucial to avoid respiratory
problems and aid recovery. Post-surgery, intensive monitoring
is essential to quickly identify and address potential
complications like infections, hematomas, or neurological
decline.

In the long term, management after surgery emphasizes

rehabilitation tailored to the challenges of a complete C4
injury, which is classified as AIS-A. The rehabilitation
process seeks to improve mobility and daily living skills
120
through assistive devices, respiratory care, and physical
therapy. For patients with AIS-A classification, where there
is total motor and sensory loss below the injury site, the
primary focus shifts to maximizing any remaining functions and
enhancing quality of life rather than regaining lost
abilities. A collaborative approach that includes surgical,
rehabilitative, and supportive care strives to achieve the
best possible outcomes concerning mobility, independence, and
overall life satisfaction, despite the challenges posed by a
high-level spinal cord injury.

Client Based
The surgical management of this patient with a complete
spinal cord injury (SCI) at the motor level of C4, secondary
to an intradural intramedullary mass of T10, AIS-A, addresses
multiple urgent needs, including maintaining bladder function,
respiratory support, and direct spinal intervention for the
tumor. Given the patient's high-level C4 SCI, a suprapubic
cystostomy was performed to manage bladder function. This
ultrasound-guided procedure, which involved inserting a French
16 catheter, ensures consistent urinary drainage, reducing the
risk of urinary complications such as infections and renal
damage due to impaired bladder control associated with high
cervical SCI. The use of sterile technique and ultrasound
verification helped maintain safety, and a secure silk tie
further stabilized the catheter for ongoing management of
bladder function, crucial for patients who lack motor and
sensory function below the injury level.

For respiratory management, a tracheostomy was essential,

as a C4 injury severely affects diaphragm function, requiring
ventilatory support. In this procedure, a horizontal incision
was made just above the sternal notch to insert a size 6-0
tracheal tube, ensuring a secure airway. Following layered
dissection to expose the tracheal rings, the tracheal tube was
121
connected to a ventilator, allowing for reliable respiratory
support. This intervention is critical for C4 SCI patients, as
they typically lack sufficient voluntary control over
breathing and require mechanical ventilation. The tracheostomy
was carefully secured with sterile dressings to minimize
infection risks, supporting the patient’s respiratory needs
for the long term.

Finally, the patient underwent an open laminectomy with

an excision biopsy at T10 to remove the intramedullary tumor.
This part of the surgical plan was aimed at relieving spinal
cord compression caused by the mass, which likely contributed
to the patient’s neurological deficits. After confirming the
T10 level with portable X-ray, a midline incision exposed the
spine, and a laminectomy was performed to access the dura and
spinal cord. Approximately 80% of the tumor was debulked for
histopathological analysis, which is crucial for determining
the mass's nature and planning further treatment if necessary.
The dura was meticulously repaired, and the absence of leaks
was confirmed using the Valsalva maneuver. This spinal
intervention aimed to prevent any further spinal cord
compromise and maintain structural integrity, addressing the
underlying cause of the patient’s SCI at C4 while ensuring
that adequate samples were collected for a more definitive
diagnosis.

122
 CHAPTER III. NURSING MANAGEMENT

PROBLEM IDENTIFICATION, ANALYSIS, AND PRIORITIZATION

Nursing Type and Rank Justification

Diagnosis/ Cues
Impaired Skin
Integrity related
The patient has a significant
to immobility and
pressure injury (Stage III)
prolonged
that is at risk for further
pressure on bony Problem-
deterioration or infection.
prominences Focused / Actual
Addressing skin integrity is
secondary to (Rank 1)
crucial to prevent worsening
spinal cord
and support healing,
injury (SCI) and
especially with sepsis risk
Stage III sacral
pressure injury.
Impaired Physical
Mobility related Complete immobility restricts
to complete motor independence, increases
impairment of dependency, and raises the
Problem-
upper and lower risk for complications such
Focused / Actual
extremities as contractures, muscle
(Rank 2)
secondary to atrophy, and respiratory
spinal cord issues, impacting quality of
injury (motor life and care complexity.
level C4).
Imbalanced
Nutrition: Less
than Body
Requirements
The patient is underweight
related to
with anemia, likely requiring
increased
enhanced nutritional intake
metabolic demands Problem-
to support wound healing,
and inadequate Focused / Actual
infection resistance, and
intake secondary (Rank 3)
overall recovery, which is
to weight loss,
essential for improving
underweight
patient outcomes.
status (BMI 18.3
kg/m²), and
anemia (low
Hgb/Hct).

123
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Impaired Short-term Independent Regular Short-term:

"Nararamdaman ng Skin Goal: 1. Reposition the repositioning Patient shows
kapatid ko ang Integrity Within 48 patient every 2 hours to minimizes no signs of
hindi related to hours, the alleviate pressure on prolonged additional
komportableng limited patient’s bony prominences. pressure on high- pressure
pakiramdam at mobility and wound will 2. Perform meticulous risk areas, injuries, and
pagdepende sa iba prolonged show signs of wound cleaning with reducing the the sacral
dahil sa pressure pressure stabilization, sterile saline solution likelihood of wound shows
injury at exposure with reduced and apply prescribed additional skin stable or
limitadong secondary to erythema and dressings to promote breakdown. reduced
paggalaw." neurogenic no new areas optimal healing. Maintaining erythema.
Patient’ sibling paralysis of skin 3. Encourage high- sterile technique
reports breakdown. protein, high-calorie helps prevent Long-term:
discomfort and diet to support tissue infection, while Progress
dependency due to Long-term repair and overall prescribed toward
pressure injury Goal: healing. dressings create healing
and limited Within 2 an optimal wound observed,
mobility. weeks, the Dependent environment for with
sacral wound 1. Administer prescribed healing. granulation
Objective Data: will show pain medications as Protein intake is tissue
signs of needed to promote critical for present and
- Sacral pressure healing, with comfort during dressing collagen wound depth
injury Stage III decreased changes and synthesis and reduced,
- Limited depth and mobilization. wound repair. indicating
mobility with healthy 2. Follow the healthcare Pain management effective
total dependence granulation provider's order for enhances comfort, wound
on assistance for tissue wound care products or allowing better management
ADLs evident. topical antibiotics cooperation with and patient
- GCS score: 11 based on wound status care measures. response.
(E4V2M5) and lab culture results. Collaboration
- Signs of with wound care
irritability and Collaborative specialists
124
 provides access
1. Consult with a wound
to specialized
care specialist for
distress due to care that may
comprehensive assessment
dependency improve outcomes,
and potential advanced
particularly for
interventions if the
complex, non-
wound does not improve.
healing wounds.

125
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Impaired Short-term Independent Passive ROM Short-term:

"Sabi niya, Physical Goal: 1. Perform passive ROM exercises are The patient
naiinis siya Mobility Within 3 days, exercises on major essential for exhibits no
dahil hindi niya related to the patient joints twice daily to preventing muscle
kayang gumalaw spinal cord will maintain flexibility and contractures in stiffness,
nang mag-isa at injury with participate in prevent contractures. immobile patients and ROM
gawin ang mga complete passive range 2. Educate the patient and maintaining exercises are
pang-araw-araw na motor of motion and caregivers on the flexibility. performed
gawain." impairment (ROM) importance of correct Proper without
The patient of upper and exercises body positioning and use positioning discomfort.
expresses lower without of splints or support prevents
frustration with extremities discomfort or devices to reduce strain additional strain Long-term:
his inability to muscle on joints. on immobile Improvement
move stiffness. 3. Encourage deep joints and in joint
independently and breathing exercises to reduces pressure, flexibility
perform daily Long-term promote circulation and enhancing observed,
activities. Goal: respiratory function. circulation. with no signs
Over the next Deep breathing of
Objective Data: two weeks, the Dependent exercises help contractures
- Complete loss patient will 1. Administer prescribed prevent or muscle
of movement in maintain joint muscle relaxants to respiratory atrophy,
upper and lower flexibility manage spasticity and complications indicating
extremities (SCI, and prevent ensure comfort during from immobility. effective
motor level C4). contractures exercises. Collaboration mobility
- Limited or muscle 2. Arrange for physical with physical interventions
activity per atrophy with therapy sessions as therapists .
Gordon’s regular recommended to aid in enables a
Functional Health therapeutic the patient’s mobility structured
Pattern interventions. program. approach, using
(activity- specialized
exercise). Collaborative techniques to
- Blood pressure: 1. Collaborate with support joint
126
 physical therapists to
create a customized
health and
90/60 mmHg; mobility plan with
mitigate atrophy.
Pulse: 96 bpm electrical muscle
stimulation to minimize
muscle atrophy.

127
 NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Imbalanced Short-term Independent Monitoring intake Short-term:

"Sabi ng kapatid Nutrition: Goal: 1. Monitor and document ensures adequacy The patient
ko, kailangan Less than Within 3 days, daily food intake to of nutritional achieves
niya ng tulong sa Body the patient’s ensure the patient meets support for target intake
pagpapakain at Requirements daily caloric nutritional needs. tissue repair and levels for
hindi siya masaya related to and protein 2. Educate patient and recovery. calories and
dahil sa mababa increased intake will caregivers on the Frequent, small protein.
ang timbang metabolic increase to importance of a meals can improve
niya." demands and meet daily nutrient-dense diet to caloric intake Long-term:
The patient inadequate requirements. support wound healing and patient Weight and
requires intake and prevent further tolerance, lab values
assistance with Long-term weight loss. especially for improve,
feeding and Goal: 3. Encourage frequent those with low indicating a
expresses By discharge, small meals and snacks appetite. positive
dissatisfaction the patient’s as tolerated to meet Iron response to
with underweight weight and caloric needs. supplementation enhanced
status. nutritional addresses anemia, nutritional
markers Dependent which supports support.
Objective Data: (hemoglobin, 1. Administer prescribed increased energy
- BMI: 18.3 kg/m² hematocrit) iron supplements to and recovery
(underweight will show improve hemoglobin capacity.
classification). improvement, levels. Dietitian
- Laboratory indicating 2. Follow dietary collaboration
results show enhanced recommendations and enhances the
anemia nutritional provide any prescribed quality of the
(hemoglobin: 114 status. supplements, such as nutrition plan,
g/L, hematocrit: high-protein or high- ensuring all
0.34). calorie formulas. dietary needs are
met to facilitate
Collaborative healing and
128
1. Collaborate with a
dietitian to create a
improve
tailored nutrition plan
nutritional
that addresses the
markers.
patient’s specific
metabolic needs.

129
130