Spinal Disorder Case Study Essay
Case Study Spinal disorder Ryan Allen Institute of Technology
Abstract
45 year old patient at a health care facility is being treated for a spinal disorder with non-opioid medications but is still complaining of pain. Doctors are not completing spinal surgery. The patient stated being overwhelmed with helplessness during the assessment.
Spinal Disorder Overview Myelopathy is a degenerative disease of the spinal cord that is a result of the spinal cord
Compression. With age the spine’s natural degenerative changes and that can affect basic
Anatomy.(Ethridge, 2014). But in this case the patient is only 45 year old
Management of the Disease
Management of myelopathy can …show more content…
Urine color and odor WNL
Musculoskeletal- Unsteady gait. Distal weakness. Paresthesia right hand.
Psych- social- Patient states being overwhelmed with helplessness due to illness.
Integumentary- skin is clean and intact .
Medications
Tylenol 500 mg Q4 Hrs PRN for pain level 6-10
Gabapentin 900 mg Tid for nerve pain
Vitamin c 500mg QD Vitamin b12 1,000 mcg QD
Colace 100 mg 2 tabs po PRN
Laboratory
No labs are usually taken for a patient with Myelopathy just a CT scan or MRI .
Nutritional
A patient who has Myelopathy can be on a high protein diet to help gain muscle strength.
Nursing Diagnosis: impaired mobility related to unsteady gait.
Objective: The patient will be able to ambulate from bed to bathroom with limited assistants
Intervention : Preform ROM on lower extremities, turn patient q two hours if in bed, have physical therapy work with the patient.
Rationale: Gaining the patient’s mobility will prevent injuries such as falling.
Evaluation: the patient successfully ambulated from bed to bathroom with limited assistants.
Teaching Plan
The nurse will teach the patient about comfort measure such as the patient asking for a pain
Abstract
45 year old patient at a health care facility is being treated for a spinal disorder with non-opioid medications but is still complaining of pain. Doctors are not completing spinal surgery. The patient stated being overwhelmed with helplessness during the assessment.
Spinal Disorder Overview Myelopathy is a degenerative disease of the spinal cord that is a result of the spinal cord
Compression. With age the spine’s natural degenerative changes and that can affect basic
Anatomy.(Ethridge, 2014). But in this case the patient is only 45 year old
Management of the Disease
Management of myelopathy can …show more content…
Urine color and odor WNL
Musculoskeletal- Unsteady gait. Distal weakness. Paresthesia right hand.
Psych- social- Patient states being overwhelmed with helplessness due to illness.
Integumentary- skin is clean and intact .
Medications
Tylenol 500 mg Q4 Hrs PRN for pain level 6-10
Gabapentin 900 mg Tid for nerve pain
Vitamin c 500mg QD Vitamin b12 1,000 mcg QD
Colace 100 mg 2 tabs po PRN
Laboratory
No labs are usually taken for a patient with Myelopathy just a CT scan or MRI .
Nutritional
A patient who has Myelopathy can be on a high protein diet to help gain muscle strength.
Nursing Diagnosis: impaired mobility related to unsteady gait.
Objective: The patient will be able to ambulate from bed to bathroom with limited assistants
Intervention : Preform ROM on lower extremities, turn patient q two hours if in bed, have physical therapy work with the patient.
Rationale: Gaining the patient’s mobility will prevent injuries such as falling.
Evaluation: the patient successfully ambulated from bed to bathroom with limited assistants.
Teaching Plan
The nurse will teach the patient about comfort measure such as the patient asking for a pain