ASSESSMENT OF SPINAL

CORD ABNORMALITIES

ARRANGED BY:
NOVITA DELVI
ASSESMENT
Assessment in one component of the nursing
process is done by nurses in exploring the assessment
of problems in spinal cord abnormalities in the system
to determine vertebral fractures, most cervical and
lumbar fractures can be simple fractures,
compression, comminutive and dislocations, while
spinal sumsung can be in the form of bruises,
contusions, transverse damage, lacerations with or
without circulatory disorders. Assessment of
spinal cord abnormalities includes:
1. ANAMNESA
2. PHYSICAL ASSESSMENT( HEAD TO TOE)
1. Anamnesa
Anamnesa is a technique for obtaining
information or data about patient health through
interviews between nurses and health workers
with patients or other people who know the
patient's condition in history, information that
needs to be obtained are:
● patient’s bio
● main complaints
● currents disease history
● past medical history
● family history
● work history and lifestyle
Patient's bio
Patient biographical data that needs to be
examined in history includes:
 the patient’s name

 patient’s age

 Sex

 Age

 Full address

 Occupation

 Marital status

 Reliqion

 ethnicity
Main complaint
In making a nursing history related to
disorders of the spinal system, it is important to
know the signs and symptoms. Included in the
main complaints of disorders of
the spinal cord disorders namely, simple
fractures, compression, cominutive and
dislocation. The main complaint is that
complaints are felt to be very disruptive to the
patient's condition which encourages the patient
to come for health care.
Current medical history
Checking the current history of the
disease in the spinal cord abnormalities such
as asking about the history of the disease
since the onset of a complaint so the client
asks for help. This data consists of 4
components, including:
- disease chronology,
- description of the main complaint
- comorbid complaints and
- treatment efforts.
Past medical history
The nurse asked about the illness that the client
dialalmi before. For example, whether the client
has been treated before, with what disease, had
experienced a severe illness, and so on. The
nurse asked about the patient's backbone
history. In general nurses need to ask about the
following:
 Fallhistory
 Current and previous treatment
 Al ergi drug
 Residence
Family history
Study of family history in the spinal system is
a problem that supports patient complaints, it is
necessary to look for family history that can
affect complaints such as a history of
abnormalities in the spinal cord, simple
fractures, compatibility, kominutif and
dislocation. 
Work history and lifestyle
Nurses must also ask about workplace
situations and the environment. Social habits,
work habits that do not pay attention to work
safety, procedures or work methods that are
wrong, as well as neglect and lack of vigilance
towards injured workers that cause falls from
heights or hit by hard objects on bones.
 
2. Physical assessment (Head to Toe )
 Inspection

The client has a cough, increased sputum production, shortness of

breath, use of breathing muscles, increased respiratory
frequency, intercostal retractions, and asymmetrical lung
development.
 Palpation

Decreased premitus compared to the other side will be obtained

if trauma occurs in the thoracic cavity.
 Percussion

Obtained a faint sound to deaf if trauma occurs in the thorax /

hematorax.
  Auscultation
Additional breathing sounds, such as breathing sounds, stridor,
ronchi in clients with increased secretion production, and
decreased coughing ability are often found in spinal cord injury
clients who experience a reduced level of consciousness (coma).
 Innervation
Level of awareness. The degree of guardianship and response to the environment are the
most sensitive indicators for nervous system dysfunction. Examination of cerebral
function. The examination is carried out by observing the appearance, behavior, speaking
style, facial expressions, and motor activity of the client. Clients who have long suffered
spinal injuries usually experience a change in mental status.
Cranial nerve examination :
 - Nerves I. There are usually no abnormalities in the client's spinal cord injury and no
olfactory function abnormalities.         
 - Nerve II. After the test, the sharpness of vision under normal conditions.         
 - Nerves III, IV, and VI. There is usually no disturbance in lifting the eyelids and isochoric
pupils.         
 - V. nerve. Spinal injury patients generally do not experience paralysis of the facial muscles
and corneal reflexes are usually absent.         
 - Nerve VII. The perception of taste is within normal limits and the face is
symmetrical.         
 - Nerve VIII. No conductive deafness and perception deafness were found.         
 - Nerve XI. There is no atrophy of the sternocleidomastoid and trapezius muscles. There is
a client's attempt to flex the neck and stiff neck.         
 - Nerve XII. The tongue is symmetrical, there is no deviation on one side and no
fasciculation, the sense of taste is normal.  
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