APPLYING NURSING PROCESS

CARE OF THE CLIENT WITH A

PROBLEM ON
PID L4-L5 (Rt side)

TN DAW NANN KYIN OO

29.5.2023

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 2. BRIEF HISTORY

Name - U Zaw Myo Htun

Age - 47 years
Sex - male
Register No - 0757/23
Race / Religion -B/B
Marital status - married
Education - Grade 11
Occupation - Restaurant
Address - Monywa city
Admission Date - 9:00 am, 10.5.2023
Client’s reason for seeking health care : severe low back pain for 4 months
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History of present Illness
Previously well and had ability to work his job.

4 month ago, he suffered severe pain and having difficuly maintaining a reasonable level of daily

functions, such as standing or walking.

After 2 months, he suffered progressive neurological symptoms, such as worsening Rt leg

weakness, pain and numbness.

After that,he went to a private hospital( Mingalar hospital ) and took medical treatment.

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Past Health History
• No history of hospitalization
• No known history of TB , HT , DM
• No prolonged use of self medication
• No history of cough, breathlessness, Dyspnea, chest pain, dizziness
• No history of surgical history
• No known drug allergy
• No history of bobacco chewing or alcohol drinking
• No history of any other disease ( heart disease , COPD etc )
• he has well balanced diet and 3 meals/day.
• he has normal bowel pattern ( 1 time / day )
• he has normal sleep pattern of 8hr / day

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Family Health History (parents, siblings , spouse , children )
• he has 1 son.
• No known history of hierarchy diseases ( such as hypertension, DM , heart disease , etc).
• No known history of TB or any other communicable diseases

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Physical Examination
General Examination:
• GC fair
• Heart & Lungs clear
• No scars, oedema, rashes, leasions at abdomen
• No papable of spleen / liver
• Bowel sounds (+)
Respiratory : no obvious abnormality
Circulatory : physician noted no obvious abnormality

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Local Examination:
• No open wound
• Rt leg pain (+), numbness (+)
• Weakness in extending the big toe and potentially in the ankle
• Difficulty in sitting and standing
• Forward flexion aggravating back pain
• Extension relieving back pain
• Pain in the lower back intermittently in both severity and frequency, worsen by activity.
• Increased pain on coughing, sneezing, or straining to go to the toilet
• Pain on straight leg raise
• Change in sleep pattern
• Nerve root compression at L4- L5 (Rt side)
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Activities of Daily Living
Feeding : assistant with person
Bathing :assistant with person
Dressing :assistant with person
Grooming : total independence
Toileting :assistant with person and device
Ambulation : assistant with person and device

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Vital signs
Temperature – 98.6F
Pulse rate – 96 bpm
Respiration rate – 20/min
Blood pressure – 120/80 mmHg
SPO2 – 99% on air

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Diagnosis - PID L4- L5 (Rt side)
Opreative Treatment- Decompression and Disectomy
Opreative Daate – 12.5.2023
Discharge date - 20.5.2023

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 TREATMENT AND INVESTIGATION
Treatment
Injection
12.5.23 IV Ceftriaxone 1G - 12hr (ATD)
IV Ketorolac 30mg – 12 hr
IV Pantocid 40 mg – 12 hr
ORAL
10.5.23 O’ Para – 1 tds
O’ Aceclofenac 100mg – 1 bd
O’ Omeprazole 20 mg – 1 bd
O’ Pregabalin 75 mg – 1 hs
O’ Betex – 1 od
20.5.23 O’ Cefixime 200mg – 1 bd 14
Investigation
10.5.2023
Test Result Normal Range

Blood Grouping O(+)

HBS Ag Non reactive
HCV Ab Non reactive
HIV Ab Non reactive
CRP Negative < 6 mg/L

Creatinine 0.8 0.5- 1.1 mg/dl

WBC 9.3 4.0 – 11.0

RBC 4.79 3.8 – 5.8

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Investigation
10.5.2023

Test Result Normal Range

HGB 13.5 11.5 -15.0

PLT 230 150 – 400

OSPT 9.8 10 - 14
INR 0.83 0.8 – 1.2

ESR 38 <20

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Investigation
10.5.2023
Test Result Normal Range

Electrolyte

Sodium 141 133 – 145

Potassium 3.6 3.5 – 5.4
Chloride 104 95 – 105

Bicarbonate 24 23 – 29

ECG physician noted no obvious abnormalities

CXR radiologist noted no obvious abnormalities

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Operation Report
Surgeon Prof Dr. Zaw Min Han
Assistant SAS Dr. HLP, SAS Dr.NH, PG Dr. TLKKA
Anaesthesia SAB
Anesthesiologist Dr. HHK
Pre OP diagnosis
PID L4- L5
Post OP diagnosis
PID L4- L5 (Rt side)
Date/Time 12.5.2023/10:15 am to 12:10 pm
Operation performed Decompression and Disectomy
Operation Note Under asptic condition, Decompression and Laminectomy+ Disectomy (Rt
side) was done. Post-op drain was inserted. No complication.

Position prone
Post op Treatment Inj: Ceftriaxone 1 G – 12 hr
Inj: Ketorolac – 12 hr
O’ Para – 1 tds,O’ Aceclofenac 100mg – 1 bd,O’ Omeprazole 20 mg – 1 bd

Exam C- Arm

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 LITERATURE REVIEW

Definition
Herniated nucleus pulposus is a condition in which part or all of the soft, gelatinous
central portion of an intervertebral disk is forced through a weakened part of the disk,
resulting in back pain and nerve root irritation

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Epidemiology
a. Peak incidence is in the fourth and fifth decades of life.
b. Only 4% to 6% of LDHs become symptomatic.
c. Men are three times more likely to sustain LDH.
d. Of all individuals, 1% to 3% will undergo surgical intervention for LDH at some point in their lives.
e. Fewer than 10% of patients with LDH are surgical candidates.
f. Caudal segments are affected more commonly (L5-S1 more commonly affected than L4-L5).

Natural history
a. Within 3 months of symptom onset, approximately 90% of patients will experience symptomatic
improvement without surgery.
b. Most LDHs, particularly contained ones, resorb and diminish in size over time

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Clinical presentation
a. LDH may or may not be associated with an inciting event (such as load bearing).
b. The patient typically presents with varying degrees of back and leg pain.
c. Leg pain usually follows the dermatomal path of the affected root(s).
d. Radicular pain may be accompanied by motor, sensory, and/or reflex disturbances.
e. The presence of sciatica is the most sensitive and specific finding for LDH.
f. Cauda equina syndrome secondary to large central LDHs is rare.
Herniation morphology
g. Protrusion—Eccentric bulging through an intact anulus fibrosus
h. Extrusion—Disk material that crosses the anulus fibrosus but is continuous within the disk space
i. Sequestered—Herniation that is not continuous within the disk space; also known as a free fragment

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Signs and Symptoms

Signs and symptoms will depend on the site of the disc prolapse and the nerves involved. This may include:

• Pain in the lower back or neck. intermittent in both severity and frequency but made worsen by activity.
• Pain down one or both legs (sciatica) on in the shoulder or arm
• Increased pain on coughing, sneezing or straining to go to the toilet.
• Pain on straight leg raising..
• Bladder or bowel dysfunction.
• Paraesthesia / loss of sensation, depending on the nerve root affected.

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Etiology
Disc herniation and disc degeneration are associated terms, being nucleus pulposus herniation a possible
evolution from a degenerative disc.
Disc degeneration is usually associated with loss of proteoglycans.
Multiple factors influence the degenerative process such as genetic, mechanical, and behavioral.
The intervertebral disc is a structure that provides flexibility and transmits loads through the spine.
Mechanical load is important in maintaining a healthy IVD by generating signals to cells that regulate
proper matrix homeostasis.
On the other hand, prolonged exposure to hypo or hyper loading correlates with disc degeneration
induction

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Pathophysiology
Disc herniation is a consequence of degenerative changes in the annulus; those changes are age-related
adaptive modifications in the disc structure that encompass desiccation, fissures, disc narrowing,
mucinous degeneration, intradiscal gas (vacuum), osteophytes, inflammatory changes, and subchondral
sclerosis. Annulus fissures predispose to a weakness, which allows disc material to bulge or migrate
outside the annulus margins.

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Classification Region
Proper understanding of anatomical zones and vertebral level is essential to interpret the
clinical manifestations secondary to a disc herniation. Wiltse proposed these anatomical
zones, based on the following landmarks: medial border of the articular facet, lateral, upper
and medial borders of the pedicles, coronal and sagittal planes at the center of the disc. On
the axial plane, these landmarks determine the central zone, the subarticular zone (lateral
recess), foraminal, and extraforaminal zones. On the sagittal plane, the levels are termed as
follows: The supra pedicular level, the pedicular level, the infrapedicular level, and the disc
level. The correct knowledge of anatomy and relationship between nerve roots and disc
herniation allows the proper understanding of common clinical findings associated with this
problem.

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There are two main mechanisms to explain radicular pain secondary to a nucleus pulposus
herniation: Mechanical compression and inflammatory reaction. Clinical symptoms may
vary according to several factors such as the location of the herniation (level), neural
compression, and evolution. Nucleus pulposus herniation can produce low back pain;
however, the primary clinical manifestation is radiculopathy, which is mainly manifested
by radiating pain and sensitive changes that encompass nerve distribution. Additionally,
reflexes assessment (decreased reflex) may help to identify the compromised nerve root.
We summarize the anatomy, motor function, sensitive distribution, and reflex of the most
commons nerve roots involved in cervical and lumbosacral nucleus pulposus herniation:

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Cervical:
• C5 nerve root: Exits between C4 and C5 foramina, innervates deltoids and biceps (with C6),
sensory distribution: lateral arm (axillary nerve) and is assessed with biceps reflex.
• C6 nerve root: Exits between C5 and C6 foramina, innervates biceps (with C5) and wrist
extensors, sensory distribution: lateral forearm (musculocutaneous nerve), assessed with
brachioradialis reflex.
• C7 nerve root: Exits between C6 and C7 foramina, innervates triceps, wrist flexors, and finger
extensors, sensory distribution: middle finger, assessed with triceps reflex.
• C8 nerve root: Exits between C7 and T1 foramina, innervates interosseus muscles and finger
flexors, sensory distribution: ring and little fingers and distal half of the forearm (ulnar side),
no reflex.

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Lumbosacral:
• L1 nerve root: Exits between L1 and L2 foramina, innervates iliopsoas muscle, sensory distribution: upper
third thigh, assessed with the cremasteric reflex (male).
• L2 nerve root: Exits between L2 and L3 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps,
sensory distribution: middle third thigh, no reflex.
• L3 nerve root: Exits between L3 and L4 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps,
sensory distribution: lower third thigh, no reflex.
• L4 nerve root: Exits between L4 and L5 foramina, innervates quadriceps and tibialis anterior, sensory
distribution: anterior knee, medial side of the leg, assessed with patellar reflex.
• L5 nerve root: Exits between L5 and S1 foramina, innervates extensor hallucis longus, extensor digitorum
longus, and brevis, and gluteus medius, sensory distribution: anterior leg, lateral leg, and dorsum of the foot,
no reflex.
• S1 nerve root: Exits between S1 and S2 foramina, innervates gastrocnemius, soleus, and gluteus maximus,
sensitive distribution: posterior thigh, plantar region, assessed with Achilles reflex. 28
Prognosis
The majority of patients suffering from nucleus pulposus herniation experience symptoms resolution
without surgery.
Conservative treatment is effective, and patients usually experience symptom relief after a couple of
weeks.
However, some cases do not improve with conservative treatment and may require more invasive
therapies such as nerve root steroid injection or even surgery.
The presence of myelopathy in cases of central nucleus pulposus herniation in the cervical or thoracic
region is an indication for surgery, especially in the setting of symptoms progression.

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Complications
Complications associated with nucleus pulposus herniation can result from the compression effect on the
nerve root in severe cases resulting in motor deficit, in the cervical and thoracic spine there is also a risk
of spinal cord compression in severe cases.
These complications are relatively uncommon but should be considered and properly treated to avoid a
permanent neurological deficit.
Cauda equina syndrome is another complication that results from lumbosacral nerve roots compression
with possible bowel or bladder dysfunction.
It is a rarely occurring condition (less than 1%).
However, it is considered an absolute indication for acute surgical resolution, and early decompression is
associated with symptoms improvement

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 DIAGNOSTIC MEASURES

The history taken from the patient is crucial and should include:
• Exact signs, symptoms and location.
• Duration of the symptoms.
• A history of any injury sustained and any previous surgical treatments.
• Social and financial impact and coping
• Any personal igiwy litigation pending
Investigations will depend on the severity of the patient's symptoms and may include
• Full physical and neurdagical examination
• Observation of gait, reflex testing, motor strength, toe touching, and pulse
• Radiography - although this will not show a disc prolapse but will show any degeneration and other skeletal abnormalities.
• CT or MRI scan will provide a clear picture of the prolapse
• Discogram may be used to identify the physical status of a disc.
• Differential nerve blocks can identify. difficult nerve root problems 31
Physical examination
a. The ipsilateral hip and knee may be flexed and externally rotated to relieve root tension.
b. Pain with straight leg raise testing results from increased nerve root tension and a lack of
normal excursion of the root at the herniation site. A positive crossed straight leg raise test has
a higher specificity than a positive ipsilateral test, but the sensitivity varies. Table 4 lists the
relevant provocative testing.
c. The nerve root(s) affected depends on the level of the herniation and the region within a
particular segment where a disk is herniated. Figure 2 lists the motor, sensory, and reflex
contributions of roots L4 through S1. A radiculopathy can result in sensory, motor, or reflex
examination deficits for the affected root. It is critical to understand the anatomy as it relates to
normal and abnormal examinations.

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• A paracentral disk herniation will affect the traversing nerve root (eg, an L4-L5 right
paracentral LDH will affect the right traversing L5 nerve root and present as an L5
radiculopathy).
• A far lateral disk herniation (also known as intraforaminal or extraforaminal), which
represents a minority of LDHs, will affect the exiting nerve root (eg, an L4-L5 right far
lateral LDH will affect the right exiting L4 nerve root).
• An axillary LDH can affect both the exiting and traversing roots.

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 THERAPEUTIC MANAGEMENT

Nonsurgical treatment—See Table 5.

Epidural steroid injections are successful in alleviating pain and avoiding surgery.
Surgical treatment
a. Surgery is rarely indicated earlier than 6 weeks from the onset of symptoms, but it should
not be delayed beyond 3 to 4 months. After 6 months, patients may see less benefit with
surgery.

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b. Absolute indications are cauda equina or progressive neurologic deficit, but both are rare.
c. Relative indications Radicular pain not responsive to nonsurgical management Neurologic deficit
that does not improve with nonsurgical care and “tincture of time” Recurrent sciatica following a
successful trial of nonsurgical care Substantial motor deficit (controversy exists as to what constitutes
this) with positive tension signs
d. Surgical procedures A partial diskectomy remains the standard of care. This can be performed
through an open approach or a minimally invasive approach (such as tubular access). No level I
evidence demonstrates the superiority of either type of surgery in the long term.
e. Outcomes—The most consistent finding postoperatively is improvement in leg pain.

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f. SPORT Trial 8-year Follow-up: the advantage of surgical intervention versus
nonsurgical management was seen for all primary and secondary outcomes in
selected patients.
g. Reherniation—Common (23%) but less commonly symptomatic (10%); patients
undergoing revision diskectomy can expect similar results as with the primary
surgery.

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 NURSING MANAGEMENT

Preoperative
1. Describe the surgical procedure to patient and family.
2. Informed consent obtained by surgeon.
3. Describe the expected outcomes, both postoperative and long term.
4. Arrange for required preoperative testing.
5. Advise patient to discontinue medications such as herbal products, NSAIDs, anticoagulants,
aspirin, warfarin, and clopidogrel bisulfate.
6. Encourage patient to anticipate and arrange for perioperative and postoperative care needs.

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Perioperative
1. Explain to patient where and when to arrive, as well as surgery time.
2. Instruct patient as to eating and drinking restrictions.
3. Instruct patient about medications to be taken the morning of surgery with a sip of water.
4. Remind patient to wear comfortable clothing and to leave jewelry and valuables at home.
5. Tell patient to remove dentures, partial plates, eyeglasses, contact lenses, nail polish, and
sculptured nails.

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Intraoperative
1. “Time Out”—right patient, right surgery, right site
2. Proper patient positioning
a) Table options are surgeon specific.
b) If patient is obese, consider using a Jackson table.
3. Intraoperative needs anticipation
a) Equipment
b) Patient-specific needs (e.g., latex allergy)

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Postoperative
1. Neurological assessment
a) Strength and sensation assessment, as compared with preoperative status.
b) Special attention to neurological assessment and correlation with the operative intervention.
2. Mobility
a) Patient should mobilize quickly unless ordered differently due to complication (e.g., CSF
leak).
b) Instruct and help patient to roll to side and bring legs down while simultaneously rising up
with the torso from the bed. This minimizes twisting at the waist.
c) Instruct and help patient to rise from a chair using the legs, rather than pushing off with the
back.

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3. Pain control
a) The degree of pain varies considerably.
b) Intravenous hydromorphone or morphine sulfate may be used as needed until the patient is able to take oral
medications.
c) Codeine, hydrocodone, or oxycodone, with or without acetaminophen, may be prescribed as needed when the
patient is able to take oral medications.
d) NSAIDs, as needed, can be very beneficial.
e) Neuropathic pain medications (e.g., gabapentin) may be beneficial.
f) Antispasmodics may be prescribed if muscle spasms are present.
g) Heat may be applied for spasms and muscular tension.
h) Ice may be applied for radicular pain for no more than 20 minutes per hour.
i) Gentle massage may be used away from the incision.
j) Have patient change positions frequently.
k) Modest activity may be conducted as tolerated. 44
4. Constipation prevention
a) Consider initiating techniques preoperatively.
b) Ensure adequate water intake.
c) Diet should include adequate fresh fruits, vegetables, and fiber.
d) Stool softener (e.g., docusate) may be used two to three times per day.
e) Motility agents (e.g., senna) should be used only as needed.
5. Urination
f) Urinary hesitancy, especially immediately postoperative, is usually transient.
g) Assess urinary output, frequency, and volume.
h) Assess to be sure there is adequate emptying. Bladder scanning or intermittent bladder
catheterization may be necessary to assess for retention or incomplete emptying.

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 A S S E S S M E N T D ATA

Subjective Data Objective Data

Patient said that:
• I feel severe pain at my lower back.
• I feel worsen my Rt leg weakness, pain, and numbness.
• I feel difficulty in my daily functions and I can’t go
anywhere without assistance.
• I feel discomfort and tender around the incisional
wound.
• I can’t sleep well.
• It is so difficulty to understand about this treatment and
care.
• I have difficulties in walking.
• I feel like I have no control over anything.
• Request for information frequently.
I observed that:
• Nerve root compression L4-L5
• Pain in the lower back intermittently in both severity and
frequency
• Pain score of 7 to 9.
• Progresssive radicular pain at Rt leg
• Pain on SLR
• Inability to mobilize or transfer independently
• Unable to perform self care tasks
• Presence of incisional wound and drainage
• Uncomfortable sleeping positions
• Insufficient knowledge of activity restrictions, assistive
devices, home care, follow up care and suppotive
services.
• Unfamiliarity with the use of mobility aids
• Anxiety for sudden pain and loss of mobility
• Insufficient knowledge about her condition, treatment
and self care management.

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Nursing Diagnosis with Prioritization
1. Altered in comfort (acute pain) related to presence of nerve root compression as evidenced by
verbalization of pain and guarding behaviors.
2. Impaired physical mobility related to pain and disease pathology as evidenced by pain and numbness
of Rt leg.
3. Self care deficit (feeding,hygience,toileting) related to inability to mobilize or transfer independently
as evidenced by unable to perform self care tasks.
4. Risk for infection related to invasive procedure.
5. Impaired skin integrity related to presence of incisional wound and drainage.

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6. Sleep pattern disturbance related to pain brought by external factors such as uncomfortable sleeping
position.
7. Risk for ineffective therapeutic regimen management related to insufficient knowledge of activity
restrictions, assistive devices , home care , follow up care and supportive services.
8. Potential for injury related to unfamiliarity with the use of ambulatory aids.
9. Anxiety related to sudden pain and loss of mobility.
10. Knowledge deficit related to unfamiliarity with information resources about their condition,
treatment , and self-care management.

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 HEALTH EDUCATION AND DISCHARGE PLAN

When you are stable and your pain controlled, you can be discharged to home. You will typically
stay in the hospital for 0-2 days before being discharged home. Certain patients may be
discharged to a rehab center to recover further before they eventually go home. You may shower
on the third day after surgery as long as the wound is not draining. You should keep the incision
clean and dry. Follow up after surgery with your surgeon is required, and x-rays will be performed
from time to time.

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Physical Therapy and Activity
You will be encouraged to walk often, being careful not do any excessive bending, lifting, or
twisting. For specific instructions, speak to your surgeon.
Ice
Ice therapy may continue to provide comfort, decrease swelling and help with pain control for
up to two weeks following surgery. Be sure to place a towel between the skin and the ice bag.
Ice the area for 20 minutes or less to prevent frostbite.

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Blood Clot Prevention
After an orthopedic surgery, patients are at an increased risk for developing blood clots or deep venous
thrombosis (DVT). Upon discharge, you will be given a specific regimen that may include aspirin or
prescription blood thinners. It is important to follow the instructions exactly and attend all scheduled
follow up appointments.
Symptoms of deep venous thrombosis or pulmonary embolism may include swelling or tenderness in
the calves, legs or arms, shortness of breath, increased heart rate or palpitations, or chest pain. If you
experience any of these symptoms, notify your surgeon and go to an emergency room.

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Wound Care
A surgical wound that requires daily attention and monitoring. Your healthcare team will instruct you
about how to care for your wound before you leave the hospital. Please keep your incision clean and dry at all
times. Do not immerse your incision in water. This includes pools, hot tubs, lakes, and bath water. You may
shower on the third day after surgery, as long as your wound is not draining.
Do not apply any lotions, creams or ointments unless prescribed by your surgeon. Your healed wound is
new skin and should be protected from the sun with sun block especially in the year following surgery.
Monitor your incision daily for any signs of infection. Some swelling and redness is normal but if there is an
increase or if you develop any of the symptoms below notify your surgeon.
Symptoms of a wound infection may include redness, drainage, swelling, warmth at/around the incision
site or if you experience chills, shaking, an increase in pain or a fever over 101° orally. If you experience any
of these symptoms, notify your surgeon immediately.
A follow-up appointment will have already been scheduled for you 10-14 days following surgery for an
incision check and removal of any sutures.
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Preventing Infection
Following your surgery, antibiotics should be taken before any dental or invasive procedure (i.e.
dental cleaning, oral surgery, bladder scopes, urinary catheterizations, colonoscopy, etc.). Your surgeon
will give you exact instructions after surgery. Please feel free to contact our office with any questions.
Symptoms of possible infection are persistent fever (higher than 101° orally), shaking, chills,
increased redness/tenderness/pain at surgical site.
Diet
Some loss of appetite following surgery is common. Make sure you are eating a balanced diet rich in
protein to promote muscle healing and strength. It may help to eat smaller meals more frequently and
drink plenty of liquids.
Medications
Physician will determine resuming your home medications. Take the medicine exactly as prescribed.
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Discharge planning
a) Discharge planning should be initiated preoperatively.
b) Reinforce the following: no lifting, bending, or twisting; no sitting for long periods of time.
c) Remind patient to change positions frequently.
d) Remind patient not to drive while using narcotic pain medications.
e) Explain to patient that sexual activity may be resumed 2 weeks after surgery and when it is
comfortable.
f) Ensure the patient is aware of return-towork and activity recommendations.
g) Reinforce alternative planning and problem solving for practical everyday activities (e.g.,
vacuuming, doing laundry, and performing child care).
h) Incision care varies with the type of closure.
i) Ensure the patient is aware of postoperative follow-up recommendations.
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