Client with T10 compression fracture with T9/T10 spinal cord stenosis.

Spinal Stenosis is a condition characterized by the compression of the nerve roots. The patient had a road traffic accident in September 2020 causing his his T9-T10 to fracture which cause by hig velocity impacts to the spinal cord. Thus leading to symptoms such as pain, numbness or tingling, weak muscles or even paralysis. :

PATHOPHYSIOLOGY

Mohd. Erzza Huzaiman bin Mohd. Junar, 33 years old, male:
T10 compression fracture with T9/T10 spinal cord stenosis, non-smoker, non-alcoholic, a chef.
History:
-Left Interrochanteric femur fracture, post alleged road traffic accident in September,2020
-Operation done at Sarawak General Hospital.

SOCIAL HISTORY

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ASSESSMENT


  • Difficulty in mobilizing and transfer from bed to wheelchair.
  • Need assistive device to ambulate.

Impaired physical mobility related to lower body weakness as evidenced by patient need assistive devices such as wheelchair and crane walker to ambulate

Goal: Patient can perform physical activity independently throughout the hospitalization.

  1. Assess for impediments to mobility o identify barriers to mobility guides design of an optimal treatment plan.
  2. Assess the strength to perform ROM to all joints to provide data on extent of any physical problems and guides therapy.
  3. Evaluate patient's ability to perform activities of daily living efficiently and safety on a daily basis to determine strength or insufficiency which helps in further nursing care plan.
  4. Evaluate the need of assistive devices to help the patient enhance ADLs and lessen the danger of falls.
  5. Monitor nutritional needs as they relate to immobility because good nutritional gives required energy for participating in an exercise or rehab activities.

NURSING INTERVENTIONS

NURSING DIAGNOSIS

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Self-esteem, situational low related to situational loss as evidenced by patient verbalized of forced change in lifestyle

Goals:

  1. Patient verbalize acceptance of self in situation.
  2. Recognize and incorporate changes into self-concept in accurate manner without negative self-esteem.
  • Patient verbalized that he need to change his lifestyle after this.
  • Noted that patient express negative feelings about his body since he has leg fracture and on wheelchair when he verbalized.
  1. listen to patient's comments and response to situation to provide clues to view of self, role changes and needs and is useful for providing information at patient's level of acceptance.
  2. Encourage family members to treat patient as normally as possible which by involving patient in family unit can reduce feelings of social isolation, helplessness and uselessness.
  3. Provide accurate information to patient, discuss concerns about prognosis and treatment honestly at patient's level of acceptance so that patient acknowledge with his condition.
  4. Accept patient, show concern for individual as a person by encourage patient, identify and build on strengths, give positive reinforcement.
  5. Include patient in care, allow patient to make decisions and participate in self-care activities as possible to recognizes that patient is still responsible for own life and provides some sense of control over situation.

ASSESSMENT

NURSING DIAGNOSIS

NURSING INTERVENTIONS

  1. To avoid aggravating factors such as excessive lumbar extension and downhill ambulation.
  2. Patient should sit or lying down on correct posture.
  3. advice patient to exercise at least 30 minutes a day, 3 times in a week to maintain mobility for as long as possible.
  4. Encourage patient to eat healthy diet to provide energy.

HEALTH EDUCATION