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0PART 1: INTRODUCTION and PROFILE

Overview of the Case

A case of Patient ADAM, 44 years old, male who has been staying at
Northern Mindanao Medical Center – Orthopedic Ward for 5 days (December 14,
2010 – last day of our duty and the 5th day of his stay) diagnosed with Acute Spinal
Cord Injury, complete, C4 level bilateral facet dislocation (C4-C5), spontaneously
reduced to secondary to vehicular accident.

Spinal Cord Injuries (SCIs) are a major health problem. Most spinal cord
injuries result from motor vehicle crashes. Other causes include falls, violence, and
recreational sporting activities. Half of the victims are between 16 and 30 years of
age; most are males.

Injury to the spinal cord results in compression, twisting, severing or pulling

on the spinal cord. The damage of the cord may involve the entire thickness of the
cord (complete), or only a partial area of the spinal cord (incomplete). The most
common cause of spinal cord injury is trauma. Any level of the spinal cord may have
been affected by the injury or within 1 to 2 vertebrae or spinal nerves above the level
of injury. The loss may be unilateral or bilateral. Damage to the vertebrae may have
occurred at the same time as the spinal cord injury. Swelling due to the initial trauma
may make the injury seem more severe than it actually is. When the initial swelling
resolves, the actual degree of permanent injury can be more accurately assessed.

The level of injury will determine the degree of disability the patient is likely to
sustain. A high-level injury, such as cervical injury, will more likely result in
quadriplegia and compromise of the respiratory drive. A complete spinal cord injury
will result in greater disability than an incomplete injury. Spinal cord tissue does not
regenerate after an injury. Swelling that occurs immediately following an injury may
be controlled with medications and some clinical improvement may occur, but the
damage to the cord cannot be undone.

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Objectives of the Study
General Objectives
The general objectives for conducting this case study is for the
students in their Orthopedic Ward rotation to be able to integrate concepts of
Orthopedic nursing, apply appropriate nursing management and
consequently develop a meticulous attitude on rendering nursing
interventions to patients with this health condition.

Specific Objectives
At the end of 1 hour of case presentation this case study specifically
aims to:
a. Present the condition of patient ADAM suffering from Acute
Spinal Cord Injury.
b. To acquire knowledge and understanding of the
pathophysiology of Spinal Cord Injuries.
c. Design a nursing care plan appropriate in providing care to
prevent further complications associated with Spinal Cord Injuries.
d. To manage efficiently the complications that the patient have
experience.
e. To identify and provide the health teaching needs for the
continuum of care.
f. To apply knowledge in Medical Surgical Nursing, particularly on the
management of a client with Spinal Cord Injury.
g. To apply and enhance our skills in nursing procedures and to
demonstrate appropriate attitude in relation to the management of a
client with Spinal cord injury.
h. To use the nursing process as the framework of care for the
patient.

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Scope and Limitations
This care study conducted, concentrates mainly to the case of patient
ADAM having Acute Spinal Cord Injury - Complete. The areas of concern are limited
to the discussion of the disease process and the Medical and Nursing management
of Spinal Cord Injury. The quantity and quality of the information are limited to the
data gathered from the client, significant others and his medical records and an
approximately 24 hours of cumulative interaction with the client and with his
Significant other, specifically on December 13-14, 2010. The source of information is
limited to the patient’s chart, interview, nursing history and assessment records.

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Patient’s Profile
Name of Patient: ADAM
Age: 44 years old
Gender: Male
Date of Birth: April 14, 1966
Address: Purok 4, Guinoyuran, Valencia Bukidnon
Occupation: Farmer
Civil Status: Married
Religion: Baptist
Nationality: Filipino
Informant: ABRAHAM
Relation to Informant: Brother
Chief Complaint: Quadriplegia (Paralysis on Upper and
Lower Extremities)
Date of Admission: December 9, 2010
Time of Admission: 2:30 am
Attending Physician: Dr. Bernard Antolin
Allergies: ADAM has no known allergies both food
and drugs
Diagnosis/Impression: Acute Spinal Cord Injury, Complete, C4
level secondary to bilateral facet dislocation
(C4-C5), spontaneously reduced secondary
to Vehicular accident (Motorcycle).

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PART 2: HEALTH HISTORY and PRESENT ILLNESS

Personal History
ADAM, a 44 year-old male, married, has 2 daughters and a son. He was born
on April 14, 1966. ADAM was a farmer and part time driver (habal-habal). He works
having 2 jobs since his wife is not here in the Philippines. A day prior to his
admission he drove home with his motorcycle. On his way home, he lost balance
with the motorcycle and fell, feeling a snap in his back which caused his upper and
lower extremities paralysis. He was rushed to the nearest hospital in Valencia and
consequently referred at Northern Mindanao Medical Center.

Family History
As the group conducted the assessment, the informant (ABRAHAM) that the
family only experiences common illnesses like fever, cough, colds, toothaches,
headaches, etc. but has never occurred to them any major diseases or illnesses.

History of Present Illness

Eight (8) hours prior to admission, patient was driving a motorcycle when
accidentally lost balance and fell hitting posterior neck first and immediately felt a
snapping sensation on posterior neck with associated inability to move right and left
Upper Extremities and Lower Extremities.

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PART 3: NURSING ASSESSMENT

Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
__ Hearing Loss Comments: __ Glasses __ Languages
X Visual Changes “Dili naman kaayo na siya __ Contact Lens __ Hearing Aide
makastorya tungod sa
__ Denied R L X Speech Difficulties
tubo nga gitaod. Amo lang
na siya ipa-hunghung Due to tracheostomy tube inserted .
kung unsa iyang gusto,” as
verbalized by the patient’s
Pupil Size: Both Right and Left eye 3mm
SO. Reaction: Pupil Equal Round Reactive to light Accomodation.
OXYGENATION:
X Dyspnea Comments: Respiration: __ Regular X Irregular
X Smoking History “Sa una raman siya Describe: Shallow and labored breathing with
gapanigarilyo. Mahurot
One pack per week Increased respiratory rate (31cpm)
ang tunga sa kaha sa isa
__ Cough ka simana. Galisod naman
X Sputum siya ug ginhawa karon kay R: Anatomically, the right lung is symmetrical to the
__ Denied dili na malihok iyang baga, Left lung.
ingon sa doctor nga
paralyze daw siya tibook L: The left lung is also symmetrical to the right lung.
lawas” As verbalized by But due to the body paralysis the diaphragm is
patient’s SO. helping the lungs exert effort when breathing.
CIRCULATION:
__ Chest Pain Comments: Heart Rhythm: __ Regular X Irregular
__ Leg Pain “Gareklamo siya nga Ankle Edema: present in both ankles and non-pitting
X Numbness of sakit kaayo iyang ulo.”
As verbalized by the Pulse Car Rad DP Fem*
extremities
patient’s SO. Right 79 weak weak Not taken
__ Denied
Left 82 weak weak Not taken

Comments: Radial & DP are palpable but weak. Femoral

pulse not taken due to patient’s SO request not to and for
privacy.
NUTRITION:
Diet: Osteorized Feeding __ Dentures X None
__ N __ V Comments:
Character “Pina-agi lang ang
_______________ pagkaon niya sa tubo kay Full Partial With Patient
__ Recent change maglisod naman siya ug
ginhawa kung wala ang
in weight, appetite tubo, ug sambol sa tubo Upper
X Swallowing difficulty kung mukaon siya paagi
__ Denied sa baba.” As verbalized by
Not applicable
Lower
patient’s SO.

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ELIMINATION:
Usual bowel pattern: __ Urinary Frequency Comments: Bowel sounds:
Every morning (PTA) FBC in place “Sa wala pa siya na admit, kada Hypoactive
X Constipation __ Urgency buntag malibang siya. Sukad Abdominal Distension
X Remedy __ Dysuria pag-admit niya wala pa siya Present:
Analgesic Agents naka-libang,” – Dec. 12, 2010 X Yes __ No
__ Hematuria
(Tramadol) __ Incontinence Urine:
__ Date of last BM __ Polyuria Color: Yellow(iced tea)
Dec. 14, 2010 afternoon X Foly in place Odor: Not Assessed
__ Diarrhea __ Denied Consistency:
__ Character 50-70ml per urination

MGT. OF HEALTH & ILLNESS:

X Alcohol __ Denied Briefly describe the patient’s ability to follow
__ Amount & Frequency treatments (diet, meds, etc.) for chronic problems (if
Gainom siya sa una pero undang naman present).
siya. Mga 2 ka-litro iyang mahurot kada The patient is assisted by his SOs and health
workers in the hospital since he is not able to
simana. mobilize himself due to paralysis of his upper and
SBE Last Pap Smear:Not applicable lower extremities.
LMP: Not applicable
SKIN INTEGRITY:
X Dry Comments: X Dry __ Cold __ Pale
__ Itching “naa siya mga samad- X Flushed X Warm
__ Other samad gumikan sa __ Moist __ Cyanotic
__ Denied aksidente.” As
vervablized by the *Rashes, ulcers, decubitus (describe size,
patient’s SO. *location, drainage):
Lesions at the lower extremities and scars are found at the
head.
ACTIVITY/SAFETY:
__ Convulsion Comments: X Level of Consciousness and Orientation
__ Dizziness “Dili naman siya He is awake and well oriented to date, time, place and
__ Limited motion of makalihok. Tabangan Person
__ joints na gyud siya sa tanan __ Gait: __ Walker __ Cane X Other
buhatonon. Sa ilis sa __ Gait: __ Steady
iya, pagilis sa diaper, __ Gait: __ Unsteady:_____________
Limitation in ability to: kung trapohan pud
X Ambulate X Sensory and motor losses in face of
namo siya.” As __extremities: The patient has sensory and motor
X Bathe Self verbalized by the
__ Other loss in the upper and lower extremities.
patient’s SO.
__ Denied X Range of Motion Limitations:
Upper and lower extremities are paralyzed due to the
Spinal cord injury.
COMFORT/SLEEP/AWAKE:
X Pain Comments: X Facial Grimaces
Location: “Gahunghung siya sa __ Guarding
Head – Headache ako nga sakit kuno __ Other Signs of Pain:
Frequency: iyang ulo. Tungod pud
siguro sa kanang
Every hour interval
puthaw nga naa sa
Remedies: iyang ulo. Ug gamata-
Given Tramadol mata siya matag gabii __ Siderail release form signed (60+ years)
__ Nocturia sa gamay lang nga
X Sleep Difficulties saba ug sa kanang dli
__ Denied na siya katarong ug
ginhawa kay kailangan
siya magpasuction.” As
verbalized by the

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 patient’s SO.

COPING:
Occupation: Motorized Driver & Farmer
Members of household: 7 members
Most supportive person: Wife, mother and his
Brother.
Observe non-verbal behavior: Patient uses his eyes
eyes to points at the things he needs in assistance.
The person and his phone number that can
Be reached anytime: Not taken

Nursing System Review Chart

Name: ADAM Date Assessed: December 14, 2010
Body Measurements:
Weight: not assessed Height: 5’6”
Vital Signs upon Assessment:
Pulse Rate: 71bpm (taken from the pulse oximeter) Respiratory Rate: 33 cpm
Temperature: 38.7°C Blood Pressure: 100/70 mmHg
ALL ABNORMALITIES ARE SHOWN IN THE FRONT VIEW OF THE DRAWING

Gardner-Wells EENT:
EENT Tracheostomy Tube
Tong Impaired vision – Using of glasses
Teeth – Full of cavities
[X] Impaired Vision [ ] Blind NGT Gums – Dry and has mouth ulcers

[ ] Pain Redden [ ] Drainage RESPIRATORY:

Tachypnea – RR=31cpm
[X] Gums [ ] Impaired Hearing Shallow – due to increase oxygen
demand
[ ] Deaf [ ] Burning Sputum – due to tracheostomy tube,
a foreign object which stimulate the
bronchioles to produce the stupum.
[ ] Lesion [X] Teeth Diminished – diminished breathing
mechanism due to the paralysis of the
[ ] Edema respiratory muscles.
Dyspnea – uncomfortable breathing
Assess Eyes, Ears, Nose, due to the paralysis of the respiratory
muscle.
Throat for abnormality Labored – increasing effort of
CARDIOVASCULAR:
breathing due to increase oxygen
Numbness – due to decrease
demand.
[ ] No Problem circulation in decrease of oxygen
supply.
Diminished Pulse – decrease blood
circulation to the affected nerves.
Irregular – Irregular heart rate –
Fluctuating heart rate (71bpm, 63bpm,
75bpm, 95bpm, 80bpm) – Dec. 14, 8
2010 HR monitoring taken from
thePulse oximeter.
Tingling – decrease oxygen supply
and blood circulation in the lower
extremities.
RESPIRATORY
[ ] Asymmetrical [X] Tachypnea
[ ] Barrel Chest [ ] Apnea
[ ] Rales [ ] Cough
[ ] Bradypnea [X] Shallow
[ ] Rhonchi [X] Sputum
GASTROINTESTINAL:
[X] Diminished [X] Dyspnea Distention – due to the complete
paralysis of the abdomen.
Dysphagia – due to tracheostomy
[ ] Orthopnea [X] Labored tube in place.

[ ] Wheezing [ ] Pain NEUROLOGIC:

Paralysis – due to spinal cord injury
[ ] Cyanotic Grip – muscle paralysis

Assess respiratory rate, rhythm, blood pulse, MUSCULOSKELETAL:

Breath sounds, comfort [ ] No Problem
CARDIOVASCULAR
Hot – the skin is warm to touch
Lesion – found in the lower extremities from the accident
Poor Turgor – slowing of fluid shift due to injury.
Swelling – compensatory mechanism when the body is
OTHER PHYSICAL ABNORMALITIES
injured
SHOWN IN THE BACK
Flushed
NOTED DURING ASSESSMENT ARE
– due VIEW OF THE DRAWING
to fever

[ ] Arrhythmia [ ] Tachycardia
Dry Scalp with Dandruff
[X] Numbness [X] Diminished Pulse
Dry Skin
[ ] Edema [ ] Fatigue
[X] Irregular [ ] Bradycardia
[ ] Mur-mur [X] Tingling
[ ] Absent Pulse [ ] Pain
Assess heart sounds, rate, rhythm, pulse,
Blood pressure, circulation, fluid retention, IV Line PNSS 1L
regulated at 20gtts/min
Comfort
Untrimmed and dirty
[ ] No Problem fingernails both hands

FBC in place

GASTROINTESTINAL
Untrimmed and dirty
[ ] Obese [X] Distension fingernails on feet

[ ] Mass [X] Dysphagia Non-pitting ankle

edema
[ ] Rigidity [ ] Pain
Lesions obtained from
Assess abdomen, bowel habits, the vehicular accident

Swallowing, Bowel sounds, comfort

[ ] No Problem

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GENITO – URINARY and GYNE
[ ] Pain [ ] Urine
[ ] Color [ ] Vaginal Bleeding
[ ] Hematruia [ ] Discharges
[ ] Nucturia
Assess Urine frequency, control, color, odor,
Comfort, Gyne Bleeding, Discharges
[X] No Problem

NEUROLOGIC
[X] Paralysis [ ] Stuporus
[ ] Unsteady [ ] Seizure
[ ] Lethargic [ ] Comatose
[ ] Vertigo [ ] Tremors
[ ] Confused [ ] Vision
[X] Grip
Assess motor function, sensation, LOC,
Strength, Grip, gait, coordination, speech
[ ] No Problem

MUSCULOSKELETAL and SKIN

[ ] Appliance [ ] Stiffness
[ ] Itching [ ] Petechiae
[X] Hot [X] Drainage/Discharges
[ ] Prosthesis [X] Swelling
[X] Lesion [X] Poor Turgor
[ ] Cool [X] Flushed
[ ] Atrophy [ ] Pain
[ ] Ecchymosis [ ] Diaphoretic
[ ] Moist [ ] Rash

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Assess mobility, motion gait, alignment, joint function,
Skin color, texture, turgor, integrity
[ ] No Problem

PART 4: DEVEPLOPMENTAL DATA

Developmental Task Theory of Robert Havighurst

A developmental task is a task which arises at or about a certain period in the
life of an individual. Havighurst has identified six major age periods: infancy and
early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18
years), early adulthood (19-29 years), middle adulthood (30-60 years), and later
maturity (61+).
♣ Basing on Havighurst’s theory, Mr. Adam belongs in the middle
adulthood stage wherein he already achieved adult civic and social
responsibility. In this stage, one responsibility of Mr. Adam is to assist his
children to become responsible and happy adults. Mr. Adam is working as a
farmer and driver, to support his children and to help his wife who is working
abroad.

Psychosexual Theory of Sigmund Freud

The psychosexual stages of Sigmund Freud are five different developmental
periods during which the individual seeks pleasure from different areas of the body
associated with sexual feelings. These stages are as follows:

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Oral Birth to 1 year
Anal 2 – 3 years
Phallic 4 – 5 years
Latency 6 – 12 years
Genital 13 – Up

♣ Basing on Psychosexual Theory of Sigmund Freud, Mr. Adam belongs

to the genital stage wherein he has achieved sexual desires. He is married
and with three children.

Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life as a sequence of levels of achievement. Each
stage signals a task that must be achieved. He believed that the greater that task
achievement, the healthier the personality of the person. Failure to achieve a task
influences the person’s ability to achieve the next task. Stages of Erikson’s
Psychosocial Theory are as follows:

 Infancy Birth – 18 months Trust vs. Mistrust

 Early Childhood 18 months – 3 years Autonomy vs. Shame & Doubt
 Late Childhood 3 – 5 years Initiative vs. Guilt
 School Age 6 – 12 years Industry vs. Inferiority
 Adolescence 12 – 20 years Identity vs. Role Confusion
 Young Adulthood 18 – 25 years Intimacy vs. Isolation
 Adulthood 25 – 65 years Generativity vs. Stagnation
 Maturity 65 years to death Integrity vs. Despair
♣ Basing on this theory, Mr. Adam belongs to adulthood. The adulthood
stage is a stage wherein the person needs to assist the younger generation.
He achieved Generativity by supporting his children and even helped his
relatives.

Cognitive Theory of Jean Piaget

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 Cognitive development refers to how a person perceives, thinks, and gains
understanding of his or her world through the interaction and influence of genetic
and learning factors. This is divided into five major phases:
Sensorimotor Phase Birth to 2 years
Pre-conceptual Phase 2 – 3 years
Intuitive Thought Phase 4 – 6 years
Concrete Operations Phase 7 – 11 years
Formal Operational Phase 12 – adulthood
♣ Basing on Cognitive Theory of Jean Piaget Mr. Adam belongs to the
Formal operational stage in which he has solved previously encountered
problems in a logical manner and has used rational thinking. These include
financial problems and also with regards to his health.

PART 5: MEDICAL ORDERS with RATIONALE

Doctor’s Order Rationale

December 9, 2010
2:30am
> Please admit patient to Ortho- > For further medical management and
Ward (P3F2) under the service of treatment of condition.
Dr. Antolin / Dr. Lao.

> Secure consent to care > To allow the medical team give
appropriate medical and surgical
interventions.

> TPR every 4 hours > To monitor the vital signs and changes

> NPO temporarily > Since the patient is in complete

paralysis. The patient might swallow
any food or object that might impede
the airway or might choke to death.

> Laboratory: CBC with Platelet > To screen the patient’s blood to detect
any abnormalities that might contribute
to further complications.

> Continue venoclysis with D5NSS > To replace fluid loss

1L at 20gtts/min

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 > IVFTF with PNSS sedimentation > Sedimentation rate is done to find out if
rate inflammation is present, check on the
progress of the disease, and see how
well the treatment is working.

> Tramadol: to relieve pain associated by

> Medications: the severe headache the patient is
Tramadol 50mg IVTT q6H experiencing. Ranitidine: to prevent
Ranitidine 50mg IVTT gastric ulcer.

> Temporarily immobilize the patient’s

> Cervical Collar Applied neck

> Referred accordingly

9:30am > CT and myelogram to produce a clear

> For CT-Myelogram (Cervical structure of the bones and nerves of
Spine) the spine.

> To aide an effective airway clearance

> For Insertion of Tracheostomy > Consent to grant that the patient will
Tube have a Tracheostomy tube inserted.

> Secure Consent > Referred ENT for any signs of Vision
lost.

> Refer to ENT > Realigning of the injured cervical spine

> For application of Gardner-Wells
tong at bedside
and providing stabilization of the
cervical spine.
> Consent to grant that the patient will
have a Gardner-Wells tong applied.

> Secure Consent > To administer medications and feeding

since the patient is not able to swallow
3:00pm well.
> Insert NGT
> To supplement patient’s need for food,
this is also nutritious.

> May feed with OF through NGT > To note for a kidney failure and
poisoning of the blood.

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 > For Serum Creatinine

> If the blurring of vision or light

> Gardner-Wells tong applied headedness exists, it might indicate a
side-effect from the Gardner-Wells tong
> Refer for blurring of vision or light applied.
headedness

> For Tracheostomy Tube insertion.

December 10, 2010
7:00am
> For elective tracheostomy under > Informing OR personnel for the
local anesthesia at the OR. schedule T-Tube insertion.

> Inform OR > Care done to ensure and maintain

patent airway.
10:35am
> Post Tracheostomy Care

> Care done to ensure and maintain

> To Ward patent airway.

> For Tracheostomy Care daily > To minimized secretions and to clear
the airway.

> Suction Secretions regularly > For treatment of respiratory tract

infection

> Start Cefuroxime 750mg IVTT > Tramadol for pain relief.
q8H Negative ANST
> To monitor respiratory failure
> Continue Tramadol for pain relief

> Vital signs q4H, please include O2

Saturation determination and > To detect impending respiratory failure
record on separate sheet

> Monitor and refer for dyspnea and

cyanosis or O2 sat <90%.
> Resume osteorized feeding for the
December 11, 2010 patient to have adequate nutrition.
6:45am
> Resume OTF > To minimized secretions and to clear
the airway.

> Continue Tracheostomy care > So the patient will not be irritated

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 > Deflate Tracheostomy Balloon > To minimized secretions and to clear
q2H every 15 minutes the airway.

> Continue suctioning of secretions > For relief of fever.

4:00pm
> May give paracetamol 300mg
IVTT then PRN for fever q4H

> Continue meds for further treatment

December 12, 2010
7:30am > To minimized secretions and to clear
> Continue Meds the airway and prevent infection.

> Continue Tracheostomy Care > To minimized secretions and to clear

the airway.

> Continue Suction of Secretions

> Continue meds for further treatment
December 13, 2010
7:30am
> Continue Meds
> Osteorized feeding Calories needed for
December 14, 2010 the patient to have proper nutrition.
7:30am
> OFC 1.2 Kcal q6H

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PART 6: LABORATORY EXAMS

Blood Chemistry
Date Taken: December 9, 2010
Component Unit Reference Results Interpretation
Within normal range but at
Creatinine mg/dL 0.59 – 1.20 0.90
high risk for Kidney failure

The Attending Physician ordered a Complete Blood Count test for the patient and
CT-Scan but the results were not placed / attached in the Patient’s Chart.

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PART 7: DRUG STUDY

Name of Drug Generic (Brand): Tramadol – Ultram

Date Ordered: December 9, 2010
Classification: Opioid Analgesics (centrally acting)
Dose/Frequency/Route: 50 mg IVTT q6°
Mechanism of Action: Tramadol is a centrally acting synthetic opioid analgesic.
Although its mode of action is not completely understood, from animal tests, at least
two complementary mechanisms appear applicable: binding of parent and M1
metabolite to mu-opioid receptors and weak inhibition of reuptake of norepinephrine
and serotonin.
Specific Indication: Management of moderate to moderately severe pain
Contraindication: previous hypersensitivity to tramadol or in cases of acute
intoxication with alcohol, hypnotics, centrally acting analgesics, opioids or
psychotropic drugs.
Side Effects/Toxic Effects: agitation, hallucinations, fever, fast heart rate,
overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting,

18
seizure (convulsions), a red, blistering, peeling skin rash, shallow breathing,
weak pulse.
Nursing Precaution: Assess BP & RR before and periodically during
administration. Assess bowel function routinely. Prevention of constipation should be
instituted with increased intake of fluids and bulk and with laxatives to minimize
constipating effects. Monitor patient for seizures. Encourage patient to cough and
breathe deeply every 2 hr to prevent atelactasis and pneumonia.

Name of Drug Generic (Brand): Ranitidine - Zantac

Date Ordered: December 9, 2010
Classification: Anti-ulcer agent - Histamine H2 antagonists
Dose/Frequency/Route: 50 mg IVTT q6°
Mechanism of Action: Potent anti-ulcer drug that competitively and reversibly
inhibits histamine action at H2-receptor sites on parietal cells, thus blocking gastric
acid secretion. Indirectly reduces pepsin secretion but appears to have minimal
effect on fasting and postprandial serum gastric concentrations or secretion of
gastric intrinsic factor or mucus
Specific Indication: Short-term treatment of active duodenal ulcer; treatment of
pathologic GI hypersecretory conditions
Contraindication: Hypersensitivity to drug, renal impairment, pregnancy or
lactation, geriatric and pediatric patients
Side Effects/Toxic Effects: Confusion, dizziness, drowsiness, hallucinations,
headache, arrhythmias, altered taste, black tongue, constipation, dark stools,
diarrhea, drug-induced hepatitis, nausea, decreased sperm count, impotence,
gynecomastia, pain at IM site, granulocytosis, aplastic anemia, neutropenia,
thrombocytopenia
Nursing Precaution: Antacids should be taken one hour before or one hour after
ranitidine, as they inhibit the effectiveness. Inform patient that it may cause
drowsiness or dizziness. Inform patient that increased fluid and fiber intake may
minimize constipation. Inform patient that medication may temporarily cause stools
and tongue to appear gray black. Avoid stomach and GI irritants -- this includes

19
smoking and ETOH. Watch for signs of GI bleeds.

Name of Drug Generic (Brand): Cefuroxime - Ceftin

Date Ordered: December 10, 2010
Classification: An anti-infective; antibiotic; second-generation cephalosporin
Dose/Frequency/Route: 750 mg IVTT q8° (-) ANST
Mechanism of Action: Cefuroxime is a bactericidal antibiotic, which exerts
antibacterial activity by inhibition of bacterial cell wall synthesis in susceptible
species. Cefuroxime has good stability to several bacterial beta-lactamase enzymes
and, consequently, is active against many penicillin-resistant and amoxicillin-
resistant strains of susceptible species.
Specific Indication: Skin and skin-structure infections, bone and joint infections,
perioperative prophylaxis
Contraindication: Hypersensitivity to Allergy to cephalosporins or penicillins, renal
failure, lactation
Side Effects/Toxic Effects: Headache, dizziness, lethargy, paresthesias, nausea,
vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous colitis,
liver toxicity, bone marrow depression: decreased WBC, decreased platelets,
decreased Hct, nephrotoxicity, ranging from rash to fever to anaphylaxis, serum
sickness reaction, pain, abscess at injection site; phlebitis, inflammation at IV site,
superinfections, disulfiram-like reaction with alcohol
Nursing Precaution: Inspect IM and IV injection sites frequently for signs of
phlebitis. Report onset of loose stools or diarrhea. Monitor for manifestations of
hypersensitivity. Monitor I & O rates and pattern: Especially important in severely ill
patients receiving high doses.

Name of Drug Generic (Brand): Paracetamol - Biogesic

Date Ordered: December 11, 2010
Classification: Non-opioid Analgesics, Anti-pyretic
Dose/Frequency/Route: 300 mg IVTT PRN q4°

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Mechanism of Action: Reduces fever by acting directly on the hypothalamic heat-
regulating center to cause vasodilation and sweating, which helps dissipate heat.
Specific Indication: Common cold, flu, other viral and bacterial infections with pain
and fever.
Contraindication: Contraindicated with allergy to acetaminophen. Use cautiously
with impaired hepatic function, chronic alcoholism, pregnancy, lactation.
Side Effects/Toxic Effects: Headache, dizziness, lethargy, nausea, vomiting,
jaundice, acute kidney failure, rash
Nursing Precaution: Inspect IM and IV injection sites frequently for signs of
phlebitis. Do not exceed the recommended dosage. Monitor for manifestations of
hypersensitivity.

PART 8: ANATOMY and PHYSIOLOGY

Anatomy of the Spinal Cord

The spine works as the main support for the spinal cord and the nerve
pathways that carry information from the arms, legs, and rest of the body, and
carries signals from the brain to the body.

Your back is composed of 33 bones called vertebrae, 31 pairs of nerves, 40

muscles and numerous connecting tendons and ligaments running from the base of
your skull to your tailbone. Between your vertebrae are fibrous, elastic cartilage
called discs. These "shock absorbers" keep your spine flexible and cushion the hard
vertebrae as you move.

21
Cervical Spine
There are seven cervical bones or vertebrae. The cervical bones are
designed to allow flexion, extension, bending, and turning of the head. They are
smaller than the other vertebra, which allows a greater amount of movement.
Each cervical vertebra consists of two parts, a body and a protective arch for
the spinal cord called the neural arch. Fractures or injuries can occur to the body, lim
pedicles, or processes. Each vertebra articulates with the one above it and the one
below it.

Thoracic Spine
In the chest region the thoracic
spine attaches to the ribs. There are 12
vertebrae in the thoracic region. The
spinal canal in the thoracic region is
relatively smaller than the cervical or
lumbar areas. This makes the thoracic
spinal cord at greater risk if there is a
fracture.

22
 The motion that occurs in the thoracic spine is mostly rotation. The ribs
prevent bending to the side. A small amount of movement occurs in bending forward
and backward.

Lumbosacral Spine
The lumbar vertebrae are large, wide, and thick. There are five vertebrae in
the lumbar spine. The lowest lumbar vertebra, L5, articulates with the sacrum. The
sacrum attaches to the pelvis. The main motions of the lumbar area are bending
forward and extending backwards. Bending to the side also occurs.

Just like the spinal column is divided into cervical, thoracic, and lumbar
regions, so is the spinal cord. Each portion of the spinal cord is divided into specific
neurological segments.The cervical spinal cord is divided into eight levels. Each
level contributes to different functions in the neck and the arms (see diagram).
Sensations from the body are similarly transported from the skin and other areas of
the body from the neck, shoulders, and arms up to the brain.In the thoracic region
the nerves of the spinal cord supply muscles of the chest that help in breathing and
coughing. This region also contains nerves in the sympathetic nervous system.

23
 The lumbosacral spinal cord and nerve supply legs, pelvis, and bowel and
bladder. Sensations from the feet, legs, pelvis, and lower abdomen are transmitted
through the lumbosacral nerves and spinal cord to higher segments and eventually
the brain.

There are many nerve pathways that transmit signals up and down the spinal
cord. Some supply sensation from the skin and outer portions of the body. Others
supply sensation from deeper structures such as the organs in the belly, the pelvis,
or other areas. Other nerves transmit signals from the brain to the body. Still others
work at the level of the spinal cord and act as "go betweens" in the signal
transmission process.
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 The upper motor neuron refers to injuries that are above the level of the
anterior horn cell. This results in a spastic type of paralysis. Conversely, the lower
motor neuron injury refers to an injury at or below the anterior horn cell that results in
the flaccid type paralysis. This is usually seen in nerve root injuries or in the cauda
equina syndrome that was mentioned previously. The terms neurogenic bowel and
neurogenic bladder are used to describe abnormal bowel and bladder function and
can be classified as either an upper motor neuron or lower motor neuron type of
problem. In general, those patients with an upper motor neuron paralysis will have
an upper motor neuron bowel and bladder, and those with lower motor neuron
injuries will have a lower motor neuron picture of the bowel and bladder.
Adequate bowel and bladder management is critical for adequate reintegration of the
patient/client into the community and hopefully into the work place.

Feelings from the body such as hot, cold, pain, and touch, are transmitted to
the skin and other parts of the body to the brain where sensations are "felt." These
pathways are called the sensory pathways.

Once signals enter the spinal cord, they are sent up to the brain. Different
types of sensation are sent in different pathways, called "tracts." The tracts that carry
sensations of pain and temperature to the brain are in the middle part of the spinal
cord. These tracts are called the "spinothalamic." Other tracts carry sensation of
position and light touch. These nerve impulses are carried along the back part of the
spinal cord in what are called "dorsal columns" of the spinal cord.

Another type of special nerves are the autonomic nerves. In spinal cord
injuries, they are very important. The autonomic nerves are divided into two types:
the sympathetic and parasympathetic nerves.

The autonomic nervous system influences the activities of involuntary (also

known as smooth) muscles, the heart muscle, and glands that release certain

25
hormones. It controls cardiovascular, digestive, and respiratory systems. These
systems work in a generally "involuntary" fashion. The primary role of the autonomic
nervous system is to maintain a stable internal environment within the body. The
heart and blood vessels are controlled by the autonomic nervous system. The
sympathetic nerves help to control blood pressure based on the physical demands
placed on the body. It also helps to control heart rate. The sympathetic nerves, when
stimulated, cause the heart to beat faster.

The sympathetic nerves also cause constriction of the blood vessels

throughout the body. When this happens, the amount of blood that is returned to the
heart increases. These effects will increase blood pressure. Other effects include an
increase in sweating and increased irritability or a sensation of anxiety.

When spinal cord injury is at or above the T6 level the sympathetic nerves
below the injury become disconnected from the nerves above. They continue to
operate automatically once the period of spinal shock is over. Anything that
simulates the sympathetic nerves can cause them to become overactive. This
overactivity of the sympathetic nerves is what is called autonomic dysreflexia.

The parasympathetic nerves act in an opposite manner to the sympathetic

nerves. These nerves tend to dilate blood vessels and slow down the heart. The
most important nerve that carries sympathetic fibers is the vagus nerve. This nerve
carries parasympathetic signals to the heart to decrease heart rate. Other nerves
supply the blood vessels to the organs of the abdomen and skin.

The parasympathetic nerves arise from two areas. The fibers that supply the
organs of the abdomen, heart, lungs, and skin above the waist begin at the level of
the brain and very high spinal cord. The nerves that supply the reproductive organs,
pelvis, and leg begin at the sacral level, or lowest part of the spinal cord. After a
spinal cord injury, the parasympathetic nerves that begin at the brain continue to
work, even during the phase of spinal shock. When dysreflexia occurs, the

26
parasympathetic nerves attempt to control rapidly increasing blood pressure by
slowing down the heart.

Physiology of the Spinal Cord

The spinal cord is a highly organized and complex part of the central nervous
system. Its complexity is due to the role it plays in the 3 most important functions of
the individual: sensation, autonomic and motor control. If it was to simply report to
the brain the information that it receives from the large number and variety of
afferent inputs and relay back to the motoneurons and preganglionic neurons the
outcome of processing performed by the supraspinal centres the situation would be
more straight forward. However, as is well established, this is not the case and the
spinal cord has, in addition to relaying information from the rest of the body to the
brain and receiving efferent commands from varied portions of the brain the ability to
integrate and modify both afferent signals from the periphery, and efferent signals
from segmental afferents and supraspinal centres. Thus there is a complicated
network of neurons that normally operates in conjunction with the rest of the CNS to
allow perfect control of sensory, autonomic and motor functions. This complex
circuitry is critically dependent on its connections with the brain and it can not
function appropriately when it is either completely or even partially disconnected
from it. It is rather regrettable, that we understand so little of the potential of the
complex intrinsic circuitry of the spinal cord that when it looses connection with the
brain we are unable to exploit its' potential function and restore deficits caused by
spinal cord lesions.

Primarily, spinal cord functions include transmission of information and

initiation of reflexes. In simple words, the spinal cord helps in connecting the
various organs of human body to the brain. On one hand, it accepts the electrical
information through sensory neurons, and sends it to the brain. While on the other
hand, it sends the signals from the motor area of the brain back to the various parts
of the body. Yet another function of spinal cord is to coordinate various reflexes in
our body. Reflexes are basically the built in responses of our body to the danger

27
stimuli. Although the speed at which the information travels from the body to the
brain and back to the body is very fast, sometimes we need the information to travel
at a greater speed. This is where the reflex action triggered by the spinal cord comes
into the picture. the situation is generally referred to as fight or flight response. As a
defense mechanism, the body reacts faster than the normal time it usually takes.
The best example of this reflex action would be the way you take your hand back,
within split seconds, as soon as you touch some hot object.

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PART 9: PATHOPHYSIOLOGY

Narrative Pathophysiology
Upon initial impact or injury, there is immediate mechanical damage to neural
and other soft tissue, including endothelial cells of the vasculature. Thus necrosis, or
cell death, results from these mechanical and ischemic insults, is instantaneous,
and, in a contusion injury, appears to be more predominant in the grey matter of the
spinal cord than in the white matter, resulting in a ring of preserved white matter at
the contusion site. After the insult, over the next few minutes, the injured nerve cells
respond with an injury-induced barrage of action potentials.

Accompanying this are significant electrolytic shifts, principally involving the

monovalent and divalent cations Na+(intracellular concentrations increase),
K+ (extracellular concentrations increase), and Ca2+ (intracellular concentrations
increase to toxic levels), that contribute to a failure in normal neural function and
spinal shock, which lasts for about 24 hours and represents a generalized failure of
circuitry in the spinal neural network. Hemorrhage occurs, with localized edema, loss
of microcirculation by thrombosis, vasospasm and mechanical damage, and loss of
vasculature autoregulation, all of which further exacerbate the neural injury.

Furthermore, compression of the spinal cord occurs as a result of vertebral

displacement followed by edema and later by fibrotic responses, contributing further
to the neural injury. Because in the best circumstances the time to admission after
spinal cord injury is about three hours, the immediate acute injury processes do not
offer a clinically useful target for therapeutic intervention unless the Emergency
Medical Service can adapt an easy-to-administer intervention, and/or the population
adopts a preventative stance, such as taking aspirin once a day to prevent cardiac
death after an episode of cardiac ischemia as recommended by the American Heart
Association. In contrast, the secondary and chronic injury processes, because these
occur within minutes to weeks after injury, are strategically better for therapeutic
targets.

29
 In the secondary phase (which occurs over the time course of minutes to
weeks), the ischemic cellular death, electrolytic shifts, and edema continue from the
acute phase. Within the first 15 minutes after injury, extracellular concentrations of
glutamate and other excitatory amino acids reach cytotoxic concentrations that are
six- to eightfold higher than normal as a result of cell lysis from mechanical injury
and both synaptic and nonsynaptic transport. In addition, lipid peroxidation and free-
radical production also occur as a result of glutamate receptor-activated and
subsequently mediated pathways.

Apoptosis—a secondary, programmable cell death different from necrosis—

occurs and involves reactive gliosis that includes increased expression of glial
fibrillary acidic protein (GFAP) and astrocytic proliferation. Neutrophils (which
secrete myeloperoxidase) invade the spinal parenchyma from the circulatory system
within 24 hours, followed by lymphocytes (which secrete a variety of cytokines and
growth factors) that invade and reach peak numbers within 48 hours. The invading
inflammatory cells increase the local concentrations of cytokines (cyto = ‘cell’; kine =
‘small protein’) and chemokines (chemotactic cytokine). In addition, inhibitory factors
and/or barriers to regeneration are expressed in the perilesion site. The lesion grows
in size from the initial core of cell death with cells at risk of dying in the perilesioned
region, to a larger region of cell death.

30
31
PART 10: IDEAL NURSING MANAGEMENT
Nursing Diagnosis: INEFFECTIVE BREATHING PATTERN
ACTIONS/INTERVENTIONS
Independent
Observe skin color for developing
cyanosis, duskiness.
Maintain client airway.
Assist client in “taking control” of
respirations as indicated.
Suction as necessary. Monitor pulse
oximetry and heart rate during
suctioning.
Dependent
Administer oxygen by appropriate
method
RATIONALE
May reveal impending respiratory
failure, need for immediate medical
evaluation and intervention.
Clients with high cervical injury and
impaired gag/cough reflex require
assistance in preventing
aspiration/maintaining patent airway.
Breathing may no longer be a totally
voluntary activity but requires conscious
effort, depending on level of
injury/involvement of respiratory
muscles.
If cough is ineffective, suctioning may
be needed to remove secretions,
enhance gas exchange, and reduce risk
of respiratory infections. “Routine”
suctioning increases risk of hypoxia and
bradycardia. Suctioning needs are
based on presence of/inability to move
secretions.
Method is determined by level of injury,
degree of respiratory insufficiency, and
amount of recovery of respiratory
muscle function after spinal shock
phase.
32
IMPAIRED PHYSICAL MOBILITY
ACTIONS/INTERVENTIONS RATIONALE
Independent
Provide means to summon help. Enables client to have a sense of
control, and reduces fear of being left
alone.

Perform/assist with passive ROM Enhances circulation,

exercises on all extremities and joints, restores/maintains muscle tone and
using slow, smooth movements. joint mobility, and prevents disuse
contractures and muscle atrophy.

Position arms at 90-degree angle at Prevents frozen shoulder contractures.

regular intervals.

Altered circulation, loss of sensation,

Inspect skin daily. Observe for pressure and paralysis potentiate pressure sore
areas, and provide meticulous skin formation.
care.

Apply antiembolic hose/leotard or Limits pooling of blood in lower

sequential compression devices (SCDs) extremities or abdomen, thus improving
to legs as appropriate. vasomotor tone and reducing incidence
of thrombus formation and pulmonary
emboli.

33
RISK FOR IMPAIRED SKIN INTEGRITY
ACTIONS/INTERVENTIONS
Independent
Inspect all skin areas, noting capillary
blanching/refill, redness, swelling. Pay
particular attention to back of head, skin
under halo frame or vest, and folds
where skin continuously touches.
Observe halo and tong insertion sites.
Note swelling, redness, drainage.
Encourage continuation of regular
exercise program.
Elevate lower extremities periodically if
tolerated.
Wash and dry skin
Keep bedclothes dry and free of
wrinkles, crumbs.
RATIONALE
Skin is especially prone to breakdown
because of changes in peripheral
circulation, inability to sense pressure,
immobility, altered temperature
regulation.
These sites are prone to inflammation
and infection and provide route for
pathologic
microorganisms to enter cranial cavity.
Stimulates circulation, enhancing
cellular nutrition/oxygenation to improve
tissue health.
Enhances venous return, reduces
edema formation.
Clean, dry skin is less prone to
excoriation/breakdown.
Reduces/prevents skin irritation.
34
PART 11: ACTUAL NURSING MANAGEMENT

Priority Number 1
“Ga lisod naman siya ug ginhawa karon kay dili na daw malihok iyang
S baga, ingon sa doctor nga paralyzed daw siya tibuok lawas.” As
verbalized by the patient’s SO.
● Shallow/labored breathing
O ● Respiration rate of: 31 cpm
●
Ineffective breathing pattern related to paralysis of abdominal and
A
intercostals muscles secondary to spinal cord injury.
At the end 2 days of nursing intervention, the patient will be able to
P maintain adequate ventilation as evidenced by the patient’s o2 sat and
respiratory rate are within normal range.
1. Suctioned secretions in ● Since cough is ineffective,
tracheostomy tube. suctioning is needed to remove
secretions, enhance gas
exchange and reduce risk of
respiratory infection.

2. Monitored pulse oximetry ● To detect any abnormalities

and respiratory rate. or any impending respiratory
distress.

3. Monitored oxygen level of ● There is an increase in

6L/min as prescribed by the oxygen demand by the patient
I doctor. because of paralysis of
respiratory muscles. Any
decrease in oxygen level would
lead to respiratory failure.

4. Maintained patient airway. ● Patient’s with cough reflex

requires assistance in
preventing aspiration/
maintaining patent airway.

5. Ensured proper ● This prevents the secretions

humidification and hydration. from becoming thick and difficult
to remove even with suctioning.
At the end of 2 days of nursing intervention, the patient wasn’t able to
E maintain adequate ventilation as evidenced by the decrease in the
patient’s o2 sat and increase in respiratory rate.

35
Priority Number 2
“Dili naman siya makalihok. Tabangan na gyud siya sa tanan
S buhatonon. Sa pagilis sa iyaha, pagilis sa diaper, kung trapuhan pud
namo siya.” As verbalized by the patient’s SO.
● Limited range of motion
O ● Numbness of the extremities
● Inability to perform gross and fine motor skills
Impaired physical mobility related to motor and sensory impairment
A
secondary to spinal cord injury
At the end 2 days of nursing intervention, the patient will be able to
P maintain position of function and skin integrity as evidenced by absence
of contractures, decubitus and so forth.
1. Performed passive ROM ● This enhances circulation,
exercises on all extremities and maintains muscle tone and joint
joints, using slow, smooth mobility and prevents muscle
movements. atrophy.

2. Inspected skin and ● Altered circulation occurs,

observed pressure areas loss of sensation and paralysis
potentiate pressure sore
formation.

3. Observed skin for reddened ● This reduces friction,

areas or shearing injuries. maintains safe skin and tissue
I Provided appropriate pressure pressure, and wick away
relief and surface support moisture.
mattress.

4. Assist with activities of

hygiene, skin care, toileting as ● Helps in preventing skin
indicated. breakdown and further
complication.

5. Instructed and ● Maintains and enhances

demonstrated the patient’s SO gain in strength and muscle
on continuous ROM exercises. control.
At the end 2 days of nursing intervention, the patient was able to
E maintain position of function and skin integrity as evidenced by absence
of contractures, decubitus and so forth.

36
Priority Number 3
“Init kayo siya, nag hilantan man siya bago lang ug gahunghung siya sa
S
ako nga sakit kuno iyang ulo.” As verbalized by the patient’s SO.
● Skin Warm to touch
O ● Flushed and dry skin
● Temperature of 38.7°C
Hyperthermia related to autonomic disruption secondary to spinal cord
A
injury.
At the end 2 days of nursing intervention, the patient will be able to have
P
a reduce in body temperature.
1. Tepid sponge bath done. ● Results in heat loss by
evaporation and conduction.

2. Applied ice cap. ● Assists with measures to

reduce body temperature.

3. Monitored intake and ● It potentiates fluid and

output. electrolyte losses.

I Dependent ● It lowers the

4. Administer antipyretics as thermodetection set point of the
prescribed by the doctor such as hypothalamic heat regulatory
paracetamol. center, which results on
vasodilation and sweating.

5. Administered ● Supports circulating

replacement fluids and volume and tissue perfusion.
electrolytes as prescribed by
the doctor such as PNSS 1L.
At the end 2 days of nursing intervention, the patient’s body temperature
E
reduced from 38.7 to 37.6°C.

37
PART 12: REFERRALS and FOLLOW-UP

Health Teachings
1. The client’s significant others is advice to let the client
follow strict compliance with the medications being given.
2. Teach the client’s significant others the importance of
medication regimen
Medications
3. Tell the client’s significant others to report to the
nearest emergency care center of hospitals any
abnormalities or unusual changes or reactions during the
treatment course.
Since the patient is completely paralyzed below the neck, the
patient’s significant others will be taught on how to do the
passive exercises, this is to prevent pressure ulcers, further
injury by keeping joints and muscle flexible. This can also help
Exercise
maintain muscles and encourage circulation between joints.

Early rehabilitation is encouraged once stabilization of the

spine has been achieved.
1. Have the spine immobilized by have a cervical collar
inserted.
Treatment 2. Let the patient have aggressive treatment and
rehabilitation can minimize damage to the nervous system
and even restore limited abilities.
Dietary changes to maximize bowel function may be indicated.
Diet Calcium and vitamin D supplementation should be considered
to avoid osteoporosis.

Follow – Up Care / Out Patient Check – Up

As the patient is discharge, the patient and significant others is advice to:
1. Return to his physician to schedule a follow-up.
2. Report any unusual reactions or complications to the physician.
3. Visit the nearest health center for early signs of complications.
4. Ask the physician if there are things that they are unclear of.
5. Take the prescribed medications obediently as ordered by his
physician.
6. Report any changes and improvement to his physician.

38
7. In the acute phase, severe SCI, especially after high lesions, requires
the attention of a specialized trauma team.
8. For long-term management, consultations with many specialists are
often necessary because of the multiple organ complications that follow
SCI.
9. Specifically, referral to a urologist, a gastroenterologist, a psychiatrist,
a plastic surgeon, a dermatologist, and a pain management specialist may
be necessary.
10. Rehabilitation specialists such as physiatrists or neurologists become
involved after the immediate hospitalization.

39
PART 13: EVALUATION
For two days of clinical duty at Northern Mindanao Medical Center –
Orthopedic Ward, the proponents was able to assess the patient thoroughly and
gave appropriate nursing interventions dependently and independently. It was a
challenge for us to have assessed the patient for a very limited time. Though the
information gathered was insufficient, we were able to finish a fairly accurate care
study paper.

This care study enabled us more knowledge about the disease condition of
the patient as well as the signs and symptoms he manifested and the possible
complications that might occur.

40
BIBLIOGRAPHY

Books
Deglin, Judith Hopfer et.al. Davis’s Drug Guide for Nurse’s.10th edition.F.A.
Davis Company:Philadelphia(2007).
Doenges, Marilynn E. et.al. Nurse’s Pocket Guide: Diagnoses, Prioritized
Interventions, and Rationales.11th edition. F.A Davis Company:
Philadelphia (2008).
McCann Schilling, Judith A. Lipincott Manual of Nursing Practice
series.Diagnostic Tests. Lipincott Williams & Wilkins.
Smeltzer, Suzanne C. et.al Brunner and Suddarth’s textbook of Medical-
Surgical Nursing 12th edition Vol. 2. Lippincott Williams and Wilkins.
(2010).
Nowak, Thomas J. et.al. Essentials of Pathophysiology: Concepts and
Applications for Health Care Professional 2nd edition. McGraw-Hill
(2000).
Black, Joyce M. et.al. Medical-Surgical Nursing: Clinical Management for
Positive Outcomes 8th edition. Saunders and Elsevier. (2009).
McCann, Judith A. et.al. Pathophysiology: Made Incredibly Visual. Lippincott
Williams and Wilkins. (2008).

Internet
http://www.spinalinjury.net/html/_anatomy_of_the_spinal_cord_co.html
http://advan.physiology.org/content/26/4/238.full
http://www.buzzle.com/articles/spinal-cord-function.html

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