Herniated Intervertebral disc ppt. Concept mapping, medical mgt, diagnoses, pharmacologic approach and nursing responsibilities.

1. Herniated Intervertebral
Disc

2. CONCEPT MAP
Age Occupational stress
Surgical Management: Diagnostic Tests:
Discectomy, Herniated MRI, CT Scan and
X Ray
Laminectomy, Intervertebral Disk
Foramenotomy,
Medical Management:
Pharmacologic Therapy: Bed rest, immobilization
Analgesics, muscle relaxant,
corticosteroid, sedatives Clinical Manifestations:
Muscle weakness,
Back pain , also in knees, alteration in
thighs or feet. reflexes
Postural deformity Sensory loss
Acute Pain Disturbed Body Image Disturbed sensory Impaired physical
perception mobility
Current Evidenced- Bioethical/ Nursing Health
Trends/Updates Based Practice Ethico-Legal Theories Teachings

3. Herniated Intervertebral Disk
In herniation of the intervertebral disk
(ruptured disk), the nucleus of the disk
protrudes into the annulus (the fibrous ring
around the disk), with subsequent nerve
compression. Protrusion or rupture of the
nucleus pulposus usually is preceded by
degenerative changes that occur with
aging.
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6. Normal Herniated Intervertebral Disk
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7. Predisposing Factor: Precipitating Factor:
•Age
-Degenerative changes
that occur with aging. •Occupational stress:
Usually at 4th decade of - Causes chronic disc
life. degeneration
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9. Clinical Manifestations
Back pain, knifelike, aggravated by coughing,
sneezing, bending, lifting, defecation, straight
legraising.
Postural deformity/altered posture and gait
Sensory Loss
Altered reflexes and Muscle weakness
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10. DIAGNOSTIC STUDIES
Spinal x-rays: may show degenerative
changes in spine/intervertebral space or
rule out other suspected pathology, e.g.,
tumors, osteomyelitis.
Ct scan with/without
enhancement: may reveal spinal
canal narrowing, disc protrusion.
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11. MRI: can reveal changes in bone, discs, and soft
tissues and can validate disc herniation/surgical
decisions.
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12. Nursing Considerations:
1. Explain procedure.
2. Remove all metals from the client such as jewelry, braces, dentures
3. Not indicated for patients with artificial pacemakers, skeletal tractions
and prosthesis.
3. Assess for claustrophobia ; give psychosocial support.
Sedate patient if necessary.

13. Electrophysiological studies—electromyoneurography (emg) and
nerve conduction studies (ncs): can localize lesion
to level of particular spinal nerve root involved; nerve conduction and
velocity study usually done in conjunction with study of muscle
response to assist in diagnosis of peripheral nerve impairment and
effect on skeletal muscle.
Myelogram: rarely performed, but when done, may be normal or show
“narrowing” of disc space, specific location and
size of herniation.
Provocative tests (discography, nerve root blocks): determine site
of origin of pain by replicating and then relieving
symptoms. can also be used to rule out sacroiliac joint involvement.
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14. Medical Management
The goals of treatment are (1) to rest and immobilize the cervical spine to
give the soft tissues time to heal and (2) to reduce inflammation in the
supporting tissues and the affected nerve roots in the cervical spine.
This could be achieved by:
•Bed rest
•Proper positioning on a firm mattress may bring dramatic
relief from pain.
•Immobilization by traction or brace (e.g., neck collar)
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15. Non-surgical care alternatives to treat the pain, including:
1. Chiropractic
2. Bed rest and lumbo-sacral support belt.
3. Physical therapy
4. Massage therapy
5. Weight control
6. Spinal decompression
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16. Pharmacologic therapy
Analgesics
•NSAIDs
•Propoxyphene [Darvon]
•Oxycodone [Tylox]
Muscle relaxants
•Cyclobenzaprine [Flexeril]
•Methocarbamol
•[Robaxin]
•Metaxalone [Skelaxin])
Sedatives
Corticosteroids
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17. Surgical Management
Discectomy: removal of herniated or extruded fragments of
intervertebral disk
Laminectomy: removal of the bone between the spinal
process and facet pedicle junction to expose the neural
elements in the spinal canal ; allows the surgeon to inspect the
spinal canal, identify and remove pathology, and relieve
compression of the cord and roots
Hemilaminectomy: removal of part of the lamina and part of the
posterior arch of the vertebra.
Partial laminectomy or laminotomy: creation of a hole in the lamina
of a vertebra.
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18. • Discectomy with fusion: a bone graft (from iliac crest or
bone bank) is used to fuse the vertebral spinous process; the
object of spinal fusion is to bridge over the defective disk to
stabilize the spine and reduce the rate of recurrence
• Foraminotomy: removal of the intervertebral foramen to increase
the space for exit of a spinal nerve, resulting in reduced
pain, compression, and edema
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19. Nursing Process
NURSING PRIORITIES
1. reduce back stress, muscle spasm,
and pain.
2. promote optimal functioning.
3. support patient/so in rehabilitation process.
4. provide information concerning
condition/prognosis and treatment needs.

20. Nursing Assessment
ACTIVITY/REST
may report: history of occupation requiring heavy lifting, sitting, driving
for long periods
may exhibit: atrophy of muscles on the affected side
gait disturbances
EGO INTEGRITY
may report: fear of paralysis
financial, employment concerns
may exhibit: anxiety, depression, withdrawal from family/so
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21. NEUROSENSORY
may report: tingling, numbness, weakness of affected
extremity/extremities
may exhibit: decreased deep tendon reflexes; muscle weakness,
hypotonia
tenderness/spasm of paravertebral muscles
decreased pain perception (sensory)
PAIN/DISCOMFORT
may report: pain knifelike, aggravated by
coughing, sneezing, bending, lifting, defecation, straight leg
raising; unremitting pain or intermittent episodes of more severe pain; radiation
to leg/feet, buttocks area (lumbar), or shoulder or head/face, neck (cervical)
heard “snapping” sound at time of initial pain/trauma or felt “back giving way”
limited mobility/forward bending
may exhibit: stance: leans away from affected area
altered gait, walking with a limp, elevated hip on affected side
pain on palpation
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22. Nursing Diagnoses
cute related to physical injury agents:
nerve compression, muscle spasm
mpaired physical mobility related to pain and
discomfort, muscle spasms restrictive therapies,
e.g., bedrest, traction neuromuscular impairment
nxiety related to situational crisis
isturbed body image related to postural deformity
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23. Planning
The goals for the patient may include relief of pain,
improved mobility, increased knowledge and self care
ability, and prevention of complications.
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24. Nursing Interventions/ Management
POSITIONING THE PATIENT
To position the patient, a pillow is placed under the head and
the knee rest is elevated slightly to relax the back muscles.
The patient is encouraged to move from side to side
to relieve pressure and is reassured that no injury will
result from moving.
The patient turns as a unit (logrolls), without twisting the
back.
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25. LOGROLLING
The patient’s arms will be
crossed and the spine aligned.
To avoid twisting the spine, the
head, shoulders, knees, and
hips are turned at
the same time so that the
patient rolls over like a log.
When in a side-lying position,
the patient’s back, buttocks,
and legs are supported with
pillows.
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26. Bed rest for 1 to 2 days on a firm mattress (to limit spinal flexion)
is encouraged to reduce the weight load and gravitational forces,
thereby freeing the disk from stress
The patient is allowed to assume a comfortable position; usually, a semi-
Fowler’s position with moderate hip and knee flexion relaxes the
back muscles.
When the patient is in a side-lying position, a pillow is placed between
the legs.
To get out of bed, the patient lies on one side while pushing up to a
sitting position.
NSAIDs and systemic corticosteroids may be administered to counter the
inflammation that usually occurs in the supporting tissues and the
affected nerve roots.
Moist heat and massage help to relax spastic muscles and have a
sedative effect.
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27. Evaluation
Expected patient outcomes may include:
1. Reports decreasing frequency and severity of pain
2. Demonstrates improved mobility:
a. Demonstrates progressive participation in self-care
activities
b. Identifies prescribed activity limitations and restrictions
c. Demonstrates proper body mechanic
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28. Current Trends/Updates/Researches
Genes Linked To Spinal Disc Degeneration Identified
ScienceDaily (Mar. 17, 2009) — Lumbar disc degeneration is an uncomfortable
condition that affects millions of people, but two University of Alberta researchers
have identified some of the genes that are causing problems.
and Tapio Videman, in the Faculty of Rehabilitation Michele Crites-Battie
Medicine, have discovered eight genes that are directly related to disc
degeneration.
"We found more genes associated with disc degeneration than was discovered in
30 prior studies," said Videman. "This is very exciting.“
The pair started by studying 25 specific genes they thought could be linked to the
disease.
They picked these "candidate" genes based on the views of two leading experts
and Videman have collaborated with through the in the field who Crites-Battie
years. They narrowed their search down using state-of-the-art DNA
analyzers, then applying statistical methods and analyzing MRIs of twins' spines.
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29. "Identifying genes involved can provide important insights into the biological
mechanisms behind disc degeneration and a better understanding of . "This can
eventually what is going wrong in the system," said Crites-Battie lead to effective
interventions for the problem.“
The pair will now look at the interaction between these eight genes and their
environment. This will help them identify what gene forms indicate susceptibility.
"This will tell us who should avoid physical loading, and in which people obesity
could be a risk factor for spine problems," said Videman.
But this could be a long process as disc degeneration is what's called polygenic,
meaning it involves more than one gene.
"There are likely to be quite a number of genes involved and a system of complex
gene-gene and gene-environment interactions," said Crites-Battie. "Obtaining a full
appreciation of the genetic architecture of disc degeneration is likely to be a very
lengthy, involved process."
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30. This discovery comes about a year after the pair's award winning 10-year
international twin-spine study proved that disc degeneration is affected largely
by genetics.
"For years it has been thought that wear and tear was the main cause," said
.Crites-Battie
The U of A researchers have made huge strides in the field and are
determined to put an end to lower-back pain.
"This study could lead to interventions and actions individuals could take to
minimize disc degeneration to which [patients] might be particularly prone," .
"We are very excited about continuing down this trail and said Crites-Battie
believe there is still much more to be learned."
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31. Evidence-Based Practice
Narrowing of Lumbar Spinal Canal Predicts Chronic Low Back Pain More
Accurately than Intervertebral Disc Degeneration: A Magnetic Resonance
Imaging Study in Young Finnish Male Conscripts
The objective of this magnetic resonance imaging study was to evaluate the role
of degenerative changes, developmental spinal stenosis, and compression of
spinal nerve roots in chronic low back (CLBP) and radicular pain in Finnish
conscripts. The degree of degeneration, protrusion, and herniation of the
intervertebral discs and stenosis of the nerve root canals was evaluated, and
the midsagittal diameter and cross-sectional area of the lumbar vertebrae canal
were measured in 108 conscripts with CLBP and 90 asymptomatic controls.
The midsagittal diameters at L1-L4 levels were significantly smaller in the
patients with CLBP than in the controls. Moreover, degeneration of the L4/5 disc
and protrusion or herniation of the L5/S1 disc and stenosis of the nerve root
canals at level L5/S1 were more frequent among the CLBP patients.
Multifactorial analysis of the magnetic resonance imaging findings provided a
total explanatory rate of only 33%. Narrowing of the vertebral canal in the
anteroposterior direction was more likely to produce CLBP and radiating pain
than intervertebral disc degeneration or narrowing of the intervertebral nerve
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32. Bioethical Principles/Ethico-Legal
Principle of Beneficence
Principle of Respect for Autonomy
Principle of Human Dignity
Principle of Informed Consent
Principle of Double Effect
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33. Nursing Theories
Sister Callista Roy Adaptation Model
Jean Watson Human Caring
Other theory
Wear and Tear Theory of Aging
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34. Health Teachings
Pain Management
• Limit bed rest; keep knees flexed to decrease strain on back
• Nonpharmacologic approaches: distraction, relaxation, imagery,
thermal interventions (eg, ice or heat), stress reduction
• Pharmacologic approaches: nonsteroidal anti-inflammatory
drugs,analgesics, muscle relaxants
Exercise
• Stretch to enhance flexibility, do strengthening exercises
• Perform prescribed back exercises to increase function,
emphasizing gradual increases in time and repetitions
Body Mechanics
• Practice good posture
• Avoid twisting body
• Push objects rather than pull them
• Keep load close to body when lifting
• Bend knees and tighten abdominal muscles when lifting
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35. •Avoid overreaching
• Use wide base of support
• Use back brace to protect back
Work Modifications
• Adjust work area to avoid stress on back
• Adjust height of chair or work table
• Use lumbar support in chair
• Avoid prolonged standing and repetitive tasks
• Avoid bending, twisting, and lifting heavy objects
• Avoid work involving continuous vibrations
Stress Reduction
• Discuss with patient the interdependence of stress and anxiety on
muscle tension and pain
• Explore effective coping mechanisms
• Teach stress reduction techniques
• Refer patient to back clinic
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36. Health Promotion
Standing
• Avoid prolonged standing and walking.
• When standing for any length of time, rest one foot on a small
stool or box to relieve lumbar lordosis.
• Avoid forward flexion work positions.
• Avoid high heels.
Sitting
• Avoid sitting for prolonged periods.
• Sit in a straight-back chair with back well supported and arm rests to support some
of the body weight; use a footstool to position knees higher than hips if necessary.
• Eradicate the hollow of the back by sitting with the buttocks “tucked under.”
• Maintain back support; use a soft support at the small of the back.
• Avoid knee and hip extension. When driving a car, have the seat pushed forward as
far as possible for comfort.
• Guard against extension strains—reaching, pushing, sitting with legs straight out.
• Alternate periods of sitting with walking.
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37. •Place a firm bed board under the mattress.
• Avoid sleeping in a prone position.
• When lying on the side, place a pillow under the head and one
between the legs, with the legs flexed at the hips and knees.
• When supine, use a pillow under the knees to decrease lordosis.
Lifting
• When lifting, keep the back straight and hold the load as close to the body
as possible.
• Lift with the large leg muscles, not the back muscles.
• Use trunk muscles to stabilize the spine.
• Squat while keeping the back straight when it is necessary to pick something
off the floor.
• Avoid twisting the trunk of the body, lifting above waist level, and reaching up
for any length of time.
Exercising
• Daily exercise is important in the prevention of back problems.
• Walking and gradually increasing the distance and pace of walking is
recommended.
• Perform prescribed back exercises twice daily, increasing exercise gradually.
• Avoid jumping and jarring activities.
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