Nursing Care Plan Herniated Nucleus Pulposus (Ruptured Intervertebral Disc)

CARE SETTING

Most disc problems are treated conservatively at the community level, although diagnostics and therapy services may be provided through outpatient facilities. Brief hospitalization is restricted to episodes of severe debilitating pain/neurological deficit.

RELATED CONCERNS

1. Disc surgery
2. Psychosocial aspects of care
3. Patient Assessment Database
4. Data depend on site, severity, whether acute/chronic, effects on surrounding structures, and degree of nerve root compression.

ACTIVITY/REST

May report: 

1. History of occupation requiring heavy lifting, sitting, driving for long periods
2. Need to sleep on bedboard/firm mattress, difficulty falling asleep/staying asleep
3. Decreased range of motion of affected extremity/extremities
4. Inability to perform usual/desired activities

May exhibit: 

1. Atrophy of muscles on the affected side
2. Gait disturbances

ELIMINATION

May report: 

1. Constipation, difficulty in defecation
2. Urinary incontinence/retention

EGO INTEGRITY

May report: 

1. Fear of paralysis
2. Financial, employment concerns

May exhibit: 
Anxiety, depression, withdrawal from family/SO

NEUROSENSORY

May report: 
Tingling, numbness, weakness of affected extremity/extremities

May exhibit: 

1. Decreased deep tendon reflexes; muscle weakness, hypotonia
2. Tenderness/spasm of paravertebral muscles
3. Decreased pain perception (sensory)

PAIN/DISCOMFORT

May report: 

1. 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)
2. Heard “snapping” sound at time of initial pain/trauma or felt “back giving way”
3. Limited mobility/forward bending

May exhibit: 

1. Stance: Leans away from affected area
2. Altered gait, walking with a limp, elevated hip on affected side
3. Pain on palpation

SAFETY

May report:
History of previous back problems

TEACHING/LEARNING

May report: 

1. Lifestyle sedentary or overactive
2. Discharge plan DRG projected mean length of inpatient stay: 4.9–6.5 days considerations: May require assistance with transportation, self-care, and homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Spinal x-rays: May show degenerative changes in spine/intervertebral space or rule out other suspected pathology, e.g., tumors, osteomyelitis.
2. CT scan with/without enhancement: May reveal spinal canal narrowing, disc protrusion.
3. MRI: Can reveal changes in bone, discs, and soft tissues and can validate disc herniation/surgical decisions.
4. 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.
5. 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.
6. Myelogram: Rarely performed, but when done, may be normal or show “narrowing” of disc space, specific location and size of herniation.
7. Epidural venogram: May be done for cases where myelogram accuracy is limited.

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.

DISCHARGE GOALS

1. Pain relieved/manageable.
2. Proper lifting, posture, exercises demonstrated.
3. Motor function/sensation restored to optimal level.
4. Disease/injury process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.