A herniated disc (herniated nucleus pulposus) [HNP] is a major cause of severe, chronic, and recurrent back pain.
Herniation, either complete or partial, of the nuclear material in the vertebral areas of L-4 to L-5, L-5 to S-1, or C-5 to C-6, C-6 to C-7 is most common and may be the result of trauma or degenerative changes associated with the aging process.
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
Disc surgery
Psychosocial aspects of care
Patient Assessment Database
Data depend on site, severity, whether acute/chronic, effects on surrounding structures, and degree of nerve root compression.
ACTIVITY/REST
May report: History of occupation requiring heavy lifting, sitting, driving for long periods
Need to sleep on bedboard/firm mattress, difficulty falling asleep/staying asleep
Decreased range of motion of affected extremity/extremities
Inability to perform usual/desired activities
May exhibit: Atrophy of muscles on the affected side
Gait disturbances
ELIMINATION
May report: Constipation, difficulty in defecation
Urinary incontinence/retention
EGO INTEGRITY
May report: Fear of paralysis
Financial, employment concerns
May exhibit: Anxiety, depression, withdrawal from family/SO
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
SAFETY
May report: History of previous back problems
TEACHING/LEARNING
May report: Lifestyle sedentary or overactive
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
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.
MRI: Can reveal changes in bone, discs, and soft tissues and can validate disc herniation/surgical decisions.
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.
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.
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.
Herniation, either complete or partial, of the nuclear material in the vertebral areas of L-4 to L-5, L-5 to S-1, or C-5 to C-6, C-6 to C-7 is most common and may be the result of trauma or degenerative changes associated with the aging process.
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
Disc surgery
Psychosocial aspects of care
Patient Assessment Database
Data depend on site, severity, whether acute/chronic, effects on surrounding structures, and degree of nerve root compression.
ACTIVITY/REST
May report: History of occupation requiring heavy lifting, sitting, driving for long periods
Need to sleep on bedboard/firm mattress, difficulty falling asleep/staying asleep
Decreased range of motion of affected extremity/extremities
Inability to perform usual/desired activities
May exhibit: Atrophy of muscles on the affected side
Gait disturbances
ELIMINATION
May report: Constipation, difficulty in defecation
Urinary incontinence/retention
EGO INTEGRITY
May report: Fear of paralysis
Financial, employment concerns
May exhibit: Anxiety, depression, withdrawal from family/SO
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
SAFETY
May report: History of previous back problems
TEACHING/LEARNING
May report: Lifestyle sedentary or overactive
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
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.
MRI: Can reveal changes in bone, discs, and soft tissues and can validate disc herniation/surgical decisions.
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.
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.
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.
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