10. Herniated/ruptured disk (ruptured nucleus pulposus): strain or injury to a weakened cartilage between vertebrae can result in herniation of the nucleus, causing pressure on nerve roots in spinal canal, pain, and disability.
    1. Pathophysiology: pulpy substance of disk interior (nucleus pulposus) bulges or ruptures through the outer annulus fibrosus irritation and pressure on nerve endings in the spinal ligaments muscle spasm and distortion of the joints of vertebral arches.
    2. Risk factors:
       1. Strain as result of poor body mechanics.
       2. Trauma
       3. History of back injuries.
       4. Degenerative disc (Spondylosis).
    3. Assessment:
       1. Lumbar injuries (90% of herniations):
          1. Subjective data:
             1. Pain: low back, radiating to buttocks, posterior thigh, and calf; relieved by recumbency; aggravated by sneezing, coughing, and flexion; sciatic pain continues even when back pain subsides.
             2. Numbness, tinglin
          2. Objective data:
             1. Muscle weakness—leg and foot.
             2. Inability to flex le
             3. Sensory loss, leg and foot.
             4. Alterations in posture: leans to side, unable to stand up straight.
             5. Edema: leg and foot.
             6. Positive Lasegue’s sign: straight leg raising with hip flexed and knee extended will produce sciatic pain.
       2. Cervical injuries (10% of herniations):
          1. Subjective data:
             1. Pain—upper extremities, radiating to hands and fingers; aggravated by coughing, sneezing, and strainin
             2. Tingling, burning sensation in upper extremities and back of neck.
          2. Objective data:
             1. Upper extremities: weakness and atrophy.
             2. Neck: restricted movement.
             3. Diagnostic tests for both lumbar and cervical injuries.
                1. Spine x-rays.
                2. CT scan.
                3. MR
                4. Myelography (less preferred than CAT scan or MRI).
                5. Electromyography.
                6. Neurological exam: special attention to sensory status, including pain, touch, and temperature identification, and to motor status, including strength, gait, and reflexes.
    4. Analysis/nursing diagnosis:
       1. Pain related to pressure on nerve roots.
       2. Fear related to disease progression and/or potential surgery.
       3. Knowledge deficit related to correct body mechanics.
       4. Impaired physical mobility related to continued pain.
       5. Sleep pattern disturbance related to difficulty finding comfortable position.
    5. Nursing care plan/implementation:
       1. Goal: relieve pain and promote comfort.
          1. Bed rest with bedboar
          2. Position—avoid twistin
             1. Lumbar disk: William’s (head elevated 30 degrees, knee gatch elevated to flatten the lumbosacral curve). Can be duplicated at home with pillow placement.
             2. Cervical: low Fowler’s.
          3. Medications as ordered:
             1. Analgesics.
             2. Muscle relaxants.
             3. Anti-inflammatory.
             4. Stool softeners.
          4. Moist heat.
          5. Fracture bedpan.
          6. Gradual increase in activity.
          7. Brace application for support.
          8. Traction application pm for comfort.
          9. Prepare for surgery if medical regimen unsuccessful.
       2. Goal: health teachin
          1. Correct body mechanics, keep back straight.
          2. Exercise program as symptoms decreas
    6. Evaluation/outcome criteria:
       1. Reports pain decrease
       2. Mobility increased, normal body posture attained.