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Sara Hurley

Patient Education Developmental Stage Pathophysiology

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Medical Management

The Cauda Equina is the name given to the group of nerves that arise from the culmination of the spinal cord (the conus medullaris) and extend inferiorly in the intradural space towards the coccyx.

Generally considered to be comprised of nine pair of nerve roots starting with the L2 and extending to and including the S5. Provides motor innervation to the hips, knees, ankles, and feet, as well as other sphincter innervation, sensory innervation to the saddle region and parasympathetic innervation to the bladder (distal bowel).

It is caused by compression or injury to the nerve roots which descend from the conus medullaris.

Sensory loss is seen around the anus, lower genitalia, perineum and buttocks. This can cause the bowel and bladder dysfunction in the patient.

The bladder receives innervation from the parasympathetic nervous system (pelvic splanchnic nerves and the inferior hypogastric plexus) and sympathetic plexus (hypogastric plexus), the external sphincter of the bladder is controlled by the pudenal nerve, and the lower motor neuron lesions of the Cauda Equina will interrupt the nerves forming the bladder reflex arcs.

It can cause space occupying lesion with lumbosacral canal including an abscess.

(https://www.orthobullets.com/spine/2065/cauda-equina-syndrome)

Teach the patient that it is normal to experience some pain in the first few weeks as the nerves and tissues around the wound recover. Back pain can usually be helped by taking painkillers regularly. Some people still have leg pain even though the operation has taken the pressure off the nerves. This is because the nerves are still inflamed or ‘irritable’. It can also relate to changes in how pain is perceived within the nervous system. The pain may vary according to how much you do or your posture/position. It is important to avoid being in any one position for too long (change posture at least every half an hour), and to keep gently mobile with proper rests in between. Painkillers, including anti-inflammatories or medication for what is called ‘neuropathic pain’ can also be very helpful. You should take them regularly according to the instructions on the packet, especially in the early stages of your recovery. Teach the patient how important it is to report any changes in bladder control to prevent kidney or bladder damage. If urinary incontinence develops again after the Foley is taken out then to let his doctor know immediately. Also teach the pt to do exercises to help promote strength in the extremities. Also report anymore numbness or tingling that prevents the pt from walking because this may indicate further spinal dysfunction.

(https://www.orthobullets.com/spine/2065/cauda-equina-syndrome)

Client is in Erikson’s stage of Generativity vs Stagnation. Pt seems to have generativity because he is very positive despite his health. He is very in love with his wife and two children and has no regrets in life. And states he tries to “live life to the fullest”.

-CBC; elevated WBC count indicating infection.

-wound culture; showed the pt had ESBL in his incisional wound.

-Negative pressure wound vac to incisional wound to help promote wound healing.

-MRI of spine; showed abscess on the spine on the L4-S1 and cauda equina. And relieving pressure on the spine.

-Laminectomy- drained abscess.

-creatine and Na- low, but slowly improving. Can indicate damage to the kidneys.

-CXR- showed normal lung inflation with small to moderate volume bilateral pleural effusion. Normal heart size.

-Urinalysis- showed no presence of protein, blood, or glucose in the urine,

Cauda Equina

Abscess on the spine.

Client fell at home. And was having intense back pain. Also was involuntarily urinating on self.

The treatment for Cauda Equina requires to first identifying the signs and symptoms of the disorder. Which is bowel and bladder dysfunction, numbness and tingling to lower extremities or to the inner thighs or back of the legs. Then there is a need to check the strength and sensation of the extremities to assess stability. There will need to be an order for an MRI, and x-ray to help assess the problem. A urinary catheter will need to be put into place due to incontinence. After all this is done there is an immediate surgical decompression in order to eliminate pressure on the impacted nerves and drain the abscess that is causing the pain and pressure. After surgery the pt will need to be started on abx due to ESBL found in wound. There is also a wound vac in place with negative pressure to promote healing. Monitor the fluids draining from wound vac for any abnormalities. The pt will need to be bladder trained and to notify the nurse when he clamps and unclamps the Foley when he feels the need to urinate. There will need to be pain management with around the clock pain meds. PT to help the patient promote strength in the weak extremities.

Nursing Diagnosis #2

Acute pain r/t inflammation in surgical incision aeb patient reporting a 10/10 pain to lower back throughout shift, around the clock morphine and prn dilaudid providing no pain relief, and pt stating the pain makes him uncomfortable.

Nursing Diagnosis #1

Infection r/t presence of gram negative bacteria in the lower back incisional wound aeb ESBL found in wound culture, WBC’s of 16, and patient on antibiotics.

Nursing Diagnosis #3

Impaired urinary elimination r/t neurovascular impairment aeb urinary incontinence, and pt bladder training, and the need for a Foley catheter.

Patient

53 y/o male admitted on 01/29/19 with an admitting diagnosis of Cauda Equina, and abscess on the spine after he fell at home and had intense back pain and was also involuntarily urinating on himself. Taken to the ED and the MRI on 01/29 showed confirmed Cauda Equina an abscess on the spine on the L4-S1. PMH of CHF, diabetes, GERD, HTN, liver cancer, and heroin addiction. Pt lives in a home with his wife and uses occasional walker to help him around the house. Pt is alert and orients x’s 4. PEERLA. Pt is very anxious to get out of the hospital. Pts EKG showed sinus tachycardia with a pulse of 120 with a regular rhythm, S1 and S2 heart sounds present, cap refill <3 seconds, radial and pedal pulses present +2 up and +1 down, no edema present. BUL lung sound’s clear and BLL lung sounds diminished, SPO2 98% on RA. Foley catheter in place since admission and pt is currently bladder training to be taken off Foley, pt voiding clear yellow odorless urine with 100ml/hr. Bowel sounds present in all quadrants, LBM 03/01/19, full ROM in BUE and right lower extremities, numbness and tingling in left lower extremity. Skin is warm, dry, and with an incisional wound to the lower right back with a wound vac in place draining serosanguinous fluid . Skin turgor normal. Left upper arm picc line with Imipenem cilastin 500mg IVPB mixed in with D5W running at 100ml/hr, site is clean, dry, and intact. Vitals at 0800 BP 156/71, HR 69, Resp 18, temp 97.6, and pain 10/10 sharp pain to the lower back with around the clock pain meds. Recent vitals BP 157/92, HR 79, Resp 18, temp 97.6, and pain 10/10 sharp pain to lower back.

Outcome #2

Pt will not show signs of worsening pain aeb pt stating a pain level of 4/10, comfort at rest, and decrease in need for pain meds.

Outcome #3

Pt will not show worsening signs of impaired urinary elimination aeb pt being able to urinate on their own and dc foley.

Outcome #1

Pt will not show signs of worsening infection aeb decrease in WBC’s, temp < 100 degrees Fahrenheit, and HR 60-100.

Interventions #3

-Teach the pt how to bladder train (decreasing incidence of urinary retention and, therefore, decreasing the need for catheter reinsertion).

- Monitor I&O’s q 1 hr (this can indicate if the pt is holding on to fluids or not).

-Monitor creatine, BUN, and GFR q shift or prn (can indicate if there is any injury to the kidneys).

-Educate the pt to let the nurse know when he clamps the foley (this can indicate if he can urinate without the foley).

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Interventions #2

-Administer morphine q 4 hrs (opioid agonist to control pain)

-Administer dilaudid q 4hrs or prn (control pain).

-Monitor pain level q 4hrs or prn (can indicate if pain meds are effective or if pt needs more pain management).

-Promote rest periods to promote relaxation (peaceful environment can promote rest).

Interventions #1

-Administer Imipenem cilastin 500mg IVPB (abx to treat infection)

-Monitor trend in CBC and WBC’s daily or prn (elevation can indicate inflammation and worsening of infection).

-Assess temp and HR q 4 hrs (increase can indicate worsening of infection).

-Monitor wound site for unusual redness or discharge (redness and discharge can indicate worsening of infection at the site).

Evaluation #3

Goal not met pt will continue bladder training and educate pt the importance of clamping and unclamping when he feels the need to urinate.

Evaluation #1

Goal not met. Pt still required abx and no change In WBCS. Continue to treat with abx.

Evaluation #2

Not met still needed around the clock pain meds. Continue to provide pain meds and comfort.

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