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Cervical Spondylosis) - si.mahidol.ac.th · คู่มือการพยาบาล ผู้ป่วยโรคกระดูกคอเสื่อม (Cervical Spondylosis)

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(Cervical Spondylosis)

.. 2558

i

(cervical spondylosis) (clinical practice guideline) (cervical spondylosis)

. 84 4

2558

ii

i ii iii iv 1 1 - 1 - 3 - 3 - 4 - 4 2 5 - 5 - 9 - 10 - 11 - 13 * 13 * 13 - 15 - 16 - 16 3 19 - 19 - 28 4 55 - 55

ii

- 55 - 56 - 57 - 58 - 59 - 61 - 65 - 78 5 80 93 - Emergent surgical cricothyrotomy - - Dermatome Map of the Body -

iii

1 (cervical spine) 5 2 1 atlas 6 3 2 axis 7 4 7 7 5 9 6 normal cervical spine 12 7 cervical spondylotic myelopathy at C4,C5 and C6 12 8 MRI shows cervical spondylotic myelopathy at C4,5 and C6 12 9 14 10 X-ray 14 11 open door laminoplasty 15 12 17 13 incentive spirometer 21 14 log rolling 22 15 22 16 soft cervical collar 23 17 hard cervical collar 23 18 philadelphia collar 24 19 philadelphia collar 24 20 philadelphia collar 25 21 philadelphia collar 25 22 (BACK) philadelphia collar 26 23 philadelphia collar 26 24 philadelphia collar (BACK) 27 25 philadelphia collar 27 26 (quadriceps setting exercise) 44 27 45

iii

28 45 29 45 30 C5 49 31 C6 49 32 C7 50 33 C7 50 34 C7 50 35 C8 51 36 52 37 53 38 53 39 54 40 83 41 84 42 84 43 84 44 87

iv

1 49 2 51 3 58 4 59 5 80

1

1

1 63 2 .. 2554 - 2557 18,782 2,053 10.93 495 24.11 3 1

(cervical spondylotic radiculopathy) (cervical spondylotic myelopathy)

2

24 72 (philadelphia collar or soft collar) 24 4 C3-5 5

24 (philadelphia collar or soft collar)

3

.. 2557 84 4 11 3 27.27 (cervical spondylosis)

1. 2.

4

(cervical spondylosis)

6 (cervical spondylosis) (osteophyte) / central spinal canal / intervertebral foramen spinal cord (Cervical Spondylotic Myelopathy : CSM) / nerve root (Cervical Spondylotic Radiculopathy : CSR)

6 (Anterior Cervical Discectomy And Fusion: ACDF) / (anterior approach)

5

2 (cervical spondylosis)

1,6 (cervical vertebrae) 7

C2 C3, C4, C5 C6 typical cervical vertebrae typical cervical vertebrae body neuron arch typical cervical vertebrae transverse process (foramen transversarium transverse foramen) (vertebral artery) body vertebral foramen spinous process (bifid) (atlas) (axis)

Typical cervical vertebrae

1 (cervical spine)

Credit picture from http://www.spinesurgeon.com.au/Neurological_Conditions/Spinal-Surgery.htm search : 3/11/2014 10 .

http://th.wikipedia.org/w/index.php?title=%E0%B8%81%E0%B9%89%E0%B8%B2%E0%B8%99%E0%B8%AA%E0%B8%A1%E0%B8%AD%E0%B8%87&action=edit&redlink=1http://th.wikipedia.org/wiki/%E0%B9%84%E0%B8%82%E0%B8%AA%E0%B8%B1%E0%B8%99%E0%B8%AB%E0%B8%A5%E0%B8%B1%E0%B8%87

6

(first cervical vertebra) (atlas) body (occipital condyle) (atlanto-occipital joint) superior articular process (dens) body (transverse ligaments of atlas) transverse processes (atlanto-axial joint) 2

Atlas

2 1 atlas7

Credit picture from http://www.spinesurgeon.com.au/Neurological_Conditions/Spinal-Surgery.htm search : 3/11/2014 10 .

(second cervical vertebra) (axis)

dens dens alar ligaments dens occipital condyle 3

7

Axis

3 2 axis7 Credit picture from http://www.spinesurgeon.com.au/Neurological_Conditions/Spinal-

Surgery.htm search : 3/11/2014 10 . 7 typical cervical vertebrae spinous process

2 vertebral prominence 7 foramen transversarium vertebral artery 4

Cervical vertebrae 7

4 77 Credit picture from http://www.spinesurgeon.com.au/Neurological_Conditions/Spinal-

Surgery.htm search : 3/11/2014 10 .

8

6,8

1 1. Vertebral body (intervertebral discs) vertebral body 2. Vertebral arch body (vertebral foramen) (spinal cord) vertebral arch (pedicles) vertebral body (laminae) 3. Spinous process 4. Transverse process transverse process (foramen transversarium transverse foramen) (vertebral artery) 5. Superior and inferior articular processes

http://th.wikipedia.org/w/index.php?title=%E0%B8%AB%E0%B8%A1%E0%B8%AD%E0%B8%99%E0%B8%A3%E0%B8%AD%E0%B8%87%E0%B8%81%E0%B8%A3%E0%B8%B0%E0%B8%94%E0%B8%B9%E0%B8%81%E0%B8%AA%E0%B8%B1%E0%B8%99%E0%B8%AB%E0%B8%A5%E0%B8%B1%E0%B8%87&action=edit&redlink=1http://th.wikipedia.org/wiki/%E0%B9%80%E0%B8%AD%E0%B9%87%E0%B8%99http://th.wikipedia.org/wiki/%E0%B9%80%E0%B8%AD%E0%B9%87%E0%B8%99http://th.wikipedia.org/wiki/%E0%B9%84%E0%B8%82%E0%B8%AA%E0%B8%B1%E0%B8%99%E0%B8%AB%E0%B8%A5%E0%B8%B1%E0%B8%87http://th.wikipedia.org/wiki/%E0%B8%81%E0%B8%A5%E0%B9%89%E0%B8%B2%E0%B8%A1%E0%B9%80%E0%B8%99%E0%B8%B7%E0%B9%89%E0%B8%ADhttp://th.wikipedia.org/wiki/%E0%B9%80%E0%B8%AD%E0%B9%87%E0%B8%99http://th.wikipedia.org/wiki/%E0%B8%81%E0%B8%A3%E0%B8%B0%E0%B8%94%E0%B8%B9%E0%B8%81%E0%B8%8B%E0%B8%B5%E0%B9%88%E0%B9%82%E0%B8%84%E0%B8%A3%E0%B8%87http://th.wikipedia.org/w/index.php?title=%E0%B8%81%E0%B9%89%E0%B8%B2%E0%B8%99%E0%B8%AA%E0%B8%A1%E0%B8%AD%E0%B8%87&action=edit&redlink=1http://th.wikipedia.org/wiki/%E0%B9%84%E0%B8%82%E0%B8%AA%E0%B8%B1%E0%B8%99%E0%B8%AB%E0%B8%A5%E0%B8%B1%E0%B8%87

9

5 9 Credit picture from www.thaispineclinic.com/ articles./cervical-

spondylosis search : 25/10/2014 8 . (cervical spondylosis)

(cervical spondylosis) (facet joint) (axial neck pain) (facet joint) (Cervical Spondylotic Radiculopathy : CSR) (Cervical Spondylotic Myelopathy:CSM)

cervical spondylotic myelopathy 5 6,8

1. nerve root symptoms (radiculopathy)

2. medial myelopathic syndrome (spinal cord) fiber tracts pathway (long tract sign) ()

3. combined syndrome (nerve root) (spinal cord) cervical spondylotic myelopathy

http://www.thaispineclinic.com/%20articles./cervical-spondylosishttp://www.thaispineclinic.com/%20articles./cervical-spondylosis

10

4. vascular syndrome (spinal cord) (sensory and motor deficit)

5. anterior syndrome anterior horn cell

1,6,8 cervical spondylotic myelopathy

(spondylotic bars osteophytes) spinal canal ligamentum flavum (elasticity) uncovertebral joint (cervical spondylotic radiculopathy)

1,6,8

(wide based gait) (lhermitte sign)

11

1,6,8 cervical spondylotic myelopathy lower motor

neuron sign upper motor neuron sign upper motor neuron sign posterior column dorsal nerve root cervical spondylotic myelopathy multiple sclerosis, cerebrovascular disease, intracranial or spinal cord tumor, syringomylia, amyotrophic lateral sclerosis MRI, electrodiagnosis

1,6,8 electrodiagnosis cervical spondylotic myelopathy

somotosensory motor evoked potentials (MEP) MEP Somatosensory Evoked Potentials (SSEP) Somatosensory Evoked Potentials (SSEP) electrodiagnosis

1,6,8 antero-posterior, oblique lateral lateral

MRI cervical spondylotic myelopathy

12

CT - myelography MRI MRI

6 Film normal cervical spine10

Credit picture from http://boneandspine.com/spine/cervical-spine/xray-of-normal-cervical-spine search : 25/10/2014 8 .

7 Film shows cervical spondylotic myelopathy C 3-4 (AP,Lat, Flexion, Extension View) Credit picture from sirirajs patient

8 MRI shows cervical spondylotic myelopathy at C3-4 Credit picture from sirirajs patient

http://boneandspine.com/spine/cervical-spine/xray-of-normal-cervical-spinehttp://www.flickr.com/photos/[email protected]://www.flickr.com/photos/[email protected]

13

1,6,8

6 (non-surgical treatment) (collar) (traction) (NSAID) 6

6 (surgical indications)

6 6-12

2

1. (anterior approach)11 (Anterior Cervical Discectomy And

Fusion: ACDF) (iliac crest)

14

9 12 Credit picture from http://www.thaispine.com/Exam_CSM.htm

search : 25/10/2014 11 .

10 X-ray (ACDF C3-4) Credit picture from sirirajs patient

2. (posterior apporch) 11 3 3

(laminectomy) (laminoplasty) (laminectomy) (progressive cervical kyphosis)

http://www.flickr.com/photos/[email protected]

15

(laminectomy and fusion)

11 open door laminoplasty13

Credit picture from http://www.thaispine.com/Exam_CSM.htm search : 25/10/2014 11 .

14

4

1. (esophageal injury) 0.2-1.5% vertebral (vertebral artery injury) 0.3-0.5% dural tear 3.7% spinal cord injury 0.2-0.9%

2. 1 acute air way obstruction 1.7-2.8% radiculopathy 0.2-3.2%

3. 1-6 (dysphagia) 11-60% 70% 2 dysphonia 2-30% bone graft extrusion 6.4% wound Infection 0.2-1.6%

4. 6 /

16

bone morphogenetic proteins (BMPs) 23-27% 8

(cervical spondylosis) 55 MRI CT scan 70 , 15

1. 1

2. (isometric exercise) (stretching exercise) 3 12

17

12

3.

4. (soft collar) 1

5.

6.

1-5 3-5

18

(Anterior Cervical Discectomy and Fusion ; ACDF)

1. 2. 3. , , 4. - 5. 6.

7.

8. 9.

10.

19

3 (cervical spondylosis)

11 12 2

1:

- -

- -

-

20

- 8 -

18-30

1.

2.

3. VCD

4. / 18-19 4.1

4.2 (deep breathing exercise)

incentive spirometer20

4.2.1 incentive spirometer incentive spirometer lobe

4.2.2 2-3 mouth piece 3- 5 ( 1 5)

21

13 incentive spirometer

4.2.3 incentive spirometer

5-10 incentive spirometer 1

4.2.4 incentive spirometer deep breathing exercise

4.3 (cough effective) - 4-5 3 10

4.4 0 - 10 ( 0 10 ) 3

4.5 log rolling

22

4.5.1 (log rolling) 2 soft collar philadelphia collar 14

14 log rolling

4.6

4.7 10 15

15

23

4.8 21 three-point pressure

4.8.1 soft cervical collar

16 soft cervical collar 4.8.2 hard cervical collar

soft cervical collar soft cervical collar

17 hard cervical collar22 Picture from https://en.wikipedia.org/wiki/Cervical_collar search : 18/04/2015 22 .

4.8.3 philadelphia collar - 2

24

tracheostomy tube philadelphia collar anterior disectomy interbody fusion

18 philadelphia collar

4.9 (philadelphia collar) 23

4.9.1 philadelphia collar

front back

19 philadelphia collar FRONT collar

https://mobile.facebook.com/messages/attachment_preview/?mid=mid.1473434524285:b74ec23cbb2ca29897&threadid=mid.1404120236290:dec3a533b104835494&fbid=10210144823807838&refid=12https://mobile.facebook.com/messages/attachment_preview/?mid=mid.1473434524285:b74ec23cbb2ca29897&threadid=mid.1404120236290:dec3a533b104835494&fbid=10210144823807838&refid=12https://mobile.facebook.com/messages/attachment_preview/?mid=mid.1473434524285:b74ec23cbb2ca29897&threadid=mid.1404120236290:dec3a533b104835494&fbid=10210144823807838&refid=12

25

20 philadelphia collar BACK

4.9.2 philadelphia collar (small, medium, large)

4.9.3 philadelphia collar

21 philadelphia collar23 4.9.4 philadelphia collar

collar

26

22 (BACK) philadelphia collar 23

4.9.5 philadelphia collar (Back)

23 philadelphia collar 23

4.9.6 philadelphia collar (Front) Velcro philadelphia collar

27

24 (FRONT) philadelphia collar (BACK) 23

25 philadelphia collar collar ()() 23

4.10 /

1-2

4.11

5.

6.

28

7. 2

8. 18-32

(diaphragm) phrenic C3-C5 C5-T7 intercostals muscle 18 2 (lung atelectasis) (pneumonia)24 (cervical spondylosis) (C2-C4) (airway obstruction)

29

1:

- (anterior) C3-4 (diaphragm)

- 24 /

- - (oxygen saturation)

< 95 % - - 14-22 / - -

- (oxygen saturation) 97 % 3 LPM (oxygen saturation) 95 % 13,24

1. 15 4 2 1 4 2 4 4 72 2. (oxygen saturation) 3. (cough effective) - 4-5 3 10 4. (deep breathing exercise) 2-3

30

incentive spirometer incentive spirometer 3-5 ( ) 5 1-2 5. (cough effective) (abdominal compression) 6. 7. (cyanosis) 8. 9. 12 / 24 / 95% 10. ( 46) 2: - 200 ml/hr. - 100 / - 90/60 mmHg - 24 / - Hct < 30% - capillary refilling time 3 - PT< 10.5 sec., APTT< 23 sec., Plt. < 150,000/ul -

31

- 200 ./ - 30 / - - 60-100 / - 90/60 mmHg - 14-22 / - Hct > 30% - - capillary refilling time 3 - PT > 13 sec., APTT > 32 sec., Plt. > 440,000 /ul

- - 200 ./ - 30-50 / 18,25

1. systolic 90

2.

3. (vacuum drain) drain vacuum drain (vacuum drain)

4. 30 1.5-2

32

200 ./ 500 . 24 30% 25

4.1 4.2 4.3

100-120 / 120 / 20-30 / systolic 90-100 pulse pressure

4.4 delay capillary refilling time 3 ( capillary filling time 3 )

4.5 25-30 / ( 30-50/) 5.

25 5.1 20-30

5.2 (bleeding)

5.3 10-15 5.4 Hct 5.6 NSS, ringers lactate solution

5.7 O2 canular 2-3 /

5.8 1

1 / 1 / 30-50 /

3: - pain score > 3

33

- - - - pain score 3 - - / -

1. numeric rating scale (0-10) 1 4 2 4 4 72 pain score (monitoring nursing record)

2. (sedation score)28 0 1 2 3 s (pain score) (sedation score) 5-15 30-60 opioids sedation score 1-2 24 sedation score 2

sedation score 2 10 /28 - (recovery

position) - canula 3 LPM -

sedation score 3 10 /28

34

- - mask with bag 8-10 LPM - mask with self-Inflating bag tube - pupil RR, BP, consciousness pupil - naloxone dilute 0.1 mg/ml

3. philadelphia collar soft collar 2 log rolling

4. () 3

5. -

6. 4: / -

35

- / - / - /

1. 4

2. 1 (general anesthesia)

3. (graphic sheet)

4. (special mouth wash)

5. 6.

5: - > 37.5 - - / - - / - ESR > 20 mm/hr, CRP > 5 mg/L, WBC > 11.0 x10*3 /ul - - 36.5-37.5

- - / - - - ESR 0-20 mm/hr

36

- CRP < 5 mg/L - WBC 4.0-11.0 x10*3 /ul

31

1. 4 38.5 C 2,000-3,000

2. /

3.

4. (radivac drain)

5.

6.

7.

8.

37

2,000 - 3,000

9. 10. ESR , CRP, WBC

6: - - - -

1. /

2. // 2.1 33 2.1.1 2.1.2 2.1.3 2.2 2.3 90 ()

38

2.4 1 5 2.5 2.1 2.6 2.7 2.8 2.9

3. /

4.

5. 2,000-3,000 7: - 1-2 -

39

- O2 sat < 95% - 24 / - 37.5 - - CXR - (sputum culture) (growth)

- -

- 14-22 / - O2 sat > 95% - 36.5-37.5 - CXR - - (sputum culture) (no growth)

31

1. (deep breathing exercise) - 3 10 incentive spirometer incentive spirometer 3-5 5-10 1-2

2. (cough effective) 4-5 3 10

40

3. 1-2 12 4 72

4. (stethoscope)

5. 2,000-3,000 /

6. log rolling 2

7. CXR (sputum culture) CBC

8.

8: (deep vein thrombosis) - 1-2 - - blanching test > 3 - (deep vein thrombosis) - - -

- blanching test < 3

41

25

1.

2. philadelphia collar soft collar

3. blanching test34 5 2-3

4. (range of motion) (quardriceps setting exercise)

5. pneumatic compression device (deep vein thrombosis)

6. (pulmonary embolism)

7. Low Molecular Weight Heparin (LMWH) 72 bleeding hematocrit (coagulogram) 9: - 1-2

- - braden scale 18

- -

42

18,25

(immobilize) 2 Philadelphia collar

1. braden scale35 6 (sensory perception) (skin moisture) (activity) (mobility) (nutrition) (friction and shear) 1 () 4 () 1-3 3 12 13 - 14 15 18

2.

3. log rolling 2

4.

5.

6.

7.

43

8. PATSLIDE / 10: (philadelphia collar/soft collar) - - - - - - - - -

1. 2.

3. 4.

5.

11: - 1-2 -

44

- - 25

1. muscle tone

1.1 / -

1.2 / (quadriceps setting exercise)

26 (quadriceps setting exercise)

1.3 / 1 (straight leg raising exercise)

45

27 (straight leg raising exercise)

1.4 / (dorsiflexion) (plantar flexion) (inversion) (eversion) (foot drop)

28 (dorsiflexion) (plantar flexion)

29 (inversion) (eversion)

2.

46

12: - 1-2

- - - - - - 25

1. (bowel sound) 4-5 /

2. 2,000-3,000 /

3.

4. log rolling

5.

6.

7.

47

13: /

(nerve root injury) -////

-

/ - ////

18,25,34

1. record vital sign 1-2 12 4 72

2. (neurovascular status blanching test)25,34 neurovascular status 6 P

Pain Pallor Polar Paralysis Paresthesia Pulse

() blanching test25,34 2-3 blanching test positive

48

3. - 4 24 8 72 12 4-7

3.1 36

3.1.1 (muscle power) (flexor) (extensor) (abductor) (adductor) (rotator) - (motor power) 6 /

/ 0 = / 1 = / 2 = / 3 = / 4 = / 5 =

3.1.2

American Spinal Injury Association (ASIA)37 C1-3 Respiration ability C4 Trapezieus muscle C5 Elbow flexors C6 Wrist extensors C7 Elbow extensors C8 Finger flexors

3.1.3 34,36-39

49

1

C5 Deltoid deltoid Biceps C6 Wrist extensors Brachioradialis C7 Triceps, finger extensors Triceps C8 Finger flexors

C5

30 : C5

() supination 30 C6

31 : C6

extend

50

C7

32 : C7 90

33 : C7

34 : C7

51

C8

35 : C8

4. - ( sensation )39

0 (absent) 1 (Impaire) 2 (Normal) NT (Not testable)

5. (radicular pain) 2 (radicular pain)

C2 C3 C4 C5 C6 C7 C8

52

6. (motor power) (sensory)

14:

-

- -

-

-

1.

2.

3. / 1 10 1-10 3 40

36

53

4. 5

5. 6

6. (soft collar, philadelphia collar) soft collar 20-30 philadelphia

7. 4-6

37

38

54

8. 9.

10.

39

11. 15-20

55

4 (cervical spondylosis)

71

30,000 / : () 84/4 21 2558 27 2558 21 2558 CSM C3-4 with DLP CSM C3-4 with

DLP ACDF C3-4 with Iliac bone graft 22 2558 2 4 ..

4 2 MRI Diagnosis CSM C3-4

BPH 4 .. 1 on Lopid (600) 1x1 ac, Simvastatin (20) 1 tab hs

56

36.5

80 / 20 / 130/80

1. :

2. :

2 - - vocal cord impairment

3. : 20 /

4. : 80 / 130/80 (Capillary refill) 2

5. : (bowel sound) 8 /

6. : (sensory) dermatome

57

7. : (motor power): / (motor power grade 5)

8. :

(pain score) 2-3

:

: (20 2558) : BUN 10.6 mg/dl, Cr 0.8 mg/dl, BS 100

mg/dl, Na+ 140 mmol/L, K+ 3.9 mmol/L, Cl_ 103 mmol/L, HCO3_ 26 mmol/L, Chol 160 mg/dl,

TG 267 mg/dl, HDL-CHOL 36 mg/dl, LDL-CHOL 70.6 mg/dl, AST 28 U/L, ALT 21 U/L, CBC : Hb 14.7 g/dl, Hct 44.8 %, WBC 8,420 /ul, Plt. 338,000 /ul

: 1.015, 0-1 cell/HPF, 0-1 cell/HPF,

Film chest - Film C-Spine AP, Lat -

C3-4 MRI C-Spine

- Severe cervical spondylosis change with severe cord compression at C3-4 (central) with caused from grade 1 retrolisthesis C3-4, broad based central disc extrusion, posterior osteophyte complexes and thickening of ligament flavum.

- Small area of myelopathy within the cervical cord at C3-4. - Mild narrowing of both C3-4 neural foramens.

58

- Cervical spondylosis and disc degeneration at other cervical levels without cervical cord compression

Magnetic Resonance Imaging (MRI) C3-4 (CSM C3-4) (Anterior Cervical Discectomy and Fusion ; ACDF) C3-4 (iliac bone graft)

CSM C3-4 1

3

(facet joint) (axial neck pain) (facet joint) (Cervical Spondylotic Myelopathy : CSM) X - ray

71

59

MRI /

MRI

4

1

21 .. 58 - Set OR for ACDF C3-4 with IBG 21/1/58 - G/M PRC 1 unit - NPO AMN - cefazolin 1 gm OR - Pre med - Diazepam (5) 1 tab hs - Diazepam (5) 1 tab + 30 cc oncall to OR

21 .. 58 - Regular diet - Paracetamol (500) 2 tab prn q 6 hr. - Simvastatin (20) 1 tab hs

22 .. 58 post op order for ACDF C3-4 with IBG

- V/S q 1 hr. until stable then q 2 hr. - Record urine output q 2 hr. keep 50 cc/2 hr. - Heat nebulizer q 6 hr., Observe

22 .. 58 - NPO - 30-60 - Record VS, I/O, Vac Drain - cefazolin 1 gm v q 6 hr

60

1 - On O2 canular 3 LPM - Beradual 1 NB q 6 hr. - Record O2 sat q 2 hr. keep 95 % - NSS 1000 CC v 80 cc/hr. - Record drain q 2 hr. 100 cc notify - Plan film collar - Morphine 2 mg v prn q 2 hr. - Plasil 10 mg v prn q 6 hr.

- ultracet 1 tab q 6 hr - Paracetamol (500) 1 tab prn q 6 hr. - B co 1x3 pc - Lopid (600) 1x1 ac - Simvas (20) 1 tab hs - Fluimucil (200) 1x3 pc

23 .. 58 - On O2 canular 3 LPM - IVF off on Nss Lock - Morphine 2 mg v prn q 2 hr. - Plasil 10 mg v prn q 6 hr.

23 .. 58 - Liquid , Soft Diet - 0-90

24 .. 58 - Morphine 2 mg v prn q 2 hr. - Plasil 10 mg v prn q 6 hr. - Off O2 keep O2 sat 95 % - off vac drain D/S - Off foley cath - Consult PT ambulate with walker - film post op

24 .. 58 - Sitting Balance - off cefazolin - keflex (500) 1x4 ac,hs - Senokot 1x1 hs

25 .. 58 - Morphine 2 mg v prn q 2 hr. - Plasil 10 mg v prn q 6 hr.

25 .. 58 - ASA (81) 1x1 pc

61

1 26 .. 58

- Morphine 2 mg v prn q 2 hr. - Plasil 10 mg v prn q 6 hr.

27 .. 58 - Total stitches off - Discharge - F/U 6 .. 58 film C-Spine AP,Lat.

- Plan collar 6 weeks Philadelphia collar soft collar

HM - keflex (500) 1x4 ac,hs # 30 - ASA (81) 1x1 pc # 30 - ultracet 1 tab q 6 hr. # 30 - B co 1x3 pc # 90 - Lopid (600) 1x1 ac # 30 - Simvas (20) 1 tab hs # 30

21 2558

2 pain score = 0

62

1 :

- -

-

-

- - 6 -

1.

2.

3. VCD

4. / 4.1

4.2 (deep breathing exercise)

incentive spirometer

63

4.2.1 incentive spirometer incentive spirometer lobe

4.2.2 2-3 mouth piece 3- 5 ( 1 5)

13 incentive spirometer ( 21)

4.2.3 incentive spirometer

5-10 incentive spirometer 1

4.2.4 incentive spirometer deep breathing exercise

4.3 (cough effective) - 4-5 3 10

64

4.4 0-10 ( 0 10 ) 3

4.5 log rolling

4.5.1 (log rolling) 2 soft collar philadelphia collar 14

14 log rolling ( 22)

4.6

4.7 ( 15 22)

4.8 ( 16-25 23-27 )

4.9 / 1-2

4.10

65

5.

6. 7.

2

8. Diazepam (5mg) 1 tab hs

1.

2. / (deep breathing exercise) (cough effective) 0-10 log rolling

3.

1 ( 23 2558)

ACDF C3-4 with iliac bone graft 1

sedation score = 0 Fixomulll philadelphia collar vacuum drain 1 content 30 cc on IVF NSS 1000 CC v 80 cc/hr on foley cath 1 urine flow

66

400 cc 36.8 90 / 24 / 140/70 O2 sat (room air) 93 % 45 pain score = 6 1:

- (anterior) C3-4

(diaphragm)

- - 24-26 / - - (oxygen saturation) 93 % (

) - - 14-22 / -

- (oxygen saturation)

3 LPM 97 % (oxygen saturation) 95 %

1. 15 4 2 1 4 2 4 4 72

2. (oxygen saturation)

3. (cough effective) 4-5 3

67

10

4. (deep breathing exercise) 2-3 incentive spirometer incentive spirometer 3-5 5 1-2

5. Beradual 1 NB q 6 hr. Fluimucil (200) 1x3 pc (heat nebulizer q 6 hr.) (cough effective) (abdominal compression)

6. 7. O2 canular 3 LPM

(cyanosis) 8. /

( 23 2558)

1. incentive spirometer 3 5-10 / 10-12 /

2. 16-20 /

3. (oxygen saturation) 93 % (oxygen saturation) 97-98 %

68

2: - 6

- - - - pain score 3 - - / -

1. numeric rating scale (0-10) 1 4 2 4 4 72 pain score (monitoring nursing record)

2. (pain score) (sedation score) Morphine 2 mg v prn q 2 hr. 5-15 sedation score 1-2 24 sedation score 2

3. philadelphia collar soft collar 2 log rolling

69

4. () 3

5. -

6. ( 23 2558)

6 3 sedation score = 0 20 / Morphine / / 3 - - - - -

70

1. (liquid diet)

(soft diet) /

2. /

3. //

3.1 33

3.1.1 3.1.2 3.1.3

3.2

3.3 90 3.4 1

5 3.5 3.1

3.6

71

3.7

3.8

3.9 4.

5. 2,000-3,000 ( 23 2558)

lopid 600 mg 4: (philadelphia collar/soft collar) - - - - - - - - -

72

1. philadelphia collar

2. size M

3. 0-90

4.

5. 1

6. ( 23 2558)

/ 2 ( 24 2558)

ACDF C3-4 with iliac bone graft 2

off vaccum drain Fixomull philadelphia collar off foley cath 37.1 70 / 20 / 140/80 O2 sat room air = 97 % 90 pain score = 3

73

1:

( 24 2558) (oxygen saturation) 97 %

20-22 / (deep breathing exercise) / incentive spirometer 3 2: ( 24 2558)

2-3 3: ( 24 2558)

() 4: (philadelphia/soft collar) ( 24 2558)

/ 5: - - - -

74

- - -

1. (bowel sound) 4-5 /

2. 2,000-3,000 /

3.

4.

5.

6. senokot 1x1 hs

( 24 2558)

3 ( 27 2558)

71 ACDF C3-4 with iliac bone graft 5

Fixomull philadelphia collar (

75

) 36.4 78 / 20 / 130/70 O2 sat room air = 97-98 % pain score = 1-2 1:

( 27 2558)

(deep breathing exercise) 20 / incentive spirometer 3 (oxygen saturation) 97-98 % () 2: ( 27 2558)

( ) 0-2

4: (philadelphia/soft collar) ( 27 2558)

philadelphia collar soft collar 5: ( 27 2558)

()

76

6: - -

- - -

-

1.

2. keflex (500) 1x4 ac,hs ultracet 1 tab q 6 hr. / paracetamol(500) 1 tab q 4-6 hr. ASA (81) 1x1 pc 7-10

3. / 1 10 1-10 3 ( 36 52)

4. 5

77

5. (philadelphia/soft collar) 6 philadelphia collar soft collar

6. (soft collar, philadelphia collar) soft collar 20-30 philadelphia

7. 4-6 ( 37-38 53)

8. 6 2558 104 1 film C-Spine AP,Lat.

9. 1-2

10. ( 39 54)

11. 15-20

78

( 27 2558)

()

71 CSM C3-4 with DLP 21 2558 ACDF C3-4 with IBG 22 2558 Cefazolin 1 gm iv q 6 hr., Ultracet 1 tab prn q 6 hr., Paracetamol (500) 1 tab q 6 hr., Bco 1 tab tid pc, Lopid (600) 1 tab OD, Simvastatin (20) 1 tab hs. Fluimucil (200) 1x3 pc ASA (81) 1 tab OD 25 2558 Keflex (500) 1 tab qid ac hs. 30 Ultracet 1 tab prn q 6 hr. 30 Bco 1 tab tid pc 90 Lopid (600) 1 tab OD 30 Simvastatin (20) 1 tab hs. 30 ASA (81) 1 tab OD 30 6 2558 / 1-2

6-12

79

72 (deep breathing exercise) (cough effective) philadelphia collar (philadelphia collar) (philadelphia collar) (philadelphia collar)

80

5

5 (cervical spondylosis)

/ (deep breathing exercise) (cough effective) / /

81

(deep breathing exercise and cough effective) incentive spirometer 1 ( 5-10 ) 4 / (suction clear airway) (heat nebulizer) 6-8 41 (oropharyngeal tube oral airway) (lung collapse) 12-14 french (suction wall) 80-120 . 10 (laryngospasm) vagus nerve - 2-3

82

carina 1 cm. 3 20 30 15-30 30 ( semi fowler 's position)

1. 2. 14- 20 / 60- 80 / 3. 4. 5.

() oxygen saturation 1 4 2 4 4 72 - - - - (adventitions sound) crepitation, rhonchi - (cyanosis) cricothyroidotomy ( )

83

( )

( > 3) philadelphia collar soft collar 24 30

40

84

4-6

41

42

43

85

/

(log rolling) 2 soft collar philadelphia collar

14 log rolling ( 22)

42 (dysphagia) 1. 1.1 1.2 1.3

86

2. 3. 90 () 4. 1 5 5. 1 6. 7. 8. 9.

( philadelphia/ soft collar)

(philadelphia/soft

collar)

1.

2.

()

3. ( )

87

( philadelphia/ soft collar)

collar

4.

44

philadelphia collar (

-)

philadelphia collar

/

(philadelphia collar) 23

1. philadelphia collar

front back

2. philadelphia collar (small, medium, large)

3.

philadelphia collar

4. philadelphia collar

collar

88

( philadelphia/ soft collar)

5. philadelphia collar (Back)

6. philadelphia collar (Front)

Velcro philadelphia collar

philadelphia collar

collar front back ( 19-25 24-27)

(philadelphia/soft collar)

(philadelphia/soft collar) (philadelphia/soft collar) philadelphia collar soft collar philadelphia collar (size) Philadelphia collar philadelphia collar philadelphia collar (webril) conform philadelphia collar hydrocellular dressing

89

(philadelphia/soft collar)

2 (soft collar, philadelphia collar) soft collar 20 - 30 philadelphia

2,000-3,000 / - quadriceps exercise, ankle pumping (early ambulation)

90

/ / METHOD

M : Medication

E : Environment Economy (wide based gait) / (pick up walker) 6 / ( 53,85)

91

T : Treatment 2 /

H : Health -

6 (soft collar, philadelphia collar)

- Home Program 3

12 ( 17)

1-5 3-5

92

- 1 15-20

- ( 39 54)

O : Outpatient Referral

D : Diet 5

24

93

1. . . : . ; 2552.

2. . : 1. : ; 2556.

3. . .. 2554-2557. ; 2554-2557.

4. . . ( ). : ; 2551.

5. Cloyd JM, Acosta FL, Ames CP. Effect of age on the perioperative and radiographic complications of multilevel cervicothoracic spinal fusions. Spine 2008; 33(26): E977E982.

6. . Degenerative Diseases of The Cervical Spine. , , , , , . Comprehensive spine course 2010. : S.M. Circuit Press; 2553. 69-120.

7. Raoul E Pope. Spinal anatomy. (Internet). 2014 (cited 2014 Nov 3). Available from: http://www.spinesurgeon.com.au/Neurological_Conditions/Spinal-Surgery.htm

8. . . : . ; 2550. 9. . . (Internet). 2014 (cited 2014 Oct 25).

Available from: http://www.thaispineclinic.com/articles./cervical-spondylosis 10. Arun Pal Singh. Anatomy of Cervical Spine. (Internet). 2014 (cited 2014 Oct 25). Available

from: http://boneandspine.com/spine/cervical-spine/xray-of-normal-cervical-spine 11. . Perioperative management in spine. : Avanced orthopaedic nursing

care 120 . : ; 2551.

12. . . (Internet). 2014 (cited 2014 Oct 25). Available from: http://www.thaispine.com/Exam_CSM.htm

http://www.thaispineclinic.com/articles./cervical-spondylosishttp://boneandspine.com/spine/cervical-spine/xray-of-normal-cervical-spine

94

13. . open door laminoplasty. (Internet). 2014 (cited 2014 Oct 25). Available from: http://www.thaispine.com/Exam_CSM.htm

14. . Adverse Event Associated with Anterior Cervical Spine Surgery. , , , , , , . Comprehensive spine course 2010. : S.M. Circuit Press; 2553. 169-186.

15. . 10 . : ; 2556.

16. , , . . 2554;2:3.

17. . . 2557; 15:3.

18. , . 7. : ; 2553.

19. Harvey CV. Spinal surgery patient care. Orthopaedic nursing 2005; 24(6): 426-440. 20. (CoP : Community of Practice). Triflo

CoP Respiratory Care 2556. (). : ; 2556 ( 11 .. 2558). : http://www1.si.mahidol.ac.th/km/sites/default/files/u11/asset09.pdf

21. Eric D.Schwartz, Adam E.Flanders(Editors). Spinal Trauma:Imaging, Diagnosis and Management. Philadelphia, PA. Lippincott Williams&Wilkins; 2007.

22. Wikipedia. Cervical collar. (Internet). 2015 (cited 2015 Apr 18). Available from: https://en.wikipedia.org/wiki/Cervical_collar 23. . Cervical spinal injury RASU 504

5 (). : ; 2547 ( 11 .. 2558). : http://med.mahidol.ac.th/surgery/sites/default/files/public/pdf/neuro/Cervical%20spinal%20 injury%20.pdf

24. , , , . . : ; 2555.

http://med.mahidol.ac.th/surgery/sites/default/files/public/pdf/neuro/Cervical%20spinal%20%20injury%20.pdfhttp://med.mahidol.ac.th/surgery/sites/default/files/public/pdf/neuro/Cervical%20spinal%20%20injury%20.pdf

95

25. . . : ; 2553.

26. Dewit SC, Kumagai CK. Medical-surgical nursing concepts & practice. 2 nd ed. St. Louis: Saunders Elsevier; 2009.

27. Doenges ME, Moorhouse MF, Murr AC. Nursing care plans. 8 th ed. Philadelphia: F.A. Davis; 2006.

28. (CoP : Community of Practice). Sedation score. . ; 2554.

29. . : 1. : ; 2551.

30. . 3. : ; 2553.

31. . . : ; 2549.

32. . 2 Basic to Advance Orthopaedic Nursing II. : N P Press Limited Partnership; 2550.

33. . . . 2552;24:2.

34. , , . . : ; 2556

35. . (The Braden Scale for Predicting Pressure Sore Risk). . ; 2556

36. . . ; 2550 1-57.

96

37. Steven C. Kirshblum, William Waring, Fin Biering-Sorensen, Stephen P. Burns, Mark Johansen, Mary Schmidt-Read, et al. International standards for neurological classification of spinal cord injury (Revised 2011). J Spinal Cord Med. 2011 November; 34(6): 547554.

38. . . : ..; 2537. 39. . (basic knowledge

of clinical practice in orthopedic). : ; 2553 40. . . :

; 2552. 41. .

Suction. (). : ; 2556 ( 11 .. 2558). :

http://www.ns.mahidol.ac.th/english/th/departments/FN/th/km/km_Suction.html 42. . (Dysphagia in Elderly)

2556; 23(3): 73-80 ; 2556. 43. . (Trecheostomy) : Siriraj E Public Library. ().

: ; 2558 ( 31 .. 2558). : http://www.rcot.org/data_detail.php?op=knowledge&id=52

44. . . (). : ; 2554 ( 11 .. 2558). : http://library.md.chula.ac.th/guide/vancouver2011.pdf

45. . (Vancouver Style). : . (). ; 2554 ( 11 .. 2558). : http://www.en.mahidol.ac.th/thai/curriculum/ets/thesis/02.pdf

http://www.ns.mahidol.ac.th/english/th/departments/FN/th/km/km_Suction.htmlhttp://www.rcot.org/data_detail.php?op=knowledge&id=52http://library.md.chula.ac.th/guide/vancouver2011.pdfhttp://www.en.mahidol.ac.th/thai/curriculum/ets/thesis/02.pdf

(Motor power) ( Sensory ) ...................................................................................... ......................................................................... .................................................

/

C5 T1 L2 S1

C5 C6 C7 C8 T1 L2 L3 L4 L5 S1

M S M S M S M S M S M S M S M S M S M S

L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R

;MkkkKKkkkkk;;;;MMM M = Motor

S = Sensory

L = Left

R = Right

24 . 4 1- 3 8 4- 7 12 8 -14 1

Motor 0 = / Sensory 0 = ( absent ) 1 = / 1 = ( impaired ) 2 = 2 = ( normal ) 3 = NT = ( not testable ) 4 = 5 =

(Motor power) Dermatome Map of the Body (Sensory)

C5

,

C5

C6

C6

C7

C7

C8

C8

T1

T1

L2

L1-2

L3

L3

L4

L4

L5

L5

S1

S1