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CHAPTER 2

THEORYTICAL BACKGROUND

2.1 Anatomy Physiology

2.1.1 Anatomy of Central Nervous System

2.1.1.1 Spinal Cord

The spinal cord is continuous with the medulla oblongata above

and constitutes the CNS (central nervous system) below the brain.

It is approximately 45cm length and width 11cm. The spinal

nerve exits from each segment of the spinal cord (31 spinal nerve

pair) and consists of motor or anterior roots (root) and sensory or

posterior root.In detail divided spinal cord into vertebral sections

8 cervicals, 12 thoracics,5 lumbars, 5 sacrals, 1 coccygeal that

correspond to paired nerves. At its lower end, it tapers off into a

conical shape called the conus medullaris, from the end of which

the filum terminale descends to the coccyx, surrounded by nerve

roots called the cauda equine (Muttaqin, 2008).

Picture 2.1 Anatomy of Medulla Spinalis (Smeltzer, 2010)

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2.1.2 Physiology of Spinal Cord System

The physiology of Spinal cord as Ginsberg (2008) explains, are part of

the somatic nervous system; starting from the tip of the dorsal and

ventral nerve from the spinal cord (the portion outside of the spinal

cord). Those nerves leads out the cavity and branches along its

journey to the muscle or sensory receptors to a branch of spinal nerves

is generally accompanied by blood vessels, especially the branches

leading to the muscles of the head (skeletal muscles).

Mechanism of input (entry of sensory information to the spinal cord)

and the output of the process that generates the information the motor

can be described as follows: Soma axon-axon cells from spinal nerves

that bring sensory information to the brain and spinal cord are located

outside the central nervous system (except for the visual system

because the retina is the part of the brain). Axon-axon that carries

sensory information coming to the nerves, this is the afferent nerves.

Soma-soma cells from axon that carries sensory information of the

dorsal root ganglia in the gathering. This neuron is unipolar neurons.

The axon branching stems near the soma cell send information to the

spinal cord and to the sensory organs. All of the axon in dorsal root

pass on the information sensorymotoric.

While according to Albert and Vaccaro (2013), the spinal cord has

two general functions. Briefly, it provides conduction routes to and

from the brain and work as the integrator or reflex center for all spinal

reflexes. Spinal cord tracts provide conduction paths to and from the

brain. Ascending tracts conduct sensory impulses up the cord to the

brain. Descending tracts conduct motor impulses down the cord from

the brain. Bundles of axons compose all tracts.

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2.2 Basic Concepts of Myelopathy

2.2.1 Definition

According to Batticaca (2008), myelopathy refers to the neurological

deficits associated with damage to the spinal cord. In general,

clinically myelopathy divided into several categories based on

whether or not there is significant trauma, and the presence or absence

of pain.

As Muttaqin (2008) explains, that myelopathy include injury to the

medulla spinalis due to trauma direct or indirect resulting in the main

function of the disorders, such as the dysfunction of motor, sensory,

autonomic, and reflex, either complete or incomplete. So, from the

definitions above the writer have a conclusion that the myelopathy

include injury to the medulla spinalis due to trauma direct or indirect

resulting in the main function of the disorders, such as the function of

motor, sensory, autonomic, and reflex, either complete or incomplete,

which is the clinically myelopathy divided into several categories

based on whether or not there is significant trauma, and the presence

or absence of pain.

2.2.2 Classification

2.2.2.1 According to Spinal Cord Injury degree according to the

scale of the ASIAN/IMSOP (American Spinal Cord Injury

Association/International Medical Society of Paraplegia,

Chin, 2016)

Table 2.1 Spinal Cord Injury degree according to the scale of

the ASIA/IMSOP Grade Type Disorder of Medulla Spinalis

A Complete Dysfunctions of motor and sensory up to S4-S5

B Incomplete Sensory function half good but the motor is

interrupted until the sacral segments S4-S5

C Incomplete Motor function below the level of the disturbed

but the main motor muscles still have strength <

3

D Incomplete Motor function below the level of the disturbed,

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the power of the main motor muscles > 3

E Normal No abnormality

2.2.2.2 According to NSCISC (2016) divided into 4 syndrome

depends on the part that occur injury

Table 2.2 NSCISC (2016) 4 syndromes of myelopathy

Clinic

Characteristics

Central cord

syndrome

Anterior

cord

syndrome

Brown-

Sequard

syndrome

Posterior

cord

syndrome

Biomechanics

Accident

Common

hyperextenssion

rare

hiperfleksi

Rare

penetration

Very rare

hyperextensi

on

Motoric

The disorder

varies;

rarely the complete

Often the

complete

paralysis

usually

bilateral;

traktus

disorders

descendent

The

weakness of

the limbs

ipsilateral

lesions;

traktus

disorders

descendent

The disorder

varies,

impaired

traktus

descendent

light

Protopatic

The disorder varies,

not typical

Often

missing total

bilateral;

traktus

disorders

ascendant

Often lost a

total of

contralateral;

traktus

disorders

ascendant

The disorder

varies,

usually mild

Propioseptik

Rarely interrupted

Usually

intact

Missing total

Agenesis;

traktus

disorders

ascendant

Disturbed

Repair

Real, fast, frequent;

the typical

weaknesses of the

hand fingers settle

Worst than

another

Bad

function; but

best

independenc

e

-

2.3 Etiology

2.3.1 According to Muttaqin (2008), the etiology of myelopathy are :

2.3.1.1 Accident (most common cause).

2.3.1.2 Sport.

2.3.1.3 Diving in shallow water.

2.3.1.4 The blast Wounds or cuts have pierced.

2.3.1.5 infectious processes

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2.3.1.6 primary Carcinoma

2.3.1.7 A cause of intradural cyst includes, post traumatic

progressive myelomalacic myelopathy, and benign neoplasm

(meningiomas, arachnoid cyst, epidermoid cyst,).

2.3.2 While as in Smeltzer (2010) views the etiology of myelopathy are ;

2.3.2.1 Spondiliosis cervical by myelopathy, which produces a

narrow channel and led to the injury of the medulla spinalis

and against progressive roots

2.3.2.2 Myelitis inflammatory processes resulting from infection or

non-infection;

2.3.2.3 Osteoporosis caused by compression fractures in the

vertebrae;

2.3.2.4 Siringmielia; tumor infiltration as well as compression;

2.3.2.5 Vascular disease.

2.3.2.6 Disc herniation that is reduction of the diameter of the spinal

canal and spinal cord compression, spinal instability,

congenital stenosi and others

2.3.2.7 In addition problem on the in vertebral disc, so that the

vertebrae can be the collapse, formation of osteophytes on the

nerve channels and reduces the vast canalis spinalis and

improves the surface anchoring the load on the bones and

because it reduces the effective strength.

2.3.2.8 On the spinal ischemia may also play a role in the

development of myelopathy. Blood flow on a less adequate

spinalis causes nerve and spinalis network does not get

enough nutrients, so the ligaments that hold the vertebrae can

be thinned and pressing the nerve channels as well as the

disruption of nerve function.

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2.4 Pathophysiology

Muttaqins (2008) views that the pathophysiology of myelopathy is trauma to

the neck can manifest on the broken the structure of the vertebrae, column

compression of the disc, cervical ligament, rupture and compression medulla

spinalis on each side that can suppress the spinal compression and manifests

on the nervous distribution and appropriate radix segments of the spine

cervical. Trauma to the cervical could cause injury spinal stable and unstable.

Stable injuries are injuries that the vertebral components will not be move by

normal movement so that the spinal cord are not broken and are usually more

low-risk . Unstable injury is an injury that can undergo further shift in where

there is a change of the structure of posterior oseoligamentosa (prediculus,

surface of joints, arcus posterior bone, interspinosa and supraspinosa

ligaments), and anterior column (two-thirds of the anterior portion of the

corpus vertebrae, part of the anteriordiskus invertebralis, and the anterior

longitudinal ligament). On injury hyperextension cervical, hit, on face or

forehead will force the head backwards and nobody supporting occipital to

head it strikes the top of the back. The anterior circulate ligament and the disc

can be damaged or it may damage nerves arcus.On injuries of the vertebral

body bruises flexi became the wedge; this is a stable injuries and vertebral

fracture is a type most frequently found. If the posterior ligament be ripped,

injuries are unstable vertebral bodies and the top although the tilting forward

over the body of the vertebra below it.

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2.5 Pathway

Injury of columna vertebral,

Injury of medulla spinalis

Parasimpatic nerve block Microscopic bleeding Damage of sipatetic line

ascending

Inflamation reaction

Broke of

nerve tissue

medulla

spinalis

Lose of

control on

vasomoto

r tonus

simpatic

nerves to heart

Numbness of respiratory muscle

Anesthetic

reaction

Oedema Spinal

shock Ischemia and hypoxemia

Paralysis

and

paraphlegy

1,Impaired of breathing

pattern Compression

of nerves and

vessels

Pain

respons

heavy

and

acute

Spinal

reflex Hypoventilation Paralitic

of ileus,

impaired

of rectum

function

and

bladder

7. impaired

of physical

mobility 3. Decrease

of tissue

perfusion

Activatio

n simpatic

nerve

system

Breathing failure

4. Pain

Weaknesses

general Response of

uncomfortable

in rest

Blood

vesselscont

riction

7. Impaired

of alvi

elimination

and urine

Death

5. impaired of

sleeppattern Risk of

infark on

miocardiac Dysfunction

of perception

spatial and

lose of

sensory

coma Decrease

level of

awareness Decrease of

cough ability,

less of

physical

9. Deficiency

of self care

Compression

of tissue

regional

15. Knowledge

deficit

Changed of

sensory

perception

Inadequate

nutrition Decubity

2. Risk of

ineffective

airway

13. Ineffective coping

individual

14. Risk of ineffective

managementthera

peutic

6. Imbalance

nutrition

11. Risk of

impaired of

skin

integrity

16. Impaired of psychology

17. Changed of family

process

18. Family anxiety and

client

19. Risk of decrease of

praying / spiritual

9.Risk of

injury

Picture 2.2

Pathophysiology myelopathy with modification (Muttaqin,

2008)

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2.6 Clinical Manifestations

2.6.1 According to National Spinal Cord Injury Statistical Center (2016) and

Batticaca (2012) a partial list of common spinal cord injury

symptoms includes:

2.6.1.1 Varying degrees of paralysis, including

tetraplegia/quadriplegia, paraplegia, and hemiphlegy.

2.6.1.2 Difficulty breathing; the need to be on a respirator

2.6.1.3 Problems with bladder and bowel function

2.6.1.4 Bedsores

2.6.1.5 Loss of perspiration,

2.6.1.6 Triafismus,

2.6.1.7 Bradycardia

2.6.1.8 Hypotension.

2.6.1.9 Chronic pain

2.6.1.10 Headaches

2.6.1.11 Changes in mood or personality

2.6.1.12 Nerve pain

2.6.1.13 Chronic muscle pain

2.6.1.14 Pneumonia (more than half of cervical spinal cord injury

survivors struggle with bouts of pneumonia)

2.7 Early Management and Medical Management Of Myelopathy

2.7.1 As Batticaca (2012) explains that early management for myelopathy is

the patient immediately places the incident is very important, because

improper treatment can lead to damage of the loss of function

neurologic. Victims of motor vehicle accidents or accidents drive,

contact sports trauma, falls, or direct trauma to the head and neck

should be considered experienced the myelopathy until evidence of

trauma is removed.

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2.7.1.1 With respect to the accident, the victim has to be mobilized

on a spinal board (back), with the head and neck in a neutral

position, to prevent trauma to complete.

2.7.1.2 One team member had to manage the patient's head to

prevent the flexi, rotation or extension of the head.

2.7.1.3 Hands are placed on either side of the ear to maintain traction

and a temporary alignment tool immobilization cervical

spinal or board is installed.

2.7.1.4 Of at least four victims raised the people must carefully over

the boards to move home sick. The existence of a twisting

motion may damage the medulla spinalis irreversible that

cause fragments of vertebrae is lost, broken, or cut the

medulla complete.

2.7.2 Acute phase management of myelopathy Batticaca (2012) ;

2.7.2.1 Therapy done to maintain neurological function that still

exist, neurological recovery, maximize action on other

injuries, prevent complications and heal, as well as damage to

the neural further. Reeducation over the subluksasi part on

the joints in one's bones to the coral spiral and decompressing

action immobilizes of the spine to the coral protected spiral.

2.7.2.2 The operation of early neural decompression as an indication,

internal fixation, or debridement opens cuts.

2.7.2.3 Elective internal Fixation is performed on the client by the

instability of the spine, ligaments injury without fracture,

progressive spine deformities, injuries that could not

reabduktion, and fracture non-union.

2.7.2.4 Steroid therapy, nomidipin, or dopamine to fix coral blood

flow spiral as need as weight of patient.

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2.7.2.5 Neurological State every hour, including observation of

sensory function, the motor, and it is important to track the

progressive deficit or ascendant.

2.7.2.6 Maintains a network of adequate perfusion, function

ventilation, and track state of decompensation.

2.7.2.7 The management of neurological deficits without a stable

injury such as angulasi or wedge from the body of the

vertebrae, fracture process of transverse foramen, spinosus,

and more. His actions symptomatic (rest pain reduced to

baring), immobilizes with physiotherapy for the recovery of

muscle strength gradually.

2.7.2.8 Injury neurological deficits accompanied by instability. If

there is a shift, fracture requires reabduction and the position

must be maintained.

2.8 Diagnostic Examination

2.8.1 According to Muttaqin (2008),the support examination of diagnostic

findings are :

2.8.1.1 CT-scan Examination

See the scene cuts or lesion, to evaluating the disturbed

structural on medulla spinalis.

2.8.1.2 MRI

Identify the presence of spinal nerve damage, edema and

compression.

2.8.1.3 X –ray

Determine the location and type of bone injuries (fractures,

dislocations), to alignment, reduction after a traction or

surgery.

2.8.1.4 Myelography

To show the column spinalis (vertebral Canal) if pathologic

factors are not clear or suspected dilution on the medulla

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spinalis arachnoids sub space (usually will not be done after

suffering wounds penetrating).

2.8.1.5 Thoracic x-rays

Exposing their lungs (example: changes to the diaphragm,

atelektasis).

2.8.2 Batticaca (2012) suggests that another support examination are :

2.8.2.1 Pulmonary function examination (tidal volume, vital

capacity)

Measure the volume of maximal inspiration especially in

patients with trauma cervical at the bottom or on torakal

trauma with disorders of the nervous frenikus/intercostals

muscles).

2.8.2.2 Serum chemistry

The presence of value Hyperglycemia or hypoglycemia,

electrolyte imbalances, the possibility of a decrease in Hb and

Hemathocryte.

2.8.3 NSCISC (2016) suggest another support examination, there are :

2.8.3.1 Arterial Blood Gas (ABG) examination: the result useful to

measurement the adequacy of respiration (oxygenation and

ventilation)

2.8.3.2 Count of lactate: to know perfusion status

2.8.3.3 Urinalysis: to detect any associated genitourinary damage.

2.9 Complications

According to Dewit and Kumagai (2013), based on the data assessment,

potential complications that may develop include the following:

2.9.1 Spinal shock and neurogenic shock

The disruption in the nerve transmission pathway between up and low

motor neuron may cause spinal shock. Spinal shock occurs actually

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after injury and end in 48 hours to several weeks. Neurogenic shock

may follow within 24 hours and create by loss vasomotor tone.

2.9.2 Muscle spasm

Actually after an accident to medulla spinalis, the victim will usually

have a flaccid type of paralysis.

2.9.3 Orthostatic Hypotension

Vasoconstriction is damaged after injury to the medulla spinalis, and

dysfunction in the legs made pooling of blood in the lower limb. An

quick change imposition from supine to sitting, or from lower to

higher position may cause giddiness and fainting.

2.9.4 Deep vein thrombosis

The drop of blood pressure combined with loss of muscle movement

slows venous back to the heart.

2.9.5 Infection

Damaged of respiratory muscles, with the signs less of cough and

shallow of patient with a high myelopathy to respiratory infection.

2.9.6 Damaged of skin

Loss of sensation and inability to transfer to another place the patient

at high risk for skin damaged and pressure ulcers.

2.9.7 Renal complication

Urinary decrease from the bladder to the kidney often occurs due to

damaged bladder function. The infection could travel up the ureter to

the kidneys. The long lasting kidney damage may occur from such

infection sooner or later.

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2.10 Prognosis

Patient with myelopathy usually have permanent and often devastating

neurologic deficit and disability. The most important aspect of clinical care

for the myelopathy Patient is preventing complications related to disability.

Chin (2016) reports that the complications of myelopathy patient they have

under than 5% a chance to return to be normal. The complete paralysis

continue up till 72 hours after damage will made the recovery is essentially

nil. In the recent 1900s, the cases of death made by myelopathy rate 1 year

after the accident in patients with full lesion approached 100%.

2.11 Basic Concepts of Nursing Care Myelopathy

Nursing care is a therapeutic process that in valves the cooperative

relationship between the nurse with clients, families, or communities to

achieve optimal health status in providing nursing care by using the methods

which include nursing process: assessment, nursing diagnosis, planning,

implementation and evaluation.

2.11.1 Assessment

2.11.1.1 According to Muttaqin(2008), the basic concept of

nursing care with myelopathy are :

a. The identity of the client.

Include: name, age, gender, status, race, religion,

address, education, medical diagnosis, date ofhospital

admission, and the date of assessment was taken.

b. Main Complaint

Mostly the reason for the client ask for help is because

limb weakness on the half of body, incontinent of

urinate and elimination, pressure pain on muscle, and

deformity in injury location.

c. Health History of Current Disease

There are histories of injury in spinal cord caused by

accident, fall, stab wound, gunshot, and the fall of

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hard objects. Assessments obtained include pain, loss

of sensibility and paralysis. This early symptoms from

spinal shock that will be continuing until a several

weeks, paralyticileuses, urine retention and losses of

reflex.

d. Health History of Previous Disease

Any history of hypertension, history of injury in

spinal cord before, anemia, heart disease, the use of

anti-coagulant drugs, aspirin, vasodilators, drugs

addictive and obesity. Assessment of this history can

support the assessment of current disease and the

basic data to further assessment and to provide further

actions.

e. Health History of Family Disease

There is usually a family history of hypertension,

diabetes mellitus.

2.11.1.2 According to Nanda (2014), physical examination head

to toe

a. General condition

Contents about the general condition of the patient,

history of vital signs, awareness and anthropometry

b. Skin

Content of integument / skin system assessment data,

general skin condition, skin intestines, texture,

moisture, presence of ulcers / wounds, turgor, skin

color and skin lesion

c. Head and neck

Include of data from head area assessment, symmetry,

presence of head abnormalities in general, headache of

varying intensity and restlessness and muscle or facial

tension. Assessment of the neck; the existence of

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widening jugulars, enlargement of the thyroid calendar,

enlargement of lymph nodes, and other disorders.

d. Vision and eyes

Content about the results of eye assessment and vision

system function, general eye condition, conjunctiva

(anemic, inflammation, and trauma)

e. Smelling and nose

The content of the nasal area assessment and the

function of the olfactory system, the general condition

of the nose, the airway or the occlusion of the nasal

passages, blood, secretions, and difficulty breathing.

Test the olfactory acuity by using odor stimulation

f. Hearing and ears

Contents of data on ear assessment and hearing system

function, general state of the ear, interruption of

hearing, use of hearing aids and other disorders

g. Mouth and teeth

The contents of the data of the oral assessment and

upper digestive function, the general state of teeth and

mouth swallowing disorders, the presence of

inflammation of the mouth (oral mucosa, gums,

pharynx), the presence of deformities and other

disorders

h. Chest, breathing, heart, and circulation

Contents of data on chest assessment of chest, is from

inspection, (chest expansion or development, chest

symmetry), palpation (chest symmetry,

tactileprematus), percussion and resonance / sonor (air).

Hypersonic (mostly air), dim (fluid), deafness (presence

of mass), respiratory auscultation, (wheezing, vesicular

and ronchi breathing sounds).

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Signs : History of cardiac disease tomyocardial

infarction (MI), rheumatic and vascular

heart disease, heart failure (HF), bacterial

endocarditic, polycythemia

Symptoms : Arterial hypertension which is common

unless CVA is due to embolism or

vascular malformation. Pulse rate may

vary due to various factors, such as

preexisting heart conditions, medications,

effect of stroke on vasomotor center.

Dysrhythmia, changes of

electrocardiographic (ECG). Bruit in

carotid, femoral, or iliac arteries, or

abdominal aorta may or may not be

present.

i. Abdomen

The contents of inspection results that include the

general state of the abdomen, abdominal hygiene,

convex abdominal shape, concave, flat, breathe

movements, presence of lumps in time and symmetry.

The auscultation the sound of bowel per minute. A

general palpation of the abdomen is data about

abdominal life, skin turgor or astringent

j. Genital and reproduction

The contents of the assessment results of the general

state of the genetic apparatus and the function of the

reproductive system. The aabnormalities in anatomy

and function, complaints and disorders of the

reproductive system.

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k. Extremity upper and lower

The results of upper and lower limb assessment range

of motion, muscle strength, ability to mobilize, pitting

edema, pain, physical limitations, motion, presence on

the feet or hands.

According to Nanda (2014), need physical, physiology,

social, and spiritual

1) Activity / Rest

Signs : Difficulty with activity due to

weakness, loss sensation, or paralysis

(hemyphlegy). Tired easily and

difficulty resting, pain or muscle

twitching.

Symptoms : Altered muscle tone (flaccid or spastic),

generalized weakness, one side

paralysis, and altered level of

consciousness (LOC)

2) Psychosocial

Signs : Feelings of helplessness, hopelessness.

Symptoms : Emotional liability, exaggerated or

inappropriate responses to anger,

sadness, happiness and difficulty

expressing self.

3) Elimination

Symptoms : Change in voiding patterns—

incontinence, anuria, distended

abdomen, and distended bladder. May

have absent or diminished bowel

sounds if neurogenic paralytic ileuses

present.

23

4) Nutrition

Signs : History of diabetes, elevated serum

lipids (risk factors), lack of appetite,

nausea or vomiting during acute event

(increased intracranial pressure [ICP]),

dysphagia, loss of sensation in tongue,

cheek, and throat.

Symptoms: Obesity (risk factor), chewing and

swallowing problems.

5) Personal hygiene

Contents about the situation at home and in the

hospital, about bathing, shampooing, brushing, teeth,

general overview of clients when hospitalized and

able to self care

6) Sexuality

Content about sexuality, about complaint sexuality

and disturb sexuality

7) Spiritual

The content is the client's trust in God, the client's

belief about illness and client's activities when

healthy and sick.

8) Psychological Assessment

Psychological assessment of myelopathy includes

several dimensions that allow nurses to obtain a

clear perception of the status of emotional,

cognitive, and client’s behavioral. Assessment of

coping mechanisms was used by client was also

important to assess the client's emotional response to

the disease and changes in the client's role in the

family and society as well as the responses or

24

influence in their daily lives, whether in the family

or in the community.

2.11.2 Cranial nerve assessment

According to Muttaqin (2008), the procedures of cranial nerve

examination are:

2.11.2.1 Cranial nerve I (olfactory): Test ability to identify

familiar aromatic odor, one nark at a time with eyes

closed. Usually on myelopathy patient there is no

damaged and dysfunction.

2.11.2.2 Cranial nerve II (optic): Test vision with Snellen chart

and Rosenbaum near vision chart. Usually normal.

2.11.2.3 Cranial nerve III (oculomotor), cranial nerve IV

(trochlear), cranial nerve VI (abducens) : Test visual aids

by confrontation and extinction of vision. Inspect eyelids

for drooping. Inspect pupil’s size for equality and their

direct and consensual response to light and

accomodation. Test extraocular eye movements. Usually

no damaged.

2.11.2.4 Cranial nerve V (trigeminal): Inspect face for muscle

atrophy and tremors. Palpate jaw muscles for tone and

strength when patient clenches teeth. Test superficial

pain and touch sensation in each branch (test temperature

sensation if there are unexpected findings to pain or

touch).

2.11.2.5 Cranial nerve VII (facial): Inspect symmetry of facial

features with various expressions (example: smile,

frown, puffed, cheeks, and wrinkled forehead). Usually

normal and symmetric face.

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2.11.2.6 Cranial nerve VIII (acoustic): Test sense of hearing with

whisper screening test or by audiometric. Usually in

normal condition.

2.11.2.7 Cranial nerve IX (glossopharyngeal), cranial nerve X

(vagus): Test ability to identify sour and bitter taste.

Tests gag reflex and ability to swallow. Inspect palpate

and uvula for symmetry with speech sounds and gag

reflex.. Evaluate quality of guttural speech sounds

(presence of nasal or hoarse quality to voice). Usually in

good condition, there is no inability in swallowing.

2.11.2.8 Cranial nerve XI (accessory): Test trapezius muscle

strength (shrug shoulders against resistance). Test

sternocleidomastoid muscle strength (turn head to each

side against resistance).usually there are existence try

from patient to do cervical flexion and stiff neck (

rigidities nukal)

2.11.2.9 Cranial nerve XII (hypoglossal): Inspect tongue in mouth

and while protruded for symmetry, tremors, and atrophy.

Inspect tongue movement toward nose and chin. Test

tongue strength with index finger when tongue is pressed

against cheek. Evaluate quality of lingual speech sounds.

Usually tongue function normal, symmetric tongue, there

is no deviation and fasciculation.

2.12 Analysis of Data

The collected data must be analyzed to determine the client's problem. Data

analysis is an intellectual process which includes grouping the data,

identifying gaps and determining the pattern of the data collected and

compares the composition or groups of data with a standard normal values,

interpreting the data and ultimately make conclusions. The results of the

analysis are nursing problem statement.

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2.13 Nursing Diagnosis

2.13.1 According to Mutaqqin (2008), nursing diagnosis is a statement

that describes the health status or actual or potential problems.

Nurses wear the nursing process in identifying and synthesizing

clinical data and determine nursing interventions to reduce,

eliminate or prevent the health problems that exist on the client's

responsibility. The nursing diagnoses that often appears on the

status of clients and interventions that can be given as follows:

2.13.1.1 Ineffective breathing pattern related to respiratory

muscle weakness / diaphragm muscle paralysis

2.13.1.2 Ineffective airway clearance related to accumulation of

secrete, decreasing of cough ability, decreasing of

secondary physical mobility, and change of

consciousness level.

2.13.1.3 Decrease of perfusion tissue periphery related to

decrease cardiac output.

2.13.1.4 Pain related to compression of nerve, neuromuscular

injury.

2.13.1.5 Imbalanced nutrition less than body requirement related

to impaired swallowing.

2.13.1.6 Impaired physical mobility related to

hemisparase/hemyphlegi, neuromuscular impairment on

the extremity.

2.13.1.7 Change of elimination pattern of urinate related to

paralysis of urinate nerve.

2.13.1.8 Impaired of alvi elimination/ constipation related to

impaired of bowel and rectum nerve.

2.13.1.9 Impaired of fulfillment of daily activity related to lower

extremity weaknesses

2.13.1.10 Risk of infection related to decrease of primary defense

system.

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2.13.1.11 Risk for impaired tissue integrity related to bed rest

2.13.1.12 Change of sensory perception related to dysfunction of

perception spatial and loss of sensory.

2.13.1.13 Ineffective coping individual related to disease

prognosis, medication program, and bed rest.

2.13.1.14 Anxiety related to critical situational.

2.13.1.15 Family anxiety related to critical situation to client.

2.13.1.16 Risk of ineffective regiment therapeutic related to

tension of client situation.

2.14 Nursing Intervention

According to North American Nursing Diagnosis Asociation (NANDA,

2014) there are some nursing interventions in accordance with existing

diagnostics disease myelopathy are:

2.14.1 Pain related to compression of nerve, neuromuscular injury, relaxes

muscle spasm secondary.

Goal : In 3 x 24 hours after treatment the pain decrease or lose.

(Pain scale 2-0) with outcome criteria:

a. Subjectively report decrease of pain or lose

b. Can identify activity that could increasing or decreasing of pain

c. Client do not restless

Intervention:

a. Explain and help client with no pharmacologic and non invasive

relieve pain.

Rational: approaches using other relaxation and no

pharmacologic have shown effectiveness in reducing pain.

b. Give pain management, set physiology position.

Rational: physiology position will increase intake of oxygen into

ischemia tissue.

c. Teach relaxation technique (deep breath).

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Rational: increasing intake of oxygen with the result that

secondary pain from brain tissue ischemic.

d. Observation of pain level and response of motoric client 30

minutes after give analgesic to assess the effectiveness.

Rational: the optimal assessment will give a nurse the objective

data to prevent possibility of complication.

e. Collaboration with doctor in give analgesic.

Rational: analgesic will block pain track, with the result pain

will decrease.

2.14.2 Impaired physical mobility related to hemisparase/hemiplagia,

neuromuscular impairment on the extremity.

Goal: In 2x24 hours after treatment, client able to did his/her

activity as he/she can with outcome criteria:

a. Client able to participate in the exercise program, there is no

joint contracture, increasing of muscle strength, client perform

mobilization.

Intervention:

a. Assess for the ability to move and change position

Rationale: There may be differing degrees of involvement on the

affected side.

b. Observe for activities that increase or decrease muscle tone

Rationale: Initially muscles demonstrate hyporeflexia, which

later progress to hyperreflexia.

c. Change the position of the client at least every 2 hours.

Rationale: Position changes optimize circulation to all tissues

and relieve pressure.

d. Monitor the client’s skin integrity for areas of blanching or

redness.

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Rationale: Impaired mobility increases the risk for skin

breakdown.

e. Perform activities in quite environment with little distraction.

Rationale: Impaired cognitive function that occurs with stroke

may decrease the client’s attention span and concentration.

f. Perform active and passive ROM exercises in all extremities

several times daily

Rationale: ROM activities preserve muscle strength and prevent

contractures.

g. Refer to physical and occupational therapist as indicated

Rationale: Useful in determining individual needs, therapeutic

activities and assistive devices.

2.14.3 Impaired sleep pattern related to unfamiliar with environment

Goal: In 1 x 8 hours after treatment, impaired sleep pattern not occur

with outcome criteria:

a. Sleep pattern in normal range 6-8 hours per day.

b. Sleep pattern in normal range.

c. Feel fresh after wake up.

Intervention:

a. Asses the General State of the patient

Rational: Know the consciousness and the condition of the body

under normal circumstances or not.

b. Review the sleep pattern.

Rational: To know the ease in bed.

c. Examine the respiratory function: the sound of the breath, pace,

rhythm.

Rational: To knowing the level of anxiety

d. Examine the factors that lead to sleep disorders (pain, fear,

stress, anxieties, immobility, urinary elimination disorder such

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as frequently, disorders of metabolism, transport, environment,

temperature, the activity of which is not adequate).

Rational: To identify the actual cause of sleep disorders

e. Write down the action ability to reduce anxiety.

Rational: To monitors how far it can be calm and relax.

f. Create a cozy atmosphere, reduce or eliminate the distraction of

environment and sleep disorders.

Rational: To help relaxation while sleeping.

g. Limit of visitors during the period of rest that is optimal (e.g.;

after a meal).

Rational: sleep would be hard to do without relaxation,

h. Ask the client to restrict fluid intake and urination at night

before bed.

Rational:. Nighttime Urination can interfere with sleep.

i. Recommend or provide care in the evening hours (e.g.; personal

hygiene, linen and clothes are clean).

Rational: Comfort in body hygiene related patient myself and

wear.

j. Use tools (e.g.; the warm water to compress muscle relaxation,

reading material, a massage on your back, soft music, etc.

Rational: Ease in getting optimal sleep

k. Give the medication with the collaboration of the doctor.

Rational: Drug fits his schedule

2.14.4 Knowledge deficit related to inadequate information about disease

process a medication

Goal: In 1 x1hours after treatment, client and family show

understand about the disease, with outcome criteria:

a. Client and family said understand about the disease, condition,

prognosis and medication program.

b. Client and family can do the procedure correctly.

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c. Client and family can explain about the nurse explain before.

Intervention:

a. Review the level of knowledge of the client and family about

his illness.

Rational: Knowing how far the experience and knowledge of the

client and family about his illness.

b. Give an explanation on the client about his illness and his

condition now.

Rational: by knowing the illness and his condition now, clients

and their families will feel calm and relieve anxiety.

c. Discuss and give health education about client disease to

client and his family.

Rational: the client to reduce anxiety and increase client

knowledge about his illness.

d. Ask the client and family to repeat back about material that

has been given.

Rational: knowing how much understanding of clients and

families as well as assess the success of the action undertaken.

2.14.5 Ineffective management therapeutic related to therapeutic regimen

disobedience

Goal: In 1x 30 minutes after treatment, Ineffective management

therapeutic problem will be solved with outcome criteria:

a. Develop and follow a therapeutic regiment.

b. Being able to prevent risky behaviors.

c. Notice and take down the signs of change in health status.3. Notice

and take down the signs of change in health status

Intervention:

a. Help patients and families in making decisions about patient

care.

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Rational: Develop relationships with patients, families, and

other health workers in providing care.

b. Explain to the client and family about the disease.

Rational: Education will increase the ability client to take care

of the therapeutic of his disease.

c. Give client or the family education in the importance of self-

care

Rational: Discuss lifestyle changes that may be needed to

prevent the next complication or control the disease process

2.15 Implementation

As the same with other stages in the nursing process, the implementation

phase consists of several activities as follow:

2.15.1 Validation (validation) of nursing plans

2.15.2 Creating / documenting nursing plan

2.15.3 Provide nursing care

2.15.4 Continue for collecting the data

2.16 Evaluation

According to Smeltzer (2010),the result of expectation after the nursing

interventions have be done, are:

2.16.1 Demonstrating adequate cerebral tissue perfusion

2.16.2 Demonstrating joint mobility repair

2.16.3 Demonstrating adequate skin integrity

2.16.4 Regain bladder function

2.16.5 Regain bowel function

2.16.6 Admitted to not experiencing pain and discomfort

2.16.7 Free from complications