Herniated Nucleus Pulposus (HNP)

  1. General information
    1. Protrusion of nucleus pulposus (central part of intervertebral disc) into spinal canal causing compression of spinal nerve roots
    2. Occurs more often in men
    3. Herniation most commonly occurs at the fourth and fifth intervertebral spaces in the lumbar region
    4. Predisposing factors include heavy lifting or pulling and trauma
  2. Medical management
    1. Conservative treatment
      1. Bed rest
      2. Traction
        1. lumbosacral disc: pelvic traction
        2. cervical disc: cervical traction
      3. Drug therapy
        1. anti-inflammatory agents
        2. muscle relaxants
        3. analgesics
      4. Local application of heat and diathermy
      5. Corset for lumbosacral disc
      6. Cervical collar for cervical disc
      7. Epidural injections of corticosteroids
    2. Surgery
      1. Discectomy with or without spinal fusion
      2. Chemonucleolysis
        1. injection of chymopapain (derivative of papaya plant) into disc to reduce size and pressure on affected nerve root
        2. used as alternative to laminectomy in selected cases
  3. Assessment findings
    1. Lumbosacral disc
      1. Back pain radiating across buttock and down leg (along sciatic nerve)
      2. Weakness of leg and foot on affected side
      3. Numbness and tingling in toes and foot
      4. Positive straight-leg raise test: pain on raising leg
      5. Depressed or absent Achilles reflex
      6. Muscle spasm in lumbar region
    2. Cervical disc
      1. Shoulder pain radiating down arm to hand
      2. Weakness of affected upper extremity
      3. Paresthesias and sensory disturbances
    3. Diagnostic tests: myelogram localizes site of herniation
  4. Nursing interventions
    1. Ensure bed rest on a firm mattress with bed board.
    2. Assist client in applying pelvic or cervical traction as ordered.
    3. Maintain proper body alignment.
    4. Administer medications as ordered.
    5. Prevent complications of immobility.
    6. Provide additional comfort measures to relieve pain.
    7. Provide pre-op care for client receiving chemonucleolysis.
      1. Administer cimetidine (Tagamet) and diphenhydramine HCl (Benadryl) every 6 hours as ordered to reduce possibility of allergic reaction.
      2. Possibly administer corticosteroids before procedure.
    8. Provide post-op care for client receiving chemonucleolysis.
      1. Observe for anaphylaxis.
      2. Observe for less serious allergic reaction (e.g., rash, itching, rhinitis, difficulty in breathing).
      3. Monitor for neurologic deficits (numbness or tingling in extremities or inability to void).
    9. Provide client teaching and discharge planning concerning
      1. Back-strengthening exercises as prescribed
      2. Maintenance of good posture
      3. Use of proper body mechanics, how to lift heavy objects correctly
        1. maintain straight spine.
        2. flex knees and hips while stooping.
        3. keep load close to body.
      4. Prescribed medications and side effects
      5. Proper application of corset or cervical collar
      6. Weight reduction if needed

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