Back Problems Exemplar PDF

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Student Name __Reb __Rebecca ecca Y Yohn__ ohn__ EXEMPL EXEMPLAR: AR: __Back Problems_____

Date __8/14/19__ CONCEPT CONCEPT:: ____Mobility____________ ____________

Exemplar Ov Overview: erview: -

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One of the most common medical problems in the US o Major:  Herniated Discs  Scoliosis 1 out of 4 adults experience 1 day of pain in a 3 month period Back pain is not always a specific problem, usually stimulates from years of improper lifting, bending, and standing. Bad Lifestyle Habits – Bad posture, low fitness level, smoking, athletic injuries, and occupational risk factors. Children can get back pain from carrying heavy backpacks Diseases: o Degenerative Disorders (Spondylosis, Spinal Stenosis, Osteoporosis) o Systemic Disorders (Osteomyelitis, Osteoporosis, Neoplasms) o Referred Pain (Gastrointestinal or genitourinary disorders, Abdominal Aortic Aneurysms, Hip Pathology) o Others (Fibromyalgia and Post-Lyme disease syndrome. o Pregnancy, due to the increasing weight in the anterior region.

Path Pathophysiology ophysiology Highl Highlights: ights: Intervertebral discs lie between adjacent bones, providing cushioning, shock absorption, and support during movement. Outer annulus fibrosus is strong fibrocartilage. Inner nucleus pulposus is loose fibers in a mucoprotein gel. Herniation occurs when the nucleus pulposus protrudes through the annulus fibrosus. Most common in the Cervical and Lumbar. Herniation of the Thoracic discs is a medical emergency that may result in paralysis.

Risk F Factors: actors:

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__ -

Date __8/14/19__

Most common between ages of 30 and 50, due to discs naturally degenerating with age. Excess weight, regular heavy lifting, bending, and twisting; Previous back problems, and smoking. Genetic Factors at an increased risk: o Male gender, tall height, bone disorders, and degenerative disc disorders

Complications: -

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An untreated, severe slipped disc can lead to permanent nerve damage. In very rare cases, a slipped disc can cut off nerve impulses to the cauda equina nerves in your lower back and legs. If this occurs, you may lose bowel or bladder control. Another long-term complication is known as saddle anesthesia. In this case, the slipped disc compresses nerves and causes you to lose sensation in your inner thighs, the back of your legs, and around your rectum. While the symptoms of a slipped disc may improve, they also can worsen. If you cannot perform the activities you once could, it’s time to see your doctor.

Collaborat Collaboration: ion: 

Dx. T Tests ests – o Mobility tests, Imaging tests, and blood tests  Help determine the location, intensity, and cause of the pain o CT scan is most common imaging test, MRI for more severe cases o Myelogr Myelogram am  Dye is injected into the spinal fluid and visualized by x-ray, may be used to identify areas of pressure on the spinal cord or nerves due to herniated discs. o Electrom Electromyogr yogr yogram am  Measures the electrical activity of the muscles at rest and during contraction. o Nerve conduction study  Measure the speed of the electrical impulse through the nerve, this is helpful to identify damage and destruction.

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

o Blood tests  Test for inflammation, infection, and arthritis, including a complete blood count (CBC), erythrocyte sedimentation rate, C-reactive protein, and HLA-B27

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Pharmacological Ther Therapies apies – o First Line - NSAIDs – to reduce pain and swelling  Neurological problems  Sciatica or numbness – Additional meds may include opioids for severe pain and antispasmodics to reduce muscle spasms.  Neuropathic Pain Medications  Gabapentin, Pregabalin, Duloxetine; Useful for reducing pain related to nerve damage and have milder side effects compared to opioids.  Tramadol (Ultram), Centrally acting opiate receptor agonist; May be used to treat moderate to severe pain.  Epidural Injections of Cortisone/Corticosteroids or anesthetics may also help reduce pain and inflammation  If pain and neurological symptoms are still present after 1-2 months, surgery may be considered.

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Nonpharmacological Ther Therapies apies – o Hot or cold packs, to dilate blood vessels and increase oxygen supply to the area (heat) or to reduce inflammation by decreasing blood flow to the area (cold). o Mild, low-impact exercise may be helpful to strengthen the back. o Collaboration  PT or Chiropractor  Intradiscal Electrothermal Therapy – A needle is inserted into the disc and heated to thicken and seal the disc wall to prevent bulging.  Massage Therapy – Relieving muscle tension, stiffness, and spasms and improving joint flexibility and ROM.

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

Lifespan Consider Considerations: ations: -

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Children o Rare, but more common through trauma o Children may not experience back pain o Symptoms – Sciatica, numbness, tingling, or weakness in one or both legs. o Treatment – PT, if that is not effective then a discectomy may be necessary. Pregnant W Women omen o 50% report back pain, 70% reported that it was severe. o Herniated discs are rare, 1 in 10,000 o Symptoms most often resolve after delivery Older Adults o As people age, the Nucleus Pulposus dries out and the space between the discs becomes smaller, making the discs unlikely to herniate.

Nursing Process/Clinical Ju Judgment dgment 

Assessment/Noticing (Signs & S Symptoms): ymptoms): o Description of pain, previous back injuries or surgeries, current medications, risk factors for back pain, type of employment, and typical recreational activities. o Physical Assessment  Muscle Strength, coordination, gait and posture, sensation, and reflexes. o Five P’s 

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Pain, Pallor, Pulse, Paresthesia, and Paralysis

Diagnosis/Interpreting ((Associated Associated Problems): o Injury, Risk for o o o o

Mobility: Physical, Impaired Pain, Acute Pain, Chronic Sleep Pattern, Disturbed

o Knowledge, Deficient

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

o Role Performance, Ineffective 

Planning/R Planning/Respon espon esponding ding (Goal Devel Development): opment): o The pt. will develop no motor deficits. o The pt. will develop no sensory deficits. o The pt. will remain free from infection. o The pt. will demonstrate normal bowel function, including the presence of bowel sounds in all quadrants.

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Nursing Care/Action ((Interventions): Interventions): o Promoting Safety, preventing onset or exacerbation of neurologic deficits, providing adequate pain relief, and explaining treatment options.  Assess for signs of anxiety, as heightened anxiety affects learning ability.  Discuss the treatment plan as prescribed, and give the patient time to ask questions; provide information as indicated. (May also help reduce anxiety)  Discuss the need for a ride home, as indicated for some outpatient procedures. For example, pts. Receiving epidural steroid injections require a driver, whereas pts. Receiving cortisone injections may be able to drive themselves home. 

Client Education: o Provide medication teaching o Provide information about diagnostic procedures o Teach patients about physical restrictions as ordered by the primary care provider.

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Eval Evaluat uat uation/R ion/R ion/Ref ef eflection: lection: o Decrease in pain o o o o

Increased mobility Fill ROM of joints Normal sensory perception Lack of neurologic deficits, and absence of infection and other complications from surgery.

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

Exemplar Ov Overview: erview: -

Scoliosis – Lateral, or sideways, curve of the spine. It can be C-shaped or Sshaped. It is often noticed during the growth spurt just before puberty. o Most cases are mild, but severe scoliosis can cause a rotation of the spine, leading to deformities and disability.

Path Pathophysiology ophysiology Highl Highliights: - Diagnosed if the sideways curvature measures more than 10 degrees. - Mild Scoliosis reflects a curve between 10 and 20 degrees - Moderate Scoliosis is between 20 and 40 degrees - Severe Scoliosis is anything over 40 degrees - Nonstructur Nonstructura al Scoliosis o Occurs as the spine bends to compensate for poor posture, differences in

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leg length, presence of tumors, adaptation to pain, or other physical conditions. o Usually corrected by alleviating the underlying cause of the curve. Structural Scoliosis o More severe from that involves deformities of the bones in the spinal column.

Risk F Factors: actors: -

Adolescents are at greatest risk as they go through puberty; ages 9-15. Girls are more likely to develop a greater curvature. Neuromuscular disorder such as cerebral palsy or MD and having a family history of scoliosis.

Complications: -

Breathing problems (in severe scoliosis) Low back pain. Lower self-esteem. Persistent pain if there is wear and tear of the spine bones.

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__ -

Date __8/14/19__

Spinal infection after surgery. Spine or nerve damage from an uncorrected curve or spinal surgery. Leakage of spinal fluid.

Types of Scoliosis -

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Infantile Idiopathic Scoliosis o Occurs from birth to 3 years of age. It typically results in a left thoracic curve of the spine and is most commonly seen in boys of European descent. Infantile scoliosis may resolve as the child ages. Juvenile Idiopathic Scoliosis o Occurs in children between 3 and 9 years of age. Symptoms are similar to those of adolescent scoliosis. Children with juvenile idiopathic scoliosis are most likely to have progression of the curve and require surgery. Adolescent Idiopathic Scoliosis o Occurs in children between 10 and 19 years old. This is the most common type of scoliosis; progression of the curvature is seen more frequently in girls. Progression is more likely to occur in younger children with large curves than in older children with small curves. Adult Idiopathic Scoliosis o May be present from childhood or may develop as a result of aging. Aging causes may be related to degenerative changes of the spine (often called adult degenerative scoliosis), osteoporosis previous fractures, spondylolisthesis, Infections, or tumors. Involvement of the entire spine, including the neck, is more common in adults than in children. Back pain and pain radiating down the legs is also more common in adults.

Collaborat Collaboration: ion: 

Dx. T Tests ests – o Adam’s Forward Test  Screening for children 10-15 years of age in schools  Lean forward at the waist with the arms hanging straight down. This allows the clinician to see the spine more clearly. If they have it, then an obvious rib hump will show usually on the right side.  Can prove to be a false negative.

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

o Scoliometer  Used to measure the pts. Rib hump when in the Adam position. o X-Rays  Most common imaging test  Find the angle of the spine with the Cobb method with uses lines drawn from the end vertebrae (from top of the curve to the bottom) to estimate the degree of curvature. The angle found at the intersection of the two lines is the Cobb Angle.  The degree of Vertical Rotation can be determined with the NashMoe Method Method. In this method, a vertebra at the apex of the curve is divided into 3 segments on the half of the vertebra on the convex side of the curve. The location of the pedicle of the vertebra in relation to the segments determines the grade of rotation.  Graded from no rotation as the lowest to a grade of 4 rotation being the highest at over 90 degrees of rotation.

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Pharmacological Ther Therapies apies – o Not usually treated with medication. o If needed, pts. Can take over-the-counter (OTC) analgesics, such as acetaminophen (for mild pain), prescription NSAIDs or opioids (For severe scoliosis or spinal surgery)

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Nonpharmacological Ther Therapies apies – o Depends on the Cobb Angle  Angles of 15-25 degrees were treated with PT.  Angles of 20-40 degrees medical management includes wearing a brace. (Should be worn for 12-23 hours a day)  Angles of over 40 degrees were considered for spinal fusion in the long term.

Lifespan Consider Considerations: ations: -

Children and Adolescen Adolescents ts

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

o Congenital scoliosis is a sideways curve that is present at birth, not usually

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found until adolescent years. Children may also be born with kidney and bladder problems  Very rare type, but there is a 75% chance of progressing without surgical intervention. Pregnant W Women omen o Risk factors for the mom does not effect the baby, but should know about the mothers condition as it may effect the birthing process and epidurals. o Higher back pain Adults and Older Adu Adults lts o Myopathic deformity and secondary scoliosis may develop in adulthood. o Treatment begins with conservative measures similar to those used for adolescents, including PT, exercise, and braces. o Surgery is considered as a last resort.

Nursing Process/Clinical Ju Judgment dgment 

Assessment/Noticing (Signs & S Symptoms): ymptoms): o When the pt. is standing, determine whether the head is centered; whether the hips, shoulders, or rib cage appears uneven; whether one shoulder blade is more prominent; whether the legs are the same length; or whether the body leans to one side. Closely assess the spine to determine whether it appears to be straight. o When the pt. is in the Adam position, assess the spine for obvious curvature, a rib hump, of asymmetry of the back. The physical examination should include palpation of each vertebra to detect abnormal alignment of the spine that may not be visible. If any abnormalities are detected, use a scoliometer to measure the deformity while the patient is in the Adam position. o Pts. With a spine curvature greater than 10 degrees should be monitored every 6 months for curvature progression. If the curve appears to

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

progress dramatically, the pt. should be referred to a physician for followup.

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Diagnosis/Interpreting ((Associated Associated Problems): o Breathing, Pattern, Ineffective o Skin Integrity, Risk for Impaired o Mobility: Physical, Impaired o Activity Intolerance, Risk for o Knowledge, Deficient o Body Image, Disturbed

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Planning/R Planning/Respon espon esponding ding (Goal Devel Development): opment): o The Pt. will demonstrate effective breathing patterns as evidenced by adequate oxygenation and activity tolerance. o The Pt. and family will express understanding of treatment options appropriate for severity of spine curvature. o The Pt. will report compliance with prescribed brace wear. o The Pt. will state the importance of follow-up every 6 months.

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Nursing Care/Action ((Interventions): Interventions): o Mild  Emotional support, teaching about the importance of attending regular follow-up appointments, and teaching proper body mechanics. o Moderate  For pts. Who require a bracing, nursing care will additionally include teaching the patient about brace wear and care, emphasizing the importance of wearing the brace for the prescribed amount of time each day, encouraging the pt. to maintain social interactions, and teaching the patient about clothing that can help disguise the presence of the brace. 

Client Education: o Educate about their medications

Student Name __Reb __Rebecca ecca Y Yohn__ ohn__

Date __8/14/19__

o Educate to come to follow-up appointments o Teach proper body mechanics 

Eval Evaluat uat uation/R ion/R ion/Ref ef eflection: lection: o Regular assessment of the curvature of the spine as well as the skin under the brace. o Update the Pts. goals as their needs change.

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