Back Pain

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Case Scenario: EM is a 74 year old woman admitted into the hospital with a complaint of back pain. She states that she is unable to sit for extended periods of time. During her bouts of pain, her blood pressure

rises substantially. She is a telemetry patient on the floor and is on bed rest. The patient has a

history of Crohn’s Disease and in 1997 underwent a sigmoid colon resection. She also has a

history of diverticulitis and COPD. Her final diagnosis consists of back pain related to

degenerative joint disease of the lumbrosacral spine as a result of osteoarthritis.

A. Description of the Disease – Osteoarthritis

Osteoarthritis, also known as degenerative arthritis can cause the breakdown of cartilage between the facet joints. The facet joints are located in the posterior spine. These facet joints consist of two opposing bony surfaces with cartilage in between them. There is a capsule of fluid that allows the joint to move without friction. When these fluids dissipate due to cartilage breakdown, joint movement becomes impaired and eventually, leads to bone against bone friction. Hence, the patient loses motion and as lose mobility, contributing to the onslaught of lower back pain.

B. Symptoms of Osteoarthritis

The primary clinical manifestations of OA are pain, stiffness and functional impairment of the affected joint. The pain in OA is due to an inflamed synovium, stretching of the joint capsule or ligaments, irritation of the nerve endings in the periosteum, tendinitis and muscle spasm. Stiffness is most common in the morning but generally lasts about 30 minutes or so. Functional impairment is based on pain upon movement and guarding, along with the limited motion caused by structural changes in the joints. Normally, these affected areas are palpable and non-tender to the touch unless there is notable inflammation.

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C. Causes of Osteoarthritis

Risk factors for OA include simple wear and tear, aging, female gender, genetic predisposition, obesity, mechanical joint stress, joint trauma, previous bone or joint disorders and a history of inflammatory, endocrine or metabolic disease. However, OA can be primary (idiopathic) or secondary though, the relationship between the two is not always apparent immediately. By the age of 75, 85% of the population will have undergone x-rays or other diagnostic tests to either rule out or confirm osteoarthritis. Out of this number, only 25% will experience symptoms.

D. Medical Treatments for the client with Osteoarthritis

1. Orders:

With this particular client, a complaint of back pain was the factor that brought her to the emergency room. Upon examination, it was found that the client was experiencing more pain while standing or sitting rather than lying down. The doctor ordered an x-ray which confirmed the presence of large and inflamed vertebrae in the back and the progressive loss of joint cartilage. This client also had a history of a degenerative spinal disorder. Since cartilage does not appear on x-rays, the doctor takes note of a narrowing of space between the bones, where the cartilage and fluid capsule should lie. Serum studies are not useful in this type of disorder, however, labs were drawn on this client due to evidence of infection in her system (high fever, redness and swelling over the lumbrosacral area). The client was ordered to reduce her activity level to bedrest. A K-pad was ordered to provide heat and pain relief to the area of inflammation in the back. The client was put on Flagyl and Cefzil for evidence of bone and joint infection and Demerol and Ativan for pain management. These medications will be looked at in depth in section D3 of this paper. The patient was assigned a regular diet and additional yogurt supplementation to prevent a candidas infection with relation to the extensive levels of antibiotics she is on.

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2. Procedures:

The patient is to get up with Physical Therapy three times a day. Other than that, her activities are strictly limited. The use of heat (K-pads) is indicated for whenever the client is in bed. The client is to be observed for skin breakdown, due to extensive amounts of time on bed rest. There is an outstanding order to collect stool specimens times 3 to rule out the presence of C-Diff. The clients vitals are to be monitored every 4 hours due to increases in blood pressure brought on by pain.

3. Medications:

The client is on several different medications for her osteoarthritis, and others for pain management. She is also being given maintenance medications for her hypertension and cardiac problems. They are the same medications she takes when at home through her physician. In addition, a medication for nausea and vomiting has been indicated for any adverse reactions she has had to the new medications that were introduced while hospitalized.

Atenolol: Anti-anginal/anti-hypertensive – This medication is used for the management of hypertension. It is given to this client orally, 50 mg once a day, which is in the safe range. Nausea and vomiting are common with this drug hence the use of Compazine to counter the effects. This medication is also responsible for CHF, bradycardia and generalized weakness and fatigue. It is contraindicated in those with pulmonary edema. It is important to take an apical pulse prior to administration of this medication and not administer if less than 50 bpm.

Lotensin: Anti-hypertensive – This medication is used for the management of high blood pressure/hypertension. It is given to this client orally, 20 mg., once a day, which is in the safe range. Cough and proteinuria are common side effects of this medication. It is contraindicated in those with hypersensitivity. It is recommended that the blood pressure is monitored before and after administration of this medication.

Norvasc: Anti-hypertensive – This medication is for the management of hypertension. It is given to this client orally 2.5 mg once a day, which is in the safe range. Arrhythmia, CHF and Stevens-Johnson syndrome are the most immediately dangerous side effects of this medication. It is contraindicated in those with a BP of less than 90 mm Hg. It is recommended that blood pressure be taken before and after administration and I/O be monitored closely.

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Flagyl: Anti-infective – This medication is utilized for skin, bone and joint infections, hence their direct relation to the case in point. This medication is given to the client orally, 500 mg. three times a day which is within the safe range of 250 mg four times a day. Seizures, dizziness,

abdominal pain and rashes are all common side effects of this medication. It is contraindicated in those who are hypersensitive. It is suggested that this medication be given with food and/or milk to alleviate gastric upset.

Cefzil: Anti-infective – This medication is utilized for skin, bone and joint infections, hence their direct relation to the aforementioned client. This medication is given to the client orally at a dosage of 250mg twice a day, which falls within the safe range. Seizures, nausea, vomiting, anaphylaxis are common side effects with this medication. It is contraindicated in those with allergies to cephalosporins and penicillin.

Demerol: Opiod Analgesic – This medication is used for moderate or severe pain or preoperative sedation. In the case of the client, it is used for management of back pain. This medication is administered to the client in a 50mg IV dosage every 2 hours as needed (PRN order standing). This falls within the safe spectrum of 15-35 mg per hour, if administered as a continuous infusion. Common side effects to this medication include confusion, sedation, hypertension, nausea and vomiting. The most detrimental side effect with this medication would be seizures. This medication is contraindicated people with hypersensitivity, pregnancy, or those who are taking MAO inhibitors within the last 14-21 days. It is important to teach the client that the time to request a pain medication is not after the pain has become severe but rather, before the onslaught of pain occurs. Warn the patient to change positions slowly to minimize orthostatic hypertension.

Compazine: Anti-Emetic – This medication is given for the management of nausea and vomiting. This medication is given to the client in a 5mg dose via IV infusion every 4 hours as needed (PRN standing order) which falls into the safe range of 2.5 – 10mg a day. Blurred vision, dry eyes, constipation are some of the common symptoms while neuroleptic malignant syndrome is the most life-threatening. This medication is contraindicated in those with narrow angle glaucoma, bone depression, or severe liver and cardiovascular disease. Monitor for signs and symptoms of restlessness or parkinsonian type symptoms (difficulty speaking, masklike affect, tremors) Take all vitals before and after administration.

Ativan: Anti-Anxiety Agent – This medication is given for the management of anxiety and/or insomnia. The client is given this medication in a dose of 0.5mg orally every 8 hours as necessary, (standing PRN order). This dosage falls at the lower end of the safe range, which is 0.5mg-2mg a day. Common side effects with this drug consist of dizziness, drowsiness and lethargy, though if rapidly infused through an IV, could cause apnea or cardiac arrest. This medication is contraindicated in those who are comatose or experience CNS depression. It is not recommended for those with chronic, uncontrollable pain. It is suggested that the patient remain in a supine position and under observation for at least 8 hours after administration.

4. Labs:

The client had several labs drawn while in the hospital. Most of these were drawn to find out how

advanced an inflammatory infection the patient was experiencing. These labs included:

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WBC – Normal Level: 4500 – 10,000 (mm3)

Clients Level: 19,100 or 19.1 (High)

Levels in this area are high due to an acute infection. Since the patient has a history of

diverticulitis and there is obvious inflammation to the back, this lab is drawn to ascertain

the level of infection and the effectiveness of the anti-biotics, if any.

RDW – Normal Level: 11.5- 14.5

Clients Level: 16.5 (High)

This level is indicative of three various types of anemia, iron deficient, folic acid

deficient and pernicious anemia. Due to an excessive amount of vomiting that the

patient has been experiencing as of late, it is thought that these levels are due to an

iron deficiency. RDW’s are the measurement of the width differences of RBC’s.

Glucose – Normal Level: 70-110 mg/dl

Clients Level: 121 (High)

Glucose levels can increase when paired with stressful situations. If we note that the

patient is taking ativan for the management of stress, we can build a picture here of

why one would indicate the need for the other. Infections also raise the level of glucose

in the patient. We have already established infection as positively indicated therein.

NA – Normal Level: 135-145 mmol/L

Clients Level: 134 (Low)

Decreased levels of sodium are usually due to vomiting, pain and narcotic usage, all of

which the patient is presenting. Since the level is only slightly under the normal value,

there is not much need for concern. If it was greatly decreased, we would be observing

the patient for signs and symptoms of hyponatremia, which are anxiety, muscular twitch,

headaches, tachycardia and hypotension.

5. Surgery:

This client was not considered a good risk for surgery due to her age, the potential outcomes did not

Prove to be beneficial, her history of heart failure and the client was also adamant about not having

surgery done if it is not entirely necessary.

6. Nursing Implementations:

First and foremost, is the relief of the pain. It is important to have the client describe the level of pain so you know how aggressively to treat it. You would want to protect the affected area by managing the amount of use to the joint, to avoid further disintegration of same. The application of heat and gentle

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range of motion exercise is recommended. You would administer pain meds as required by the doctor’s order and then any PRN meds as needed. A weight reduction diet may be in order if the client is overweight and it is affecting the compromised joint. Teach the client good body mechanics and keep the body aligned well during periods of rest. Keep the head of the bed elevated, to reduce pressure to the lower lumbar area. Referrals to a pain management center or back pain clinic may be in order.

Bibliography

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Bibliography

Kee-LeFever, Joyce, Laboratory and Diagnostic Tests, Fourth Edition, Reprint by Appleton & Lange.

Prentice Hall International, United Kingdom, 1995 pp. 143-167, 169, 456-459.

Deglin, Judith Hopler & Vallerand, April Hazard, Davis’ Drug Guide for Nurses, Sixth Edition.

Davis Publications, Philadelphia, PA; Reprint Edition 1999, pp. various within.

Bare, Brenda & Smeltzer, Suzanne C., Brunner and Suddarth’s Textbook of Medical Surgical Nursing,

Seventh Edition, J.B. Lippincott Company, Pennsylvania, 1992. pp. 1842- 1867.

Mayo Clinic for Education and Research, Osteoarthritis – A Self Care Guide, Online Source

Mayo Foundation, 1999. available 12/7/99. http://www.mayoclinic.org/9706/osteoart.htm

Spine Online, Advanced Outpatient Care for Sufferers of Osteoarthritis in the Lower Lumbar Region,

Online, Spine Sources Inc., 1999. Available 12/7/99. http://www.spineonline.com