Jane Doe, a 22-year-old patient with no previous medical history, presents to the emergency department with complaint of low back pain after slipping on a wet floor at work and falling. The patient states that the pain is constant aching and radiates down both legs (sciatica). The MRI shows pulled muscles and ligaments surrounding the L4- L5 area. The emergency physician provides the following discharge orders: Bed rest with bathroom privileges for two days. Apply ice pack to lower back for 20 minutes several times a day for the first 48 hours, and then starting day three and on, apply a heating pad for 20 minutes on and 20 minutes off several times per day for the next several days as needed to relieve pain. Take 400 mg of ibuprofen every six hours and 5 mg cyclobenzaprine (Flexeril) t.i.d. After two days of bed rest, sit in chair three times per day for no more than 20 minutes. Ambulate around home and yard as tolerated, gradually increasing activity. Avoid twisting, bending, or reaching for objects. Avoid lifting anything more than 5 pounds of weight for one week. See physician in one week for further evaluation.
Explain the rationale for the administration of ice for 48 hours followed by the application of heat.
Explain the rationale for the administration of the ibuprofen and muscle relaxer.
What are the expected patient outcomes for the patient in this case study?
Case Study 2
John Tuliro, a 32-year-old patient, is admitted to the medical-surgical unit after a gunshot wound of the right lower leg infected with staphylococcus was debrided. The patient is diagnosed with osteomyelitis. The patient’s right lower leg is warm to touch and edematous, and the patient states that the extremity has a constant pulsating pain that increases with any movement of the leg. The patient’s sed rate and leukocyte rates are elevated. The physician orders the following for the patient:
Admit to medical unit with vital signs every four hours
Elevate affected leg on pillows above the level of the heart
Warm sterile saline soaks for 20 minutes t.i.d. with wet-to-dry dressing change
Levofloxacin (Levaquin) 750 mg IVPB every day
Renal profile, CBC with differential in A.M.
Regular diet with high-protein supplement shakes
Vitamin C 250 mg po b.i.d.
Meperidine (Demerol) 100 mg po every four hours
Docusate sodium (Colace) 100 mg b.i.d.
The patient asks the nurse why he has to stay in bed. The nurse should provide what rationale for this measure?
What nursing interventions should the nurse provide the patient?
DISCUSS INDIVIDUAL AND LIFESTYLE RISK FACTORS FOR OSTEOPOROSIS
The following are the risk factors of Osteoporosis:
Genetics – Caucasian or Asian, Female, Family History, Small Frame – Predisposes to low bone mass
Age – Postmenopause, Advanced Age, Low testosterone in men, decreased calcitonin – Hormones (estrogen, calcitonin, and testosterone) inhibit bone loss
Nutrition – Low Calcium Intake, Low Vitamin D Intake, High Phosphate Intake, Inadequate Calories – Reduces nutrients needed for bone remodeling
Physical Exercise – Sedentary, Lack of Weight Bearing Exercises, Low Weight and Body Mass Index – Bones needs stress for bone maintenance
Lifestyle Choices – Caffeine, Alcohol, Smoking, Lack of exposure to Sunlight – Reduces osteogenesis in bone remodeling
Medications – Cortocosteroids, antiseizure medications, heparin, thyroid hormone – affects calcium absorption and metabolism
Comorbidity – Anorexia Nervosa, Hyperthyroidism, Malabsorption Syndrome. Renal Failure – Affects calcium absorption and metablosim
Hormonal variations are one of the reasons for gender differences when it comes to the development of osteoporosis. In women, estrogen has a role in relation to osteoporosis, while testosterone, estrogen and other hormones in men also relate to this. Also, menopausal period in women accounts for osteoporosis, low endogenous estrogen levels increases the risk.
Lifestyle factors such as smoking, drinking alcohol and sedentary activities, also increases the risk for osteoporosis.
Nutritional factors that increase the risk, includes the following: daily intake that is less than 1000 – 1500 mg of calcium and 400 – 600 International units of Vit. D. Eating high protein diet, drinking caffeine, sodium and phosphorus has negative effect on calcium balance in the body, therefore, increasing risk for osteoporosis.
There are certain medications that can affect bone remodeling, and increase risk for secondary osteoporosis.
DISCUSS THE DIFFERENCES IN MEDICAL MANAGEMENT FOR PRIMARY BONE TUMORS VERSUS METASTATIC BONE DISEASE.
Primary bone tumor’s goal of treatment is to destroy or remove the tumor. It is accomplished by surgical exersion, radiation therapy if the tumor is radiosensitive, and chemotherapy. Limb-sparing procedures are used to remove the tumor and adjacent tissue. Replacement of the affected tissue is very important. This can be done through the following: customized prosthesis, total joint arthroplasty or bone tissue from the patient (autograft) or from cadaver donor (allograft). Surgical removal of the affected part may require amputation.
To prevent metastasis of malignant bone tumor, chemotherapy is started before and continued after surgery, to eradicate micromestatic lesions. Palliative management is the treatment for metastatic bone cancer. Its goal is to relieve pain and discomfort while promoting quality of life.
Structural support and stabilization is needed to prevent fracture, as the bone weakens. Prophylactic internal fixation helps strengthen large bones with metastatic lesions.
DISCUSS CLINICAL MANIFESTATIONS OF PAGET’S DISEASE, AND ITS PHARMACOLOGICAL TREATMENT FOR EACH.
Paget’s disease are initially asymptomatic. The bones that are commonly involved include the vertebrae, pelvis, cranium, sternum and proximal ends of the long bones. Diagnosis of this disease is made by reports of bone pain or deformity, through X-ray or by detection of elevated serum alkaline phosphate levels found though biochemical testing.
The following are the most common complaints of patients who are suffering from Paget’s disease such as pain. Skeletal deformity, and change in skin temperature. Joint dysfunction may result from damage to cartilage and osteoarthritis. Bone pain often occurs at night, which is a result of increased pressure on the periosteum or associated hyperemia. Other manifestations that can occur include diminished mobility and unsteady gait. Neurologic complications can also occur which is caused by nerve root compression or nerve entrapment. These structures are adjacent to pagetic bone near a nerve foramen or canal. Common clinical manifestation of Paget’s disease is mixed sensorineural and conductive hearing loss. Low back pain can also occur because of vertebral body and facet enlargements, loss of lumbar lordosis, dorsal kyphosis, spinal impingement and altered gait dynamics.
The short term objective in treating Paget’s disease is to alleviate the associated bone pain, while the long term objective, is to alleviate the progression of the disease. The pharmacologic therapy includes calcitonin, plimamycin, and gallium nitrate, and the biphosphonates. The main goal of this therapy is to control the disease activity, normalize biochemical parameters and to improve the symptoms.
LIST REHABILITATION AND HEALTH EDUCATION STRATEGIES USED FOR PATIENT WITH LOW BACK PAIN.
A comprehensive rehabilitation should include a careful evaluation for a specific goal and treatments based on best evidence are exercise, cognitive behavioral treatment, health education and others.
We should instruct the patient to avoid recurrence of the following:
Standing, sitting, lying and lifting properly are necessary for a healthy back.
Alternate periods of activity with periods of rest.
Avoid prolonged sitting, standing and driving.
Change positions and rest at frequent intervals.
Avoid assuming tense, cramped positions.
Sit in a straight-back chair with the knees slightly higher than the hips. Use footstool if necessary.
Flatten the hollow back by sitting with the buttocks tucked under. Pelvic tilt decreases lordosis.
Avoid knee and hip extension. When driving a car, have the seat pushed forward as necessary for comfort. Place a cushion in the small of the back for support.
When standing for any length of time, rest one foot on a small stool or platform to relieve lumbar lurdosis.
Avoid fatigue, which contributes to spasm of back muscles.
Use good body mechanics when lifting and moving about.
Daily exercise is important in the prevention of back problems.
Do prescribed back exercises twice daily strengthens back, leg, and abdominal muscles.
Walking outdoors is recommended.
Reduce weight if necessary decreases strain on back muscles.
IDENTIFY COMMON FOOT DISORDERS. IDENTIFY THE SPECIFIC STRUCTURE INVOLVED.
Common Foot Disorders:
Plantar Fascitis – it is a plantar heel pain, which evolves from the bone (heel spur) or plantar fascia.
Morton’s Neuroma – It is the irritation and degeneration of the digital nerves in the toes that produces a painful mass near the area of metatarsals.
Hallux Disorders: Valgus, Rigidus, and Sprains – Acute injury to the ligaments and capsule of the MTP joint. Lateral deviation of the first toe greater than the the normal angle of 15 degrees between the tarsus and metatarsus This may lead to a painful prominence of the medical aspect of the MTP joint. Degenerative condition of the first MTP joint leading to pain and stiffness.
DISCUSS THE INVOLVEMENT OF VITAMIN D IN THE DEVELOPMENT OF OSTEOMALACIA. IDENTIFY TREATMENT RELATED TO CAUSE.
Vitamin D deficiency is the most common cause of osteomalacia. Essential for calcium and phosphorus metabolism is Vitamin D, it is the critical elements in mineralization of the bone. The major source of Vitamin D is synthesis in the skin exposed to sunlight. Dietary modification is needed by eating food rich in Vitamin D, such as fatty fish oils, liver and egg yolks. Vitamin D supplement is also suggested.
DEVELOP A PLAN OF CARE FOR AN ASSIGNED PATIENT WITH LOW BACK PAIN.
Nursing Intervention for Low Back Pain:
Advise patient to stay active and avoid bed rest, in most cases.
Keep pillow between flexed knees while in side-lying position minimizes strain on back muscles
Apply heat or ice as prescribed.
Administer or teach self-administration of pain medications and muscle relaxant.
Encourage ROM of all uninvolved muscle groups.
Suggest gradual increase in activities and alternating activities with rest in semi-fowler’s position.
Avoid prolonged periods of sitting, standing, or lying down.
Encourage patient to discuss problems that may be contributing to backache.
Encourage patient to do prescribed back exercises. Exercise keeps postural muscles strong, helps recondition the back and abdominal musculature, a and serves as an outlet for emotional tension.
GIVEN A TEMPLATE, COMPLETE A DISEASE MAP ON A PATIENT WITH CARPAL TUNNEL SYNDROME.
COMPLETE A THEORETICAL CASE STUDY ON AN ACTUAL CLINICAL PATIENT WITH OSTEOMYELITIS.
USING THE INTERNET, RESEARCH LITERATURE ADDRESSING MANAGEMENT OF OSTEOPOROSIS. IDENTIFY NEW MEDICATIONS ON THE MARKET TO TREAT THIS DISEASE.
As the basic objective of preventing the progress of osteoporosis to a patient is to minimize bone fracture, management of osteoporosis is discussed in this article through many ways varying on the patient’s level of fracture risk. Prevention in a non medical therapy was described as having good nutrition, healthy lifestyle and fall prevention. Exercise and the aid of vitamin D supplements can actually help in preventing or lessening the risk of osteoporosis.
Medical treatment on the other hand comes in many forms; as it is to be administered based on the guidelines for commencing pharmacologic therapy. Medications for osteoporosis management are classified in to two, the antiresorptive agents and anabolic agents, both of which acting as agents to reduce fracture risk.
In the next article, a newly approved treatment was released and approved for the management of osteoporosis. Prolia is a biological, lab-induced treatment that is said to have the ability to inactivate the body bone’s breakdown mechanism. It was approved under specified types of treatments though. It can only be administered to patients of post menopausal stage and has a high risk of bone fracture caused by osteoporosis. Or to patients who already had osteoporosis treatments but had failed. Or lastly, to patients who can’t endure other osteoporosis treatments. What this treatment does is to slow down the process of bone breakdown, making the patient less susceptible to bone fracture. In spite of the advantages of the said treatment though, side effects to this treatment also has its downsides. Most common of which is the patients feeling back, muscle, and bone pains. It is through this reason that patients with low levels of calcium were also prevented to use this kind of treatment
FIND A REASEARCH ARTICLE COMPARING PRIMARY BONE TUMORS TO METASTATIC BONE TUMORS. SUMMARIZE IN TERMS OF MANAGEMENT.
Primary & metastatic bone tumors basically differ from its origin. As primary tumor are defined as tumors which have started from the bone itself, metastatic tumors, also known as secondary tumors are defined as tumors which have originated from another parts of the body that had resulted to or affected the bone as well.
As primary bone tumors are treated the same as with other tumors found in the other parts of the body. Patients also undergo radiation and chemotherapy as well as surgery. For painful vertebral fracture, Kyphoplasty or vertebraplasty are also considered as options to alleviate pain. Metastatic bone tumors on the other are treated the same as with primary bone tumors though since it has its origin from a different area, treatment are to be considered depending on how it will affect the entire body of the patient or all of which that is with tumor (breast, lung, prostate, etc.)
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