All-Inclusive Care Plan: Musculoskeletal - Essay Example

Musculoskeletal Case Study due: Musculoskeletal Case Study The following essay presents an investigation of a musculoskeletal case study. The analysis will include an all-inclusive care plan aimed at disease prevention, health promotion and acute care of the patient, based on current scientific evidence. The plan will be customized for this specific patient and will be based on the nursing standards of care. Case Study Evaluation Subjective data Client complaints: A 40 year old Asian-American male presents to the clinic with complaints of acutely worsening low back pain with numbness; as well as a tingling effect down his right leg to his toes as a result of lifting a heavy object at work 3 days ago. History of present illness: The patient states that he has had this pain in the past, but it usually went away, and it was never this severe and he has never had the tingling sensation that he is having now. He describes the pain to be located at the middle of his back, near the waist (mainly lumbar), and is exacerbated when he bends forward. There is numbness and tingling that radiates down the back of the right thigh to the toes. The pain and numbness has been increasing for the past three days without relief, and he has tried stretching, as well as over the counter Ibuprofen. He reports that the pain is so bad that he is currently out of work, has been having problems sleeping and the only thing that helps is the use of his friend’s medication (does not state which medication it is). His main concerns today are that he will not be able to return to work to make money; he has no health insurance and is concerned that he may have a herniated disk. Past medical history: Includes similar back pain that was never this severe, and he sought the help of a chiropractor three years ago, and with manipulation, the pain was relieved. He denies any chronic medical problems, surgeries or hospitalizations. Reports increased weight gain. He does not seek medical attention on a routine basis, nor does he have any recent blood work or imaging studies. He reports having a penicillin allergy that causes rash, and does not take any prescription medication, however, has been taking ibuprofen 800mg every 4 hours for his pain and is compliant with the regimen. He is the sole offspring, and both parents are positive for hypercholesteremia, his father has prostate cancer and has a positive family history of heart disease. Review of systems: A review reveals lumbar pain with radiation to the right buttock and positive for tingling and numbness to the toe. He denies urinary or bowel incontinence, nausea, vomiting, fever, abdominal pain or pain with urination, and no gross hematuria. He has decreased strength of the right leg when compared to the left leg with resisted extension. The patient also has complaints of pain of the posterior thigh with decreased sensation. Social/personal history: The patient is a roofer, with a high school education, who makes 30K per year, and he does not enjoy his job. He lives on enough income to just get by and feels as though the last thing he desires is to spend money on health care, and he believes his body will get better on its own. He is divorced with no children, and tries to remain in contact with his ex-wife, but she refuses to have any association with him, so he feels as though he was a failure as a husband and believes he is depressed. He does not handle stress well and reports that he drinks alcohol to excess on the weekends with his friends from work and smokes marijuana. He has a poor support system, relies on his friends from work, but is socially isolated from his parents. He lives in a suburban setting and is unaware of the resources available to him. His diet consists of skipping breakfast, fast food twice daily, and sips caffeinated beverages throughout the day. He plans to go on a diet but is unsure of which diet he should follow. He does not exercise outside of work, stating he gets his exercise at work. Objective data Physical assessment: ENT: WNL, Lungs: Clear, Carotids: Not examined, Lymph Nodes: None, Heart: RRR without murmur, Abdomen: Android obesity, Rectum: Not examined, Genital/Pelvic: N/A, Extremities, Including Pulses: 2+ pulses in the lower extremities. Neurologic assessment: Mental Status: Alert and oriented, Motor Strength: Upper extremities equal strength 5/5, Cranial Nerves: II – XII intact, Lower extremities: decreased motor of right leg with resisted extension; pain in posterior thigh, Sensation is a light touch, pin prick, vibration, and position: Decreased sensation of right leg along L5:S1 dermatome to pin prick stimulation compared with the left, Reflexes: DTRs 2+ in upper and lower extremities. Cerebellar performance intact—Romberg test is negative; heel-to-toe walking is steady, Positive straight leg raise on the right at 20 degrees. Vital Signs: BP: 120/78; T: 97 po; P: 92 and regular; R: 18; Wt 220, Ht 6’; WC 40; BMI: 29.8. Lab work: CBC: WNL, UA dipstick: WNL. Radiological results: Plain film of lumbar spine: loss of disc height at L5 to S1 with mild degenerative effects of lumbar vertebrae, MRI: moderate disc bulge at L5: S1. EKG: Not performed. Pathophysiology Low back pain is a condition where the pain is experienced in the lumbosacral spinal and parsaspinal regions, including the buttocks and upper thighs. It is a common complaint among patients. Risk factors for this condition include smoking, a sedentary lifestyle, obesity, poor posture, prolonged slumped sitting, poor flexibility and certain psychological factors (Boreinstein & Calin, 2012). Although the condition is rarely the symptom of an underlying disease, it can cause significant limitations to the daily activities of an individual. It is also a principal cause of disability. Mechanical low back pain is one of the categories of spinal conditions (Buttaro et al., 2013). Although the exact etiology of low back pain is not well understood, it is commonly assumed to be a result of the normal wear and tear of the vertebral discs causing compression of the nerve roots. The lower section of the vertebral column is referred to as the lumbar spine and consists of five vertebrae, separated by intervertebral discs which act as shock absorbers. These discs are made up of nucleus pulposus surrounded by the annulus fibrosus (Buttaro et al., 2013). Other muscles that support the lumbar spine include the paraspinal muscles, the abdominal musculature and transversus abdominis and thoracolumbar fascia. These muscles also support the pelvis together with the ligaments including the anterior and posterior longitudinal ligaments, ligament flava, and supraspinous ligaments. The nerve roots in the spine help to innervate the vertebral discs. Low back pain can be classified into two broad categories i.e. radicular (involving the nerve roots) and axial (mechanical low back pain). The mechanical low back pain is mostly caused by structural dysfunctions in the vertebrae, ligaments, joints or vertebral discs. These conditions negatively affect the stability, strength and flexibility of the vertebral column. In addition to the normal wear and tear of the vertebral column, osteophytes formed from the bones and hypertrophy of the ligaments may also contribute to the compression of the nerve roots, thus causing low back pain (Buttaro et al., 2013). Other factors that can result to low back pain include obesity, age-related physiological changes, disuse of the abdominal and thoracic muscles, overstretching of the spinal supports as well as postural and structural problems. Low back pain is a disorder that limits the everyday activities of an individual. However, it is easily managed and spontaneously improves with time although patients with an indicative history and physical examination of low back pain may require specialized treatment (Boreinstein & Calin, 2012). Signs and symptoms Low back pain can be correctly diagnosed through identification of the location of the pain and a description of the radiation of the symptoms. If the presenting symptoms are only low back pain, the most common causes may be axial fractures in the lumbar or sacral regions, sacroiliac joint dysfunctions or a degenerative disk disease. Conversely, if the pain radiates to the buttocks and upper thigh, then the pain may be referred (emanating from the ligaments, muscles or bones) or radicular in nature (Battaro et al., 2013). Patients with low back pain usually report symptoms of pain, tenderness, and stiffness in the lower back region. In other cases, the pain may spread to the legs and buttocks, causing the person to experience difficulty while standing in one position, sitting for too long or driving. The patient’s gait, spinal mobility and posture may also be affected (Hoff, 2012). Other accompanying symptoms may include tingling sensation on the lower extremities, weakness, numbness and signs of root tension (Buttaro et al., 2013). In the case of this patient, he reported a history of low back pain, after which he sought medical care, and it subsided. However, the symptoms recurred and the pain has radiated to the buttocks and upper thigh region. Also, he reports a feeling of weakness in his legs, tingling sensation and numbness in the toes. The pain is very severe and prevents him from performing his occupational duties comfortably. Progression trajectory Low back pain is a recurrent condition, persisting over time (Dan et al., 2013). Most patients who frequently visit primary care facilities with low back pain report short-term improvements, although two-thirds of patients with low back pain are estimated to be suffering from the chronic case of the condition. In long term cases, the pain persists for more than 12 months without any long-lasting relief (Dan et al., 2013). Also, most people experience on and off episodes of low back pain throughout their lives, making it a life-long experience Diagnostic testing A diagnostic testing is usually recommended together with a thorough medical history and physical examination to pinpoint the cause of the low back pain. Diagnosis of the underlying condition is important so that proper management of the patient’s condition can be done. For individuals suffering from acute low back pain, imaging may not be recommended since it does not improve the clinical outcomes of treatment. However, if there is suspicion of a serious underlying condition, magnetic resonance imaging (MRI) with or without contrast may be recommended. In cases where MRI scans are contraindicated, a computerized tomography can be done as an alternative (Casazza, 2012). Also, plain radiographs of the lumbar region are required if the patient has a history of related illnesses such as osteoporosis, drug and alcohol abuse, long-term use of steroids, neurologic symptoms, or a history of cancer or trauma. In addition, if the medical history and physical examination of the patient are indicative of bone fractures, neoplasm or osteomyelitis, a radionuclide bone scintigraphy may be recommended as a diagnostic test (Buttaro et al., 2013). Recent fractures and osteoarthritis can also be identified by performing a bone scan with single photon computerized tomography (SPECT). To rule out infection or bone marrow neoplasm as the underlying conditions, laboratory tests such as C-reactive protein, complete blood count with differential and erythrocyte sedimentation rate are required. A biopsy may be helpful in determining the exact cause of the low back pain. Other diagnostic tests that may be useful in the context of low back pain include myelograms, discography, ultrasound imaging, and electrodiagnostic. Blood tests to detect HLA-B27 (a genetic marker in the blood that may point to problems due to reactive arthritis or spondylitis) may also be helpful in making a correct diagnosis. Treatment options The objectives of treatment plans include measures to relieve the patient’s pain, restoring normal functioning of the lumbar spine, and reducing the long-term disability. Treatments are also tailored to relieve specific underlying conditions and symptoms. Non-pharmacological treatment of the condition emphasizes the importance of regular physical exercise and patient education. In patient education, the patients should be constantly reassured that they do not have a serious problem and advised to maintain an active lifestyle, increasing their level of activity progressively (White et al., 2011). As a support strategy and also part of patient education, the patients should be provided with reading material that covers topics such as beneficial exercises that improve muscle coordination and balance, self-care for back pain, and how to develop proper posture. Physical therapy programs to help strengthen core muscles that support the low back and enhance the patient’s flexibility and mobility are also recommended. Alternative therapeuatic practices including acupuncture, massage therapy and spinal manipulation are other treatment options that may help the patient get relief from the back pain (Balague et al., 2012). In pharmacological approach, nonsteroidal anti-inflammatory drugs (NSAIDS) are usually the first-line drugs used in treatment of acute low back pain. Where there is chronic low back pain, antidepressants including tricyclics and serotonin and norepinephrine reuptake inhibitors are prescribed for the patient (Casazza, 2012). Topical analgesics may also assist the patient to increase the blood flow to the painful area and reduce inflammation. Differentiation from Normal Development The vertebral column forms the longitudinal axis of the skeleton as well as providing points of attachment for ligaments and muscles and allowing for free movement (Sakai et al., 2015). It is divided into five regions i.e. the cervical, thoracic, lumbar, sacral and coccygeal regions. Intervertebral discs separate the vertebrae while providing a cushion to facilitate easy movement. These discs are made of an inner layer of cartilage (nucleus pulposus) and an outer one (annulus fibrosus) to facilitate their functions. Degenerative conditions change the physiology of these discs, thus limiting the normal functioning of the spine. The normal intervertebral discs are converted into fibrocartilage tissue. If herniation occurs, for instance, the nucleus pulposus extrudes through the posterior capsule of the disc, compressing the nerve roots or the spinal cord. This process results to pain in the affected area and possible loss of sensory or motor function (Sakai et al., 2015) Physical and Psychological Demands Apart from a person’s physiology, other factors that can impact the treatment goals include their lifestyle, health habits, social support and occupational demands among others. Personal coping skills and culture can also impact the way care is observed and received. Axial symptoms of short-term low back pain are often deleterious and can result to sleep disturbances while also interrupting a person’s occupation and daily activities. Physicians should note that treatment strategies for acute low back are very different from those employed in managing chronic, persistent or recurrent low back pain. Acute low back pain is likely to cause emotional and behavioral consequences that are detrimental to pain recovery therapy and functional rehabilitation (Abassi et al., 2012). In addition, acute low back pain may cause economic, emotional and social problems. As a result, physicians are required to employ a holistic approach while managing such a patient to ensure that not only is the physiological status of the patient restored but also other areas of the patient’s life impacted by the condition. Key Concepts for Optimal Management Several issues should be considered when managing low back pain. Most of them include care when performing daily activities while also increasing the physical activity of the patient. The patient is required to maintain an active lifestyle and avoid bed rest or long periods of stagnation. When the acute pain reoccurs, the patient should rest and avoid strenuous activities for a couple of days. The patients should take care while handling or moving heavy objects as these can exacerbate the symptoms. The patient should also avoid any furniture that does not support them in the right way. The patient should also ensure that they maintain good posture by avoiding bending or stooping positions, assessing driving and sitting positions, and lying flat while sleeping instead of sleeping in a chair or propped up with pillows. The patient ought to be advised to perform regular core abdominal strength exercises and alternate between the utilization of cold and hot packs to reduce pain. In case the pain becomes severe, the patient can use over-the-counter- drugs to provide speedy pain relief. In cases where the acute pain is not cured by these analgesics, the patient should seek medical attention and follow pain management programs issued by the physician. The patient should also consider starting with gentle stretching and strengthening exercise when the acute pain subsides, and gradually increase the activity level. Key Interdisciplinary Team Personnel The management team should consist of both pharmacological and non-pharmacological therapists for an effective treatment of low back pain. Therapies should consist of spinal manipulation by a chiropractor, rehabilitation by an occupational therapist and physiotherapist, acupuncture by a licensed physician and cognitive and behavioral therapy by a psychologist. In case there are neurological deficits, persistent sciatica or a neuromotor deficit that lasts for more than four weeks, a neurosurgeon should be consulted. A nutritionist or dietitian should also be consulted to advice on weight control and management to prevent exacerbation of the symptoms. Facilitators and Barriers In this specific case, barriers are present due to the physically demanding occupation, depression, lack of knowledge od available resources and the patient’s addictive personality (which will inhibit the effectiveness of the medication therapy for pain relief. The facilitators include the fact that the patient is willing to get back to work as soon as possible because he has a limited income and needs the money. He is also motivated by the recurrent pain to seek treatment, therefore, will be willing to cooperate with the physicians to facilitate a speedy recovery. Strategies to Overcome Barriers One of the most effective strategies to overcome these barriers is through treatment of his depression. The patient will be prescribed mild antidepressants and participate in formulating a plan to ensure that he is comfortable with the treatment options. Regular exercise and strength training will also assist the patient to deal with his weight control issues, alleviate symptoms of the underlying disease as well as the depression. Since the vertebral column is supported by the back muscles, the patient will be required to engage in regular exercise to strengthen these muscles. Regular exercise of these muscles also helps the patient to relieve much of the pain that he is experiencing at the moment. Behavioral changes are also beneficial for him. He should consider changing certain behaviors such as a sedentary lifestyle and other activities that may worsen the pain. The patient should also consider using ice and other non-prescription pain relievers, and when the pain subsides, he should engage in gentle strength training exercises for the stomach, back and legs while incorporating stretching exercises. These exercises help in hastening the recovery process and reducing instances of disability due to low back pain (Lim et al., 2011). Most patients avoid exercise treatment due to the fear of pain and other related injuries. However, as a health care provider, it is important to stress the importance of exercise in the recovery process. Too little exercise may result to loss of flexibility, strength and endurance, which leads to more pain (Lim et al., 2011). The patient ought to be educated on the benefits of exercise such as a quicker recovery, re-injury prevention and a reduction in the risk of disability from pain. Care Plan Synthesis While developing a personalized care plan for this patient, it is vital that all factors that worsen the disease prognosis be addressed first. These factors include acute pain, exercise, weight control and treatment of depression. The patient should also be advised to cease his intake of alcohol and marijuana. Since the patient cannot quit his job completely, he should be advised to take some time off and get some rest to0 avid further detriment to his condition. He should also be advised to avoid lifting heavy objects especially at the acute stage of recovery. Bedrest should not be prescribed at this time. Rather, the patient should be encouraged to maintain an active lifestyle and ensure that he completes his daily activities within their limitations. Also, warm compresses should be recommended in comparison to ice. Excessive weight is another detrimental factor that should be addressed. His excessive weight puts much pressure on the spine which is supposed to provide the required support. The patient should check his diet to ensure that he takes more proteins and complex carbohydrates, and also reduce his intake of fast foods and caffeine. The alcohol and substance abuse should be halted since they contribute to his depression and inhibiting him from controlling his disease effectively. Furthermore, excessive alcohol intake may contribute to nervous damage known as alcoholic neuropathy, which is prominent in the extremities (Chopra & Tiwari, 2012). His feeling of numbness and tingling in his right lower extremity may also be as a result of his excessive alcohol intake. Pain management may be attained through the prescription of acetaminophen, NSAIDs or opioids (at the discretion of the provider) while nervous pain may be managed by prescription of anti-epileptics such as Gabapentin and Lyrica. Treatment of depression may facilitate the clinical outcomes for this patient. Depression not only affects the mind but may also contribute to chronic pain syndromes. Prescribing antidepressants for the patient may increase the patient’s motivation towards self-care, and he will be more willing to work with the physicians to complete the course of treatment. Together with a healthy diet and regular physical exercise, his mental and physical health may both be improved with this care plan. Moreover, the patient should be advised to take a prostate exam because he is at risk; this is triggered by his age and history of prostate cancer. The patient lives in the suburban area where most resources are available to him, but he is unaware. The management team should provide him with information such as where to find a dietitian for a weight loss plan at the local wellness clinic, a gym that may provide him with exercise equipment, and group classes including yoga and substance abuse support groups and other support groups for people with the same condition as his. Comprehensive and Holistic Plan for Disorder A holistic plan for low back pain involves several body systems including the neurological, musculoskeletal and psychological. To achieve an overall healthy outcome, all aspects of the patient’s life that have been affected by the condition should be addressed. The psychological aspects of the patient should be managed by cessation of alcohol and substance abuse, and management of depression. The musculoskeletal and neurological systems should be managed using physical exercise, weight control and treatment with anti-epileptics such as gabapentin or pregabalin for nerve pain. Impact of Sociocultural Background on Optimal Management and Outcomes According to the culture, Asians put emphasis on the family unit and do not accept disability as a disease because it is viewed as a failure of the family. This mentality may not be beneficial for the patient because the patient may shun the thought of being treated as a disabled person in fear that his family may disapprove of him. The Asian culture considers disabled members of the family as failures hence tend to conceal them from the public (Hill & Smith, 2014). As a result, the patient may prefer not to undergo treatment due to fear of rejection by his family. The mentality can result to lack of attainment of the patient’s goals of optimal pain management and disease outcomes. Evidence Based Approach for Key Issues Evidence-based key issues are diagnostic imaging for non-specific low back pain, nerve involvement, treatment and medication therapy with opioids. To avoid too much radiation, imaging is not recommended for acute low back pain cases which have resulted in the first four to six weeks. Also, there is little evidence to support any results that films will find the cause of the non-specific back pain. As was mentioned earlier, management of pain should be done using acetaminophen and NSAIDs. Opioids or muscle relaxants should be used in cases of severe acute exacerbations of pain, limited to not more than two weeks to prevent dependence on medication. Summary of Comprehensive Approach to Disorder Management 1. Thorough history and physical assessment a. Rule out nervous damage i. Without nerve compromise, no imaging should be recommended for the first four to six weeks of treatment ii. Where there is nerve compromise, imaging studies should be done b. Assessment of the type, location, onset, radiation of pain and duration is very important 2. Development of a treatment plan a. Regular exercise and completing activities of daily living are important in the recovery and avoidance of further detriment i. Creation of a time frame in which the patient should expect to resume work 1. This action will motivate the patient to achieve the treatment goals quickly to avoid more missed work days and disability b. Administration of acetaminophen or NSAIDs as first-line therapy for management of pain i. Opioids should only be recommended for patients with more severe symptoms and should be used for a short duration under close watch by the physician. ii. Consider anti-epileptics including gabapentin and pregabalin to treat nervous pain. c. The physicians should ensure that the patient feels he is always involved in the treatment plan, including accepting feedback from imaging studies, pain management and other forms of therapy. d. The physicians should maintain close contact with the patient to make him feel he is getting enough support from his health provider. This way, the patient will be more motivated to complete his course of treatment. 3. Management of depression a. The depression should be addressed immediately i. He should be provided with information regarding the available community resources and support groups specific to his condition b. Talking to others with a similar condition may help by encouraging him to complete his treatment. ii. The physicians can consider starting on an antidepressant iii. Alcohol intake and marijuana smoking should be stopped c. The patient can be provided with information Alcohol Anonymous and/or Narcotics Anonymous 4. Weight control a. Further weight gain is detrimental to the patient’s condition b. The patient states he is not aware of which diet to follow, but he says he is willing to lose weight. i. Information on where to find a nutritionist or dietitian should be provided for him to help with his weight control ii. Exercise on a daily basis ought to be encouraged Conclusion Management of low back pain requires a multilevel system of care. The patients and healthcare providers should ensure that they work together in development and implementation of a plan of care that will be optimal and successful so that ideal outcomes can be realized from the plan. For this case, the goals of treatment include management of symptoms, pain control and avoidance of recurrent instances of acute back pain. References Abbasi, M., Dehghani, M., Keefe, F. J., Jafari, H., Behtash, H., & Shams, J. (2012). Spouse assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: A 1‐year randomized controlled trial. European Journal of Pain, 16(7), 1033-1043. Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482-491. Borenstein, D. G., & Calin, A. (2012). Fast Facts: Low Back Pain. 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