Back Pain Page 1 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.

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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. Page 2 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. Page 4 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. Page 5 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 ...