Instructions Response posts to peers have no minimum word requirement but must

Instructions

Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments unless specified in the instructions. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.

Initial Response (FOR REFERENCE)

Instructions:

Scenario: A 59-year-old female presents with complaints of low back pain. She reports having difficulty standing upright and must change position frequently when sitting or lying down. She denies any specific incident that preceded the pain, stating that it just started as stiffness, but it has progressively worsened. When asked about pain radiation, the patient confirms that pain is radiating down to her mid-thighs, bilaterally. The patient reports that her activities are limited by the pain despite the use of acetaminophen, ibuprofen, and ice. A full physical exam is needed to determine the cause of pain and to identify treatment options.

The patient reports activity intolerance as a result of the low back pain. What should you include when performing your initial physical assessment?

What questions should you ask to appropriately gather this patient’s history?

The patient seems surprised when you begin asking questions about her psychosocial status. Why is a psychosocial evaluation important for patients with low back pain?

Concerned that “something serious” is going on, the patient insists on having an x-ray to be certain. To warrant an order for an x-ray (radiograph) for acute low back pain (ALBP), what conditions should exist?

You inform the patient that most ALBP episodes (almost 90%) resolve within 1 to 6 weeks and that pain management will focus on symptom control through pharmacological and nonpharmacological methods. What is your plan of care for this patient? Provide full prescription details if medications are ordered.

What will you include in patient education and instructions?

Please be sure to validate your opinions and ideas with citations and references in APA format.

Peer Response

Instructions:

Please respond to at least two of your fellow classmates postings as well and challenge each other to go beyond just the surface.

Share your thoughts on how you support their ideas and explain why.

Present new references that support your opinions.

Please be sure to validate your opinions and ideas with citations and references in APA format. 

Please respond to each students post individually.

(Hey Sarah, great post! I agree/disagree with….)

Ashley’s Post:

The patient reports activity intolerance as a result of the low back pain. What should you include when performing your initial physical assessment?

            The physical assessment of a patient with low back pain should include observation, palpation, patient movement, and the performance of special tests (See et al., 2021). The physical assessment should focus on the patient’s posture, including spinal curvature, pelvis asymmetry of shoulders, signs of scoliosis, and gait. Palpation of the patient’s back will attempt to help narrow down any specific anatomic pain generators that can help determine a potential cause of the pain. The assessment of the range of motion of the lumbar spine is essential to determine whether the pain is worse with flexion or extension, which can help narrow down the specific causes of pain (Dunphy et al., 2023).

           The physical assessment should also include a thorough review of bilateral lower extremities’ deep tendon reflexes, sensation, and motor strength. The performance of special tests, including the straight-leg-raise, reverse straight-leg raise, and prone rectus femoris, allows the provider to assess the patient’s lower back and help determine the level of spinal involvement related to pain (Dunphy et al., 2023). The patient should also be asked to safely reproduce the type of activity that causes them the most pain, limiting her physical activity. Understanding the red flags upon physical assessment is essential to accurately diagnose and treat the patient (See et al., 2021). The patient should be assessed for the inability to walk on her toes or heels and to dorsiflex the great toe (Dunphy et al., 2023).

What questions should you ask to gather this patient’s history appropriately?

A thorough and comprehensive history should be the initial step to help reach an accurate diagnosis based on the patient’s complaints (See et al., 2021).

Questions focused on low back pain should include:

When did the pain first start? How did the pain start?

Where is the pain located?

Have you had any recent injuries or illnesses?

Describe the pain and the course of the pain. Is it burning, sharp, dull? Course: progressive, episodic, fluctuating, increasing, or decreasing?

Does the pain radiate to any other areas?

Do you have any other symptoms present with the pain, such as numbness, weakness, cramps, paresthesia, atrophy, or fasciculations?

Does anything make the pain better or worse?

What is the severity of the pain? Rated on a scale of 0-10.

Does posture affect the pain?

Do activities such as sneezing, straining, or coughing affect the pain?

Does exercise or exertion affect the pain?

Does rest and sleep affect the pain?

Have you ever experienced this pain or similar pain before?

If so, what treatment was used, and how did the treatment help?

Do you have any other associated symptoms with low back pain, such as urinary or bowel problems?

What is your occupation?

Any history of medical problems?

Previous surgical history?

Use of daily medications?

The patient seems surprised when you begin asking questions about her psychosocial status. What is a psychosocial evaluation critical for patients with low back pain?

            A psychosocial evaluation is essential in assessing low back pain as various psychosocial factors have been identified to influence the onset of pain. Numerous behavioral, cognitive, emotional, and environmental factors can influence pain processes and how pain transitions from acute to chronic (Moore, 2010). Pain, more specifically low back pain, is a multidimensional and dynamic interaction of psychological, social, and physiological factors that influence one another, resulting in pain. The psychosocial evaluation should include the patient’s cognitive and emotional state, conditioned responses, and psychological vulnerability. Anxiety and depression are associated with negative emotions, behaviors, and thoughts and are the most commonly associated psychological factors in patients with chronic pain (Meints & Edwards, 2018).

Concerned that “something serious” is going on, the patient insists on having an x-ray, to be specific. To warrant an order for an x-ray (radiograph) for acute low back pain (ALBP), what conditions should exist?

For an x-ray to be warranted, the patient should be exhibiting red flag signs or symptoms such as a spinal infection, malignancy, fracture, or a severe and progressive neurological deficit from cauda equina syndrome. The provider may also consider an x-ray if the suspected pathology would be treated differently than low back pain.

You inform the patient that most ALBP episodes (almost 90%) resolve within 1 to 6 weeks and that pain management will focus on symptom control through pharmacological and nonpharmacological methods. What is your plan of care for this patient?

Weight management, including weight loss if indicated

Progressive physical activity as tolerated

Avoid bedrest

Physical therapy sessions for low back pain

Smoking cessation, if indicated

Intermittent heat application to lower back

Use of complementary therapies such as meditation, transcutaneous electrical nerve stimulation, relaxation techniques, massage, or yoga as tolerated

Naproxen 500 mg tablet, PO, one tablet by mouth twice daily with food as needed for back pain, #56 tablets, 0 refills – To be used in addition to a skeletal muscle relaxant

Baclofen 5 mg tablet, PO, Take one tablet by mouth every 8 hours as needed for muscle pain, #42 tablets, 0 refills

What will you include in the patient education and instructions?

            It should be highly stressed to the patient that rest will not help to resolve the presence of low back pain, and the patient should avoid bed rest. The patient should be educated on participating in physical activity that is tolerable and continues to advance activity. The patient should be educated on the importance of weight reduction, daily physical exercise of at least 30 minutes, such as walking or bicycling, and smoking cessation if indicated. The patient should be educated on the importance of good body mechanics and the use of nonpharmacological therapies as treatment’s mainstay (Dunphy et al., 2023).

             The patient should be instructed on the correct use of prescribed medications and not to take any other non-steroidal anti-inflammatory medicines while taking naproxen. The patient should be instructed to take each medication with food. The patient should be educated that using skeletal muscle relaxants is short-term, and the potential side effects include dizziness and drowsiness. The patient should be instructed not to operate a vehicle or heavy machinery while taking Baclofen. The patient should be instructed on the possible side effects of both medications. The patient is instructed to call the office if any side effects develop. The patient should be instructed to follow up in two weeks for a follow-up evaluation (Dunphy et al., 2023).

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2023). Primary care: The art and science of advanced practice nursing – an interprofessional approach (6th ed.). F.A. Davis Company. https://bookshelf.vitalsource.com/reader/books/9781719649469/epubcfi/6/8[vnd.vst.idrefcop]!/4/2/2/2[cop]/14/1:89[ecomme]Links to an external site.

Meints, S. M., & Edwards, R. R. (2018). Evaluating psychosocial contributions to chronic pain outcomes. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 87, 168–182. https://doi.org/10.1016/j.pnpbp.2018.01.017Links to an external site.

Moore, J. E. (2010). Chronic low back pain and psychosocial issues. Physical Medicine and Rehabilitation Clinics of North America, 21(4), 801–815. https://doi.org/10.1016/j.pmr.2010.06.005Links to an external site.

See, Q., Tan, J.-N., & Kumar, D. (2021). Acute low back pain: Diagnosis and management. Singapore Medical Journal, 62(6), 271–275. https://doi.org/10.11622/smedj.2021086Links to an external site.

Natasha’s Post:

Scenario: A 59-year-old female presents with complaints of low back pain. She reports having difficulty standing upright and must change position frequently when sitting or lying down. She denies any specific incident that preceded the pain, stating that it just started as stiffness, but it has progressively worsened. When asked about pain radiation, the patient confirms that pain is radiating down to her mid-thighs, bilaterally. The patient reports that her activities are limited by the pain despite the use of acetaminophen, ibuprofen, and ice. A full physical exam is needed to determine the cause of pain and to identify treatment options.

Initial history and Physical assessment

 History should include a focused medical history of present illness:

Onset- abrupt or gradual?

Location on the back?

Duration- How long has this been going on?

Characteristics, provoking, aggravating, or relieving factors?

Effects on activities such as posture, coughing, sneezing, straining, exercise, exertion, sleep?

History of pain worsening, getting better, unchanged, episodic?

Limb or Neurological symptoms pain, paresthesia, numbness, weakness, fasciculations, muscle spasms?

Associated symptoms urine or bowel involvement?

History of back pain, treatment (Dunphy et al., 2022).

Physical exam should include observing gait, positioning, and facial expressions.

Test lumbar spine ROM.

Evaluate point tenderness or muscle spasms, assess for muscle atrophy.

Evaluate reflexes, strength, pulses, and sensation.

Perform slump test, straight leg test, stork test, saddle anesthesia, wink reflex, FABER and FADIR test of hips bilaterally, evaluate psychological distress via Waddell sign (Domino, 2024).

            Psychosocial evaluations with low back pain

            Psychosocial factors that predict poor-long term prognosis are lack of social support at home or work, depression/ anxiety, substance abuse, h/0 physical or sexual abuse, excessive mobility of spine or other joints, fear of reinjury, movement or pain, low expectation of recovery, and passive coping style (Domino, 2024). Psychological distress can amplify or prolong the pain (Dunphy et al., 2022).

            Indication for x-rays

            Indications for x-rays for acute low back pain are: pain at night or at rest, fever > 100.4 for > 48 hours, progressive neuromotor deficit, extremity pain with numbness and weakness, trauma, loss of bowel or bladder function, h/o cancer, osteoporosis, chronic steroid use, use of immunosuppressive medications past or present, substance abuse, or suspicion of ankylosing spondylitis (Dunphy et al., 2022).

ALBP treatment and medications

For ALBP < 6 weeks duration with no red flags, order physical therapy. May prescribe a Medrol dose pack or naproxen 500 mg q 12 PRN pain for 14 days. May also prescribe a muscle relaxer Robaxin 500 mg QID PRN for muscle spasms (Domino, 2024).

Patient education and instructions

Educate the patient to take the medications as prescribed. Slowly and gradually add activities into day as tolerated, can start with walking. May apply heat or ice to back. Provide sciatic exercises to incorporate. May also mention cognitive behavioral therapy, yoga, tai-chi, and mindful stress reduction techniques (Dunphy et al., 2022). Have the patient follow up in 4-6 weeks.

References

Domino, F.J. (2024). The 5-Minute Clinical Consult (32nd Edition). Wolters Kluwer

Dunphy, D. J., Winland-Brown, L. M., Porter, J. E., & Thomas, B. O. (2022). Primary care: The art and science of advanced practice nursing – An interprofessional approach. (6th ed.). F.A. Davis. ISBN -13: 978-1719644655