Diagnosis: Chronic Lower Back Pain Paper
Choose an experience from your nursing practice. Using the \”SBAR\” template, explain the situation in detail, followed with background information. Then explain your immediate assessment and recommendations you have for the provider.
Include the following in the \”SBAR\” template:
Be sure to include three or four evidence-based references, not older than 5 years.Diagnosis: Chronic Lower Back Pain Paper
When giving your recommendation discuss how you would educate the client using evidence-based research and guidelines. How would you deliver your recommendation in various learning environments?
APA style is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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| Situation | Patient Initials: WT
Age: 30
Room :35_clinic Primary or Admitting Diagnosis: Chronic lower back pain
Fall Risk: Yes Restraints: NA Isolation: NA
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| Background |
HPI (History of Present Illness): Complaints of a persistent cough and fatigue that have lasted for 2 weeks. It started as a common cold, but she was concerned that it was something more serious since the cough and fatigue have not resolved yet. History of low back pain acquired at her job as a construction worker, and she is also being medicated for depression. PMHx (Past Medical History): History of low back pain acquired at her job as a construction worker, and she is also being medicated for depression Allergies: NKA
Current VS: Respirations – 20 breaths per minute Blood pressure – 112/76 Temperature – 99F (37C) Conscious -alert and focused Heart rate – 94 bpm Pulse – 95 per minute Pain- 5 out of 10 on pain scale
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| Assessment | Neurologic and Psychosocial
PERRLA: PERRLA and reactive Pupils L-_6__mm R-_6__mm GCS score: __15__/15 LOC/Orientation: Alert and oriented Mood: Tired, fatiqued due to chronic lower back pain Appearance: Skin cool and very sweaty Behavior: Tired or in pain Hallucinations/Delusions: None Breath Sounds: Clear of obstruction, clear breath sounds, and equally bilateral chest movement Diagnosis: Chronic Lower Back Pain Paper Skin: cool and very sweaty, normal elasticity of skin Wounds: A Location: A Dressing: A Assessment: checked skin and patient is clear and free from skin breakdown Braden Score: __NA____
Medications Scheduled Meds: Cyclobenzaprine 5 mg x 3 daily, duloxetine 60 mg x 1 daily, tramadol 50 mg x 4-6 daily, and hydrocodone 5 mg/acetaminophen 325 mg x 4 daily (Elabd et al., 2016)
Nyquil 3 tablespoons a day for the cold and acetaminophen 500 mg x 4 daily, and sometimes I drink 1 cup of willow bark tea for the pain.
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| Recommendation | The patient should be educated about excessive use of medication (Selter et al., 2017).Diagnosis: Chronic Lower Back Pain Paper
Daily amounts of acetemetphen should be administered to the patient Medication reconciliation should be performed and interactions recognized between prescribed medications and additional over-the-counter and herbal medications taken by the patient at home (Searle et al., 2015). Also, students should calculate the maximum daily amount of over-the-counter analgesic medications, and educate the patient about pain medication management and safety at home.
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| References | Elabd, C., Centeno, C. J., Schultz, J. R., Lutz, G., Ichim, T., & Silva, F. J. (2016). Intra-discal injection of autologous, hypoxic cultured bone marrow-derived mesenchymal stem cells in five patients with chronic lower back pain: a long-term safety and feasibility study. Journal of translational medicine, 14(1), 253.
Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation, 29(12), 1155-1167. Selter, A., Tsangouri, C., Ali, S. B., Freed, D., Vatchinsky, A., Kizer, J., … & Estrin, D. (2018). An mHealth app for self-management of chronic lower back pain (Limbr): pilot study. JMIR mHealth and uHealth, 6(9), e179. |
Diagnosis: Chronic Lower Back Pain Paper