Question

KB, a 91 year old male presenting with a complaint of onset of acute back pain this AM, along with fever noted upon admission to the ER. HPI: The patient noted acute lower back pain today either when getting up from chair or getting into bed (he is unclear) early today. Tylenol at home and ice packs were not helpful and he was unable to ambulate or get out of bed. He was brought to the ER by Rescue. In the ER he was noted to be in acute pain as well as having a fever of 103 rectally. Full culture were done. He also had XRAY of the thoracic and lumbar spine. He was also admitted and discharged a week ago for change in mental status and diagnosed with pontine stroke. He was discharged home on noted medications as well as prednisone for ankle OA. He has a cough in the hospital but had improved in the last few days. The patient denies SOB or CP and also note no dysuria, N/V or diarrhea. He is admitted for the fever and r/o bactermia. (CXR pending). Current coverage with Vancomycin and Zosyn. Past Med Hist: Diabetes Mellitus, Arthritis, Transfusion history, GI bleeding (current admission), History of bleeding ulcers, Depression, Spinal stenosis, essential hypertension, Past Surg Hist: Back surg Joint replacement Total knee arthroplasty Foot surgry Proceedure: EGD (Esophagogastroduodenoscopy) with Biopsy. Open Laminectomy lumber 2/3 and L3-4 for spinal stenos Former smoker. Family hist: Cancer: brother Allergies: NSAIDS- avoid because of ulcer hx. Tylenol – Acetaminophen: Slight Itching Neurological: He is alert. Positive for weakness, Neg for dizziness. Sluggish and trouble to answer some questions, however he had 6 mg morphine prior to exam. V/S: BP 184/92 | Pluse 117 | Temp 39.1 C (102.4 F) (oral) | Resp 30 | Ht 5’ 10” | Wt 90.719 kg (200lb) IBM 28.70 kg/m2 | SpO2 92% Physical Exam: He appears well-developed and well-nourished, distressed. HENT: normal. Tachycardiac in 90-100 range. No stridor. No respiratory distress. No wheezes. He has rales (at the bases after 2 liters of fluid in the ER Labs: WBC: 9.04 RBC normal Hemo normal Mean Corpus Hgb normal Neutrophil% 92.4 40.0-70.0% Lymp 2.0 24.0-44.0% Monocyte 4.9 2.0-11.0% Eosin 0.1 1.0-4.0 Baso 0.3 0.0-2.0 Immature Granu 0.03 0.00-0.05 Eosin Absolute 0.01 0.12-0.30 Assessment: 1. Fever: full culture done and antibiotic started 2. Back pain: No findings on imaging studies. Might be secondary to infection elsewhere such as pneumonia. 3. DM2: Continue current meds 4. HTN: continue current meds Problem List: Epidural Abscess Resulved. Ankle inflammation (Right) Type 2 diabetes CVA Lumber Spinal stenosis Increase weakness when ambulating Essential hypertension Sinus pause Confusion GI bleeding due to NSAIDs Altered mental Status, unspecified. Osteomyelitis due to Staphylococcus aureusType 2 DM with hyperglycemia, without long term current use of insulin. Atelectasis Slow transit constipation CVA due to thrombosis of precerebral artery DVT Hypokalemia Soft tissue injury Hyperkalemia Fall risk Laminectomy defects are present at L2 -3 Levoscoliosis of the limber spine centered at L4-5. Findings: There remains edema within the L2 and L3 vertibral bodies as well as the Invertibral discs. There is stable moderate loss of tissue within the prevertebral soft tissues as well as the left psoas muscular tear L2-3 Facet hyperthophy as well as the epidural fluid collection remaining. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Nursing Assessment 20% • Demonstrate understanding of components of nursing assessment for this pt. 8 point. Clinical Understanding 30%. • Demonstrate through understanding of pt’s diagnoses, treatment and potential complications. 12 points Rarely, back pain is caused by a potentially serious spinal condition, such as infection, fracture, or tumor, or a disorder called cauda equina syndrome, which causes leg weakness and bowel or bladder dysfunction as well as back pain. Back pain that is associated with leg pain, numbness, or weakness can be due to a herniated disc or spinal stenosis. Plan of Care 20% • Outline a complete and effective plan of care for the pt. • Priority nursing diagnoses while caring for pt. • Also provide nursing diagnoses on admission. 8 points. = Professional Rules 20% • Demonstrates understanding of roles of professional team members. (roles of other professionals in care of the patient. (8 points). Assignment Instructions 10% • Follow all instructions in the assignment. (Including comprehensive responses to all questions related to the pt. (4 points) Sample comprehensive questions that she would expect responses from each one of us. Therefore, let prepare to answer them. 1. What first action should the nurse (you) take for this patient and what are the rationales for these actions. 2. For what clinical manifestations should you assess to correlate his acute back pain and fever 3. What nursing care should the nurse continue to provide (the role of the nurse during the management of this client’s condition)? 4. Prioritize nursing diagnoses and collaborative problems for this patient. 5. What potential complications are associated with this patient’s condition? 6. What patient education should the nurse provide?

Answer 1

1.

• Monitor level of consciousness and vital signs -These provide critical information needed to take lifesaving decisions and also to note the expected outcomes of the treatment modalities if provided
• Provide icepacks , open windows and maintain a cool environment and also an antipyretic prescribed by physician as temperature is 102.4F -Helps in reducing the temperature and maintain comfort.
• Provide oxygen therapy- As he was administered with inj .Morphine, and also enhance comfortable breathing pattern.
• Monitor fluid and electrolyte balances and intake&output chart- Helps in assessing whether patient body maintains a homeostasis environment and also fluid overload if present can be detected and also dehydration can be assessed.
• Provide him comfortable position- It helps in giving comfort , enhance rest, improve the general status of patient .

2. Temperature of 102.4 F, tachycardia 117 beats /min ,Neutrophil and lymphocytes count ,and his family history of cancer .He also has Depression, Spinal stenosis, may be prednisolone has caused back pain.Steroid usage affects not only the body but the mind as well. The mental effects of using the drug can be just as dangerous and even more serious than the side effects that are physical. There is a lot of emphasis on the physical changes associated with steroid usage, and the mental aspects of the drug use is often overlooked.(https://www.livestrong.com/article/321367-what-steroids-are-used-for-weight-loss/)

3.Monitor his vital signs, collect his blood culture and electrolyte reports, Perform a ECG, assess his intake and output, Continous close monitoring of 24 *7.

4.Acute pain related to degenerative changes , Hyperthermia related to infection, Imbalanced fluid and electrolyte imbalance related to pain

5.Cancer.septicemia