KB, a 91 year old male present
KB, a 91 year old male presenting with a complaint of onset ofacute back pain this AM, along with fever noted upon admission tothe ER. HPI: The patient noted acute lower back pain today eitherwhen getting up from chair or getting into bed (he is unclear)early today. Tylenol at home and ice packs were not helpful and hewas unable to ambulate or get out of bed. He was brought to the ERby Rescue. In the ER he was noted to be in acute pain as well ashaving a fever of 103 rectally. Full culture were done. He also hadXRAY of the thoracic and lumbar spine. He was also admitted anddischarged a week ago for change in mental status and diagnosedwith pontine stroke. He was discharged home on noted medications aswell as prednisone for ankle OA. He has a cough in the hospital buthad improved in the last few days. The patient denies SOB or CP andalso note no dysuria, N/V or diarrhea. He is admitted for the feverand r/o bactermia. (CXR pending). Current coverage with Vancomycinand Zosyn. Past Med Hist: Diabetes Mellitus, Arthritis, Transfusionhistory, GI bleeding (current admission), History of bleedingulcers, Depression, Spinal stenosis, essential hypertension, PastSurg Hist: Back surg Joint replacement Total knee arthroplasty Footsurgry Proceedure: EGD (Esophagogastroduodenoscopy) with Biopsy.Open Laminectomy lumber 2/3 and L3-4 for spinal stenos Formersmoker. Family hist: Cancer: brother Allergies: NSAIDS- avoidbecause of ulcer hx. Tylenol – Acetaminophen: Slight ItchingNeurological: He is alert. Positive for weakness, Neg fordizziness. Sluggish and trouble to answer some questions, howeverhe 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 appearswell-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 inthe ER Labs: WBC: 9.04 RBC normal Hemo normal Mean Corpus Hgbnormal Neutrophil% 92.4 40.0-70.0% Lymp 2.0 24.0-44.0% Monocyte 4.92.0-11.0% Eosin 0.1 1.0-4.0 Baso 0.3 0.0-2.0 Immature Granu 0.030.00-0.05 Eosin Absolute 0.01 0.12-0.30 Assessment: 1. Fever: fullculture done and antibiotic started 2. Back pain: No findings onimaging studies. Might be secondary to infection elsewhere such aspneumonia. 3. DM2: Continue current meds 4. HTN: continue currentmeds Problem List: Epidural Abscess Resulved. Ankle inflammation(Right) Type 2 diabetes CVA Lumber Spinal stenosis Increaseweakness when ambulating Essential hypertension Sinus pauseConfusion GI bleeding due to NSAIDs Altered mental Status,unspecified. Osteomyelitis due to Staphylococcus aureusType 2 DMwith hyperglycemia, without long term current use of insulin.Atelectasis Slow transit constipation CVA due to thrombosis ofprecerebral artery DVT Hypokalemia Soft tissue injury HyperkalemiaFall risk Laminectomy defects are present at L2 -3 Levoscoliosis ofthe limber spine centered at L4-5. Findings: There remains edemawithin the L2 and L3 vertibral bodies as well as the Invertibraldiscs. There is stable moderate loss of tissue within theprevertebral soft tissues as well as the left psoas muscular tearL2-3 Facet hyperthophy as well as the epidural fluid collectionremaining.XxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxNursing Assessment 20% • Demonstrate understanding of components ofnursing assessment for this pt. 8 point. Clinical Understanding30%. • Demonstrate through understanding of pt’s diagnoses,treatment and potential complications. 12 points Rarely, back painis caused by a potentially serious spinal condition, such asinfection, fracture, or tumor, or a disorder called cauda equinasyndrome, which causes leg weakness and bowel or bladderdysfunction as well as back pain. Back pain that is associated withleg pain, numbness, or weakness can be due to a herniated disc orspinal stenosis. Plan of Care 20% • Outline a complete andeffective plan of care for the pt. • Priority nursing diagnoseswhile caring for pt. • Also provide nursing diagnoses on admission.8 points. = Professional Rules 20% • Demonstrates understanding ofroles of professional team members. (roles of other professionalsin care of the patient. (8 points). Assignment Instructions 10% •Follow all instructions in the assignment. (Including comprehensiveresponses to all questions related to the pt. (4 points) Samplecomprehensive questions that she would expect responses from eachone of us. Therefore, let prepare to answer them. 1. What firstaction should the nurse (you) take for this patient and what arethe rationales for these actions. 2. For what clinicalmanifestations should you assess to correlate his acute back painand fever 3. What nursing care should the nurse continue to provide(the role of the nurse during the management of this client’scondition)? 4. Prioritize nursing diagnoses and collaborativeproblems for this patient. 5. What potential complications areassociated with this patient’s condition? 6. What patient educationshould the nurse provide?
- Monitor level of consciousness and vital signs -These providecritical information needed to take lifesaving decisions and alsoto note the expected outcomes of the treatment modalities ifprovided
- Provide icepacks , open windows and maintain a cool environmentand also an antipyretic prescribed by physician as temperature is102.4F -Helps in reducing the temperature and maintaincomfort.
- Provide oxygen therapy- As he was administered with inj.Morphine, and also enhance comfortable breathing pattern.
- Monitor fluid and electrolyte balances and intake&outputchart- Helps in assessing whether patient body maintains ahomeostasis environment and also fluid overload if present can bedetected 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 hascaused back pain.Steroid usage affects not only the body but themind as well. The mental effects of using the drug can be just asdangerous and even more serious than the side effects that arephysical. There is a lot of emphasis on the physical changesassociated with steroid usage, and the mental aspects of the druguse is oftenoverlooked.(https://www.livestrong.com/article/321367-what-steroids-are-used-for-weight-loss/)
3.Monitor his vital signs, collect his blood culture andelectrolyte reports, Perform a ECG, assess his intake and output,Continous close monitoring of 24 *7.
4.Acute pain related to degenerative changes , Hyperthermiarelated to infection, Imbalanced fluid and electrolyte imbalancerelated to pain