medsurg11 exam 2 study guide.

CHAPTER 41 MANAGEMENT OF PATIENT WITH MUSCULOSKELETAL DISORDERS Low Back Pain Generally, back pain due to musculoskeletal disorders is aggravated by activity, whereas pain due to other conditions is not. Pathophysiology Vertebrae- rigid units intervertebral discs- flexible units Obesity, postural problems, structural problems, and overstretching of the spinal supports may result in back pain The lower lumbar discs, L4–5 and L5–S1, are subject to the greatest mechanical stress and the greatest degenerative changes. A young person’s discs are mainly fibrocartilage with a gelatinous matrix Clinical Manifestations acute back pain (lasting fewer than 3 months) chronic back pain (3 months or longer without improvement) and fatigue radiculopathy-pain radiating from a diseased spinal nerve root or radiating down the legs sciatica- pain radiating from an inflamed sciatic nerve paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) Assessment and Diagnostic Findings The presence of bruising, older age and prolonged use of glucocorticoid medications increases the risk of a fracture posttraumatic injury The diagnostic procedures are contraindicated in suspected spinal infection, severe neurologic weakness, urinary or fecal incontinence, and a new onset of back pain in a patient with cancer Diagnostic Procedures for Low Back Pain X-ray of the spine: may demonstrate a fracture, dislocation, infection, osteoarthritis, or scoliosis Bone scan and blood studies: may disclose infections, tumors, and bone marrow abnormalities Computed tomography (CT) scan: useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral discs Magnetic resonance imaging (MRI) scan: permits visualization of the nature and location of spinal pathology Electromyogram (EMG) and nerve conduction studies: used to evaluate spinal nerve root disorders (radiculopathies) Myelogram: permits visualization of segments of the spinal cord that may have herniated or may be compressed (infrequently performed; indicated when MRI scan is contraindicated) Ultrasound: useful in detecting tears in ligaments, muscles, tendons, and soft tissues in the back Medical Management Most back pain is self-limited and resolves within 4 to 6 weeks with analgesics, rest, and avoidance of strain Management focuses on relief of discomfort, activity modification, and patient education acute low back pain- nonsteroidal anti-inflammatory drugs (NSAIDs) short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) chronic low back pain- Tricyclic antidepressants (e.g., amitriptyline [Elavil]) serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta]) radiculopathy pain - atypical anticonvulsant medications (e.g., gabapentin [Neurontin] Systemic corticosteroids and acetaminophen (Tylenol) are not effective in alleviating low back pain nonpharmacologic interventions thermal applications (hot or cold) spinal manipulation (e.g., chiropractic therapy) Lumbar support belts are not recommended to treat acute low back pain but effective in preventing low back pain in occupational health settings Orthopedic shoe inserts are not recommended for prevention, Cognitive-behavioral therapy (e.g., biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga are all effective nonpharmacologic interventions for treating chronic low back pain The patient is taught to change position frequently Sitting should be limited to 20 to 50 minutes based on level of comfort Conditioning exercises for both back and trunk muscles are begun after about 2 weeks to help prevent recurrence of pain. Nursing Assessment During the interview, the nurse observes the patient’s posture, position changes, and gait. Often, the patient’s movements are guarded, with the back kept as still as possible The patient should be directed to a chair of standard seat height with arms for support. The patient may sit and stand in an unusual position, leaning away from the most painful side The nurse palpates the paraspinal muscles and notes spasm and tenderness prone position- relax the paraspinal muscles and any deformity caused by spasm can subside assessing deep tendon reflexes, sensations (e.g., paresthesia), and muscle strength. straight-leg raising with the patient supine, the patient’s leg is lifted upward with the knee extended suggests nerve root involvement. Nursing Management nursing goals is relief of pain, improved physical mobility, the use of back-conserving techniques of body mechanics, improved self-esteem, and weight reduction As the acute pain subsides, medication dosages are reduced. The nurse cautions the patient with severe pain not to remain on bed rest because extended periods of inactivity are not effective and result in deconditioning. A medium to firm, nonsagging mattress (a bed board may be used) is recommended