Lower Back Pain(2)(1)
description
Transcript of Lower Back Pain(2)(1)
Lower Back Pain
Objectives
• At the end of the session the student will be enabled to:• Discuss with understanding risk factors for lower
back injury• Demonstrate theoretical knowledge of nursing
and collaborative care management – diagnosis and treatment.• Describe patient teaching requirements in
managing and preventing further injury
Etiology & Pathophysiology
• Common b/c lumbar region• Bears most of the weight of body• Is the most flexible region of spinal column• Contains nerve roots that are vulnerable to
injury or disease• Has an inherently poor biomechanical
structure
Risk factors
• Lack of muscle tone• Excess body weight•Poor posture•Cigarette smoking• Stress•Prolonged periods of seating•Repetitive heavy lifting•Vibration
Causes of musculoskeletal problems
•Acute lumbosacral strain• Instability of lumbosacral bony
mechanism•Osteoarthritis of lumbosacral
vertebrae•Degenerative Disk Disease (DDD)•Herniation of intervertebral disk
Acute Lower Back Pain
• Lasts 4 weeks or less• Symptoms do not appear at time of
injury but develop later b/c of gradual ↑ pressure on the nerve by an intervertebral disk• Straight-Leg Raise Test• (+) Disk herniation when radicular pain
occurs while lifting the leg in supine position
Outpatient Treatment
• Analgesics (e.g. NSAIDs)•Muscle relaxants (e.g. Flexeril)•Massage & back manipulation• Alternating use of heat & cold compresses• Opioid analgesics for severe pain• Brief period of rest (1-2 days) but avoid
prolonged bed rest• Refrain from activities that aggravate the
pain
Outpatient management
• Analgesics (e.g. NSAIDs)•Muscle relaxants (e.g. Flexeril)•Massage & back manipulation• Alternating use of heat & cold compresses• Opioid analgesics for severe pain• Brief period of rest (1-2 days) but avoid
prolonged bed rest• Refrain from anything that aggravates the
pain
Subjective data • Previous health history • Pain – anything which aggrevates it or relieves it • Sleep rest pattern• Exercise • Elimination• Occupation • Change in role within family
Objective Data
• Guarded movement• Depressed or absent Achilles tendon reflex• Patellar tendon reflex• (+) Straight-Leg Raise Test•↓ ROM of spine• Tense, tight paravertebral muscles on
palpation
Teaching advice -DOs• Prevent lower back from straining forward by placing
a foot on a step or stool during prolonged standing• Sleep in a side-lying position with knees & hips bent• Sleep on back with a lift under knees & legs or on
back with 10-inch-high pillow under knees to flex hips & knees• Exercise 15 minutes in the morning & evening
regularly• Carry light items close to body• Maintain appropriate body weight• Use local heat & cold application• Use a lumbar roll or pillow for sitting
Teaching Advice – Do nots
• Lean forward without bending knees• Lift anything above level of elbows• Stand in one position for prolonged time• Sleep on abdomen or on back or side with legs
out straight• Exercise without consulting health care provider
if having severe pain
Chronic Back Pain
• Lasts more than 3 months or is a repeated incapacitating episode • Causes• Degenerative Disk Disease (DDD)• Lack of physical exercise• Prior injury• Obesity• Structural abnormalities• Systemic disease
Spinal Stenosis
• Narrowing of vertebral canal or nerve root canals caused by movement of bone into the space• Compression of nerve roots result w/
subsequent disk herniation• Pain starts in low back & radiates to
buttock/leg•Worsens w/ walking or standing
Treatment
• Formal back pain program• Rest & local heat application when cold, damp
weather aggravates back pain• Mild analgesics to ↓ pain & stiffness• Weight reduction• Sufficient rest periods• Local heat & cold application• Exercise & activity throughout day• Antidepressants – Pain relief & sleep problems• Epidural corticosteroid injections
Surgical intervention indicated If: •Not responding to conservative
treatment•Patient is in consistent pain•Persistent neurologic deficit•Acute intervertebral disc protrusion
which requires immediate removal
Clinical manifestation• Low back pain• Radicular pain that radiates down buttock & below knee,
along distribution of sciatic nerve• Positive Straight-Leg Raising Test• Depressed/Absent Reflexes• Paraesthesia or muscle weakness• Multiple nerve root (Cauda Equina) compression may be
manifested as bowel & bladder incontinence or impotence (medical emergency)
• Cervical Disk Damage -Radicular pain radiating into the arms & hands, ↓Reflexes & weakness in hand grips
Subjective Pain Affective reflex
Motor function Sensation
L3-L4 Back to buttocks to posterior thigh and inner calf
Patella Quadriceps Anterior tibialis
Inner aspect of lower leg anterior part of thigh
L4 –L5 Back to buttocks to dorsum of foot and big toe
None Anterior tibialis extensor hallucis longus, gluteus medius
Dorsum of foot and big toe
L5 –S1 Back to buttocks to sole of foot and heel
Achilles Gastrocnemius, hamstring, gluteus maximus
Heel and lateral foot
Surgical Treatments
Laminectomy
Spinal Fusion
Intradiscal Electrothermoplasty (IDET)
Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty)
Interspinous Process Decompression System (X Stop)
Diskectomy
Percutaneous Laser Diskectomy
Nursing Management Post Operative • Maintain proper alignment of spine • Pillows under thighs of each leg when supine & between legs
when side-lying• Fears of any movement that increases pain• Sufficient staff should be available to move patient• Opioids for 24 to 48 hours w/ patient-controlled analgesia
(PCA) pumps• Once fluids are being taken, switch to oral drugs & possible
muscle relaxant (e.g. Valium)
Post Operative • Check for cerebrospinal fluid (CSF) leakage• Severe headaches• Monitor peripheral neurologic signs of extremities • Extremity circulation should be assessed by
temperature, capillary refill, & pulses• Repeat assessments q2-4 hours during first 48 hours
post surgery• Paresthesias may not be immediately relieved after
surgery• Note new muscle weakness or paresthesias & report
to surgeon• Paralytic Ileus
Post operative Care
• Altered bladder emptying• Use commode or ambulate to bathroom when
allowed• Ensure patient privacy
• Intermittent catheterization or indwelling catheter may be necessary• Patient usually ambulates as early in
postoperative period• Before discharge home will be assessed on the
stairs and will need to pass urine normally
Spinal fusion & bone graft
• Longer recovery time• Rigid Orthosis (thoracic-lumbar-sacral brace)
used• Teach patient preferred way to put on & take off
brace• Logrolling• Sitting or standing and mobility• Posterior iliac crest most common donor site
Class question • A 42 year old man with a large herniated disc at L4/5 has
been admitted to your ward he is diaphoretic, pale and clammy and in severe pain. On questioning it appears he has not passed urine in the last 24 hours. You have t prepare him to go for surgery in the morning
• What are your nursing priorities? • What is the nursing diagnosis?• Planning/ Goal setting • Implementation