ihuman9
Primary Diagnosis:
Status/Condition: Stable
Code Status: Full
Allergies: NKDA/NKFA
Admit to Unit: Will treat as outpatient
Activity Level: . May have bedrest 24 hours with medication then star
...
ihuman9
Primary Diagnosis:
Status/Condition: Stable
Code Status: Full
Allergies: NKDA/NKFA
Admit to Unit: Will treat as outpatient
Activity Level: . May have bedrest 24 hours with medication then start light activity. Rest helps with swelling and gives your back time to heal. More than 2 days will cause your joints and muscles to stiffen. Then continue as tolerated with light to moderate activity
Diet: Low sodium
IVF (if ordered, include type and rate ): N/A
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol): N/A
Respiratory: 0xygen (if ordered, include type and rate), pulmonary toilet needs, ventilator settings: N/A
Medications: (include ALL, tx of primary condition, underlying conditions, pain, comfort needs etc. dose and route)
Continue home medications
Tylenol 650 mg PO Q6H. Max of 3000 mg/day for pain
Diclofenac 100 mg PO BID PRN for pain
Robaxin 500 mg PO QID. May take 1-2 tabs Q6H as needed for muscle spams
D/C home dose of Prednisone and start Prednisone 30 mg taper
Day 1: 30 mg divided as 10 mg before breakfast, 5 mg at lunch, 5 mg at dinner, 10 mg at bedtime
Day 2: 5 mg at breakfast, 5 mg at lunch, 5 mg at dinner, 10 mg at bedtime
Day 3: 5 mg 4 times daily (with meals and at bedtime)
Day 4: 5 mg 3 times daily (breakfast, lunch, bedtime)
Day 5: 5 mg 2 times daily (breakfast, bedtime)
Day 6: 5 mg before breakfast
Lansoprazole 15 mg PO every day for GI prophylaxis
Singular 10 mg PO every day for asthma
Capsaicin topical 0.025% Apply small amount to right leg 3 times a day as needed for leg pain. Please use gloves.
Nursing Orders: vital signs, skin care, toileting, ambulation etc.- N/A
Follow Up Lab tests : N/A
Diagnostic testing (CXR, US, 2D Echo, etc…) Include indication for test, for example CXR to evaluate pneumonia): N/A
Consults: [Do not defer management to a specialist. As an ACNP you must manage the patient’s acute needs for at least a 24 hour period]. Include indication for consult, for example “Cardiology consult for evaluation of new-onset atrial fibrillation., or Nutrition consult for TPN recommendations.”
May need to refer for physical therapy if no improvement within the next 4 weeks for treatment of persistent pain. May consider earlier since patient is at risk for developing chronic back pain due to age, job, and history of osteoporosis.
May need orthopedic referral if physical therapy is unsuccessful
Patient Education and Health Promotion (address age appropriate patient education if applicable):
Continue smoking cessation
May alternate using ice and heat.
Light duty activates- no lifting greater than 10 pounds, light walking if tolerated. May increase activity as pain is decreasing
Practice good body mechanics
Will provide patient with some exercises for home
Discharge planning and required follow-up care:
Follow up in clinic in 14 days
Return to clinic if pain does not get any better within 5 days, symptoms such as numbness of both lower extremities, fever, loss of bowel or bladder start
References (minimum of 3, timely, that prove this plan follows current standard of care).
Discogenic low back pain Treatment Approach - Epocrates Online. (2018). Retrieved from https://online.epocrates.com/diseases/19041/Discogenic-low-back-pain/Treatment-Approach
Knight, C., Deyo, R., Steiger, T., & Wipf, J. (2017). UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-acute-low-back-pain
Levin, k., Hsu, P., Armon, C. (2018). Acute lumbosacral radiculopathy: Treatment and prognosis. Retrieved from https://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-treatment-and-prognosis?topicRef=7780&source=see_link#H93636885
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