Walden University - NURS 6560 ihuman9_100% Correct.

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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 [Show More]

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