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NURS 479 Care Plan

Student: Sarai Valle Unit: Med Surg/Ortho Clinical Faculty: Professor: Sara King

Pt Initials: N.A. Age: 67 Gender: Male

Code Status: Full Code Allergies: Lisinopril

SECTION ONE: Background

(10 POINTS)
Date: Reason patient came to ED or hospital and chief complaints:
2/12/2024
The patient came into the the hospital to have an elective surgery for chronic lower
back pain that has been ongoing since 2019. This lower back pain has caused the pa-
tient’s legs to be affected, resulting in the patient having increased difficulty walk-
ing. This has worsened in the last six months. Patient has complained of difficulty
walking long to short distances.

Date: Admitting Diagnosis:

2/12/2024
Radiculopathy

Date: Why is your patient still hospitalized and what is the level of care (M/
S, ICU, Rehab, etc.) ?
2/12/2024
The patient is currently receiving med/surg level of care. He has complaints of new-
found tingling and numbness of his upper and lower bilateral extremities. He also
has been having a lot of pain post surgery.
Date(s): List all important past medical and surgical history:

Past Medical History:

Acute Back Pain with Sciatica
Bilateral Hearing Loss
Hemorrhoids
Kidney Stones
Hypertension
Pre-diabetes
S/P Epidural Steroid Injection
Osteoarthritis
Sleep Apnea

Surgical History:
Cholecystectomy, 2022
Colonoscopy, 2012

SECTION TWO: Pathophysiology

Must use, and correctly cite, two timely and credible sources. One source must be
your pathophysiology text.

(20 POINTS)
Disease Name: Radiculopathy
 1. What causes this condition?

Radiculopathy, specifically lumbar radiculopathy, is a degenerative process of the spinal column, and
it specifically affects middle aged men and women. The degenerative process begins for the men as
early as their 40s, and for females, this can begin as early as their 50s (Berry et al., 2019). Both fe-
males and males may have a degenerative process be accelerated with increased weight and through la-
borious jobs that requires usage of their back frequently. Furthermore, the degeneration process of the
spinal column can also result from chronic osteoarthritis, which can occur with more weight accumula-
tion that is being supported by the back. As the spinal column degenerates with time, this can cause for
spinal nerve root pain, and as a result, this can lead to leg pain, which can also eventually lead to mus-
cle weakness, numbness, tingling and decreased reflexes (Khorami et al., 2021).

2. What is happening at the tissue or cellular level to cause this problem?

With wear and tear over time through chronic inflammation and disc herniation, this can cause for in-
creased pressure and pain through the spinal column, or more specifically, the sacral region. With in-
creased weight or wear and tear, osteophytes form as abnormal growths to attempt to support the col-
umn, and this can result in either bone beginning to gradually become out of place, or this can also lead
to spinal stenosis, resulting in nerve compression at the roots. Chronic inflammation and disc hernia-
tion are the most common causes of radiculopathy (Samuelly-LeichTag, 2022 ).

3. What are the common s/s and clinical manifestations of this condition? Under-
line the s/s that your patient has.

The most common symptoms a patient may feel as a nerve is being compressed is lower back pain.
This pain can radiate down the legs, and this can affect the patient’s ability to be able to walk, resulting
in walking shorter distances. Furthermore, this pain can be described as an electric, burning or sharp
pain (Berry et al., 2019). The patient stated they were primarily experiencing a throbbing pain initially.
The throbbing pain continued after surgery, however as pain medication such as Oxycodone 10mg PO
q 4 hours was administered, the pain would gradually begin to become sore, and the patient also would
gradually begin to ambulate.
 4. What are potential complications of this condition?

If left untreated, this can be a leading cause for disability for patients, as patients may no longer be able
to ambulate as they initially had. This can also be debilitating for a patient as they may be impacted
with their ability to be able to go to the bathroom, and will also affect their quality of life of becoming
gradually more sedentary with time. Furthermore, without proper ambulation, this can also possibly
lead to muscle atrophy.

SECTION THREE: Diagnosis and Treatment

Must use and correctly cite two timely and credible sources. One source must
be one of your textbooks.
(25 POINTS)
1. Labs or tests used to diagnose this condition. Which ones did your pa-
tient get and what were the results? List all abnormal results.

Lab Normal Value Patient Result

Potassium (Initially) 3.6-5.0 mmol/L 3.0 mmol/L

Potassium (After Replace- 3.6-5.0 mmol/L 3.2 mmol/L

ment)

WBC 4.0-10.9 10^8 uL 11.8 10^8 uL

RBC 3.90-5.70 10^6 uL 4.80 10^6 uL

Hgb 13.5-18.0 g/dL 13.5 g/dL

Hct 40-52% 37.9%

MCV 80.0-98.0 fL 78.6 fL

Glucose 70-99 mg/dL 138 mg/dL

BUN 8.4-25.7 mg/dL 20.3 mg/dL

 SECTION THREE: Diagnosis and Treatment
Must use and correctly cite two timely and credible sources. One source must
be one of your textbooks.
(25 POINTS)
1. Labs or tests used to diagnose this condition. Which ones did your pa-
tient get and what were the results? List all abnormal results.

Lab Normal Value Patient Result

Potassium (Initially) 3.6-5.0 mmol/L 3.0 mmol/L

Potassium (After Replace- 3.6-5.0 mmol/L 3.2 mmol/L

ment)

Creatinine 0.7-1.2 mg/dL 1.2 mg/dL

eGFR > 60 mL/min/1.73 m^2 > 60 mL/min/1.73 m^2

Phosphorous 2.4-2.7 mg/dL 2.8 mg/dL

Magnesium 1.6-2.6 mg/dL 1.8 mg/dL

Test: Results:

FL OR Spine Limited Fluoroscopic Captures

SECTION THREE: Diagnosis and Treatment (cont.)

 2. Expected treatments or medications – Current best practice according to
literature (cited). Is your patient receiving this treatment(s)? Include all
medications used to treat conditions.

Treatments: Previously since 2019, the patient has tried multiple treatments for condi-
tion such as massage therapy, epidural heat, spine exercises, steroid injec-
tions, and transcutaneous electrical nerve stimulation unit (TENS unit).
As many other conditions, non invasive treatment methods are trialed first
prior to attempting to attempt more invasive procedures. The first line of
treatment involves for the patient to remain active and to educating about
the ramifications of a sedentary lifestyle. Furthermore, promotion of activ-
ity is essential, and specifically performing exercises such as the McKen-
zie exercises of extensions has been promoted for lower back pain (Berry
et al., 2019). When this fails, patients would then try epidural steroid injec-
tions with a combination of a steroid and anesthetic, or also spinal injec-
tions.
When non surgical interventions do not work, the patient may be offered
by their provider to have an elective spinal surgery. The surgical interven-
tions can range from a diseconomy, serving as the gold standard for treat-
ment or it can also range involve lumbar fusion for treatment. Surgical in-
tervention is not considered until 8 weeks of non surgical interventions has
been trialed (Berry et al., 2019).

Medications:
For medication interventions, NSAIDS are recommended for patients to
manage both the pain and the inflammation where the area of discomfort is
occurring (Berry et al., 2019). Steroid injections will also include anti-in-
flammatory properties if a patient elects to receive injections.

SECTION FOUR: Plan of Care

(30 Points)
 List Patient’s Top Five Priority Problems (in order of priority)

1. Pain Control
2. Fluid/Electrolye Balance
3. Ambulation
4. Bowel Movements
5. Blood Pressure Management

Priority Nursing Problem # 1:

After a spinal surgery, it is important to be able to manage pain for a patient, especially as once
the effects of anesthesia begins to wear off, and the patient’s pain levels will increase. With un-
controlled pain levels, this can affect other areas of the body such as patient’s anxiety increas-
ing, and the patient may have little to no desire to ambulate alongside with elevated blood pres-
sure.
Indications for choosing this as Priority Nursing Problem #1:

It is typical for a patient to experience pain and discomfort, especially after an invasive surgical
procedure. Pain needs to be controlled in order for the patient to begin early ambulation. Fur-
thermore, as pain becomes better managed and if the patient is able to gradually wean off pain
medications, this will also promote for the patient to be able to return to normal function, and
the patient will also be closer to discharge. Finally, it is important to distinguish pain between
pain resulting from nerve damage and also pain that could also be potentially caused from pos-
sible infection, especially if the pain may be resulting from a possible surgical site infection.
Pain monitoring alongside surgical dressing assessments is key.

Based on the Patient’s Current Condition, What is a Potential Complication for

Priority Nursing Problem #1:

The patient is currently ambulating from the bedside to the bathroom and shuffling movements
has improved. He has also been able to walk the halls currently with a front wheel walker, gait
belt, and a stand by assist. If the pain remained uncontrolled and worsened, this could result in
the patient not ambulating, possibly increasing their dosage of pain medications, which could
also result in constipation, and the patient may be at risk for other complications when not
moving from the bed such as potential pressure ulcers, or bowel/urinary concerns.

Priority Nursing Interventions for Nursing Problem # 1:

 Assess/Monitor
1. Assess type of pain patient is experiencing
alongside contributing factors such as lack of
movement, constipation
2. Assess the response to pain and know char-
acteristics such as is it sharp, burning, throb-
bing
3. Ask the patient what patient does to allevi-
ate pain in the past or preference for pain con-
trol
Therapeutic
1. Non-pharmalogical interventions such
as deep breathing, aromatherapy
2. Promote Ambulation
3. Bowel Care if patient complains of
constipation and this is worsening the
pain
4. Medications such as opioids or
NSAIDS

4. Assess/monitor vital signs 5. Therapy exercises that are recom-

mended.
5. Monitor lab values, such as possible infec-
tion causes that may have occurred

Priority Nursing Problem #2: Patient has current complains of numbness and tingling.
While the patient may have some nerve damage from the surgery, and the nerves are attempt-
ing to heal, the patient has a low potassium of 3.0, which is below the normal and therefore is
at risk for hypokalemia manifestations. The patient also previously had low phosphorous.

Indications for Choosing this as Priority Nursing Problem # 2: Numbness and tin-
gling of both lower and upper extremities may discourage the patient to begin early ambula-
tion, and could also be a potential sign for another serious condition such as hypokalemia or
permanent nerve damage, especially if the nerves specifically going to the extremities could
have been damaged to the point the patient may have issues with trying to grasp and also am-
bulation.

Based on the Patient’s Current Condition, What is a Potential Complication for

Priority Nursing Problem #2: The patient is currently taking blood pressure medications
such as Volsartan, Amlodipine, and Chlorthalidone. Patient’s diuretic may have also been a
contributor to the patient developing hypokalemia alongside having lower phosphorous levels.
With hypokalemia, the patient is at increased complication for muscle weakness, and this can
also affect muscles such as the muscles used for respiration (Castro and Sharma, 2023). Fur-
thermore, prolonged hypokalemia can cause cardiac dysthymias alongside renal impairment.

Priority Nursing Interventions for Priority Nursing Problem # 2:

 Assess/Monitor Therapeutic
1. Monitor for respirations and lung as- 1. Potassium Replacement based on or-
sessment. Also perform near checks. der

2. Cardiac Assessment/Telemetry 2. Encourage consumption of potassium

3. Bilateral Upper/Lower Extremity As-
sessment
4. Monitor Potassium Levels
5. Abdominal Assessment, including lis-
tening to bowel sounds and monitor for
urinary output
to be included in diet. Patient is on a reg-
ular diet.
3. Dietician Consult
4. Monitor input/output and encourage
patient to also observe if there have been
changes to bowel/urinary movements
5. Encourage early ambulation with
stand by assist

SECTION FIVE: Integrative Therapy, Education, and Referrals

(10 Points)
Describe the Integrative Nursing Modality used on your patient and why this
therapy was selected: (Deep breathing used to increase O2 saturations is not using
a Integrative Nursing Therapy)
For the following patient, empathetic listening was utilized. The patient had brief visits from
his family, but for the most part, he was alone in the room and did not use his cell phone much.
Empathetic listening is important for all patients, however empathetic, and attentive listening
was beneficial for this patient as the patient’s anxiety and pain levels were reduced while in the
hospital setting. I would spend at least 20 minutes in the room alongside with my nurse to
speak with this patient and address the patient’s needs. Patient also gradually showed motiva-
tion and desire to be able to ambulate in the hall ways. At first, he was nervous about not want-
ing to ask too much from the nurses, however as the relationship was established between the
patient and my preceptor and myself, the patient became more comfortable and motivated to
asking if he could get assistance to being able to walk around the halls. He further also ex-
pressed motivation to be able to discharge the following day. Through establishing rapport with
the patient and attentive listening, empathetic listening reinforces cooperation towards dis-
charging, and as a result can also increase patient satisfaction (Moudatsou et al., 2020).
 List two educational interventions you completed with your patient:

As the patient’s electrolytes were lower in combination with the surgery and patient’s prior his-
tory of taking an anti-diuretic, the patient was educated on the purpose of taking potassium and
phosphorous. Patient also expressed surprise at how he did not know we had phosphorous in
our bodies and he expressed appreciation. Writer was able to explain possible cause of patient’s
manifestations of numbing and tingling may also be caused due to low potassium.

Patient was also educated on importance of ambulation as the patient’s pain could also be re-
duced if patient is able to ambulate in integrals throughout the day. Staying in bed for long pe-
riods of time can potentially worsen the patient’s pain levels alongside with possibly delay dis-
charge as well.

List required referrals to two allied health services and/ or community re-
sources: (Physicians are not allied health services)

Physical therapy is an allied health service that could assist with patient in ambulation im-
provements and they can also teach the patient further about how to continue to maintain spinal
precautions and what exercises could be performed to maintain better alignment of his back.

Nutrition may also be beneficial for this patient as the patient is currently on a diuretic that
causes for electrolyte imbalances to occur. Finding foods that can replenish electrolytes such as
potassium will be beneficial in order to prevent chronic electrolyte imbalances.

SECTION SIX: APA 7th ed. References

(5 Points)

Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy,

Diagnosis, and Treatment. Cureus, 11(10), e5934. https://doi.org/10.7759/cureus.5934

Castro D. & Sharma, S. Hypokalemia. (2023). In: StatPearls [Internet]. Treasure Island (FL):

StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK482465/
Khorami, A. K., Oliveira, C. B., Maher, C. G., Bindels, P. J. E., Machado, G. C., Pinto, R. Z.,

Koes, B. W., & Chiarotto, A. (2021). Recommendations for Diagnosis and Treatment of

Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines. Jour-

nal of clinical medicine, 10(11), 2482. https://doi.org/10.3390/jcm10112482

Moudatsou, M., Stavropoulou, A., Philalithis, A., & Koukouli, S. (2020). The Role of Empathy

in Health and Social Care Professionals. Healthcare (Basel, Switzerland), 8(1), 26.

https://doi.org/10.3390/healthcare8010026

Samuelly-Leichtag, G., Eisenberg, E., Zohar, Y., Andraous, M., Eran, A., Sviri, G. E., & Key-

nan, O. (2022). Mechanism underlying painful radiculopathy in patients with lumbar disc

herniation. European journal of pain (London, England), 26(6), 1269–1281.

https://doi.org/10.1002/ejp.1947