intervetebral disc

causes of low back pain

- acute low back strain - instability - osteoarthritis - intervetebral disk degeneration - herniation of the intervetebral disk

lumbar region

- bears most weight of the body - most flexible region of spinal column - contains nerve roots that are vulnerable to injury or disease - poor biomechanical structure

diagnostic tests

- conventional x rays - myelogram - MRI, CT scan - epidural venogram or discogram - electromyogram

herniated intervetebral disk (slipped disk)

- intervetebral disk is interposed between the adjacent surfaces of vertebral bodies from the cervical axis to the sacrum - result of natural degeneration with age or repeated stress and trauma to spine - most common sites L4-5 and L5-S1 (may also happen at C5-6 and C6-7) - herniation could also be result of spinal stenosis

acute low back pain

- lasts 4 weeks or less - associated with some type of activity that causes undue stress - symptoms may not appear right away - muscles get tight or spasm

clinical manifestations of herniated intervertebral disk

- low back pain - positive straight leg test - reflexes may be depressed or absent - paresthesia or muscle weakness - bowel and bladder incontinence or impotence

post op implementation for cervical disk

- maintain proper alignment of the spine (wear c collar, log roll) - monitor vital signs and pain - monitor for respiratory difficulty - encourage coughing and deep breathing - monitor for hoarseness and inability to cough effectively - monitor wound drainage - check for CSF - monitor for sudden radicular pain

degenerative disk disease (DDD)

- narrowing and lessening of the intervetebral disks - progressive degeneration = normal process of aging - thinning of disk occurs as the nucleus pulposus dries out and shrinks - compression of the nerve roots and cord may occur - nuclear material may herniate and compress on the nerve root

chronic low back pain: spinal stenosis

- narrowing of the vertebral canal or nerve root canals - caused by encroachment of bone in the space - may be congenital or acquired thru degenerative or traumatic changes in the spine

overall goals

- satisfactory pain relief - avoid constipation - learn back sparing practices - return to normal acitivites

diagnostics

- straight leg raises positive = pain with leg lifted to 30-70 degrees = nerve root compression and likely herniated disc - CT and MRI scans

intervetebral lumbar disc damage

- structural degeneration of the lumbar disk is often caused by degenerative disk disease (DDD) - acute herniated intervetebral disk

A client attempting to get out of bed stops midway because of low back pain radiating down to the right heel and lateral foot. What should the nurse do in order of priority from first to last? All options must be used. 1. apply a warm compress to the clients back 2. notify the physician 3. assist the client to lie down 4. administer the prescribed celecoxib

3. Assist the client to lie down 1. apply a warm compress to the client's back 4. administer the prescribed celecoxib 2. notify the physician

implementation with cervical neck strain or sprain

Conservative treatment with no underlying disorder (immobilization with cervical collar) - heat and ice applications - massage, exercises - rest until symptoms improve - physical therapy - ultrasound - analgesics - NSAIDS

pain medications r/t back surgery/back pain

Opiod pain medications - hydrocodone/acetaminophen - oxycodone/acetaminophen - codeine/acetaminophen NSAIDS - ibuprofen Muscle relaxants - diazepam Narcan

care of acute low back pain

Outpatient treatment: - analgesics: NSAIDS - Muscle relaxants: Flexeril, Soma - Application of heat or cold - massage and back manipulation - rest with normal activities but avoid bending, twisting, or prolonged sitting - invasive treatments

occupations associated with back pain

RN's still in top 10 - nursing aides, orderlies, and attendants - truck drivers - laborers - janitors - assemblers - construction laborers - RN - superviors and propreitors - cashiers - stock handlers and baggers

which of the following individuals would be at high risk for low back pain? (select all that apply) a. 65 year old man who is a long distance truck driver b. an aerobics instructor who is 5'6 and weighs 120 lb c. 25 year old nurse who works in the newborn nursery d. an 18 year old 6'2 football player who weighs 260 lb

a. 65 year old man who is a long distance truck driver d. 18 year old 6'2 football player who weighs 260 lb

the client is 12 hours post lumbar laminectomy. which nursing interventions should be implemented? a. assess ability to void and log roll every two hours b. medicate with IV steroids and keep the bed in a trendelenburg position c. place sand bags on each side of the head and give cathartic medications d. administer IV anticoagulants and place on O2 at eight L/min

a. assess ability to void and log roll every two hours

for a patient following a diskectomy, the nurse should a. place a pillow between the patient's legs before turning to the side b. elevate the head of the bed 3 degrees and then turn the patient to the side c. ask the patient to flex the knees and push the heels into the bed during turning d. have the patient grasp the side rail on the opposite side of the bed to help with turning

a. place a pillow between the patient's legs before turning to the side

outpatient clinic complaining of numbness and pain radiating down the left leg. which other data would the nurse assess? a. posture and gait b. bending and stooping c. leg lifts and arm swing d. waist twists and neck mobility

a. posture and gait

intervention

aimed at strengthening the supporting muscles by exercise

acute interventions

assist patient to: - maintain activity limitations - promote comfort - educate about back health - teach appropriate back exercises - use of analgesics and muscle relaxants

the client diagnosed with cervical neck disk degeneration has undergone a laminectomy. which interventions should the nurse implement? a. position the client prone with the knees slightly elevated b. assess the client for difficulty speaking or breathing c. measure the drainage in the jackson pratt bulb every day d. encourage the client to postpone the use of narcotic medications

b. assess the client for difficulty speaking or breathing

which of the following assessments should alert the nurse to the development of a possible complication? a. lateral rotation of the head and neck b. clear yellowish fluid on the dressing c. use of the standing position to void d. nonproductive cough

b. clear yellowish fluid on the dressing

which of the following is controlled? a. muscle spasms b. nausea c. shivering d. dry mouth

b. nausea

which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 a. prone b. supine with the legs flexed c. high fowler's d. right sims

b. supine with the legs flexed

in caring for a patient after a spinal fusion, which patient symptom would the nurse immediately report to the physician? a. the patient experiences a single episode of emesis b. the patient is unable to move the lower extremities c. the patient is nauseated and has not voided in 6 hours d. the patient complains of pain at the bone graft donor site

b. the patient is unable to move the lower extremities

an in-service for a group of workers in a warehouse. which information should be included to help prevent on the job injuries a. increase sodium and potassium in the diet during the winter months b. use the large thigh muscles when lifting and hold the weight near the body c. use soft-cushioned chairs when performing desk duties d. have the employee arrange for assistance with household chores

b. use the large thigh muscles when lifting and hold the weight near the body

intervetebral discs

between each vertebrae, absorb shock, permit movements of vertebral column, consist of a nucleus pulpous and annulus fibrosus

which of the following activities should the nurse instruct the client with low back pain to avoid? a. keeping light objects below the level of the elbows when lifting b. leaning forward while bending the knees c. exceeding the prescribed exercise program d. sleeping on the side with legs flexed

c. exceeding the prescribed exercise program

which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy? a. knee to chest lifts b. hip tilts c. sit ups d. pelvic tilts

c. sit ups

health promotion activities for a group of factory workers. which activity would be an example of primary prevention for clients at risk for low back pain? a. teach back exercises to workers after returning from an injury b. place signs in the work area about how to perform first aid c. start a weight-reduction group that would meet at lunchtime d. administer a nonnarcotic analgesic to a client complaining of back pain

c. start a weight-reduction group that would meet at lunchtime

chronic low back pain

causes: - degenerative disk disease - lack of physical exercise - prior injury - obesity - structural abnormalities - postural abnormalities - systemic disease

cervical disk herniation

cervical traction skin and skeletal: - used for cervical disk herniation, pain, injury, torticollis - head halter attached to a pulley and weight - HOB is elevated - nursing responsibilities

diskectomy

common surgical procedure to decompress nerve root microsurgical diskectomy is another option percutaneous laser diskectomy - outpatient surgical procedure (use of fluroscopy and laser to decrease the size of the damaged portion of the disc)

L3-4 clinical manifestations

complaints of pain from back to buttocks to posterior thigh to inner calf - patellar reflex affected - motor function of quadriceps and anterior tibialis affected - inner aspect of lower leg and anterior part of thigh with altered sensation

L5-S1 clinical manifestations

complaints of pain in back to buttocks to sole of foot and heel - achilles reflex is affected - gastrosnemius, hamstring, and gluteus maximus motor function affected - sensation alteration in heel and lateral foot

L4-5 clinical manifestations

coplaints of pain in back to buttocks to dorsum of foot and big toe - no specific reflex affected - anterior tibialis and gluteus maximus with altered motor function - change in sensation to the dorsum of the foot and big toe

the nurse's primary responsibility for a patient with a suspected disk herniation who has severe pain and muscle spasms is a. teaching exercises such as straight leg raises to decrease pain b. positioning the patient on the abdomen with the legs extended c. encouraging spine strengthening exercises and taking pain medication as needed d. assisting the patient to maintain activity restrictions with a gradual increase in activity

d. assisting the patient to maintain activity restrictions with a gradual increase in activity

with a herniated nucleus purposus of L4-L5. which scientific rationale explains the incidence of a ruptured disc in the elderly? a. the client did not use good body mechanics when lifting an object b. there is an increased blood supply to the back as the body ages c. older clients develop atherosclerotic joint disease as a result of fat deposits d. clients develop intervertebral disc degeneration as they age

d. clients develop intervention disc degeneration as they age

which of the following client statements indicates effective teaching? a. i will apply lotion before putting on the brace b. i will be sure to pad the area around my iliac crest c. i can use baby powder under the brace to absorb perspiration d. i should wear a thin cotton undershirt under the brace

d. i should wear a thin cotton undershirt under the brace

scheduled for a myelogram asks the nurse about the procedure. the nurse explains that radiographs will be taken of the client's spine after an injection of which of the following? a. sterile water b. normal saline solution c. liquid nitrogen d. radiopaque dye

d. radiopaque dye

what to include when preparing a client for magnetic resonance imaging to evaluate a ruptured disc? a. informing the client that the procedure is painless b. taking a thorough history of past surgeries c. checking for previous claustrophobia d. starting an IV line at keep open rate

d. starting an IV line at keep open rate

the physician said that i can do anything i want to. which of the following client stated activities indicates the need for further teaching? a. drying the dishes b. sitting outside on firm cushions c. making the bed walking from side to side d. sweeping the front porch

d. sweeping the front porch

spinal fusion surgical interventions

delayed healing with bone graft immobilization needed over an extended time: use of rigid orthosis (back brace) patient teaching related to back brace immobility potential problems assess donor or bone graft site also limited mobility once site has healed no twisting

surgery

indications similar to those with low back pain - neurologic symptoms not resolved with conservative treatment, trauma Types of surgery is similar to lumbar: diskectomy, laminectomy, and spinal fusion Monitor client post op: spinal cord edema (respiratory distress an worsening neurologic status of the upper extremities) May need a halo or cervical collor post op

risk factors of low back pain

lack of muscle tone - excess weight - poor posture - smoking - stress - job factors (repetitive motion, prolonged sitting)

surgical treatment for herniation

laminectomy diskectomy percutaneous laser diskectomy spinal fusion PLIF

low back pain

local or referred pain at the base of the spine caused by a sprain, strain, osteoarthritis, ankylosing spondylitis, a neoplasm or a herniated intervetebral disk.

interspinous process decompression system (x stop)

made of titanium and fits onto a mount that is placed on vertebrae in the lower back indicated for clients with pain due to lumbar stenosis works by pushing open the spinal cord by pressing against parts of either side of the vertebrae (similar to laminectomy)

goal of management

make episode of acute low back pain an isolated incident

procedures for back pain

minimally invasive, outpatient helps treat back pain and sciatica pain insertion of needle into affected disk via x ray guidance thread wire thru needle and into disk- heat wire. which denervates the small nerve fibers that have grown into cracks and invaded degenerating disk

disk surgical interventions

monitor for CSF leakage - headache (clear or slightly yellow; high glucose - dipstick) monitor for strength in extremities monitor for numbness or tingling avoid extreme knee flexion assist when getting OOB, encourage early ambulation and assist with back brace

post operative nursing implementation for lumbar disk

monitor vital signs and pain and document monitor peripheral neurologic signs - sensation and motor ability instruct on positioning - logroll and pillow placement and activity orders monitor wound and drain site monitor for CSF leaking (color of drainage and headache)- report immediately monitor for urinary retention, constipation

cervical neck sprain or strain

neck pain- almost as frequent as low back pain occurs at C5 to C6 to C7 interspaces diagnosis is determined by history, physical exam, xray, MRI, CT and myelography. EMG to diagnose cervical radiculopathy pain and stiffness in neck paresthesia with herniation, DDD or stenosis

radiofrequency discal nucleoplasty (coblation nucleoplasty)

needle inserted into disc similar to IDET generates energy that breaks up the molecular bonds of the gel in the nucleus up to 20% nucleus is removed = disk decopression

preoperative implementation (disk)

offer reassurance instruct on post operative plan instruct on deep breathing and coughing instruct on log rolling and positioning may need bedrest for a short period of time

spinal fusion

performed if an unstable boney mechanism is present spin is stabilized by creating an ankylosis (fusion) of contiguous vertebrae with a bone graft use of bone (cadaver or donated from iliac crest or fibula) metal fixation with rods, plates, or screws may be implanted infuse bone graft may be used instead of bone

chronic low back pain treatment

reduce pain formal back pain program surgery may be indicated in patients with severe chronic low back pain who do not respond to conservative treatment or continued neurologic deficits

Posterior Lumbar Interbody Fusion (PLIF)

removing disc tissue pressing on the lower spine area, inserting a piece of bone between the vertebrae, and fusing this area with plates and screws. Skeletal System

overall goals for lumbar injuries

satisfactory pain relief return to previous level of activity correct performance of exercises adequate coping adequate self help management

lumbar disk herniation

surgery indicated if 4 weeks of conservative therapy unsuccessful, radiculopathy (nerve root pain) becomes worse, or if loss of bowel or bladder control (cauda equina) is doumented - muscle and sensory loss - tendon relexes are altered - pain is not relieved

laminectomy

surgical excision of part of the posterior arch of the vertebrae (lamina) to gain access to part of the protruding disk and remove - minimal hospital stay

preventing low back pain

teach, teach, teach: - proper body mechanics - maintenance of appropriate body weight - avoid sleeping in the prone position - firm mattress - no smoking and regular exercise

cervical collar

used to treat cervical disk herniation, trauma, post op care holds head in neutral of slightly flexed position may need to wear 24 hours a day inspect skin teach cervical isometric exercises

charite disk

used with degenerative disc disease (DDD) artificial disk made up of high density core between two endplates surgically placed in the spine thru a small hole in the umbilicus after damaged one is removed allows for movement at the level of the implant

interbody cage fusion

uses a hollow threaded cylinder filled with bone graft to fuse two vertebrae