NUR109 M7.6: ATI-VSIM Swift River- Ann Rails-Back Pain
Question 1: What is Ann Rails’ history and reason for seeking medical care?
Ann Rails is a 28-year-old female with a history of chronic back pain, which she attributes to her job as a cashier, where she has to stand for long hours. She also mentions that she recently had a fall at work, which worsened her back pain. NUR109 M7.6: ATI-VSIM
Question 2: What information should the nurse collect during the assessment?
The nurse should collect comprehensive information during the assessment, including Ann’s medical history, any recent falls or injuries, the duration and characteristics of her back pain, its intensity, location, radiation, associated symptoms, any alleviating or aggravating factors, her mobility, and her current pain management strategies.
Question 3: What are the potential causes of Ann’s back pain?NUR109 M7.6: ATI-VSIM
Ann’s back pain could be attributed to several potential causes, including her job-related activities, the recent fall at work, muscle strain, musculoskeletal issues, or underlying medical conditions. A thorough assessment and diagnostic workup may be necessary to determine the exact cause.
Question 4: What physical assessment techniques should the nurse perform to evaluate Ann’s back pain? NUR109 M7.6: ATI-VSIM
The nurse should perform a physical assessment, including an examination of Ann’s back, focusing on the affected area. This may involve assessing for tenderness, muscle spasms, deformities, or any visible abnormalities. Range of motion, reflexes, and sensation in the back and lower extremities should also be evaluated.
Question 5: What is the nurse’s initial plan for Ann’s pain management?
The nurse’s initial pain management plan for Ann includes providing her with pain relief through medication administration. Ann is prescribed acetaminophen and a nonsteroidal anti-inflammatory drug (NSAID) for pain relief.NUR109 M7.6: ATI-VSIM
Question 6: What education should the nurse provide to Ann regarding her back pain and its management?
The nurse should educate Ann about the importance of maintaining proper body mechanics and ergonomics at her job to prevent exacerbating her back pain. Teaching her about the correct use of over-the-counter pain relievers, their potential side effects, and when to seek medical attention is also crucial.NUR109 M7.6: ATI-VSIM
Question 7: What additional measures can be taken to manage Ann’s back pain effectively?
In addition to medication, other measures that can be taken to manage Ann’s back pain include physical therapy, exercises to improve back strength and flexibility, lifestyle modifications, and ergonomic adjustments at her workplace to minimize the strain on her back.
Question 8: How can Ann be encouraged to maintain a healthy lifestyle to support her back health?
The nurse should encourage Ann to maintain a healthy lifestyle by emphasizing the importance of regular exercise, a balanced diet, maintaining a healthy weight, staying hydrated, and avoiding smoking. These lifestyle choices can help reduce the risk of back pain and other musculoskeletal issues.
Question 9: What signs or symptoms should Ann be instructed to watch for, which may indicate a need for immediate medical attention?
Ann should be instructed to watch for signs or symptoms such as severe worsening pain, numbness or tingling in her lower extremities, weakness in her legs, loss of bowel or bladder control, or any other concerning symptoms that could indicate a more serious underlying condition. Immediate medical attention should be sought if these symptoms occur.NUR109 M7.6: ATI-VSIM
Question 10: What are the follow-up steps for Ann’s care plan, and when should she follow up with a healthcare provider?
The nurse should explain to Ann that her follow-up steps include assessing the effectiveness of the prescribed pain relief measures, monitoring her progress, and determining if further intervention or referrals are necessary. Ann should follow up with a healthcare provider as recommended or if her condition worsens.
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