Pain - Nursing Case Study

Pathophysiology

• Primary mechanism: Nociception - Pain begins when specialized nerve endings, called nociceptors, are activated by harmful stimuli (e.g., injury, heat). This triggers an electrical signal that travels to the spinal cord and brain, where pain is perceived.

• Secondary mechanism: Inflammation - Following injury, the body releases chemicals like prostaglandins and cytokines, which enhance nociceptor sensitivity and can lead to increased pain perception by promoting swelling and redness.

• Key complication: Chronic pain development - If acute pain is not managed, it can lead to changes in the nervous system that cause persistent pain even after the initial injury has healed, complicating treatment and patient quality of life.

Patient Profile

Demographics:

35, female, office worker

History:

• Key past medical history: Mild intermittent migraines

• Current medications: Ibuprofen as needed

• Allergies: None

Current Presentation:

• Chief complaint: Mild lower back pain

• Key symptoms: Slight discomfort when sitting for long periods, no radiating pain, no numbness or tingling

• Vital signs: Blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F

Section 1

Initial Assessment Findings:

During the initial nursing assessment, the patient, a 35-year-old female office worker, reported mild lower back pain that started a few weeks ago. She described the pain as a dull ache that becomes more noticeable towards the end of her workday, particularly after prolonged periods of sitting. On a scale of 0 to 10, she rated her pain as a 3 to 4 at its worst. The patient denied any radiating pain, numbness, or tingling sensations, suggesting a lack of nerve involvement at this stage. Physical examination revealed tenderness upon palpation of the lumbar region, but no visible swelling or erythema. Her range of motion was slightly limited due to discomfort, primarily in flexion and extension maneuvers.

Vital signs remained stable with a blood pressure of 120/80 mmHg, heart rate of 72 bpm, respiratory rate of 16 breaths per minute, and a temperature of 98.6°F, indicating no acute distress or systemic involvement. Upon further inquiry, the patient mentioned her sedentary lifestyle and lack of regular physical activity, contributing factors to her discomfort. Based on these findings, it was determined that her lower back pain is likely due to poor ergonomics and muscle strain, compounded by her work habits.

The nursing team discussed the importance of ergonomic adjustments at her workstation, regular breaks to stand and stretch, and incorporating low-impact exercises into her daily routine to strengthen her back muscles. Education was provided on the proper use of ibuprofen for pain management, emphasizing adherence to recommended dosages to prevent gastrointestinal side effects. The patient was advised to follow up in two weeks to reassess her pain levels and evaluate the effectiveness of the implemented interventions.

Section 2

Response to Interventions:

Two weeks following the initial assessment, the patient returned for a follow-up visit. She reported a noticeable improvement in her lower back pain, now rating it as a 1 to 2 on the pain scale. She attributed this improvement to the ergonomic adjustments she made at her workstation, including the use of a supportive chair and a standing desk converter. Additionally, she had been diligent about taking regular breaks to stand, stretch, and perform the recommended low-impact exercises, such as walking and yoga, which she felt helped increase her flexibility and strength.

During the physical examination, the nurse noted a reduction in tenderness upon palpation of the lumbar region, and the patient's range of motion had improved, with less discomfort during flexion and extension. Her vital signs remained stable, with a blood pressure of 118/78 mmHg, heart rate of 70 bpm, respiratory rate of 16 breaths per minute, and a temperature of 98.4°F. The patient reported minimal use of ibuprofen, as her pain levels had decreased significantly, and she experienced no adverse effects from the medication.

The nursing team praised the patient for her commitment to the interventions and encouraged her to continue with the ergonomic practices and exercise regimen. They provided additional education on maintaining a healthy posture and suggested incorporating core strengthening exercises to further support her back. The patient was advised to monitor her symptoms and return for another follow-up in four weeks, or sooner if her pain worsened, to ensure continued progress and address any potential issues promptly. This approach aimed to sustain the positive trend and prevent the recurrence of her symptoms.

Section 3

Four weeks later, the patient returned for her scheduled follow-up appointment. She reported continued improvement in her lower back pain, consistently rating it at 1 on the pain scale. She expressed satisfaction with her ergonomic adjustments and regular exercise routine, noting that she had incorporated the suggested core strengthening exercises, which she believed further enhanced her stability and reduced discomfort. The patient mentioned that she was able to engage in more daily activities without pain, such as gardening and light housework, which had previously been challenging.

During the examination, the nurse observed that the patient's range of motion had further improved, with minimal discomfort during movement. There was no significant tenderness upon palpation of the lumbar region. Her vital signs remained within normal limits: blood pressure was 116/76 mmHg, heart rate was 68 bpm, respiratory rate was 15 breaths per minute, and her temperature was 98.2°F. The nurse reviewed the patient's medication usage, noting that she had not needed to take ibuprofen for the past two weeks. Encouraged by these findings, the nursing team reinforced the importance of maintaining her current lifestyle changes and emphasized the role of a balanced diet and adequate hydration in supporting musculoskeletal health.

The patient was advised to be vigilant about any new or recurring symptoms and to maintain regular follow-up visits. The nursing team discussed strategies to prevent potential complications, such as muscle strain or fatigue, by suggesting she gradually increase the duration and intensity of her exercises as her strength improved. The patient left the clinic feeling optimistic and empowered to manage her condition proactively, with a follow-up appointment scheduled in eight weeks to further monitor her progress and ensure sustained improvement.

Section 4

Eight weeks later, the patient returned to the clinic for her follow-up appointment, eager to report her continued progress. During the initial assessment, the nurse noted that the patient had maintained a consistent exercise routine and had even started participating in a local yoga class. The patient's lower back pain remained well-managed, with a pain scale rating consistently at zero for the past month. She reported no new symptoms and expressed confidence in her ability to manage daily activities without discomfort. Her vital signs continued to reflect her stable condition, with a blood pressure of 114/72 mmHg, heart rate of 64 bpm, respiratory rate of 14 breaths per minute, and temperature of 98.0°F.

The nurse conducted a thorough examination, finding no signs of tenderness or muscle spasms in the lumbar region. The patient's range of motion was full and unrestricted, and she demonstrated improved core strength during functional assessments. Recognizing the positive impact of her lifestyle changes, the nursing team encouraged her to continue her current regimen, emphasizing the importance of maintaining flexibility and strength to prevent potential setbacks. The nurse also reviewed the patient's dietary habits and hydration, reinforcing their role in supporting her musculoskeletal health.

In light of her progress, the patient's care plan was updated to reflect her achievements and to set new goals for continued improvement. The nursing team recommended incorporating moderate aerobic activities to enhance cardiovascular fitness, while cautioning her to progress gradually to avoid overexertion. As the patient left the clinic, she felt reassured by the positive feedback and motivated to sustain her proactive approach to managing her condition. The next follow-up visit was scheduled in three months, aiming to ensure her long-term well-being and address any future concerns promptly.

Section 5

Three months later, the patient returned for her scheduled follow-up visit, appearing cheerful and energetic. During the initial assessment, the nurse observed that she had maintained her exercise routine and had gradually introduced moderate aerobic activities, such as brisk walking and light cycling, as previously recommended. The patient reported feeling more energetic and noted improved stamina in her daily activities. Her back pain remained absent, and she expressed a greater sense of overall well-being.

Vital signs indicated continued stability: blood pressure was 116/74 mmHg, heart rate 66 bpm, respiratory rate 14 breaths per minute, and temperature 98.2°F. The nurse noted no new symptoms or concerns during the physical examination. The patient's lumbar region remained free of tenderness, and her range of motion was full and pain-free. Additionally, she exhibited further improvements in core strength and flexibility, demonstrating the effectiveness of her continued yoga practice.

However, the nurse did identify a minor complication during the assessment: the patient mentioned experiencing occasional mild dizziness when rising quickly from a seated position. Upon further discussion, it became apparent that while her diet was generally balanced, her fluid intake had decreased slightly over the past month due to a busy schedule. The nursing team educated the patient on the importance of adequate hydration, particularly given her increased physical activity. They recommended she increase her daily water intake and rise slowly from seated positions to prevent orthostatic hypotension. The patient left the clinic feeling reassured and equipped with strategies to address this new challenge, eager to continue her journey of maintaining her health and preventing further complications.