Introduction:

The management of a patient suffering from a constellation of medical conditions is usually very complex and a comprehensive approach to understanding the basic needs of the patient and setting goals are important steps that must be followed to treat the patient. The present case of a 28-year-old man suffering from chronic back pain represents a complex case that must be addressed and managed by a multidisciplinary team (Zullig et al., 2016). The identification of a case requiring complex management is important so that there is proper coordination between different components of a multidisciplinary approach. The patient must be managed simultaneously by the care team so that his condition becomes better with time and the patient's satisfaction is thus achieved. Critical thinking and clinical reasoning are the tools to identify such patients and to disseminate safe and effective care to the patient. Nursing staff can play an important role in coordination with the team of physicians (Schaink et al., 2012). Complex chronic conditions are usually treated on a long-term basis so, the time spent with the patient for the nursing staff is greater and this patient-caregiver bond results in better healing and satisfaction among the patients (Schaink et al., 2012). Nursing staff may work by analyzing the factors that help them evaluate the patient's experience and then improvements can be made upon the analysis. That is why such indicators are being constructed and utilized frequently in medical healthcare (Ploeg et al., 2017). In this case report, the patient's health condition has been described in detail and the components/necessity of complex management of this case has been discussed. The indicators of complex management and patient experience are analyzed by critical thinking and clinical reasoning. The present care plan of the patient is evaluated as well. .

Discussion:

Ben is a middle-aged male who had been serving in the military force, but he was usually busy in his office work, so the physical efforts were normal before three years when he had an accident in the training field that resulted in spinal fusion and his movements were restricted due to chronic lower back pain. Currently, the patient is doing a mining job where the tasks of mining and use of explosives in mining aggravate his condition. Literature shows that numerous cases of lower back pain are caused after trauma; several etiologies are involved in traumatic causes of lower back pain (Schaink et al., 2012). This may include spinal fusion, spinal fractures, nerve compression, and spondylodiscitis. So, this is clear that the patient had this problem from the traumatic event (Hooten, 2016).

One aspect of this injury and restricted movement is the psychological impact on his life. The immediate after-effects of trauma were clinically described as post-traumatic stress disorder where the patient was extremely worried and stressed because of his trauma and disability (Muenchberger & Brownie, 2012). People who have encountered or witnessed a traumatic incident such as a natural disaster, a catastrophic accident, a terrorist attack, war/combat, or rape, or who have been threatened with death, sexual violence, or serious injury, may develop posttraumatic stress disorder (PTSD) (Muenchberger & Brownie, 2012). The immobility caused by lower back pain puts stress on the patient because he is unable to perform his routine activities and it is affecting his job. He wants to conceal his diagnosis from the stakeholders so that he may continue doing his job because he had an active lifestyle while he was in the military. Usually takes a sick leave while going to a doctor for a medical appointment. The medical and nursing staff must pay heed to this aspect and a clinician from psychiatry must be a part of a multidisciplinary team (Muenchberger & Brownie, 2012). The patient may need frequent reassurance and counseling to improve compliance to the therapy and care plan (Kuiper et al., 2011). Research studies show that chronic back pain and other painful conditions may precipitate major depressive disorder (Delgadillo et al., 2017) and anxiety in the patient. These conditions lead to deterioration of the patient's condition and the compliance to therapy is inversely related to psychiatric conditions of the patient (Schaink et al., 2012). The personal preference of the patient is extremely important as the patient in this case was working physically rather than doing office work or cerebral tasks (Muenchberger & Brownie, 2012) (Hooten, 2016). One of the problems he is having is the clash of his work responsibilities with his health condition (Ploeg et al., 2017). The pain experiences worsen due to exertion and resultantly the pain medications he usually takes make no effect that is why he is compelled to increase the dose of his pain medications. Currently, he is taking period pain relievers that are considered to be strong painkillers. Drinks alcohol to relieve stress and the frequency and quantity of alcohol intake have been increasing over time. Research studies show that chronic back pain and chronic pain conditions are worsened by alcohol intake (Kuiper et al., 2011). So, the use of alcohol to cope with his anxiety and stress caused by post-traumatic stress disorder may be deteriorating his back pain that is one of the main concerns of the patient (Schaink et al., 2012). This further complicates the management of the patient. Furthermore, the patient has started to show the symptoms of major depressive disorder (Kuo & Houtrow, 2016). Major depressive disorder (MDD), often known as depression, is a mental illness marked by persistent low mood, low self-esteem, and a loss of interest or pleasure in typically pleasurable activities for at least two weeks (Ploeg et al., 2017). Delusions may occur in those who are affected (Delgadillo et al., 2017). A mental status test and the person's reported experiences are used to diagnose the major depressive disorder (Kuo & Houtrow, 2016). There is no laboratory test for the disease, although testing to rule out medical conditions that can produce comparable symptoms may be done. This further complicates the case.

His care plan includes the strategies for coping against PTSD, depression and chronic lower back pain; these are the conditions that are interlinked and complicate the patient's condition, so a comprehensive care plan has been sketched out to treat the patient (Ploeg et al., 2017). The patient agreement is extremely important because the compliance of therapy directly depends upon patients’ agreement to the treatment. The patient's confidence improves the outcome of any strategy.  The treatment plan is cornered upon three components (Kuo & Houtrow, 2016). One is the medicinal therapy, second  the psychotherapy and third is the supportive care by the family and the healthcare staff (Kuo & Houtrow, 2016). The nursing staff plays an important role in patient education, counseling and support (Delgadillo et al., 2017).

The first management goal for post-traumatic stress disorder is to undergo psychotherapy and the services required for the section are to engage the patient with the help of a psychotherapist so that the psychotherapy can be continued regularly. Psychotherapies are well-established as effective acute therapy for PTSD (PTSD) (Zullig et al., 2016). The long-term efficacy of such interventions, as well as the maintenance of gains after discontinuation, are less well recognized (Delgadillo et al., 2017). The findings are optimistic in terms of the long-term efficacy of therapies and the long-term durability of symptom reduction, but they must be understood in conjunction with methodological concerns and RCT research features (Kuo & Houtrow, 2016). The condition for which the treatment has been planned is to treat the symptoms of depression and the target is to shift him to psychotherapy and behavioral changes so that he engages in social activities and increases his productivity (Ploeg et al., 2017). Psychotherapy is also associated with better outcomes when combined with pharmacotherapy but the problem with drug therapy is that it entails a risk of several side effects (Bjorkquist & Gunnar, 2018). So, the clinicians may be reluctant to give antidepressants to the patients fearing side effects as evidenced by several research studies (Kuo & Houtrow, 2016). The target of compliance is the same as for PTSD. The healthcare staff must ensure regular psychotherapy sections and monitor the progress (Kuiper et al., 2011). And the nursing staff must consult his condition to the psychologist. Research studies also evidence the good effect of exercise and physical activity over depressive symptoms. So, it makes a healthy strategy to manage the symptoms of the patients (Schaink et al., 2012). Monthly visits to a psychiatrist have been arranged for depressive symptoms. The chronic lower back pain will be managed by changing the working conditions to manage ergonomics so that the stress and strain to his body must remain minimal (Kuo & Houtrow, 2016). Manual work-related activities should be optimized. His sleep quality has also been addressed in the care plan. He complained of sleeplessness and breaking sleep due to discomfort. One of the goals is to enable him to exercise so that depression and PTSD could be controlled (Bjorkquist & Gunnar, 2018). His regular visits to attend physiotherapist and orthopedics for injury rehabilitation has also been planned by the medical care staff.  So, the multidisciplinary team in this case consists of medical staff, nursing staff, physiotherapist, orthopedics, psychologist, and psychiatrist. This comprehensive team laid out a comprehensive plan for his rehabilitation and thus this complex case can be managed effectively and timely (Ploeg et al., 2017).

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