Case study reply pain management

Reply to each post Your responses should be in a well-developed paragraph (300-350 words) to each peer. Integrating an evidence-based resource that is different than the one you used for the initial post.

Respectfully agree and disagree with your peers’ responses and explain your reasoning by Including your rationales in your explanation.

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Post 1

What pieces of the holistic assessment are missing from this scenario?

    According to the Holistic Nurses Association, holistic nursing is “all nursing practice that has healing the whole person as its goal” (HNA, n.d). The holistic nursing assessment allows nurses to formulate their care plan and diagnosis. The first piece that is missing from this scenario is what the pain feels like, I would have the patient describe the pain including the intensity and quality of the pain (Woo et al., 2020). Next, I would ask TC about the motivation and cognitive experiences related to the pain with questions like when this injury happened, how long the pain has been going on, what TC has used for medications to help the pain and does anything make the pain better or worse (Woo et al., 2020). Having the patient talk more about the injury while doing a complete assessment can add to the overall assessment.  

As a healthcare provider, what else do you need to understand about this patient related to pain management?

    As a health care provider, it would be important to understand if the patient has any allergies to medications specifically pain medications. If the patient does then we would avoid these medications and treat in other ways. I would also ask TC what other medications he is currently taking to ensure that there are no medication interactions. Next, I would run a complete blood count and a comprehensive metabolic panel on TC to ensure that his hemoglobin, hematocrit, platelets, kidney function, and liver function are all normal. NSAIDS can affect the kidneys and are metabolized in the liver (Woo et al., 2020). Similarly, acetaminophen is also metabolized in the liver (Woo et al., 2020). Next, I would need to screen the patient for substance abuse using the CAGE-AID questionnaire and the DAST-20 (Woo et al., 2020). A urine toxicology can also be run for substance abuse purpose. Last, I would also look up the patient on the MassPAT tool before prescribing narcotics to ensure that TC was not being prescribed opiates somewhere else (Mass.gov, 2021). This tool allows practitioners to view patient’s prescription history before prescribing narcotics to prevent abuse, misuse, diversion, duplicate therapy, and promotion of coordination of care between providers (Mass.gov, 2021).  

Describe the process of rational drug choice for this case study. In your process, discuss your thought processing of anti-inflammatory agents, topical agents, and narcotics.

    My rational drug choice with the limited information I have on TC and without imaging of his shoulder would lead me to believe that TC is suffering from acute pain. Acute pain is best treated with anti-inflammatory drugs (Woo et al., 2020). Due to TC rating the pain an 8/10 I would prescribe a non-steroidal anti-inflammatory and a topical agent. I would also recommend that TC try non-pharmacological measures including both heat and ice (Woo et al., 2020). I then would send TC to an orthopedic specialist where they can further evaluate his shoulder. I would tell TC he can take 200 mg to 800 mg of ibuprofen every 6 to 8 hours (Woo et al., 2020). It is recommended that TC start with a lower dose of NSAIDs as they are adequate to relieve pain in most people (Solomon, 2021). I would also recommend TC try a topical non-steroidal anti-inflammatory which is called voltaren gel. Voltaren gel 1% is typically used in arthritis but can be used to treat acute pain as it has anti-inflammatory properties (Woo et al., 2020). I did consider oxycodone for TC but because this is a schedule II drug with high chance for abuse, I would prefer to start TC on something with that does not have abusive properties. If pain is controlled on something that is not a narcotic, then I would always choose this first as an FNP. If the pain did not get better, then we could consider other options, or I am sure the orthopedic practitioner could as well.  

Include in your response the teaching you would provide to TC.

    My teaching for TC would include starting with a 200 mg dose of ibuprofen and seeing if that helps decrease his pain and then increasing as needed to 800mg maximum. It is important to tell TC that he can only take 3200 mg of ibuprofen in 24 hours. I would also counsel TC that he needs to avoid alcohol while using the NSAID for pain (Woo et al., 2020). Last, I would reiterate that TC needs to see orthopedics to evaluate the shoulder injury further.  

What is meant by the DEA Drug Classification Schedule? Explain each category/classification.

    The DEA Drug Classification Schedule are drugs, substances, and chemicals that are placed into five different categories based on what they are used for medically and the potential the drug has for abuse (DEA, n.d.). Schedule I drugs are drugs with no medical use and have the highest chance for abuse (DEA, n.d.). An example of a schedule I drug is heroin. Schedule II drugs have a high chance of abuse and can lead to both physical and psychological dependence (DEA, n.d.). An example of a schedule II drug is cocaine or oxycodone. Schedule III drugs have a moderate to low chance of physical or psychological dependence (DEA, n.d.). An example of a schedule III drug is codeine. Schedule IV drugs have a low chance of developing dependence (DEA, n.d). An example of a schedule IV drug is Ativan. Schedule V drugs are drugs that contain minimal amounts of certain narcotics, these drugs are typically used for antitussive, antidiarrheal, analgesic (DEA, n.d.). An example of a schedule V drug is lomotil. As a future APRN who can prescribe medication it is important to have an understanding of the drug classification schedule and knowing which medications have a high potential for abuse or misuse.  

Post 2

As an Advanced Nurse Practitioner (ANP), you are working in an urgent care setting. TC comes to the clinic with a work-related injury to the right shoulder. The patient rates the pain 8 on a scale of 0–10. The patient is unable to perform any ROM to the shoulder. There is no neck pain.

What pieces of the holistic assessment are missing from this scenario?

As a healthcare provider, what else do you need to understand about this patient related to pain management?

It is important to understand the type of pain and the type of injury that TC is suffering from. There are many different structures within the shoulder that could be affected by this type of injury. Due to TC being unable to perform any range of motion and complaining of an 8/10 pain level, there must be a significant internal injury to the shoulder. Treatment of pain has been a focus within healthcare for many years. With the development of pain medications, narcotics and highly addictive medications were founded. Prescribing addictive medications is dangerous for providers as well as patients. During the past 25 years, a more educated and aging population has increasingly expected pain relief when seeking treatment. Pain management was declared a human right and ethicists stated that a pain management standard of care is neither an absolute science nor is it free of risk (Woo & Robinson, 2020). For a patient such as TC, learning more about his work environment would be essential before prescribing medication. If work-related injuries are something that may occur frequently, prescribing narcotics which are addictive would not be a good plan for TC. 

Describe the process of rational drug choice for this case study. In your process, discuss your thought processing of anti-inflammatory agents, topical agents, and narcotics.

Like mentioned above, if job-related injuries are something that are frequent for TC, prescribing narcotics would not be a good therapy due to the highly addictive nature associated with them. Many areas could have been injured in TC’s shoulder such as the rotator cuff, muscles and tendons, or the subacromial bursa. Asking this patients questions including what he was doing at the time of the injury, could have a provider determine what part of the shoulder has been damaged. Determining if TC’s pain is acute or chronic will also have an impact on the treatment that will be given. Acute pain is in short duration and results from tissue injury. Chronic pain lasts for a period of time longer than 3 months. Anti-inflammatory medications such as ibuprofen, Advil or Aleve can be useful for a short time and work to target pain control without having systemic effects on the body. Topical applications of anesthetics such as lidocaine cream and voltaren gel or over the counter options can be used for minimal pain relief and therefore will only have short lasting effects on overall pain control. 

Include in your response the teaching you would provide to TC.

Teaching for TC would need to emphasize the differences between acute and chronic pain as well as how to avoid reinjuring this shoulder. Depending on the medication therapy prescribed to TC, teaching would need to be specific to that therapy. Due to TC not being able to perform any range of motion on assessment, as his provider I would recommend physical therapy, as well as anti-inflammatory medications and topical anesthetics to ease his pain during physical activity. 

What is meant by the DEA Drug Classification Schedule? Explain each category/classification.

The DEA classifies medications into five different schedules. The schedules are used to determine how medically acceptable a medication is as well as the dependency of the drug. Schedule I drugs are those that do not have any medical use and have a potential for abuse such as heroin and marijuana. Schedule II drugs are those that have an extremely high potential for abuse as well as the potential for psychological and physical dependence such as Vicodin, dilaudid, oxycodone, fentanyl, Adderall and Ritalin. Schedule III drugs have a low to moderate potential for abuse and physical dependence. Schedule III medications include Tylenol with codeine and testosterone. Schedule IV medications have a low potential for abuse and dependence such as Xanax, Valium, Ativan and Tramadol. Lastly, Schedule V medications have a lower potential for abuse that schedule IV drugs and contain a limited quantity of narcotics in them. Schedule V medications are often used for antidiarrheals and analgesics purposes such as Robitussin, Lomotil and Lyrica. 

USE APA FORMAT, CITE 3-4 REFERENCES  each ONE PEER REVIEWED ARTICLE.

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