Reply separately to two of your classmates posts (See attached classmates posts, post#1 and post#2).
Your responses should be in a well-developed paragraph (300-350 words) to each peer. Integrating an evidence-based resource!
Note: DO NOT CRITIQUE THEIR POSTS, DO NOT AGREE OR DISAGREE, just add informative content regarding to their topic that is validated via citations.
– Utilize at least two scholarly references per peer post.
Please, send me the two documents separately, for example one is the reply to my peers Post #1, and the second one is the reply to my other peer Post #2.
– Minimum of 300 words per peer reply.
– TURNITIN Assignment.
Background: I live in South Florida, I am currently enrolled in the Psych Mental Health Practitioner Program, I am a Registered Nurse, I work in a Psychiatric Hospital.
POST # 1 MELISSA
Situation 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. The purpose of this post is to discuss and answer the following questions regarding this case study:
1. What pieces of the holistic assessment are missing from this scenario? A holistic assessment of the patient includes the following aspects with special attention to patient’s preferences, privacy, and dignity while getting all information necessary for finding the right diagnosis, creating the best treatment plan, and effectively communicating and co-authoring the plan with the patient. The six aspects of a holistic assessment include a complete physical assessment, review of stressors or psychological contributing factors, review support systems at home and in the community, assess development and cognition for ability to understand what is happening, ascertain spiritual or religious beliefs related to care to assess whether this could affect the prescribed plan, and fully discuss cultural values and practices as they relate to the treatment and daily routine. A full physical assessment, review of stressors, supports, cognition, psychological state, and cultural values are missing from this assessment (Woo & Robinson, 2020).
2. As a healthcare provider, what else do you need to understand about this patient related to pain management? During the assessment, we must find out if the patient has medication allergies, what they typically use for pain, what they have been taking in between injury and time of assessment, what has worked in the past, what hasn’t worked, and if the patient is opioid naïve. If the patient is a regular opioid user, and a course of opioid pain medications are prescribed, the dose will need to be higher than that for someone who has never or rarely utilized opiates (Woo & Robinson, 2020).
3. 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. In order to make a rational drug choice to prescribe this patient, I will need to acquire imaging of the shoulder and arm and do a thorough assessment. If there is soft tissue injury versus a fracture this may alter the recommendations for type and length of treatment. This information will come from the physical assessment and imagine. Opioid medication should be avoided if NSAIDs are helpful for treating the pain, however Woo & Robinson (2020) state that NSAIDs are appropriate for mild to moderate pain, and an 8/10 pain scale would be considered acute. Utilizing only the 0-10 pain scale would be an incomplete assessment to base a prescribing decision on (Aldington & Eccleston, 2019). Topical agents may be considered as an adjunct therapy but would not be effective to treat the acute injury on their own, as they are more indicate for treatment of chronic, or at the very least post-acute, pain (Woo & Robinson, 2020). Tramadol is a non-opioid that has an opioid-like effect on pain treatment and this may be a good option depending on severity of injury and pain (Woo & Robinson, 2020). Some patients being treated for injury are given prescriptions for their different pain levels. An example would be Motrin 800mg every 8 hours as needed for pain 4-7/10 not to exceed three tablets daily and take with food, and a second prescription for Tramadol 50mg every 4-6 hours as needed for acute pain 7-10/10.
4. Include in your response the teaching you would provide to TC. If my decision is to prescribe NSAIDs, I will provide education to the patient to take the medication with plenty of food to avoid GI damage and distress, and to make sure not to take more than prescribed. If the decision is to prescribed opioids, there will be a thorough education on the risk of dependence and addiction, the importance of not taking the medication more than prescribed, the importance of safe medication storage and keeping the medication away from other people who may abuse or be injured by exposure to the medication, the risk of constipation and importance of water and fiber in the diet. Opioids may also contribute to serotonin syndrome in patients who take medications that act on increasing serotonin availability for serotonin receptor binding, and this must be a caution when prescribing. An additional education point will be encouraging the patient to take the medication before the pain becomes unbearable or severe, as the medication will not be as effective in the increasingly acute pain state (Woo & Robinson, 2020).
5. What is meant by the DEA Drug Classification Schedule? Explain each category/classification. The Drug Enforcement Agency of the United States (DEA) controls a schedule of medications based on their “acceptable medical use and abuse potential” (DEA, 2020, pp1) and in reference to the Controlled Substance Act (DEA, 2020). There are five (5) schedules for substances. Schedule 1 substances have the highest abuse potential and no acceptable medical use. Examples include heroin, LSD, and ecstasy. The DEA lists marijuana as a Schedule 1 substance however marijuana has documented medical uses and has been decriminalized in many states. Schedule 2 substances are considered to have a significantly high abuse, dependence, and addiction potential as well as to be dangerous to the individual but do have documented medical uses. Exampled of Schedule 2 substances include dilaudid, fentanyl, and Adderall. Schedule 3 substances are considered to have moderate to low abuse and dependence potential and to have acceptable medical uses. Examples include Tylenol with codeine, ketamine, testosterone, and anabolic steroids. Schedule 4 substances are considered to have a low potential for abuse or dependence and include Xanax, Ativan, soma,and tramadol. Schedule 5 substances are considered to have a lower abuse potential than Schedule 4, and include lower codeine-containing cough syrup, robitussin cough syrup, Lomotil, and lyrica (DEA, 2020).
Aldington, D., & Eccleston, C. (2019). Evidence-Based Pain Management: Building on the Foundations of Cochrane Systematic Reviews. American Journal of Public Health, 109(1), 46–49. https://doi.org/10.2105/AJPH.2018.304745. Drug Enforcement Agency (DEA). (2020). Drug scheduling. Accessed at https://www.dea.gov/drug-scheduling. Woo, T.M. & Robinson, M.V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers. F.A. Davis.
POST # 2 JOHN
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? A holistic assessment should take in the entire patient when considering health. This approach recognizes the physiological, psychological, sociological, developmental, spiritual and cultural needs of the patient. It is a vital first step, as the information gathered during this assessment determines the initial phases of care (Wallace, 2013). According to Wallace the above we are pretty much missing everything. But specifically, I would want to know he patients age and health history. Is he opiate naïve? Does he have any drug allergies? We may have to prescribe a different opioid. Does he have Kidney/liver issues. His ETOH history. How he received the injury. Does he have a chronic issues or other comorbidities?
1. As a healthcare provider, what else do you need to understand about this patient related to pain management?
We need to understand the type of pain. Woo & Robinson in our Textbook has some fine points specifically about the types of pain and their treatment options on page 1245. There are 3 types of pain acute pain, cancer pain and chronic pain. Each with a different treatment modality (Woo & Robinson, 2020).
2. 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.
• Anti-inflammatory agents. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) are used for mild to moderate pain. Some such as ibuprofen have anti-inflammatory properties. They are often the first line of treatment for pain. Most have ADRs including Cardiac issues, GI bleeding, renal and hepatic issues. Celecoxib even has a Cardiac block box warning (Woo & Robinson, 2020). Other anti-inflammatory drugs such as Corticosteroids will not be considered at this time. In our text book on page 836 in relation to pain associated with inflammation Woo & Robinson state “Aspirin is the gold standard against which others are judged” (Woo & Robinson, 2020, page 836).
• Topical Agents These are either anesthetics such as lidocaine or capsaicin are useful for neuropathic pain at peripheral sites. A Lidoderm 5% patch could be considered. They may be applied for 12 hours at a time once a day to non-inflamed intact skin (Woo & Robinson, 2020).
• Narcotics are the last line of treatments after the others have failed. The have been overprescribed for the past 20 years and we all know about the crisis.
• Over the counter Ibuprofen 400 mg PO Q6 hours. For mild to moderate pain. Not to exceed 3200 MG per day (Lexicomp, 2017).
• 5 Lidoderm 5% patches. Apply 1 patch daily to effected site for 5 days. Do not apply to red or broken skin. Take off after 12 hours (Lexicomp, 2017).
• 20 Oxycodone 5 mg tablets. Take 1 by mouth Q6 hours as needed for breakthrough pain > 6. Not to exceed 4 doses a day for 5 days. No refills. Woo & Johnson recommend a 5-day regimen in an outpatient setting (Woo & Robinson, 2020). I stayed away from the combination opioid drugs like NORCO 5-325 or Percocet 5-325 because I want the patient to try NSAID therapy first. I also do not want the patient to take NSAIDS then take a combination drug which also contains NSAIDS.
3. Include in your response the teaching you would provide to TC.
Try the Ibuprofen and patch first. Avoid the Oxycodone if possible. Call office in 5 days if pain and ROM not improving.
Nonpharmacological treatments Rest Ice Compression Elevation (RICE). For the shoulder.
Lidoderm patch to be worn for a maximum of 12 hours. If skin red or broken do not apply. Clothing may be over patch. If irritation or burning occur at site remove patch (Lexicomp, 2017).
Opioid teaching points
• Do not drink alcohol while you are taking opioids
• Do not drive a car or use dangerous machinery.
• Store your opioids in a safe place, such as a locked cabinet.
• When your pain gets better dispose of medications properly. Do not flush down toilet.
• Call office if you have constipation, nausea, dry mouth, dizziness, vision problem.
• Call 911 if patient breathing very slowly, unable to stay awake, become very confused or unable to urinate.
(Patient education: Opioids for short-term treatment of pain. 2020)
4. What is meant by the DEA Drug Classification Schedule? Explain each category/classification.
There are 5 categories called Schedules in the DEA drug classification system.
• Schedule 1 drugs or chemicals that have no currently accepted medical use and have a high potential for abuse. Drugs include heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-ethylenedioxymethamphetamine (ecstasy), methaqualone, and peyote.
• Schedule 2 drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. Drugs include products with less than 15 milligrams of hydrocodone per dosage unit), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin.
• Schedule 3 Drugs with a moderate to low potential for physical and psychological dependence. They are less addictive than Schedule 1 or 2 but more than schedule 4. Drugs include products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone.
• Schedule 4 Drugs have a low potential for abuse and dependence. Some examples include Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol
• Schedule 5 Drugs have an even lower potential for abuse than Schedule IV. They include formulations containing small quantities of certain narcotics. These drugs are used for antidiarrheal, antitussive, and analgesic purposes. Examples include cough medications with less than 200 milligrams of codeine per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin.
(Drug Scheduling, n.d.)
Drug Scheduling (n.d.) Retrieved from https://www.dea.gov/drug-scheduling Lexicomp. (2017). Drug information handbook for advanced practice nursing (17th ed.). Hudson, OH: Wolters Kluwer Clinical Drug Information. Patient education: Opioids for short-term treatment of pain. (2020) retrieved from https://www.uptodate.com/contents/opioids-for-short-term-treatment-of-pain-the-basics?search=pain%20discharge%20instructions&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Wallace S. The importance of holistic assessment – A nursing student perspective. Nuritinga 2013(12):24-30 Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers. F. A. Davis.