Assessing and Treating Clients With Pain

Required Media

Laureate Education (2016a). Case study: A Caucasian man with hip pain [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this Assignment.

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/07/mm/complex_regional_pain_disorder/index.html

To prepare for this Assignment:

Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders Assessing and Treating Clients With Pain.
ACTUAL ASSIGNMENT
PLEASE Addressed each of the following bullets with a subtopic, include references; in-text citation in each paragraph. Please use my articles and any additional one should come from USA and must be within last five years only that is from 2014 to 2018. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations) Thanks

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The Assignment

Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Include how ethical considerations might impact your treatment plan and communication with clients.
Case Study: A Caucasian Man with Hip Pain

BACKGROUND

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”

SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie Assessing and Treating Clients With Pain.”

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.

Diagnosis:

Complex regional pain disorder (reflex sympathetic dystrophy)

Decisions Made and Outcomes (Needed to formulate the paper)

Choices for Decision 1: Select what the PMHNP should do:

Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed Assessing and Treating Clients With Pain.
My decision: Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter

Outcome: RESULTS OF DECISION POINT ONE:

Client returns to clinic in four weeks
Client comes into the office to without crutches but is limping a bit. The client states that the pain is “more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, the PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, “If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.”
Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has “not been so good as of lately.” He complains of nausea today.
Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented
Choices for Decision 2: Select what the PMHNP should do:

Continue with current medication (Savella) but lower dose to 25 mg twice a day
Discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID
Discontinue Savella and start Zoloft (sertraline) 50 mg
My decision: Continue with current medication (Savella) but lower dose to 25 mg twice a day Assessing and Treating Clients With Pain.

Outcome: RESULTS OF DECISION POINT TWO:

Client returns to clinic in four weeks
Client comes to office today with use of crutches. He states that his current pain is a 7 out of 10. “I do not feel as good as I did last month.”
Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot
Client’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today
Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad.
Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:

Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME
Discontinue Savella and start tramadol 50 mg orally every 6 hours. Client may increase to 100 mg orally every 6 hours if pain is not adequately controlled
Reduce Savella to 12.5 mg orally BID and start Celexa (citalopram) 10 mg orally
My decision: Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME

Outcome: Guidance to Student

Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid-similar analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome Assessing and Treating Clients With Pain.

References/Resources

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 10, “Chronic Pain and Its Treatment”
Stahl, S. M., & Ball, S. (2009a). Stahl’s illustrated chronic pain and fibromyalgia. New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated Guides tab and then the Chronic Pain and Fibromyalgia tab.

Chapter 5, “Pain Drugs”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

National Institute of Neurological Disorders and Stroke. (2016). Pain: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_2

This is an essay on a Caucasian man who has a hip pain. It will start off with a brief case study of the client. An explanation of three decisions that concern medications that are to be prescribed to this client. The client’s factors that impact the pharmacodynamics and the pharmacokinetics will be factored in. At every point where a decision is made; one, a reason behind the particular decision will be explained, two, the expectations of the decisions made will be explained, three, the differences between the expectations and the outcomes of the decisions will be explained. The decision will include an explanation of how the ethical considerations impact the communication and the treatment plan of the client. Lastly, a conclusion to summarize the essay Assessing and Treating Clients With Pain.

Case study

        A Forty-three years old man presents with pain as the chief complaint. He is being assisted/aided to ambulate by a set of crutches. The patient’s pain started 7years ago after he fell. X-rays showed that he sustained a 75% tear of the right hip joint cartilage. He did not receive a total hip replacement as the surgeons viewed him to be too young. He reports to be experiencing cooling and severe cramping of extremities. He is diagnosed with complex regional pain disorder (Reflex sympathetic dystrophy)

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Decision point one.

The first decision made was to start him on savella 12.5mg orally on day one. On day two and three 12.5 mg twice a day. On day four and seven, 25mg twice a day which will be followed by 50mg twice a day for the following days (McQuay, Tramer, Nye, Carroll, Wiffen, & Moore., 2016).

Complex regional pain disorder occurs due to supersensitivity of the brain mechanisms which receives and integrates the nociceptive signals. The treatment regime of CRP, includes the use of selective Serotonin-Norepinephrine Reuptake Inhibitors which helps in treating the neuropathic pain (Merskey, 2016). Savella is a SNRI, that is why it was chosen (Sindrup & Jensen 2009).

The expected outcomes were both positive and negative; reduce pain while the negatives were increased blood pressure, sweating, nausea, alter sleeping pattern, pulsation and suicidal thoughts as a result of increased epinephrine and serotonin in the bloodstream. In comparison to the results exhibited by the patient, it is as expected. The patient reports the pain to be at 4/10 and has all the stated side effects except suicidal thoughts (American Psychiatric Association, 2017). The care given shows ethical consideration as it was for the patient’s benefit and not harm (Bruehl, 2016).

Decision point two

The patient is continued with the same medication (Savella) but this time the dosage is lowered to 25 mg every 12 hours. This is a wise decision because; one, it reduces the side effects as his blood pressure and pulse rate were so elevated, two, it can only be tapered and not abruptly discontinued as it has withdrawal side effects (McQuay et al., 2016).

On the second visit, the patient blood pressure and pulse rate is expected to stabilize. The pain threshold is expected to rise above the previous score, sleep patterns will still be affected due to pain and lastly, the nausea and sweating will be reduced. This will cause frustrations and disappointments to the client as his hopes to improve will have deteriorated (Stahl, 2013). When comparing the expectations and the results, the pain increases from 4/10 to 7/10, the client’s sleeping pattern is altered due to pain at night, his blood pressure and pulse rate normalizes and the patients feels discouraged as he thought he was getting better (American Psychiatric Association, 2017)Assessing and Treating Clients With Pain.

On the ethical consideration, the patient is protected from harm although his pain returns and this brings a lot of mistrust to the treatment regime. It also affects the patient-doctor communication as there is a lot of despair. At this point, the patient should be told that his pain treatment does not rely on pain medication but rather on other non-pharmacological modalities for example, massage and heat therapy (Bruehl, 2016).

Decision point three

Decision at this point entails changing savella to be 25mg orally that is to be given in the morning and a dosage of 50mg that will be given orally at bedtime. This is the most suitable decision as it cannot be discontinued abruptly and also when given with celexa, signs of serotonin toxicity needs to be monitored as it is an SSRI. In addition to this tramadol is not a good option for neuropathic pain (McQuay et al., 2016).

The expected results include reduced side effects; during the day he will be less nauseated, will have less hot flushes and also suicidal ideation will be reduced (American Psychiatric Association, 2017). During the night, the pain will be lessened hence better sleeping pattern (Stahl, 2013). The expectations and the results were the same. As explained above, the care ensures ethical considerations are being followed. The patient is not harmed. The care focuses on benefiting the client (Bruehl, 2016).

Conclusion

The decisions made at every point were wise as they focused on not harming the patient but benefiting him (ethical considerations) and also the expectations and the results did not differ at all.

References

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders; DSM-III. Washington DC.

Bruehl, S. (2016). An update on the pathophysiology of complex regional pain syndrome. Anesthesiology: The Journal of the American Society of Anesthesiologists, 113(3), 713-725.

Merskey, H. E. (2016). Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Pain.

McQuay, H. J., Tramer, M., Nye, B. A., Carroll, D., Wiffen, P. J., & Moore, R. A. (2016). A systematic review of antidepressants in neuropathic pain. Pain, 68(2-3), 217-227.

Stahl, S. M., & Stahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press Assessing and Treating Clients With Pain.

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