vSim_D_YoungBear_Clinical_Packet

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) Chronic pain is pain that lasts longer than 3 to 6 months. In many cases, this means that pain continues even after the injury or condition that first caused it has healed. The cause of chronic pain is not always clear. Sometimes it is caused by an ongoing medical problem, such as arthritis or diabetic neuropathy (a form of nerve damage from diabetes). But doctors cannot always find the cause of chronic pain. Pathophysiology: Pain is mediated by nociceptors, specialized peripheral sensory neurons that alert us to potentially damaging stimuli at the skin by transducing these stimuli into electrical signals that are relayed to higher brain centers. Nociceptors are pseudo-unipolar primary somatosensory neurons with their neuronal body located in the dorsal root ganglion. If the noxious stimulus persists, processes of peripheral and central sensitization can occur, converting pain from acute to chronic. Central sensitization is characterized by the increase in the excitability of neurons within the central nervous system, so that normal inputs begin to produce abnormal responses. Central sensitization occurs in a number of chronic pain disorders, such as temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, and lateral epicondylalgia. Despite improved knowledge of the processes leading to central sensitization, it is still difficult to treat. Peripheral and central sensitization have a key role in low back pain chronification. In fact, minimal changes in posture could easily drive long-lasting inflammation in the joints, ligaments, and muscles involved in the stability of the low back column, contributing to both peripheral and central sensitization. Furthermore, joints, discs, and bone are richly innervated by A delta fibers whose continuous stimulation could easily contribute to central sensitization. DIAGNOSTICS TESTS (Reason for Test and Results) ▪ Blood tests to check for infection, signs of inflammation, or diseases that can cause pain ▪ X-rays or other imaging tests to check for bone fractures, joint damage, cancer, or other changes in your body that could cause pain ▪ Nerve tests to check whether the nerves are working normally PATIENT INFORMATION Danielle Young Bear is a 32-year-old Native American female. Patient came to clinic for cough and fatigue after common cold. On assessment patient also has chronic low back pain from working as a construction worker. Patient also on medications for depression and takes several over the counter and herbal medications. She is at risk for polypharmacy/ overmedication. ANTICIPATED PHYSICAL FINDINGS The main symptom of chronic pain is, of course, pain. But the pain can affect the body in different ways. Some people have aches deep inside their muscle or bone. Some people have stabbing or shooting pain, often with tingling or numbness. And others have dull, throbbing pain. ANTICIPATED NURSING INTERVENTIONS ▪ Use a heating pad or a cold pack on the painful area. Check with your doctor before trying this to make sure it is OK for your individual condition. ▪ Practice relaxing. You can learn methods to relax your body, such as doing deep breathing exercises. Ask your doctor or nurse about these methods. Relaxing the mind can help with how the body feels pain. People can learn to quiet their pain or make it less bothersome. ▪ Stay as active as possible. Walking, swimming, tai chi (a kind of martial art), or biking can all help ease muscle and joint pain. If you are not active, your pain might get worse. ▪ If you feel depressed, talk to your doctor or nurse about it. Chronic pain and depression often go together, and each can make the other worse. Getting treatment for your depression can make it easier to cope with your pain. ▪ If you haven't been active for a while, start slowly. Make small increases in the intensity and amount of time you spend exercising. If exercising increases your pain, talk with your doctor. They might recommend a program that can help you get more active. vSim for Nursing ▪ Be open to trying new treatments and combinations of treatments. Sometimes you have to try a few different options before you find one that works best. ▪ Set realistic goals for your treatment. Even if you can't completely get rid of your pain, you might be able to control it enough so that you can do the things you want to do VSIM ISBAR ACTIVITY Student Worksheet INTRODUCTION Milagros Ballesteros, LPN, Clinic Your name, position (RN), unit you are working on SITUATION Danielle Young Bear is a 32-year-old Native American female. Patient came into clinic for cough and fatigue from a common cold. Patient’s name, age, specific reason for visit BACKGROUND Cough and fatigue related to common cold. Date of visit 9/19. Patient also has chronic back pain and is on prescription, over the counter and herbal medications to help. Orders are for vitals check, pain assessment, neurological assessment. Also reconciliation of medications and all prescription medications from home. Patient education on excessive use of multi medications and herbal therapies. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Patient with chronic back pain 6/10. Feeling fatigue with cough related to common cold. No other complaints from patient. All other body systems within normal limits. Vitals: Heart rate: 89. Pulse: Present. Blood pressure: 110/75 mm Hg. Respiration: 21. SpO2: 97% on room air. Temp: 99 F Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. RECOMMENDATION Recommendations to patient monitor cold/flu like symptoms for worsening. Educate/Reinforce teaching on excessive medications use: prescription, over the counter, herbal medications. Any orders or recommendations you may have for this patient vSim for Nursing NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Duloxetine (Cymbalta) CLASSIFICATION: SSNRI-Antidepressant PROTOTYPE: Duloxetine CONTRAINDICATIONS: Contraindicated in patients hypersensitive to drug or its ingredients, patients taking MAO inhibitors, and patients with a CrCl less than 30 mL/minute. Drug isn’t recommended for patients with hepatic dysfunction or ESRD. Don’t begin duloxetine in patients receiving linezolid or methylene blue. If urgent treatment with linezolid or methylene blue is needed in patient already receiving duloxetine, discontinue duloxetine; then administer linezolid or methylene blue. Monitor for serotonin syndrome for 5 days or until 24 hours after last dose of linezolid or methylene blue, whichever comes first. May resume duloxetine 24 hours after last dose of linezolid or methylene blue. Use cautiously in patients with a history of mania or seizures, patients who drink substantial amounts of alcohol, patients with HTN, patients with controlled angle-closure glaucoma, and those with conditions that slow gastric emptying. Pupil dilation that occurs after duloxetine use may trigger an angle-closure attack in a patient with anatomically narrow angles who doesn’t have a patent iridectomy. ADVERSE EFFECTS: CNS: dizziness, fatigue, headache, insomnia, somnolence, suicidal thoughts, fever, hypoesthesia, irritability, lethargy, nervousness, nightmares, restlessness, sleep disorder, anxiety, asthenia, tremor, agitation. CV: hot flashes, HTN, increased HR, palpitations. EENT: blurred vision, nasopharyngitis, pharyngolaryngeal pain. GI: constipation, diarrhea, dry mouth, nausea, dyspepsia, gastritis, vomiting, flatulence. GU: abnormal orgasm, abnormally increased frequency of urinating, delayed or dysfunctional ejaculation, dysuria, erectile dysfunction, urinary hesitation. Metabolic: decreased appetite, hypoglycemia, increased appetite, weight gain or loss, hyponatremia. Musculoskeletal: muscle cramps, myalgia. Respiratory: cough. Skin: increased sweating, night sweats, pruritus, rash. Other: decreased libido, rigors, yawning. BLACK BOX WARNINGS: Warn families or caregivers to report signs of worsening depression (such as agitation, irritability, insomnia, hostility, impulsivity) and signs of suicidal behavior to prescriber immediately. Drug may increase risk of suicidal thinking and behavior in children, adolescents, and young adults ages 18 to 24, especially during the first few months of treatment, and in those with major depressive disorder or other psychiatric disorder. Monitor all patients for worsening of depression or emergence of suicidal thoughts or behavior, especially when therapy starts or dosage changes. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO Duloxetine isn’t recommended for patients with ESRD, severe renal dysfunction (CrCl of less than 30 mL/minute), or hepatic dysfunction. Major depressive disorder Adults: Initially, 20 mg PO b.i.d. to 60 mg PO once daily or divided in two equal doses. May also start at 30 mg/day for 1 week to allow patients to adjust to medication. Maximum, 120 mg daily. Generalized anxiety disorder Adults: 60 mg PO daily. Or, 30 mg PO daily for 1 week; then increase to 60 mg PO daily. May increase in increments of 30 mg daily to 120 mg PO once daily. PURPOSE FOR TAKING THIS MEDICATION Major depressive disorder generalized anxiety disorder, fibromyalgia, neuropathic pain related to diabetic peripheral neuropathy, chronic musculoskeletal pain. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Alert: Teach patient to recognize and immediately report signs and symptoms of serotonin toxicity (fever, mental status changes, muscle twitching, excessive sweating, shivering or shaking, diarrhea, loss of coordination). ▪ Tell patient to contact prescriber immediately and to discontinue drug at first sign of hypersensitivity (including blisters, peeling rash, or mucosal erosions). ▪ Tell patient to not stop drug abruptly; dosage must be gradually reduced to avoid adverse effects. PATIENT EDUCATION WORKSHEET vSim for Nursing PATIENT EDUCATION WORKSHEET ▪ Tell patient to consult prescriber or pharmacist before taking other prescription or OTC drugs or herbal or other dietary supplements. ▪ Instruct patient to swallow capsules whole and not to chew, crush, or open them because they have an enteric coating. ▪ Urge patient to avoid activities that are hazardous or require mental alertness until drug’s effects are known. ▪ Warn against drinking alcohol during therapy. ▪ If patient takes drug for depression, explain that it may take 1 to 4 weeks to notice an effect. ▪ Advise patients with diabetes to closely monitor blood glucose level. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen CLASSIFICATION: Analgesics PROTOTYPE: Aspirin CONTRAINDICATIONS: Alert: May cause serious, potentially fatal skin reactions, including SJS, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Reaction may occur with first or subsequent use when acetaminophen is used as monotherapy or when it is one component of combination drug therapy. Monitor for reddening of the skin, rash, blisters, and detachment of the upper surface of the skin. Stop drug immediately if skin reaction is suspected. Contraindicated in patients hypersensitive to drug. IV form is contraindicated in patients with severe hepatic impairment or severe active liver disease. Use cautiously in patients with any type of liver disease, G6PD deficiency, chronic malnutrition, severe hypovolemia (dehydration, blood loss), or severe renal impairment (CrCl of 30 mL/minute or less). Use cautiously in patients with long-term alcohol use because therapeutic doses cause hepatotoxicity in these patients. Chronic alcoholics shouldn’t take more than 2 g of acetaminophen every 24 hours. ADVERSE EFFECTS: CNS: agitation (IV), anxiety, fatigue, headache, insomnia, pyrexia. CV: HTN, hypotension, peripheral edema, periorbital edema, tachycardia (IV). GI: nausea, vomiting, abdominal pain, diarrhea, constipation (IV). GU: oliguria (IV). Hematologic: hemolytic anemia, leukopenia, neutropenia, pancytopenia, anemia. Hepatic: jaundice. Metabolic: hypoalbuminemia (IV), hypoglycemia, hypokalemia, hypervolemia, hypomagnesemia, hypophosphatemia (IV). Musculoskeletal: muscle spasms, extremity pain (IV). Respiratory: abnormal breath sounds, dyspnea, hypoxia, atelectasis, pleural effusion, pulmonary edema, stridor, wheezing (IV). Skin: rash, urticaria; infusion- site pain (IV), pruritus. BLACK BOX WARNINGS: Drug can cause acute liver failure, which may require a liver transplant or cause death. Most cases of liver injury are associated with drug doses exceeding 4,000 mg/day and often involve more than one acetaminophen-containing product. Advise patient or caregiver that many OTC products contain acetaminophen and should be counted when calculating total daily dose. Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. Use caution when prescribing, preparing, and administering IV acetaminophen to avoid dosing errors leading to accidental overdose and death. Be careful not to confuse dose in milliGRAMS and dose in milliLITERS. Be sure to base dose on weight for patients weighing less than 50 kg, to properly program infusion pump, and to ensure that total daily dose of acetaminophen from all sources doesn’t exceed maximum daily limit. SAFE DOSE OR DOSE RANGE, SAFE ROUTE ROUTE: PO, IV, Rectal DOSAGE: Adults: 325 to 650 mg PO every 4 to 6 hours. Or, two extended-release caplets PO every 8 hours. Maximum, 3,250 mg daily unless under health care provider supervision, when 4 g daily (immediate-release) may be used. For long-term therapy, don’t exceed 2.6 g daily unless prescribed and monitored closely by health care provider. PURPOSE FOR TAKING THIS MEDICATION Mild to moderate pain, fever PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Tell parents to consult prescriber before giving drug to children younger than age 2. vSim for Nursing PATIENT EDUCATION WORKSHEET ▪ Advise parents that drug is only for short-term use; urge them to consult prescriber if giving to infants for longer than 3 days, children for longer than 5 days, or adults for longer than 10 days. ▪ Tell patient to consult prescriber for fever lasting longer than 3 days or recurrent fever. ▪ Alert: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution long-term alcoholics to limit drug to 2 g/day or less. ▪ Caution patient to contact health care provider if signs and symptoms of liver damage (illogical thinking, severe dyspepsia, jaundice, inability to eat, weakness) occur. ▪ Alert: Warn patient to stop drug and seek medical attention immediately if rash or other reactions occurs while using acetaminophen. ▪ Tell breastfeeding patient that drug appears in human milk in low levels. Drug may be used safely if therapy is short-term and doesn’t exceed recommended doses. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Hydrocodone Bitartrate-Acetaminophen CLASSIFICATION: Opioid Analgesic PROTOTYPE: Hydrocodone ADVERSE EFFECTS: CNS: light-headedness, dizziness, sedation, drowsiness, mental clouding, lethargy, impairment of mental and physical performance, anxiety, fear, dysphoria, psychological dependence, mood changes, stupor, coma. EENT: hearing impairment, permanent hearing loss. GI: nausea, vomiting, constipation. GU: urethral spasms, spasm of vesical sphincters, urine retention. Hepatic: increased LFT values. Musculoskeletal: muscle flaccidity. Respiratory: respiratory depression, acute airway obstruction, apnea, dyspnea. Skin: rash, pruritus, SJS, toxic epidermal necrolysis. Other: allergic reaction. CONTRAINDICATIONS/BLACK BOX WARNINGS: Black Box Warning: Acetaminophen has been associated with acute liver failure, at times resulting in liver transplant and death. Most liver injury has been associated with the use of acetaminophen at doses exceeding 4,000 mg/day, and often involves more than one acetaminophen-containing product. Black Box Warning: Opioids should only be prescribed with benzodiazepines or other CNS depressants to patients for whom alternative treatment options are inadequate. Limit dosages and durations to minimum required. Black Box Warning: Drug exposes patient to risks of addiction, abuse, and misuse, even at recommended doses, which can lead to overdose and death. Assess each patient’s risk before prescribing; monitor patients for these behaviors or conditions. Black Box Warning: The FDA has required a REMS program for this drug. Drug companies with approved opioid analgesic products must make a REMS-compliant education program available to health care providers, who are strongly encouraged to complete the education program; discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and their caregivers every time these medicines are prescribed; emphasize the importance of reading the Medication Guide every time an opioid analgesic is dispensed to them; and consider using other tools to improve patient, household, and community safety. Black Box Warning: Accidental ingestion of even one dose of this drug, especially by children, can result in a fatal hydrocodone overdose. Contraindicated in patients hypersensitive to hydrocodone or acetaminophen and in those with significant respiratory depression, acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment, or known or suspected GI obstruction, including paralytic ileus. Black Box Warning: Drug may cause serious, life-threatening, or fatal respiratory depression. Alert: May cause serious, potentially fatal skin reactions, including SJS, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Reaction may occur with first or subsequent use when acetaminophen is used as monotherapy or when it’s one component of combination drug therapy. Monitor patient for reddening of the skin, rash, blisters, and detachment of the upper surface of the skin. Stop drug immediately if skin reaction is suspected. SAFE DOSE OR DOSE RANGE, SAFE ROUTE ROUTE:PO Dosage: Adults: 1 to 2 tablets (hydrocodone 2.5 to 5 mg/acetaminophen 300 to 325 mg) PO every 4 to 6 hours as needed or 1 tablet (hydrocodone 7.5 to 10 mg/acetaminophen 300 to 325 mg) PO every 4 to 6 hours as needed. Or, for oral solution, give 15 mL (hydrocodone 7.5 mg/acetaminophen 325 mg) or 11.25 mL (hydrocodone 10 mg/acetaminophen 300 mg) PO every 4 to 6 hours as needed. Refer to manufacturer’s instructions for maximum dosages. PURPOSE FOR TAKING THIS MEDICATION Moderate to moderately severe pain PATIENT EDUCATION WHILE TAKING THIS MEDICATION vSim for Nursing PATIENT EDUCATION WORKSHEET ▪ Alert: Counsel patient not to discontinue opioids without first discussing the need for a gradual tapering regimen with prescriber. ▪ Caution patient not to share drug and to protect it from theft or misuse. ▪ Warn patient that use of drug, even when taken as recommended, can result in addiction, abuse, and misuse, which can lead to overdose or death. ▪ Inform patient that drug may cause orthostatic hypotension and fainting. Teach patient how to recognize signs and symptoms of low BP and how to reduce risk of serious consequences of hypotension (e.g., by sitting or lying down or by carefully rising from a sitting or lying position). ▪ Explain the assessment and monitoring process to patient and family. Instruct them to immediately report difficulty breathing or other signs of a potential adverse opioid-related reaction. ▪ Advise patient that drug may impair judgment and not to operate heavy machinery or drive until drug’s effects are known. ▪ Instruct patient to avoid alcohol while taking drug. ▪ Alert: Encourage patient to report all medications being taken, including prescription and OTC medications and supplements. ▪ Alert: Caution patient to immediately report signs and symptoms of serotonin syndrome, adrenal insufficiency, and decreased sex hormone levels. ▪ Teach patient to eat a high-fiber diet, drink plenty of fluids, and use a stool softener or bulk laxative to prevent constipation. ▪ Tell patient to stop drug and immediately report blurred vision, rash, or yellowing of the skin. ▪ Alert: Warn patient to stop drug and seek medical attention immediately if rash or reaction occurs while using acetaminophen. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Cyclobenzaprine Hydrochloride CLASSIFICATION: Skeletal muscle relaxants PROTOTYPE: Cyclobenzaprine CONTRAINDICATIONS: In patients hypersensitive to drug; in those with hyperthyroidism, heart block, arrhythmias, conduction disturbances, or HF; in those who have received MAO inhibitors within 14 days; and in those in the acute recovery phase of an MI. There is increased risk of potentially life-threatening serotonin syndrome when drug is used in combination with SSRIs, SSNRIs, other TCAs, tramadol, bupropion, meperidine, or verapamil. Use cautiously in elderly or debilitated patients and in those with a history of urine retention, acute angle- closure glaucoma, or increased IOP. Safety and effectiveness in children younger than age 15 haven’t been established. ADVERSE EFFECTS: CNS: dizziness, drowsiness, seizures, headache, tremor, insomnia, fatigue, asthenia, nervousness, confusion, paresthesia, depression, attention disturbances, dysarthria, ataxia, syncope. CV: arrhythmias, palpitations, hypotension, tachycardia. EENT: visual disturbances, blurred vision. GI: dry mouth, dyspepsia, abnormal taste, constipation, nausea. Skin: rash, pruritus, acne. BLACK BOX WARNINGS: Opioid class warning: Use with opioids may cause slow or difficult breathing sedation and death. Avoid use together. If use together is necessary, limit dosage and duration of each drug to the minimum necessary for desired effect. Naproxen: May increase drowsiness. Make patient aware of this interaction. Tramadol: May increase risk of seizures. Use together cautiously. Caution patient or caregiver of patient taking an opioid with a benzodiazepine, CNS depressant, or alcohol to seek immediate medical attention for dizziness, light-headedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness SAFE DOSE OR DOSE RANGE, SAFE ROUTE vSim for Nursing PATIENT EDUCATION WORKSHEET ROUTE: PO Adults and children age 15 and older: 5 mg PO t.i.d. Based on response, may increase to 7.5 or 10 mg t.i.d. Don’t exceed 30 mg/day. Or, 15 to 30 mg extended-release capsule PO once daily (adults only). Use for longer than 2 or 3 weeks isn’t recommended. PURPOSE FOR TAKING THIS MEDICATION To relieve muscle spasm from acute, painful musculoskeletal conditions without disrupting muscle function. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Advise patient to report urinary hesitancy or urine retention. If constipation is a problem, suggest that patient increase fluid intake and use a stool softener. ▪ Warn patient to avoid activities that require alertness until CNS effects of drug are known. ▪ Warn patient not to combine with alcohol or other CNS depressants, including OTC cold or allergy remedies. ▪ Instruct patient not to split the generic 10-mg tablets because of the high risk of inconsistent doses and not to crush or break capsules. ▪ Teach patient that capsule may be opened, contents sprinkled on a tablespoon of applesauce, and swallowed immediately (if patient is able to reliably swallow it without chewing). Instruct patient to then rinse mouth to ensure all of the contents were swallowed. ▪ Advise patient that using drug for longer than 2 to 3 weeks isn’t recommended. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Tramadol Hydrochloride CLASSIFICATION: Analgesics Controlled substance schedule: IV PROTOTYPE: Morphine Sulfate CONTRAINDICATIONS: In patients hypersensitive to drug or opioids, in patients with severe renal or hepatic impairment, suicidal patients, and in those with acute intoxication from alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs. Contraindicated in patients with GI obstruction, including paralytic ileus. Contraindicated with concomitant use or within 14 days of MAO inhibitor therapy. Contraindicated in patients with significant respiratory depression or acute or severe bronchial asthma or hypercapnia in unmonitored settings or where resuscitative equipment isn’t available. Alert: Serious hypersensitivity reactions can occur, usually after the first dose. Patients with history of anaphylactic reaction to codeine and opioids may be at increased risk. Alert: Patients are at increased risk for oversedation and respiratory depression if they snore or have a history of sleep apnea, haven’t used opioids recently or are first-time opioid users, have increased opioid dosage requirements or opioid habituation, have received general anesthesia for longer lengths of time or received other sedating drugs, have preexisting pulmonary or cardiac disease, or have thoracic or other surgical incisions that may impair breathing. Monitor patients carefully. Use cautiously in patients at risk for seizures or respiratory depression; in patients with increased ICP or head injury, acute abdominal conditions, or renal or hepatic impairment; and in patients with physical dependence on opioids. Withdrawal symptoms may occur if drug is abruptly discontinued. Alert: Drug can cause life-threatening serotonin syndrome. Alert: Use cautiously in patients who are experiencing depression or an emotional disturbance because of the increased risk of suicide. Alert: Drug may lead to rare but serious decrease in adrenal gland cortisol production. Alert: Drug may cause decreased sex hormone levels with long-term use. Patients who are CYP2D6