NURS 6521 Week 8 Assignment – Hawkinberry T Advanced Pharmacology Assessment Decisions Making

Subjective Information 43-year-old Caucasian male presents at the office with a chief complaint of pain. Requires crutches to assist with ambulation. Injury to right hip region form a fall seven years ago. Reports that the family doctor sent him for psychiatric assessment because his primary care provider felt that the pain was “all in his head.” He also stated that his physician believes he is just making stuff up to get “narcotics to get high.” Objective Information Alert, oriented to person, place, time, and event. Dressed appropriately for the weather and season. 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 thoughts or plans and is future oriented. Right leg color change from baseline to purple from the knee down, the foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself lasting 2-3 minutes then resumed to ethnic color with foot returning to natural alignment. Rated pain 7/10 during episode. Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy) Complex regional pain syndrome (CRPS) is a condition of intense burning pain, stiffness, swelling, and discoloration that most often affects the hand, but arms, legs, and feet can also be affected (American Academy of Orthopedic Surgeons, 2021). Decision One Neurontin 300 mg at bedtime and titrate up 300 mg to a total of 2400 mg daily if needed. Beneficial in treating neuropathic pain related to reflex sympathetic dystrophy by binding the calcium channel blockers to decrease the transmission of the neurotransmitters, reducing pain (Cochrane, 2022). 3 Patient report, Neurontin is not effectively managing pain, current pain level is a 9 out of 10. Daytime “grogginess.” Four weeks later pain 5/10 “grogginess” worse and erection difficulties are verbalized. Pain is at an acceptable level but would require additional medication to combat daytime drowsiness. Gabapentin is useful for “nerve pain,” but was not the correct choice for this patient. Mannerism displays frustration with another failed treatment. Decision Two Savella 12.5 mg 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. Milnacipran (Savella) is a selective serotonin and norepinephrine reuptake inhibitors (SNRIs). It works by increasing the amount of serotonin and norepinephrine, that help stop the transmission of pain signals in the brain (Sinha, 2021). States that his pain is currently a 4/10, decreased use of assistive device (crutches) for ambulation. Verbalized side effects of “bouts of sweating”, nausea, and sleep has “not been so good as of lately.” Vital signs: 147/92 and 110. He also admits to experiencing “butterflies” in his chest. This medication is an option but for him is not the correct choice. Mannerism displays concern because of the side effects. Decision Three Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day. Decreasing this medication caused increased pain and required the use of assistive device again for ambulation. States pain level is currently a 6/10. Can ambulate short distances without assistive device. States “achiness, throbbing, and shooting pain has decreased.”. Increasing the dosage to 125 mg at bedtime has decreased pain to 4/10 and episodes of “throbbing and shooting pain” has decreased. The 4 use of assistive device has decreased. Patient concern is weight gain (5 pounds in a month). Visibly more euthymic since pain has decreased and requires less useof crutches. Evidenced Treatment According to Fornasari (2017), amitriptyline and nortriptyline are the most widely used tricyclic antidepressants (TCAs) for treating CRPS. These medicines can often improve sleep and are usually taken in the early evening to reduce the risk of "hangover" effects the next morning. Tricyclic antidepressants relieve neuropathic pain by inhibiting presynaptic reuptake of the biogenic amines serotonin and noradrenaline, but other mechanisms such as N-methyl-D-aspartate receptor and ion channel blockade play a role in pain-relieving effect (Fornasari, 2017). Treatment Goals The best course of action would be to continue the same dose of Elavil, provide education on dietary and exercise habits also refer him with a life coach who can help with weight loss strategies in a more meaningful way. Conclusion This patient’s pain was not managed and the CPRS was left untreated which could have lea to permanent disability. Therapeutic listening and conversations are as important as the objective data collected. Chronic pain can cause depression which could leave to loss of life if ignored. The patient’s pain was at an acceptable level and with the course of action of amitriptyline, he will get back to a life that is productive and meaningful for him. 5 References American Academy of Orthopedic Surgeons. (2021). Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy). Cleveland Clinic. (2022). Chronic pain: What is it, causes, symptoms & treatment. Cochrane. (2022). Gabapentin for chronic neuropathic pain in adults. Cochrane. Fornasari, D. (2017). Pharmacotherapy for neuropathic pain: A review. Pain and Therapy, 6(S1), 25-33. MedlinePlus. (2020). Gabapentin: MedlinePlus drug information MedlinePlus. (2017). Amitriptyline: MedlinePlus drug information. MedlinePlus drug information. (2021). Milnacipran: MedlinePlus drug information Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The link between depression and chronic pain: Neural mechanisms in the brain. Neural Plasticity, 2017, 1-10. Sinha, S. (2021). Savella.