I am in acute care nurse practitioner program
DQ-1
1- 300 minimum words for question, you can go up to 700 words.
2- 2-3 Scholarly references ( NO MAYO CLINIC/AHA)
3- References should be within 5 years
4- I am in acute care nurse practitioner program.
DQ-1
Select a medication used for pain management and review available evidence and treatment guidelines to determine appropriate therapeutic options. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including CAM. In addition, share an example where you have observed an adverse event from a pain medication and explain the management taken regarding this adverse event. If you do not have an example, select an adverse event from the pain medication and explain what interventions you could make to mitigate this adverse event. Include references using APA format.
DQ-2
Read and summarize the Topic Material “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.” Discuss any ethnic, cultural, or genetic differences that need to be considered for the use of opioids to treat chronic pain. How do you intend to use the guidelines in your future practice?
DQ-3
Oxycodone is an opioid agonist for pain management of acute or chronic moderate to severe pain. It binds to opiate receptors, G-protein coupled receptors, in the central nervous systems (CNS) and activates the GDP for a GTP, which inhibits the adenylate cyclase and decreases the intracellular cAMP (Sadiq, Dice, & Mead, 2019). Consequently, oxycodone inhibits the nociceptive neurotransmitters acetylcholine, dopamine, GABA, noradrenaline, and substance P, altering perception and response to pain and producing CNS depression (Sadiq et al., 2019). Oxycodone is available in tablets and capsules in immediate-release and extended-release. Immediate-release doses range from 5 to 15 mg every 4 to 6 hours as needed while ER tablets are 10 mg and capsules are 9 mg every 12 hours (“Oxycodone,” 2019). Dosages may vary depending on opioid-tolerant patients, and for adequate pain control, dosages should titrate upwards with monitoring for potential side effects. The most common adverse effects include constipation, weakness, dizziness, dry mouth, nausea, vomiting, headache, and pruritis (Sadiq et al., 2019). Throughout initial therapy or increased dosage, the patient’s blood pressure, heart rate, and respiratory rate should be monitored, as well as, the side effects. Oxycodone may impair mental and physical abilities and cause hypotension and respiratory depression. It is important extended-release tablets are swallowed whole as crushing or chewing can cause rapid release leading to respiratory depression and further carbon dioxide retention can exacerbate sedating effects, which may be fatal (“Oxycodone,” 2019). Drug interactions that may increase the oxycodone serum concentration and enhance adverse effects, include CYP450 inhibitors, benzodiazepines, amphetamines, anticholinergic, CNS depressants, rufinamide, selective serotonin reuptake inhibitors, and zolpidem (“Oxycodone,” 2019). Complementary and alternative medicine (CAM) interactions with oxycodone include ephedra, Jamaica dogwood, kava kava, and lavender, as this may enhance the effects of CNS depressants, whereas St. John’s Wort may decrease the serum concentration of oxycodone.
There are always patients that deal with constipation after taking oxycodone. A patient came in the ER with severe abdominal pain, nausea, and vomiting. The CT scan showed a bowel obstruction and the patient was taking to the OR for an exploratory laparotomy with bowel resection. When the section of the bowel was removed, the surgeon pulled out pieces of fecal that was hard as a rock. According to the notes, the patient was at a rehab facility due to a hip hemiarthroplasty four weeks prior. Current medications included an opioid for post-operative pain management. Patient had no prior abdominal conditions, but opioid use, age, and possible concomitant medications can be causative factors for the bowel obstruction. In elderly patients, constipation is more common, which can be due to decreased mobility, medical conditions, and/or concomitant medications; however, stool softeners may be beneficial for many patients as it may improve bowel function and quality of life (Morlion et al., 2017). Other recommendations may be to increase fiber into their diet or increase physical activity to increase bowel movement. Also, other therapies should be recommended instead of prolonging the use of opioids, such as acetaminophen or NSAIDS. As prescribers it is essential to monitor all side effects and appropriate use of any opioids as we have to consider to discontinue the medication if the benefits don’t outweigh the risks.
References
Morlion, B. J., Mueller-Lissner, S. A., Vellucci, R., Leppert, W., Coffin, B. C., Dickerson, S. L., & O’Brien, T. (2017). Oral prolonged-release oxycodone/naloxone for managing pain and opioid-induced constipation: A review of the evidence. Pain Practice, 18(5), 647-665. doi:10.1111/papr.12646
Oxycodone. (2019). Retrieved from https://www.drugs.com/ppa/oxycodone.html
Sadiq, N. M., Dice, T. J., & Mead, T. (2019). Oxycodone. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482226/
DQ-4
Morphine is often chosen as a front-line drug in the management of chronic non-cancer pain (Broglio et al., 2017). Morphine is in a class of drugs called opioid analgesics and work on the delta, kappa, and mu-opioid receptors (Murphy & Barrett, 2019). Analgesic effects are achieved when binding to the mu-opioid receptor within the central nervous system (Murphy & Barrett, 2019). Once this occurs, there is an activation of descending inhibitory pathways of the central nervous system and inhibition of the nociceptive afferent neurons of the peripheral nervous system leading to an overall reduction of nociceptive transmission (Murphy & Barrett, 2019).
Morphine can be given in a variety of ways. Some routes include oral with immediate-release and extended-release, intravenous, epidural, and intrathecal formulations (Murphy & Barrett, 2019). One option that is frequently used in palliative care is sublingual and as an oral suspension (Murphy & Barrett, 2019).
Some drug-drug interactions include the concurrent use of MAOIs as they create an additive effect with morphine, causing severe hypotension, serotonin syndrome, or an increase in respiratory depression in patients (Murphy & Barrett, 2019).
Some side effects include blurred vision, numbness in the extremities, chills, confusion, dizziness, fainting, headache, hives or rash, loss of appetite, constipation, and nausea (Murphy & Barrett, 2019).
The biggest risks of morphine are addiction, abuse, and misuse (Murphy & Barrett, 2019). These side effects can lead to overdose and death (Murphy & Barrett, 2019). Each patient needs to be assessed for their risk of substance addiction and abuse before prescribing (Murphy & Barrett, 2019). Overdose of morphine displays as decreased level of consciousness and respiratory depression that can be life-threatening or fatal (Murphy & Barrett, 2019).
There are withdrawal symptoms from morphine as well (Murphy & Barrett, 2019). These symptoms include hallucinations, tremors, mood swings, and irritability (Murphy & Barrett, 2019). Some can be so extensive that they can cause seizures (Murphy & Barrett, 2019). The best way to avoid withdrawal symptoms is to taper the dose down until it is within a safe dosage to stop it altogether (Murphy & Barrett, 2019).
An example I have of the use of morphine was actually last week. We received a young patient from the ER who had developed a very large pleural effusion and was going to the ICU to meet the Intensivist to receive a thoracentesis. The procedure went well without any issues, but post-procedure the patient began to complain of pain with breathing due to lung re-expansion. The physician ordered morphine 2mg IVP Q4h PRN Pain >7, and the nurse gave the first dose. Within 30 minutes the patient began to display signs of altered mental status and confusion. Fifteen minutes later the patient was sleeping and their respiratory rate had fallen to 8 breaths per minute and their oxygen saturation had dropped to 90%. At this point, the decision was made to give the reversal agent Narcan, discontinue morphine, and treat with a combination of acetaminophen and ibuprofen. Within 30 seconds of administering Narcan, the patient became arousable, alert and oriented, and began to cough and take deep breaths. After explaining what happened to the patient, they agreed a lower regiment of pain management was appropriate.
References:
Broglio, K., Pergolizzi, J., Kowalski, M., Lynch, S. Y., He, E., & Wen, W. (2017). Efficacy and Safety of Once-Daily Extended-Release ( ER) Hydrocodone in Individuals Previously Receiving ER Morphine for Chronic Pain. Pain Practice, 17(3), 382–391. https://doi-org.lopes.idm.oclc.org/10.1111/papr.12462
Murphy, P.B, & Barrett, M.J. (2019) Statpearls for Morphine. Treasure Island. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK526115/
DQ-5
There are increasing prescription of opioids in the united states. The amount of opioid overdose death is also increasing. Primary care providers have reported that they have concerns about pain medication misuse. The problem is managing patients with chronic pain and effectively controlling their pain using this new system. The guidelines are set in place to target and help primary care providers that treat patients with chronic pain. To avoid over prescription the CDC has established guidelines in order to prescribe effectively. This grading recommendations of assessment can be a tool to help the primary care provider effectively prescribe the adequate number of opioids. The CDC has developed training sessions in order to use this new grading system effectively. There is evidence that this new system may have some benefit in…
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