NURS 6521 Complex Regional Pain Disorder White Male With Hip Pain

NURS 6521 Complex Regional Pain Disorder White Male With Hip Pain

BACKGROUND

. He walks with the assistance of crutches. The client reports at the start of the clinical interview that his family doctor sent him for psychiatric evaluation because the doctor thought the pain was “all in his head.” He goes on to say that his doctor thinks he’s just making stuff up to get “narcotics to get high.”

SUBJECTIVE

The client claims that his pain began about 7 years ago after he fell at work. He claims to have landed on his right hip. He has had numerous diagnostic tests over the years (x-rays, CT scans, and MRIs). He claims that it was discovered about 4 years ago that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to the 12 o’clock position). He claims that none of the surgeons he saw would operate because they thought he was too young for a total hip replacement and that the tissue would heal with time. He has since reported a strange constellation of symptoms, including cooling of the extremity (measured by electromyogram). He also claims to have severe cramping in his extremity. One of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy, according to his report (RSD). However, for treatment of this condition, the neurologist referred him back to his family doctor. He claims that his family doctor told him that “there is no such thing as RSD, it comes from depression,” which prompted the referral to psychiatry. He claims that a few years ago, a specialist suggested that he use a wheelchair, to which the client replied, “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.”

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.”

In the United States, and around the world, Alzheimer’s disease affects the vast majority of the elderly. Alzheimer’s is a neurological disease that begins slowly and worsens over time, according to numerous research. The disease affects more than 70 percent of older dementia sufferers worldwide, according to epidemiological data. The condition’s most telling sign is a patient’s inability to recall recent events from their life. As the disease progresses, other symptoms such as mood swings, behavioral challenges, language difficulties, confusion, and the absence of self-care management begin to emerge.. As the body loses its ability to perform all of its critical activities, it will finally die. However, despite the fact that the condition has a variable life expectancy among patients, Houmani and colleagues (2018) claim that the average post-diagnosis lifespan is no more than nine years. Furthermore, Alzheimer’s disease remains incurable, and the only option is to control it so that a patient can experience a better quality of life prior to their eventual death.

Nurse practitioner examines and treats an Iranian guy whose kid claims that he exhibits unusual habits in the current case study. Mr. Akan, according to the conversation with the patient, seems to have lost interest in some of the things he used to care about. Furthermore, the patient has recently grown forgetful and confabulated during mental health examinations. The diagnostic process reveals other symptoms, including impaired judgment and impulse control, and a restricted emotional response. The patient also has a significant neurocognitive problem, according to a mini-mental status evaluation. The nurse had a sneaking suspicion that probable Alzheimer’s was to blame for the patient’s condition. As a result, the goal of this study is to provide insight into the results of the assessment and develop a pharmacological treatment strategy based on established best practices. The illness is essentially untreatable, but it can be managed with the use of medication. But parameters like dosage, drug selection, administration duration, and route have an impact on pharmacological management. In addition, the nurse practitioner must keep tabs on a patient’s response to medication and dosages and make necessary adjustments based on frequent evaluations.

Decision Point One

Select what you should do:

Decision Point One

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

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, you ask 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 does complain 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

Decision Point Two

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

Decision Point Three

Guidance to Student

. Once that is understood, the next step is to explain to the client that his pain level expectations must be realistic and that he will always experience some level of pain on a daily basis. The key is to manage it in such a way that he can continue his daily activities with as little discomfort as possible. Next, it is critical to emphasize that medications are never the sole solution, but rather part of a comprehensive treatment plan that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is an SNRI with NMDA antagonist activity, which aids in the production of analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in this gentleman’s therapy. Tramadol should never be used in conjunction with other opioid analgesics. Agonists at Mu receptors do not provide adequate pain control in these types of neuropathic pain syndromes and are thus never recommended. It is also addictive, which can lead to secondary drug abuse. Reduced Savella dosage can help control side effects, but at the expense of uncontrolled pain. It’s always a good idea to start with dose reductions during the times of day when your pain is the most under control. Celexa should be combined with Savella with caution. Both medications inhibit serotonin reuptake, which can result in serotonin toxicity or serotonin syndrome.

Decision Point One

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
• Client’s pain level is currently a 6 out of 10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. You ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
• Client denies suicidal/homicidal ideation and is still future oriented

Decision Point Two

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
• Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
• Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it

Decision Point Three

Guidance to Student

. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.

Decision Point One

Neurontin (gabapentin) 300 mg orally at BEDTIME with weekly increases of 300 mg per day to a max of 2,400 mg if needed

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client returns to the office today and seems to be in agony. He states that the Neurontin did not help him at all. He also states that he is foggy in the morning. His current pain level is a 9 out of 10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” The client is also asked what would need to happen to get his pain from a current level of 9 to an acceptable level of 3. He states, “I guess I would like this achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
• Clientis denies suicidal/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain

Decision Point Two

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client returns today with a current pain level of 5 out of 10. He appears anxious, which is a new presentation. He states that he feels “amped up” and he cannot seem to control it
• Client also states that he hasn’t been able to get an erection in over a week and thinks his pain may be causing erectile dysfunction.
• Although client’s pain is “more manageable than it has been before”, he thinks it may have gotten the best of him. His new problems really have him discouraged

Decision Point Three

Guidance to Student

Anxiety is a temporary side effect of SSRI and SNRI therapy that should be expected. Counseling the client is critical to maintaining the therapeutic alliance you have established with the client. Short-term benzodiazepines are usually enough to get you through this period. Erectile dysfunction is a common side effect of all SSRIs and should be discussed with men. It affects approximately 10% of men who take SSRIs. A Zoloft dose reduction will almost certainly help with the side effects, but will almost certainly result in increased pain. A change in therapy is always an option at this point, but it usually does not alleviate the anxiety or erectile dysfunction and will still necessitate short-term benzodiazepine therapy and appropriate counseling. In this case, it would be prudent to add Wellbutrin XL 150 mg po QAM to help with the side effect of erectile dysfunction. Although we have said throughout this course that adding a medication to treat a side effect is not good therapy, this is one of those cases where it is recommended, particularly when the client is experiencing relief from a regimen that took time to achieve. Wellbutrin is a DNRI that does not interfere with SSRI therapy (maybe a little in the DRI of Zoloft).

For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.

Photo Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY / Science Photo Library / Getty Images

To Prepare

• Review the interactive media piece assigned by your Instructor.
• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
• You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

By Day 7 of Week 8

Write a 1- to 2-page summary paper that addresses the following:

• Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
• Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
• What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
• Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

You will submit this Assignment in Week 8.

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