Pain management

Pain management
1.A patient is currently taking acetaminophen/oxycodone (325 mg/5mg) every 4 hours for postoperative pain management but side effects are beginning to develop from the acetaminophen. The plan is to separate the oxycodone from the acetaminophen and increase the oxycodone dose.
Using oral titration guidelines, how much increase should be ordered for the oxycodone per dose, and what will that dose be after the increase?

2.Assume the patient in question # 1 has been on the higher dose of oxycodone for 3 days and has now started to rate the pain at 8 on a 0 to 10 scale. The plan is to now convert the patient to an oral form of morphine. Using equianalgesic dosing information in this unit, how much morphine should be given per dose if the morphine is ordered every 4 hours?

3.A patient is receiving 30 mg of controlled release morphine po every 8 hours for terminal cancer. The patient continues to rate his pain at 8 on a 0 to 10 scale.
Using oral titration guidelines, how much would you consider increasing the dose, and what will the new dose be?
4.Calculate the new appropriate oral breakthrough dose for the patient in question # 3.
5.A patient is taking 20mg of oxycodone every 6 hours and rating the pain at 6 on a scale of 1 to 10. The plan is to convert the patient to IV hydromorphone.
How much hydromorhpone should be order per dose if the medication can be given every four hours?
6.A patient is on morphine for cancer pain. The health care team has decided to convert the patient to continuous fentanyl drip.
How many mcg per hour should be infused if the patient has been taking 3 mg of morphine IV every two hours?
7.A patient is on an epidural morphine infusion of 0.5 mg per hour. A decision has been made to change the infusion from epidural to intravenous infusion .
How much morphine should the patient now receive per hour intravenously?

QUESTION 1

Mrs. Hernandez is a 72-year-old Hispanic patient with advanced left breast cancer with metastasis to the lungs and bones. She is referred to your home care agency for wound care services. She has three daughters and one son. Mrs. Hernandez’s husband died one year ago of lung cancer and she has lived alone since his death. Mrs. Hernandez’s condition continues to decline and her physician encourages her to seek hospice care. At this time, a change in her living arrangements is made. The family decides that Mrs. Hernandez should move in with her eldest daughter. Although her daughters have always been close to their mother and more involved in her care, the son is consulted for all decisions related to his mother’s care.
After three weeks of care, the daughter calls requesting that a nurse come as soon as possible because her mother’s pain is worse. The pain is described by Mrs. Mendez as an intense pressure pain at the site of the tumor in the base of the breast. She also describes a sharp stabbing pain in the left upper quadrant of the breast. In addition, she complains of intense pain in her mid-back which has made it very difficult to remain in bed and she has been unable to sleep for the last 2 days. She has been taking one to two pills of an oral codeine and acetaminophen preparation every four hours PRN although yesterday in which the daughter reported that out of desperation the medication was given approximately every two hours until her mother became extremely nauseated. The health care provider recalls that morphine was ordered for the patient in anticipation of increased pain not controlled with the pain pill. Upon questioning, the daughter states that they have not used the morphine as they were “saving it for the end.” The daughter also reports that the family is trying to minimize the use of the medicine since their mother is extremely constipated. The family believes the reason for the constipation is her inability to continue her herbal remedies due to nausea. Mrs. Hernandez appears very stoic with minimal expression of pain. Her only complaint is that she no longer is able to have her grandchildren over to visit due to her declining condition.

Mrs. Hernandez is started on long-acting morphine, 45 mg at BID with 10 mg shorter-acting morphine for rescue dose. Over the next week, the long-acting morphine is increased to 80 mg BID supplemented with Ibuprofen 800 mg TID. Approximately one week later, the nurse receives a call from the daughter reporting that her mother has declined rapidly over the weekend. On exam, Mrs. Hernandez is short of breath, exhausted, and the health care provider notes a general decline with minimal intake of foods or fluids. The priest is called to give her communion and the Anointing of the Sick. The extended family is at her bedside until the end. (Modified from a Case Study provided by ELNEC (2000))

Use a cultural assessment tool to identify factors that influence care in this case.

QUESTION 2
Provided the information in question 1:
How did culture influence communication with patients and family caregivers in this case.

QUESTION 3
Provided the information in question 1:
Describe the roles of various professional disciplines in this case. How best could these professionals coordinate their care?

QUESTION 4
Describe what assessment parameters you would utilize to assess the pain level of a 2-month-old and what nonpharmacologic measures would be appropriate for pain management?
QUESTION 8
How do the types and causes of pain in elderly persons differ? What are the different types and causes?
QUESTION 9
List indications and contraindications for use of each classification of pain medication (opioids, non-opioids, and adjuvant therapy).
QUESTION 10
What are some misconceptions about pain management in the elderly?
QUESTION 11
What are some ways to prevent polypharmacy?
QUESTION 12
Describe at least two of the specific pain assessment tools/methods for cognitively intact elderly, and for cognitively impaired elders.
QUESTION 1
Define “polytrauma” and discuss its impact on pain management in “Wounded Warriors”.
QUESTION 2
What is the nature of wounding by an IED that is unique to that type of injury?
QUESTION 3
Describe at least two ways that PTSD can impact pain management – be specific.
QUESTION 4
List 3 of the challenges of managing pain in the OEF/OIF (Operation Enduring Freedom/Operation Iraqi Freedom) veterans?
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