Assignment: Holistic assessment

Situation As an Advanced Nurse Practitioner (ANP), you are working in an urgent care setting. TC comes to the clinic with a work-related injury to the right shoulder. The patient rates the pain 8 on a scale of 0–10. The patient is unable to perform any ROM to the shoulder. There is no neck pain. The purpose of this post is to discuss and answer the following questions regarding this case study:

1. What pieces of the holistic assessment are missing from this scenario? A holistic assessment of the patient includes the following aspects with special attention to patient’s preferences, privacy, and dignity while getting all information necessary for finding the right diagnosis, creating the best treatment plan, and effectively communicating and co-authoring the plan with the patient. The six aspects of a holistic assessment include a complete physical assessment, review of stressors or psychological contributing factors, review support systems at home and in the community, assess development and cognition for ability to understand what is happening, ascertain spiritual or religious beliefs related to care to assess whether this could affect the prescribed plan, and fully discuss cultural values and practices as they relate to the treatment and daily routine. A full physical assessment, review of stressors, supports, cognition, psychological state, and cultural values are missing from this assessment (Woo & Robinson, 2020).

2. As a healthcare provider, what else do you need to understand about this patient related to pain management? During the assessment, we must find out if the patient has medication allergies, what they typically use for pain, what they have been taking in between injury and time of assessment, what has worked in the past, what hasn’t worked, and if the patient is opioid naïve. If the patient is a regular opioid user, and a course of opioid pain medications are prescribed, the dose will need to be higher than that for someone who has never or rarely utilized opiates (Woo & Robinson, 2020).

3. Describe the process of rational drug choice for this case study. In your process, discuss your thought processing of anti-inflammatory agents, topical agents, and narcotics. In order to make a rational drug choice to prescribe this patient, I will need to acquire imaging of the shoulder and arm and do a thorough assessment. If there is soft tissue injury versus a fracture this may alter the recommendations for type and length of treatment. This information will come from the physical assessment and imagine. Opioid medication should be avoided if NSAIDs are helpful for treating the pain, however Woo & Robinson (2020) state that NSAIDs are appropriate for mild to moderate pain, and an 8/10 pain scale would be considered acute. Utilizing only the 0-10 pain scale would be an incomplete assessment to base a prescribing decision on (Aldington & Eccleston, 2019). Topical agents may be considered as an adjunct therapy but would not be effective to treat the acute injury on their own, as they are more indicate for treatment of chronic, or at the very least post-acute, pain (Woo & Robinson, 2020). Tramadol is a non-opioid that has an opioid-like effect on pain treatment and this may be a good option depending on severity of injury and pain (Woo & Robinson, 2020). Some patients being treated for injury are given prescriptions for their different pain levels. An example would be Motrin 800mg every 8 hours as needed for pain 4-7/10 not to exceed three tablets daily and take with food, and a second prescription for Tramadol 50mg every 4-6 hours as needed for acute pain 7-10/10. Assignment: Holistic assessment

4. Include in your response the teaching you would provide to TC. If my decision is to prescribe NSAIDs, I will provide education to the patient to take the medication with plenty of food to avoid GI damage and distress, and to make sure not to take more than prescribed. If the decision is to prescribed opioids, there will be a thorough education on the risk of dependence and addiction, the importance of not taking the medication more than prescribed, the importance of safe medication storage and keeping the medication away from other people who may abuse or be injured by exposure to the medication, the risk of constipation and importance of water and fiber in the diet. Opioids may also contribute to serotonin syndrome in patients who take medications that act on increasing serotonin availability for serotonin receptor binding, and this must be a caution when prescribing. An additional education point will be encouraging the patient to take the medication before the pain becomes unbearable or severe, as the medication will not be as effective in the increasingly acute pain state (Woo & Robinson, 2020).

5. What is meant by the DEA Drug Classification Schedule? Explain each category/classification. The Drug Enforcement Agency of the United States (DEA) controls a schedule of medications based on their “acceptable medical use and abuse potential” (DEA, 2020, pp1) and in reference to the Controlled Substance Act (DEA, 2020). There are five (5) schedules for substances. Schedule 1 substances have the highest abuse potential and no acceptable medical use. Examples include heroin, LSD, and ecstasy. The DEA lists marijuana as a Schedule 1 substance however marijuana has documented medical uses and has been decriminalized in many states. Schedule 2 substances are considered to have a significantly high abuse, dependence, and addiction potential as well as to be dangerous to the individual but do have documented medical uses. Exampled of Schedule 2 substances include dilaudid, fentanyl, and Adderall. Schedule 3 substances are considered to have moderate to low abuse and dependence potential and to have acceptable medical uses. Examples include Tylenol with codeine, ketamine, testosterone, and anabolic steroids. Schedule 4 substances are considered to have a low potential for abuse or dependence and include Xanax, Ativan, soma,and tramadol. Schedule 5 substances are considered to have a lower abuse potential than Schedule 4, and include lower codeine-containing cough syrup, robitussin cough syrup, Lomotil, and lyrica (DEA, 2020). Assignment: Holistic assessment

References

Aldington, D., & Eccleston, C. (2019). Evidence-Based Pain Management: Building on the Foundations of Cochrane Systematic Reviews. American Journal of Public Health, 109(1), 46–49. https://doi.org/10.2105/AJPH.2018.304745 . Drug Enforcement Agency (DEA). (2020). Drug scheduling. Accessed at https://www.dea.gov/drug-scheduling . Woo, T.M. & Robinson, M.V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers. F.A. Davis.

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