Johnas, An Advanced Nurse Practitioner, You Are Working

Johnas An Advanced Nurse Practitioner Anp You Are Working

As an Advanced Nurse Practitioner (ANP) working in an urgent care setting, a comprehensive holistic assessment is essential for effective diagnosis and treatment planning. In the scenario involving TC with a work-related shoulder injury, initial observations include severe pain rated 8/10, inability to perform range of motion (ROM), and absence of neck pain. However, significant pieces of the holistic assessment are missing, which are critical to understanding the patient's overall health status and tailoring appropriate management strategies.

Holistic assessment encompasses physiological, psychological, sociological, developmental, spiritual, and cultural dimensions of patient care. At minimum, these include a full physical examination, psychological review, social support systems, developmental and cognitive assessments, spiritual beliefs, and cultural values. In this case, the absence of information regarding TC’s age, prior medical history, allergies, medication use, alcohol consumption, and details about how the injury occurred suggests an incomplete assessment. Such details are vital because they influence pain management decisions, potential contraindications, and medication choices.

Understanding the patient's age and comorbidities, such as liver or kidney dysfunction, impact pharmacologic strategies. For example, impairments in hepatic or renal function alter drug metabolism and excretion, necessitating dosage adjustments or alternative therapies. Additionally, knowing if the patient is opiate-naïve or has prior opioid use influences the selection and dosing of analgesics, particularly narcotics, to prevent overdose or adverse effects. Exploring TC's psychological state and social supports is equally important, as stressors, mental health conditions, or inadequate support systems can affect both pain perception and adherence to treatment.

Understanding Pain Management as a Healthcare Provider

Effective pain management begins with a thorough understanding of the pain's nature, which includes its intensity, duration, type (acute, chronic, or cancer pain), and impact on function. WP & Robinson (2020) categorize pain into three types: acute, cancer, and chronic, each requiring distinct treatment approaches. Acute pain, as in TC's case, typically warrants prompt, targeted intervention to prevent progression to chronicity and facilitate healing. Recognizing whether the pain is nociceptive—originating from tissue injury—or neuropathic due to nerve injury influences pharmacological choices. Neurophysiological assessments, psychological factors, and patient preferences also guide individualized pain strategies.

The Rational Drug Choice Process in This Case

Determining the most appropriate pharmacotherapy involves assessing injury severity, imaging findings, and patient-specific factors. Initial imaging will clarify whether the injury involves soft tissue damage or fracture, which bears upon the choice of medications and the duration of therapy. For mild to moderate inflammation and pain, NSAIDs such as ibuprofen are effective and can be prescribed at 400 mg every 6 hours, not exceeding 2400 mg per day (Lexicomp, 2017). These agents provide the benefit of anti-inflammatory effects but carry risks like gastrointestinal bleeding, renal impairment, and cardiovascular concerns, especially in predisposed individuals (Woo & Robinson, 2020).

Topical agents such as lidocaine patches (e.g., Lidoderm 5%) can serve as adjuncts, particularly for localized neuropathic pain. They should be applied for 12 hours daily, avoiding application on broken or irritated skin to minimize adverse effects like skin irritation or burning sensation. Topicals are beneficial for localized pain but are insufficient as sole therapy for acute injuries, which typically require systemic options.

In cases of severe pain (8/10), opioids should be considered only after evaluating past medication use and contraindications. Tramadol, a centrally acting analgesic with opioid-like actions, offers an alternative to traditional opioids with a lower potential for dependence. However, given the current opioid crisis, opioids like oxycodone should be reserved for severe breakthrough pain and prescribed cautiously, limited to short courses (Woo & Robinson, 2020). For TC, a combination of NSAIDs and topical agents might suffice initially, with opioids reserved for inadequate pain control, administered at the lowest effective dose and for the shortest duration necessary.

Patient Education and Teaching Points

Educating TC about medication use and safety is integral to successful pain management. If NSAIDs are prescribed, instruct the patient to take them with food to reduce gastrointestinal irritation and emphasize adherence to dosing limits. Advise the patient to monitor for adverse effects like abdominal pain or signs of bleeding.

For opioids or tramadol, comprehensive teaching regarding risks such as dependence, overdose, and side effects—constipation, nausea, dizziness—is essential. Patients should be cautioned against alcohol consumption and the use of hazardous machinery or driving under influence. Safe storage in a locked cabinet prevents accidental ingestion or misuse. Emphasize the importance of returning unused medications for proper disposal once pain subsides and to avoid stockpiling medications, which can lead to misuse (Wallace, 2013).

Additional education should include recognizing signs of serotonin syndrome, especially if TC is on serotonergic agents, and understanding that opioids should be used preemptively rather than waiting for pain to become severe, as efficacy diminishes with increased pain intensity.

DEA Drug Classification Schedule Explanation

The Drug Enforcement Agency (DEA) classifies controlled substances into five schedules based on accepted medical use, abuse potential, and dependency risk. Schedule I drugs have no accepted medical use and high abuse potential; examples include heroin, LSD, and marijuana in some states. Schedule II drugs are considered highly addictive but have accepted medical uses with strict prescribing regulations; examples are fentanyl, oxycodone, and methadone. Schedule III drugs carry moderate to low potential for abuse and dependence; examples include Tylenol with codeine, ketamine, and anabolic steroids. Schedule IV drugs such as diazepam and tramadol present low abuse potential. Finally, Schedule V substances generally consist of preparations with small quantities of controlled substances, like certain cough preparations with minimal codeine content, and are used primarily for antitussive or antidiarrheal purposes (DEA, 2020).

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.
• Drug Enforcement Agency (DEA). (2020). Drug scheduling. Retrieved from https://www.dea.gov/drug-scheduling
• Lexicomp. (2017). Drug information handbook for advanced practice nursing (17th ed.). Hudson, OH: Wolters Kluwer Clinical Drug Information.
• Wallace, S. (2013). The importance of holistic assessment – A nursing student perspective. Nursing Times, 24, 30–36.
• Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers. F. A. Davis.