Sample Answer for NUR 635 Topic 3 DQ 2 Included After Question
Samantha, a very healthy 67-year-old female, is undergoing a total hip arthroplasty surgery. The surgeon has asked for pain regimen for Samantha’s stay on Med-Surg. The plan is for Samantha to discharge from the hospital on post-op day 1. She currently takes 5mg of hydrocodone daily at home on a consistent basis. The hospital formulary consists of the following medications: oxycodone 5mg, morphine IV 2mg, ketorolac IV 30mg, pregabalin 75mg, gabapentin 300mg, dexamethasone IV 10mg, acetaminophen 500mg, and celecoxib 200mg. Use the guidelines and relevant literature in your topic Resources to discuss the following:
- Briefly explain the concept of milligram morphine equivalent (MME).
- Discuss Samantha’s MME based on her home medication use.
- Develop a plan for post-op day 0 and post-op day 1, using a multi-modal pain approach. Keep in mind the patient is to discharge on post-op day 1 after the completion of physical therapy.
- Explain your rationale for the use of each individual medication. Consider pharmacokinetic aspects related to onset, peak, and duration. Specify which medications are scheduled and which are to be given as needed. Include monitoring parameters and other relevant information for the nursing staff administering the medications (e.g., CAM, used in managing central nervous system, pain, inflammation, and bone or joint disorders).
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competencies 1.2, 2.2, 2.5. 4.2, 6.4, 9.2
A Sample Answer For the Assignment: NUR 635 Topic 3 DQ 2
Title: NUR 635 Topic 3 DQ 2
Briefly explain the concept of milligram morphine equivalent (MME).
MME allows providers to calculate the total daily dose of opioids and identify patients that may benefit from closer monitoring, tapering of opioids, and other measures to reduce risk of overdose. Extra caution must be used when converting methadone and fentanyl doses. MMEs should not be used to determine dosage when converting one opioid to another. The new opioid should lower to avoid unintentional overdose due to incomplete cross-tolerance and individual differences in pharmacokinetics. When increasing doses to >50MME/day, extra care should be taken and doses should not exceed 90MME/day (CDC, n.d.).
Discuss Samantha’s MME based on her home medication use.
Hydrocodone has a MME of 1. Being that Samantha takes 5mg of hydrocodone daily at home, her MME is 5.
Develop a plan for post-op day 0 and post-op day 1, using a multi-modal pain approach. Keep in mind the patient is to discharge on post-op day 1 after the completion of physical therapy.
The primary goal should be to reduce pain at both the central and peripheral levels using a multimodal approach.
Doing this, patients should optimize the patient’s ability to participate in physical therapy and rehabilitation improving the postoperative outcome. The first step should be patient education. Patients should be educated to manage expectations of pain and function postoperatively. (Maheshwari et. al, 2009).
Preoperative use of acetaminophen, NSAIDS, or COX-2 inhibitors one hour before surgery reduces opioid requirements. Preoperative use of gabapentins also significantly decreases opioid consumption postoperatively. Local infiltration analgesia is an injection of anesthetic into the affected area near the end of the surgical procedure. The aim is to prevent the conduction of pain signals from the incision. LIA greatly reduces pain scoes and opioid consumption. LIA also improves functional outcomes by allowing the patient to participate in range of motion exercises and rehabilitation therapy early in the postoperative period. Peripheral nerve blocks are another available modality to improve pain management postoperatively. Acetaminophen combined with NSAIDs or COX-2 inhibitors should be used for 2 weeks after discharge. Nonpharmacological therapies should also be used. Cryotherapy has been shown to reduce pain scores postoperatively. (Franzoni, et al., 2023)
Explain your rationale for the use of each individual medication. Consider pharmacokinetic aspects related to onset, peak, and duration. Specify which medications are scheduled and which are to be given as needed. Include monitoring parameters and other relevant information for the nursing staff administering the medications (e.g., CAM, used in managing central nervous system, pain, inflammation, and bone or joint disorders).
Acetaminophen 1000mg, Celebrex 200mg, and pregabalin 75mg one hour before surgery provides a widespread pre-emptive analgesic improvement.
Acetaminophen reduces nociceptive pain through selective inhibition of COX enzyme activity in the central nervous system. Recommended dose is 650mg q6h or 1000mg q8hrs.
Ketorlac can be used in the immediate post-operative period. 30mg IV q6h for a maximum of 4 days. Should be reduced to 15mg q6hrs for patients >65years of age or in impaired renal function. Transition to Celebrex 200mg q12hrs.
Initially, IV opioids can be used but should be transitioned to oral dosing once patient can tolerate oral medications. Oxycodone should be limited to severe pain and as needed for breakthrough pain. Recommended dose is 5-10mg orally q4-6hours.
Centers for Disease Control. (n.d.). Calculating total daily dose of opioids for safer dosage. U.S. Department of Health and Human Services. Retrieved on September 18, 2023, from https://eu-central-1-02900067-inspect.menlosecurity.com/safeview-fileserv/tc_download/cc0c9680b14a49ebc9eb4a207f9986f0ecd71b5f91659063be8ec6094658b0e8/?&cid=NFDD713B1D548_&rid=9f78f82ebe6f8569a55c6d1f45e3e9ce&cl=XAKJHP7HSOa&file_url=https%3A%2F%2Fwww.cdc.gov%2Fopioids%2Fproviders%2Fprescribing%2Fpdf%2Fcalculating-total-daily-dose.pdf&type=original
Maheshwari, A., Blum, Y., Shekhar, L., Ranawat, A., Ranawat, C. (2009). Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clinical Orthopaedics and Related Research 467(6), 1418-1423. https://doi.org/10.1007/s11999-009-0728-7 Franzoni, S., Rossi, S., Cassinadri, A., Sangaletti, R., Benazzo, F. (2023). Perioperative pain management in total knee arthroplasty: A narrative review of current multimodal analgesia protocols. Applied Sciences 13(6), 3798. https://doi.org/10.3390/app13063798
A Sample Answer 2 For the Assignment: NUR 635 Topic 3 DQ 2
Title: NUR 635 Topic 3 DQ 2
Greetings, Marco. Thank you for providing your insights on the multi-nodal pain management method for Samantha, who has had total hip arthroplasty. A comprehensive discussion was conducted regarding the administration of multimodal pain medications from the Progressive Care Unit (PCU) to the Medical Surgical Unit for Samantha. The medications discussed included Oxycodone 5mg, which can be administered as needed for breakthrough pain. Additionally, Ketorolac IV 30mg was mentioned as a medication typically administered every 6 hours for a duration of 3 days. It was emphasized that monitoring of creatinine and platelet levels is necessary, and special attention should be given to elderly patients with renal issues to ensure utmost caution.
In your study, you mentioned that ketololac is a nonsteroidal anti-inflammatory medication (NSAID) with analgesic, anti-inflammatory, and antipyretic characteristics. Pregabalin, administered at a dosage of 75mg every 12 hours, is an anticonvulsant medication commonly used for the management of neuropathic pain. Acetaminophen at a dosage of 1000mg intravenously is often administered every 6 hours for a duration of 24 hours, until the patient is able to tolerate oral administration of Tylenol. Subsequently, it is normally given as needed for its analgesic properties. Zhao and Davis (2019) assert that effective pain management following total knee arthroplasty and total hip arthroplasty plays a crucial role in determining the overall success of the postoperative rehabilitation.
The significance of pain management is of utmost importance owing to its profound influence on the process of recuperation. The presence of unmanaged postoperative pain among orthopedic patients can lead to a range of unfavorable outcomes, such as delayed mobilization, suboptimal surgical results, and extended hospital stays. Long-term consequences can also arise, including restricted range of motion and the development of chronic pain syndrome. The implementation of a multimodal pain management approach has been shown to improve outcomes for patients undergoing total knee arthroplasty and total hip arthroplasty, hence enhancing the effectiveness of pain management strategies. Multimodal pain management has the ability to effectively address several pain pathways.
The implementation of this approach has the potential to mitigate the negative consequences associated with opioid therapy, hence enhancing the efficacy of pain management and ultimately resulting in improved patient outcomes. The implementation of multimodal pain treatment is advised by the World Health Organization (WHO) and the American Society of Anesthesiologists (ASA) wherever feasible. It is imperative to implement a thorough strategy for managing postoperative pain, which involves the utilization of a multimodal analgesics regimen comprising of at least two agents with distinct mechanisms for pain control. Additionally, adopting a multidisciplinary approach is crucial in order to optimize the beneficial outcomes of the treatment while mitigating the potential adverse effects.
The paper authored by Zhao and Davis (2019) presents a study that examined the impact of combining multiple non-opioid analgesics on the management of postoperative pain and recovery following total knee arthroplasty and total hip arthroplasty. The study employed rigorous research methodologies to establish conclusive evidence, which yielded positive outcomes. According to the study conducted by Golladay et al. (2017), it was found that the use of multimodal analgesia had a beneficial impact on the early and long-term results of patients undergoing total knee arthroplasty and total hip arthroplasty.
The study conducted by McKenzie et al. (2013) aimed to establish a genuine multimodal pain management protocol for patients undergoing total knee arthroplasty and total hip arthroplasty. The implementation of this protocol yielded noteworthy outcomes, including a substantial drop in pain levels and a notable reduction in opioid usage. The present study employed acetaminophen, celecoxib, and pregabalin as non-opioid analgesics in order to explore the transition in pain management strategies from a predominant reliance on opioids to alternative non-opioid interventions (Zhao, J., & Davis, S. P. 2019).
Golladay, G.J., Balch, K.R., Dalury, D.F., Satpathy, J., Jiranek, W.A., 2017. Oral multimodal analgesia for total joint arthroplasty. J. Arthroplasty 32 (9S), S69– S73. doi:http://dx.doi.org/10.1016/j.arth.2017.05.02.
McKenzie, J.C., Goyal, N., Hozack, W.J., 2013. Multimodal pain management for total hip arthroplasty. Semin. Arthroplasty 24 (1), 87–93. doi:http://dx.doi.org/ 10.1053/j.sart.2013.07.007.
Zhao, J., & Davis, S. P. (2019). An integrative review of multimodal pain management on patient recovery after total hip and knee arthroplasty. International Journal of Nursing Studies, 98, 94–106. https://doi-org.lopes.idm.oclc.org/10.1016/j.ijnurstu.2019.06.010