Assessing and Treating Clients with Pain Decision Tree Paper

Assessing and Treating Clients with Pain Decision Tree Paper

Assessing and Treating Clients with Pain

Complex regional syndrome (CRPS) is a prevalent clinical conditions marked by severe, continuous in the affected extremity. The condition is characterized by vasomotor, sensory, motor, and sub-motor changes. The pain can be disproportionate to the inciting event or regionally restricted. CRPS also using featured by trauma or surgery and normally limited to one extremity. Besides, CRPS have severe impact on the quality of life patients and lead to substantial social and physical disability. Therefore, it is critical clinicians to recognize and diagnose this condition to provide appropriate care and guidance to patient suffering from this debilitating disorder (Birklein & Dimova, 2017). This paper of this article is to provide clinical decision making in prescribing the correct medication to the client.

Assessing and Treating Clients with Pain Decision Tree Paper

Summary of the Case Study

The client is a 43-year old Caucasian male referred to the clinic by his family doctors for psychiatric assessment because of his chief complaint of pain. The onset of pain was 7 years ago when he landed on his right hip after falling at work. His right hip joined cartilage were 75% torn 4 years ago. The client has developed several symptoms including cooling of the extremities. None of the surgeons he visited recommended a hip replacement because they thought he was too young. One of neurologists he attended diagnosed him with CRPS and recommended to be treated by his family doctor for the condition. During the interview, the leg of the client was turning purple from the knee down and a visible cramp was noted. His feet seemed to fold inward and the color begins to return after a few minutes. He was also prescribed with hydrocodone but stopped taking them after side effects such as sleepiness and constipation (Laureate Education, 2016a Assessing and Treating Clients with Pain Decision Tree Paper).

Decision Selected #1: 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

Reason for selecting the decision

Patients with CRPS have low pain threshold resulting from changes in central nervous system (CNS). These changes make a client to be more sensitive to pain due to incorrect neurotransmitter levels in the brain. Thus, a selective norepinephrine and serotonin reuptake inhibitor (SNRI) which has equal effect on both neurotransmitters and works on endings to produce analgesic effects is required for this patient. Savella (milnacipran) is a SNRI, similar to some drugs used in treating depression and other psychiatric disorders (Stahl, 2013). It works by promoting the reuptake of the neurotransmitters in the CNS to ease the pain, reduce fatigue, and promote memory. Serotonin and norepinephrine are two main neurotransmitters released in the brain. Savella prevents the reuptake of serotonin and epinephrine by nerves after being release (Derry et al., 2012). The mechanism is responsible for its effectiveness for treating CRPS

The administration of milnacipran is done orally without food. The recommended dose of milnacipran is 100mg/day(50mg twice daily). Based on the tolerability and efficacy doses, Savella may be titrated by 12.5mg mg once on day one, 25mg (12.5mg twice daily) on day 2-3, 50mg/day (25mg twice daily) on day 4-7, and 100mg/day(50mg twice daily) on day 7 and thereafter (Stahl, 2013). On the other hand, amitriptyline is another good option since it is a off label medication recommended for managing neuropathic pain. However, the prescription was not selected because of its associated side effects such as dizziness and drowsiness and the patient clearly stated he does not like them. Thus, prescribing this medication can cause non- compliance on the side of the client. Neurontin is an anticonvulsant widely used in treating and managing nerve pain. However, like amitriptyline , neurontin is also associated with drowsiness and since the client stopped taking hydrocodone because it made him sleepy, it was not wise to prescribe these two medications to the client.

Expected Outcome

By initiating Savella, I expected that the pain would significantly reduce to almost 3 on a scale of 1-10. I also opted that the client would be able to walk without any assistance and resume his normal work routine and be able to perform his daily activities. I also hoped that his mood would be happy and joyous and experience a stable effect. Savella has a mild affinity for inhibiting N-methyl_D aspartake (NMDA) and exerts higher selectivity for norepinephrine reuptake than duloxetine and venlafaxine (Derry et al., 2012). It is hypothesized the therapeutic properties of the medication promoted by its effects on regulating dysfunctional serotonergic pathways. Its selectivity for norepinephrine over serotonin has shown clinical benefits because it affects the pain modulation.

Actual Outcome

After four weeks, the client returned to the clinic walking with minimal limping and without crutches. Since the initiation of the medication, the pain became more manageable. The client was able to get around on his own. He said that the pain was bad in the morning, but gets better throughout the day.   He also reported a score of 4 on a pain scale of 1-10, and admitted that he was able to tolerate a level 3 pain. He mentions that at level 3, he would not need the crutches for the most of his day. However, new an unanticipated outcome of sweating, sleeping problems, nausea, and high blood pressure emerged. These new developments necessitate making the next decision of reducing the dosage of Savella.

Decision Selected #2: Continue with Current Medications but Lower Dose to 25mg twice a day

Reason for selecting the decision

During the previous check up visit, the client reported unexplained symptoms of sweats, sleep problems, nausea, and high blood pressure. In clinical trials, clients experiencing nausea described it as mild to moderate. Approximately 6 percent of those taking Savella discontinued due to nausea as compared to 0.6 of those taking placebo. These symptoms are associated with the side effects of milnacipran. According to English et al. (2010 Assessing and Treating Clients with Pain Decision Tree Paper), the side effects can be reduced by lowering the dose and improve health outcome. A dose adjustment is recommended for every patient. As commonly seen with other SNRIs, tapering of the dose is needed when the drug causes side effects.

Since showed decreased pain level, it was better to lower the dose and observe if he will tolerate the prescription with minimal side effects. Also, it is essential for the PMHNP to educate the client on the possible side effects associated with Savella and instruct him to how to reach the provider before stopping the medication. I would not recommend discontinuing Savella and starting Lyrica 50mg and Zoloft 50mg because of their associated side effect. Despite the proven efficacy managing neuropathic pain, Lyrica can put the client into risk of falling alongside other side effects such as memory impairment, poor coordination, tremor, ataxia, and peripheral edema (English et al., 2010). On the other hand, Zoloft is a SSRI used in the management of major depressive disorder and the client denied having depression

Expected Outcome

By reducing the dosage of Savella, I expected the client to report reduced pain with minimal side effects. In other words, I expected the patient to continue the current drug therapy to reduce pain with minimal side effects. I also hoped that the client will be able to perform most of the daily activities with miminal support including his professional, social, and physical functioning while ensuring the side effects of the medication will not interfere with normal life (English et al., 2010).

Actual Outcome

The client returned to the clinic after four week this time round walking in the crutches. Unfortunately, he reported that the pain was 7 out of 10 from the previous 4 out of 10, something that did not make him feel good as compared to the previous visit. The pain on his right leg made him frequently wake up at night. His pulse and blood pressure as 87 and 124/85 respectively. At this time, the client seemed sad and discouraged by the failure in the management of the pain. He denied suicidal idealization and heart palpitations. The actual results indicate that vital signs of the client were stable, no side effects reported, but the lower dosage of Savella caused increased pain.

Decision Selected #3: Change Savella to 25 mg orally in the Morning and 50 mg orally at bedtime

Reasons for selecting the decision

From the first visit at the clinic, the Caucasian man clearly stated that Savella prescription was effective in managing the pain. In the second visit, the client seemed dissatisfied with the drug therapy due to increased pain. Thus, with this resolution, the patient will be able to maintain a stable BP while eliminating side effects of nausea in the morning and daytime and greater dosage will be aimed to help him sleep at the same time controlling the pain at night (Stahl, 2013).

At this point, it is not wise to discontinue Savella and start Tramadol since tramadol is never good option along with other opioid type analgesics. The medication does not provide adequate pain control in the CRPS and therefore it is not a good option. Besides, the medication is associated with addictive properties such can result to secondary drug abuse. There is no enough evidence that prove efficacy of opioids in treating CRPS patients (Stahl, 2013). On the other hand, Celexa which is widely used in treating depression is associated with causing fatal serotonin syndrome and serotonin toxicity.

Expected Outcome

By this decision, I am hoping that the client will report a tolerable pain level with no or minimal side effects of the prescriptions. The main expectation is that the patient will experience improved functioning, less pain, and returning to normal life activities.

Actual Outcome

Finally, the client reported reduced pain with minimal side effects. The BP was normal and was able to perform daily activities with no assistance. He did not use assistance crutches and lived a happy life.

Ethical Considerations

There are several ethical considerations to exercise during the drug therapy. First, it is crucial for the PMHNP to educate the patient on the prescription and treatment plan for better health outcomes. At this point, patient education on other non-pharmacological interventions such as psychotherapy to help him cop with the problem and occupational therapy to help him focus on daily activities is essential. The education plan should include the benefits and risk, and side effects of the drug therapy. Wesemann (2019) noted that patients with CRPS may not completely respond to pain medication and thus it is critical to explain to the client that he will experience some level of pain, and the goal of the treatment plan was to allow him function on daily basis.

References for Assessing and Treating Clients with Pain Decision Tree Paper

  • Birklein, F., & Dimova, V. (2017). Complex regional pain syndrome-up-to-date. Pain reports, 2(6), e624. https://doi.org/10.1097/PR9.0000000000000624
  • Derry, S., Gill, D., Phillips, T., & Moore, R. A. (2012). Milnacipran for neuropathic pain and fibromyalgia in adults. The Cochrane database of systematic reviews, 3(3), CD008244. https://doi.org/10.1002/14651858.CD008244.pub2
  • English, C., Rey, J. A., & Rufin, C. (2010). Milnacipran (Savella), a Treatment Option for Fibromyalgia. Pharmacy and Therapeutics, 35(5), 261–266.
  • Laureate Education (2016a). Case study: A Caucasian man with hip pain [Interactive media file]. Baltimore, MD: Author
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
  • Wesemann, D. (2019). Maximizing the Use of Psychotherapy With PMHNP:: A Call to Action for Nurse Leaders. Nurse Leader, 17(6), 537-5