Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

 
The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear.  However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed.  He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.

Thank you for your response. This brings to mind King James Bible/New Living Translation 2005, Luke 8:17; For all that is secret will eventually turn to light. I was in Nursing school and happen to be tutoring a nursing student that was a class or two behind me. The student was prepared to take her med-surgical exam; we had reviewed the pathophysiology so that she would be able to look at, for example, be given a scenario regarding a patient’s lab values and know if the patient was in metabolic acidosis. We reviewed the ability to think critically. Prior to her taking the test we, both felt confident that she would pass. Day later she called and asked to come over and when she arrived, she was distraught. I was dumb founded; she explained that she had taken the exam, but it did not go very well because she decided to cheat. A couple of her classmates reassured her that they had the answers to the exam; She did not even read the exam to use anything that we had reviewed as far a critically thinking and using pathophysiology, lab values, and so on to arrive at the answers.

I was upset that she had taken up hours and days of my time to prepare for an exam and she just totally threw everything out the window and just put down answers. The class prior to hers had aced the exam, but the instructor and the Director of the Nursing department reviewed the class trends and knew that the class prior to her class should not have scored that many A’s. Therefore, the test was changed and the test that my friend took was different from the one the prior class had taken. On top of that she had to speak with the Director of the Nursing department and was expelled from the program. She needed to at least pass with a C to remain in the program. The class prior had students that were also expelled as well as the students that were in her class. I only knew about this as she confided in me regarding the situation; otherwise, the was emphasis in my class to make sure that all the concepts were understood; if not ask questions during/after lecture and because in clinical we were taking care of patients and need to know why we were administering some as simple as a vitamin E and the side effects. In my practice I have been conscientious regarding patient care. In the Neonatal Intensive Care everything we gave during the time I worked in the unit was doubled checked. If it did not fit into a 1cc syringe it was triple checked.

Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.

Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.

Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.

Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches. Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.

Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.

Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).

Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.

Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.

Decision Point 3: Change Savella to 25 mg in the morning and 50 mg at Bedtime.

I reduced the dosage in the morning since the pain is mostly under control and increased the dose at Bedtime when there is less control (Resmini et al., 2015).

Expected Result: By lowering the morning dose and increasing the bedtime dose, I expected that the client’s pain symptom would improve while at the same time controlling the side effects of Savella (Resmini et al., 2015).

Expected Vs. Actual Results: The client reported an improvement in the pain with a rate of 3/10 denied having any side effects from the drug.

Assignment: Decision Tree for Neurological and Musculoskeletal Disorders NURS 6521 References

Cording, M., Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for pain in fibromyalgia in adults. Cochrane Database of Systematic Reviews, (10).

Laureate Education. (2016). Case Study: A Caucasian man with hip pain. Baltimore, MD: Author.

Resmini, G., Ratti, C., Canton, G., Murena, L., Moretti, A., & Iolascon, G. (2015). Treatment of complex regional pain syndrome. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, 12(Suppl 1), 26–30. https://doi.org/10.11138/ccmbm/2015.12.3s.026