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).
Clinicians should consider the lowest dosage to be effective when prescribing opioids, then re-assess benefits vs risks when increasing the dose above 50 MME per day and should avoid increasing the dose above 90 MME per day. If prescribing above 90 MME/day, there must be justification for that decision (Rosenthal & Burchum, 2020).
Discuss Samantha’s MME based on her home medication use.
Samatha’s MME based on her home medication use of Hydrocodone 5mg is 5 MME which is an acceptable dose for acute pain management.
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).
Post-op day 0:
Administer IV Morphine 2mg every 4-6 hours for severe pain, then re-assess. The goal of morphine is to be an analgesic for pain management.
For IV Dexamethasone, administer a single dose pre-op of 10mg. This will reduce inflammation and relieve additional pain.
Guidelines for post-op pain medication dosing:
-Continue outpatient pain medications when appropriate
-Tylenol 1g PO q8h (max total daily dose 3 gm, reduce dose for liver disease)
-Celebrex 100mg PO BID (caution in renal insufficiency)
-Gabapentin 600mg PO TID (300 mg TID if age >70 or GFR < 50; 100mg TID for dialysis
patients). Consider decreasing dose if drowsiness occurs.
-Oxycodone: 5-10mg PO q3h PRN (increase dose as necessary for chronic pain patients).
References:
CDC. (n.d.). Calculating Total Daily Dose of opioids for safer dosage. https://www.cdc.gov/opioids/providers/prescribing/pdf/calculating-total-daily-dose.pdf
Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.
Stanford Medicine. (2015). Perioperative Pain Management Guidlines for total knee and Hip Arthroplasty (May 2015). Campus Image. https://ether.stanford.edu/policies/tha_regional_version_05_2015.html
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
