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Surgery Module 16-Pain Hevinkumar Patel

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53 views5 pages

Surgery Module 16-Pain Hevinkumar Patel

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hevinpatel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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SURGERY MODULE 16

Reading Assignment: Sabiston, 21st edition, Textbook of Surgery, pages 340-


346
Pain Management
Module: 16. Pain Management
Learning Objectives:
i. Describe the importance of pain control in the post-operative period.
ii. Describe the assessment of pain by exams and scales .
iii. Compare and contrast the different type of narcotics used in pain
control.
iv. Recognize the role of non-narcotic methods and medicines available
for pain control.
v. Recognize the variability in management bases on special patient
populations (Pediatrics, Geriatrics and Acute pain management in
Chronic Pain Management patients).
vi. Recognize the side-effects and complications of the use of opioids.
vii. Describe different treatment options for complications in both acute
and chronic use of opioids.
viii. Recognize the importance of the proper documentation of prescribing
narcotics.
ix. Recognize the signs of opioid addiction, tolerance, dependence and
abuse.
x. Define how to effectively manage opioid addiction.

Case 1:
An 82-year-old woman presents to your practice with severe chronic pain.
She has the pain from widespread osteoarthritis, thoracic compression fractures,
and a failed joint replacement of her right knee. These problems have been going
on for about 10 years. She is functional with the analgesics that she is currently
taking and is able to live independently at home. You evaluate her for this pain.

1. Describe a method to assess the severity of her pain.


Scale of 1-10

2. List 3 nonpharmacologic strategies to address her pain.


- __Ice__________________________________________________________
-____OMT Manupulation
_________________________________________________________
-
________PT/yoga_____________________________________________________

3. Describe the characteristics of her pain if some of it was neuropathic.


Burning or stabbing
Case 1 continued:
The analgesics she is taking include Norco 7.5/325 po qid, OxyContin 20
mg po q12h, and Hydromorphone 2 mg po q4h prn breakthrough pain (which she
uses once or twice daily.) You decide to adjust these to make the regimen simpler
and more effective by using only oxycodone. You also decide to add an adjuvant
to help her need less opioid overall.

4. List the steps you would go through to convert her to oxycodone alone.
a.__________Add oxycodone
_______________________________________________
b._Increase
oxycontin________________________________________________________
c.Reduce
Hyromorphine________________________________________________________
_
d.__________Reduce
norco_______________________________________________

5. Using this conversion table actually to the calculation for the total oxycodone dose
needed.

Drug PO Parenteral
Morphine 30 7.5
Oxycodone 20 4
Hydrocodone 30
Hydromorphone 7.5 1.5

Total equivalent oxycodone dose: ______52___________

6. Describe a regimen of oxycodone for her using this data.


__________________52 mg Q6 hours
________________________________________________
__________________________________________________________________
__________________________________________________________________

7. List 2 adjuvants that might be helpful.

a. ____Advil___________________________
b. ___Aspirin____________________________

Case1 continued:
During your interview and exam, you determine that she has constipation.
Her bowels are moving only once weekly and the stools are hard and difficult to
pass. You try some OMT maneuvers to help, but also decide to give medication
to help.
8. What is the likely cause of the constipation?
___________Using
opoid________________________________________________

9. List 2 medications that could be used with their mechanism of action.


a. __fiber is a bulking agent
____________________________________________________
b. ___________Loperamice would increase bowl movemnets
___________________________________________
Vignette continued:
During your interview, you determine the full list of her medications. You
have serious concerns about them due to the impact of polypharmacy.

10. Next to each medication, list at least one reason that it is ill advised.

a. fluoxetine 20 mg po qd (depression)
_______________________________Serotonin Syndrome
___________________________

b. temazepam 15 mg po qhs (insomnia)


________________Sedation
__________________________________________

c. HCTZ 50 mg po qd (hypertension)
_________increase risk of gout
_________________________________________________

d. atorvastatin 80 mg po qd (primary prevention)


________________Rabdommylosis
__________________________________________

e. alendronate 70 mg po qweek (osteoporosis)


_______________________________Jaw necrosis
___________________________

Case 2:
An 80-year-old woman is admitted to your nursing home with severe
debility and osteoarthritis with uncontrolled pain. She also has NIDDM controlled
by metformin. She is on Norco 5/325 po qid prn pain, but never asks for it. She
had a left knee replacement last week and is unable to do therapy because of the
discomfort when the leg moves.
11. Is the pain regimen rational and effective?
_______________Tylenol___________________________________________

12. What could be done to help her pain?


__________________OMT__________________________________________

13. What medication and dose would you give first?


_______________1 g
Q6hrs_____________________________________________

14. What would be for second pain management to use if the first fails after a day or
two?

_____________________Morphine______________________________________
_
15. Would you expect your analgesic for the knee and joint pain to help her neuropathy?
Why or why not?
___No because gabapentin causes nerve pain
___________________________________________________________
______________________________________________________________
______________________________________________________________

16. What benefit will this woman have if the pain is controlled other than comfort?
______________QOL______________________________________________
_________________________________________________________
_________________________________________________________

Case 2 continues:
You give her acetaminophen 325 mg ii po ac&hs with good results, but she
still hurts too much for therapy. You add tramadol 25 mg po q8h with good
effect. How would you deal with the PRN Norco 5/325 dose?

___________________Reduce dosage
_______________________________________________
__________________________________________________________________

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