NURS 6521 Assignment: Decision Tree for Neurological and Musculoskeletal
Introduction
Complex regional pain syndrome, CRPS presents with dysfunction of extremities, severe pain, contractions, and swelling (Shim, et al., 2019). The cause of the syndrome is either trauma or surgical procedures. CRPS has three clinical stages, the acute, sub-acute, and chronic phases. The acute phase lasts for approximately three months. The sub-acute phase involves symptoms progression up to nine months, and the chronic phase is over one year. CRPS clinical signs and symptoms are severe pain, usually burning in nature, with vasomotor redness that worsens dependency, hyperhidrosis, and coolness to touch. CRPS is a result of central dysregulation of the nociceptive impulses that cause vasoconstriction. The vasoconstriction causes prolonged ischemia that produces more pain. It also builds a reflex arch that promotes further sympathetic firing and vasospasm. The result is a painful, swollen, and non-functional extremity.
Chronic CRPS is the accurate diagnosis for this patient because he presents with severe cramping of the toes, cooling of extremities, and inability to use the limbs. The patient has suffered pain for seven years. He has a positive history of trauma on his right hip where he sustained a 75% cartilage tear. The patient also has mild depressive mood disorder because he has been presenting with low mood since the onset of the disease, loss of his source of income, and separation from his fiancée. He has been on hydrocodone, which he takes sparingly due to the side effects. Hydrocodone is an opioid used in the treatment of pain. It is also an antitussive used to treat cough in adults. However, the patient does not fully comply with treatment due to its adverse effects such as anxiety, drowsiness, fatigue, and shortness of breath.
The three decisions made in the treatment for this include; Savella, Amitriptyline, and Neurontin. Savella treats depression and complex regional pain syndromes. It is a serotonin and norepinephrine reuptake inhibitor whose effects on regulates dysfunctional noradrenergic and serotonin pathways thus reducing the vasoconstriction that contributes to pain (Zou, et al., 2018). Savella is well tolerated compared to amitriptyline and hydrocodone. In addition to that, it has no side effects compared to the other two drugs.
Amitriptyline is a tricyclic antidepressant that blocks both serotonin and norepinephrine neurotransmitters. It is FDA approved for a major depressive mood disorder. In addition, it is an off-label drug for post-traumatic stress disorder and CRPS. Amitriptyline achieves its therapeutic effects four to six after the initial drug administration. Amitriptyline is not the drug of choice for this patient because of its adverse effects such as hypotension, dizziness, weight gain, and increased risk for bone fractures (Meshalkina, et al., 2018). Neurontin is a GABA mimetic agent that binds to the subunit of voltage-gated calcium channels (Moore, et al., 2018). It is FDA approved for the treatment of convulsive disorders. It is an off-label opioid therapy for neuropathic pain. It is effective in the treatment of CPRS. It has beneficial effects on insomnia, fatigue, depression, and quality of life. However, it relieves 50 % of the pain and has a high chance of addition. Therefore, it is not the drug of choice for this patient because he will not experience worthwhile pain relief. Savella is the drug of choice. The desired effects are to relieve pain and improve the depressive mood.
References
Meshalkina, D. A., Kysil, E. V., Antonova, K. A., Demin, K. A., Kolesnikova, T. O., Khatsko, S. L., … & Kalueff, A. V. (2018). The effects of chronic amitriptyline on zebrafish behavior and monoamine neurochemistry. Neurochemical research, 43(6), 1191-1199.
Moore, A., Derry, S., & Wiffen, P. (2018). Gabapentin for chronic neuropathic pain. Jama, 319(8), 818-819.
Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practising clinician. British journal of anaesthesia, 123(2), e424-e433.
Zou, C. X., Becker, J. E., Phillips, A. T., Garritano, J. M., Krumholz, H. M., Miller, J. E., & Ross, J. S. (2018). Registration, results reporting, and publication bias of clinical trials supporting FDA approval of neuropsychiatric drugs before and after FDAAA: a retrospective cohort study. Trials, 19(1), 1-11.
Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019). However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.
Patient Case Study Summary
The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years. Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.
Treatment Decisions
Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018). The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.
Expected Outcome
Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021). The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.
Difference Between Expected Outcome and Actual Outcome
Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).
Conclusion
Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.
References
Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters, 29(2), 125-133. https://doi.org/10.1016/j.bmcl.2018.11.034
Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7
Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety, 9(3), 171-178. https://doi.org/10.1177/2042098617750555
Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472. https://doi.org/10.3389/fnins.2019.00472
Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48. https://doi.org/10.2217/nmt-2020-0052
Decision Tree for Neurological and Musculoskeletal Disorders
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To Prepare:
- Review the interactive media piece assigned by your Instructor.
- Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
- Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
- You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:
- Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
- Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
- What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
- Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
You will submit this Assignment in Week 8.
Decision Tree for Neurological and Musculoskeletal
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
By Day 7 of Week 8
Submit your Assignment, started in Week 6.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center offers an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm
Links to an external site.). All papers submitted must use this formatting.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK8Assgn_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Integrating Evidence-Based Practices in Complex Pain Management: A Case Study Analysis
Introduction
Complex Regional Pain Syndrome (CRPS), a challenging neurological condition, demands a nuanced and evidence-based approach to alleviate suffering and enhance patients’ quality of life. This in-depth analysis delves into the intricate case of a 43-year-old white male diagnosed with CRPS in his right hip. Through a series of carefully considered decisions, this patient’s journey sheds light on the complexities of managing CRPS while balancing medication side effects and therapeutic outcomes.
Patient Summary
The patient’s ordeal commenced seven years ago, following a fall at work resulting in significant right hip injury. Despite extensive diagnostic tests, he faced skepticism from healthcare professionals, leading to delays in appropriate treatment. The decisions taken included initiating amitriptyline at 25 mg, titrating to 125 mg at bedtime, and later reducing the dosage to 100 mg daily. These decisions were geared towards mitigating pain, enhancing functionality, and minimizing side effects such as grogginess and weight gain.
Evidence-Based Support for Decisions
The initiation of amitriptyline aligns with studies demonstrating its efficacy in managing neuropathic pain, particularly CRPS (Neyama et al., 2020). Amitriptyline, a tricyclic antidepressant, modulates pain perception through multiple pathways, making it a cornerstone in neuropathic pain management (Solomon et al., 2022). The decision to maintain the dose despite minor weight gain is substantiated by research indicating that the benefits of pain control often outweigh modest side effects (Naguib et al., 2021). Additionally, the avoidance of Qsymia was prudent, considering its potential cardiac risks and the patient’s BMI falling below the recommended threshold for its use (Lei et al., 2021).
In addition to pharmaceutical interventions, exploring alternative therapies such as neuromodulation techniques has gained significant attention. A comprehensive study by Sivanesan, & Goebel (2021) delves into the effectiveness of spinal cord stimulation and peripheral nerve stimulation in managing Complex Regional Pain Syndrome, providing valuable insights into diverse treatment modalities.
Goals and Outcomes
The overarching goal was to reduce the patient’s pain levels to an acceptable threshold (around 3 on the scale) and restore his ability to perform daily activities without crutches. The outcomes were remarkably positive; the patient’s pain diminished from a debilitating 9 to a manageable 4. This reduction facilitated enhanced mobility and daily functioning, marking a significant improvement in his overall well-being. Despite minor weight gain, the patient’s improved quality of life underscored the success of the interventions.
Discrepancies Between Expectations and Results
In this case, the outcomes closely mirrored the expectations. The patient experienced a substantial reduction in pain, improved functionality, and minimal side effects, including manageable weight gain. The decisions made successfully struck a delicate balance between therapeutic benefits and potential drawbacks, ensuring the patient’s optimal quality of life. The minor weight gain, while a concern, was overshadowed by the vast improvements in pain control and functionality, aligning with the patient’s stated preferences.
Conclusion
CRPS management necessitates a holistic and individualized approach, integrating evidence-based practices, patient preferences, and vigilant monitoring of outcomes. This case study underscores the pivotal role of healthcare providers in navigating the complexities of CRPS treatment. By employing a comprehensive understanding of available therapies and their potential effects, clinicians can significantly enhance the lives of individuals afflicted with this debilitating condition.
References
Lei, X., Ruan, J., Lai, C., Sun, Z., Yang, X., Lei, X.-G., & Ruan, J.-Q. (2021). Efficacy and Safety of Phentermine/Topiramate in Adults with Overweight or Obesity: A Systematic Review and Meta-Analysis. Obesity (19307381), 29(6), 985–994. https://doi.org/10.1002/oby.23152
Naguib, I. A., Ali, N. A., Elroby, F. A., & Elghobashy, M. R. (2021). Green HPLC-DAD and HPTLC Methods for Quantitative Determination of Binary Mixture of Pregabalin and Amitriptyline Used for Neuropathic Pain Management. Journal of Chromatographic Science, 59(6), 536–547. https://doi.org/10.1093/chromsci/bmab031
Neyama, H., Dozono, N., Uchida, H., & Ueda, H. (2020). Mirtazapine, an α 2 Antagonist-Type Antidepressant, Reverses Pain and Lack of Morphine Analgesia in Fibromyalgia-Like Mouse Models. The Journal of Pharmacology and Experimental Therapeutics, 375(1), 1–9. https://doi.org/10.1124/jpet.120.265942
Sivanesan, E., & Goebel, A. (2021). Complex regional pain syndrome: developing diagnostic tools and treatments from sympathetic nervous system, neuroimmune and neuromodulation discoveries in neuropathic pain. Regional Anesthesia & Pain Medicine, 46(3), 193–195. https://doi.org/10.1136/rapm-2020-101644
Solomon Tesfaye, Gordon Sloan, Jennifer Petrie, David White, Mike Bradburn, Tracey Young, Satyan Rajbhandari, Sanjeev Sharma, Gerry Rayman, Ravikanth Gouni, Uazman Alam, Steven A Julious, Cindy Cooper, Amanda Loban, Katie Sutherland, Rachel Glover, Simon Waterhouse, Emily Turton, Michelle Horspool, … Dinesh Selvarajah. (2022). Optimal pharmacotherapy pathway in adults with diabetic peripheral neuropathic pain: the OPTION-DM RCT. Health Technology Assessment, 26(39). https://doi.org/10.3310/RXUO6757
Rubric
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Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. |
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Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. |
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What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. |
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Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. |
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Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. |
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Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
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Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. |
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Total Points: 100
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