Nursing care plan help

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Patient Mr Bee is in his late sixties and admitted to hospital for a femoro-popliteal graft to this (L) leg. The surgery went well with no compications. Mr Bee has a PCA Morphine and also takes his regular medication of MS Contin for pain mamgement. (Check his Pain History Notes) below. Day 1 after surgery he is alert and oriented, with no nausea of vomiting or itching. He says his pain is 8/10 in both legs from the knee down.

He also has pain 6/10 in his thigh wound. He said he did not sleep well. Day 2 he used 96mg Morphine Sulphate in the PCA. He is still alert and orientated with no morphine related side-effects. He now says he has pain in both legs and it is 8/10 and his thigh would pain is 4/10. He asks you to do something to relieve his pain.

Patient Notes:

Past medical history:

Mr Bee has had a bilateral total knee replacement 5 years ago. He also has type 2 diabetes treated with metformin. He has used MS Contin for past 6 months for pain in both legs from the knees down. However his dose escalates from 30mg to 100mg BD in this time. He says it is not making any difference and it always burns from my knees down. He now reports pain in his joints whic is worse at night but improves with mobilisation and heat.

Physical Nursing Assessment reveals:

hig legs are skinny from the knee down with lots of visible varicose veins

he has no ulcers observable

his feet are visibley well cared for

he states he has decreased sensation on the soles and toes of both feet.

Nursing pain History :

Mr Bee has used MS Contin for 6 months. Dose has escalated from 30mg to 100mg BD during this time. He says it is not making any difference as it always burns from the knee down. He reports pain in his joints that are worse at night but it improves with mobiliesatiopn and heat.

What is wrong with Mr Bee and what are the nurses priorities? In what order would the priorities be carried out?

Is this diabetic neuropathy and hyperanalgesia? Is he addicted to Morphine so much now that it has no effect? Please help.

Honey Bee

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Pain should be controllable.

What is really important is his assessment , neurovascular specifically--5 P's

-Pulses

-Pallor-color of skin and area around groin site, is it soft?

-paresthesia

-paralysis-movement bilaterally/strength

-pain

Uncontrollable pain is not good.

Pseudoaneurysms can occur, seen it happen, as well as hematoma and blood loss. Now this is a tough one because of his chronic pain. If he was taking a ton of Morphine at home, then he probably will have a tolerance to a Morphine pca, I would have called the MD.

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Hyper = excessive

Analgesia = pain relief (an = none, absence of; algesia = pain)

I think you might mean "hyperalgesia," excessive pain.

Opioids are famously ineffective in neuropathic pain; increasing doses will not be helpful if that's his problem.

Addiction has a very specific definition, which is use without medical need and used for the purpose of psychoactive effects-- addicts use to get high. All people who use opioids (the proper term, not "narcotics") in high or even escalating doses are not addicts or addicted; in fact, most are not. It makes me crazy when someone labels a patient an addict because she takes, and needs, opioids to control pain.

Another concept to understand about opioid use is habituation, in which the body has become used to a particular dose and will suffer withdrawal if the dose is removed. While addicts are habituated, anyone who takes opioids for a time for any reason will become habituated, as evidenced by the fact that they will no longer have the side effects commonly associated with opioid use (drowsiness, etc) EXCEPT for constipation, which never stops. An increase in dose may result in drowsiness, decreased BP, etc. for about 72 hours, and then will go away.

The third concept you need to understand is tolerance, which means the body has gotten used to a higher dose. Addicts usually demonstrate tolerance but, again, most people using opioids are not addicts. I have seen people with chronic pain from malignancy tolerate doses of morphine that would kill an opioid-naive (that is, never taken any or not taking any) person, 500mg/hour. Yep, that is not a typo.

So. Your diabetic man with classic neuropathic pain has been taking lots of opioids for a long time, and has been escalating his dose in a vain attempt to chase his pain, because whoever is prescribing for him is an idiot and didn't assess him for neuropathy and prescribe meds specifically for neuropathic pain (which I will leave to you to look up). However, because of his prolonged use, he is also habituated and will suffer withdrawal when he cuts back his dose when his pain is appropriately addressed with the right meds.

We also see this when someone who takes large amounts of opioid orally receives an intrathecal pump to treat his pain. Intrathecal opioids are effective in a roughly 1:100 ratio to oral, meaning that someone who needs 2000 mg per day orally will need about 20mg per day intrathecally. At that point, although his pain will be relieved, he will still need to be medically withdrawn from his high oral dose because his body will have become habituated to it.

Hope this helps c some of your questions.

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It is obvious the amount of pain Mr Bee is in and the scenario is not saying that the man is using opioids for the wrong reason so you becoming crazy is not understood why this conclusion was made. I thought when anyone was prescribed these soughts of drugs, that the physician would have considered a bowel softener for constipation but often this is not done. So if a n SSRI such as amitriptyline was prescribed for Mr Bee how does wean him from his oral MS COntin and over what timeframe should this occur. Is this what is causing his pain and loss of sensation in the soles of his feet and in his joints? What are the priorities for a nurse in caring for Mr Bee? Firstly it is to review his medications and make adjustments to incorporate neuropathic medication. In educating Mr Bee about this how would a nurse go about this? Exactly what should be included in this education and how?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
It is obvious the amount of pain Mr Bee is in and the scenario is not saying that the man is using opioids for the wrong reason so you becoming crazy is not understood why this conclusion was made. I thought when anyone was prescribed these sorts of drugs, that the physician would have considered a bowel softener for constipation but often this is not done. So if a n SSRI such as amitriptyline was prescribed for Mr Bee how does this wean him from his oral MS COntin and over what timeframe should this occur. Is this what is causing his pain and loss of sensation in the soles of his feet and in his joints? What are the priorities for a nurse in caring for Mr Bee? Firstly it is to review his medications and make adjustments to incorporate neuropathic medication. In educating Mr Bee about this how would a nurse go about this? Exactly what should be included in this education and how?
Welcome to AN! The largest online nursing community!

First.....What semester are you? What is your focus this semester? YOu need to have a complete understanding of the disease processes before you can make determination of your plan of care. Your plan of care is ALL about the patient assessment and what the patient needs. The proper use of terminology, and spelling, is imperative as similar word/spelling can have completely different meanings.

The reason GrnTea addressed this with you was to explain your question....

Is he addicted to Morphine so much now that it has no effect
and was NOT
becoming crazy
You asked why this patient was having excessive pain in the presence of excessive pain medication usage.

Now....this patient is probably experiencing pain due to diabetic neuropathy. However this scenario is complicated due to the fact the patient has had fem-pop bypass to restore circulation.

Your first nursing priority should be assuring that the patient isn't experiencing a complication from the surgery and is suffering from an acute occlusion/failure of the graft from the surgery. Proper assessment of BOTH limbs is necessary to ensure circulation is not impaired. As a previous poster stated.....MendedHeart

What is really important is his assessment , neurovascular specifically--5 P's

-Pulses

-Pallor-color of skin and area around groin site, is it soft?

-paresthesia

-paralysis-movement bilaterally/strength

-pain

If your assessment proves that your patient has no impaired circulation your second consideration should be that these patient can experience intense pain from re-perfused tissue muscles and nerves.....oxygenated blood getting to tissues that were denied oxygen wake up and can cause the patient unbelievable pain, tingling,and feelings of numbness/pins and needles.....which can mimic the pain of diabetic neuropathy and is neuropathy pain from PAD (peripheral artery disease)....and thereby causing a hyperalgesia state
Hyperalgesia (/ˌhaɪpərælˈdʒiziə/ or /-siə/; 'hyper' from Greek ὑπέρ (huper, “over”), '-algesia' from Greek algos, ἄλγος (pain)) is an increased sensitivity to pain, which may be caused by damage to the peripheral nerve

There are several causes of hyperalgesia

  • Primary hyperalgesia describes pain sensitivity that occurs directly in the damaged tissues.
  • Secondary hyperalgesia describes pain sensitivity that occurs in surrounding undamaged tissues.

Opioid-induced hyperalgesia may develop as a result of long-term opioid use in the treatment of chronic pain. Various studies of humans and animals have demonstrated that primary or secondary hyperalgesia can develop in response to both chronic and acute exposure to opioids. This side effect can be severe enough to warrant discontinuation of opioid treatment.

A patient building a tolerance to a medicine as GrnTea pointed out is NOT assuming they are addicted....they are very different animals...building a tolerance to the effectiveness of the medicine because of chronic use is NOT addiction. Some patients will develop this from the med itself even after one dosage of the med and is a sensitivity reaction similar to an allergice response
Hyperalgesia is induced by platelet-activating factor (PAF) which comes about in an inflammatory or an allergic response. This seems to occur via immune cells interacting with the peripheral nervous system and releasing pain-producing chemicals
Because this patients pain is reported to be worse at night it helps you decide....AFTER assuring proper circulation is present.....that neuropathy is present. Neuropathy can be caused by many things including poor circulation, diabetes, and meds.

Now what is neuropathy and how is it treated?

Peripheral neuropathy is a disorder of the peripheral nerves—the motor, sensory and autonomic nerves that connect the spinal cord to muscles, skin and internal organs. It usually affects the hands and feet, causing weakness, numbness, tingling and pain. Peripheral neuropathy’s course is variable; it can come and go, slowly progressing over many years, or it can become severe and debilitating
Neuropathy: Neuropathy, Peripheral Neuropathy Peripheral neuropathy - MayoClinic.com

It is common that opioids (narcotics) alone are seldom effective for this type of pain. The use of SSRI/tricylic antidepressants and certain anti-seizure meds are used to treat this type of pain to assist in the decrease usage of opioids and not withdraw/weaning of these meds.Peripheral neuropathy: Treatments and drugs - MayoClinic.com

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Now according to Maslows hierarchy of needs.....tell me what you think is a priority in Mr. Bee's care?

[h=3]Five Levels of the Hierarchy of Needs[/h] There are five different levels in Maslow’s hierarchy of needs:

  1. Physiological Needs
    These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.

  2. Security Needs
    These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.

  3. Social Needs
    These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.

  4. Esteem Needs
    After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.

  5. Self-actualizing Needs
    This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

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I work with these patients all the time...You definitely want to assess pain meds and usage however you MUST make sure its nothing acute FIRST causing this uncontrolled pain.

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