Therapy for Clients With Pain and Sleep/Wake Disorders Paper

Assignment: Assessing and Treating Clients With Pain Pain can greatly influence an individual’s quality of life, as uncontrolled pain negatively impacts mood, concentration, and the overall physical and mental well-being of clients. Although pain can often be controlled with medications, the process of assessing and treating clients can be challenging because pain is such a subjective experience. Only the person experiencing the pain truly knows the intensity of the pain and whether there is a need for medication therapies. Sometimes, beliefs about pain and treatments for pain can have an adverse effect on the provider-client relationship. For this Assignment, as you examine the interactive case study consider how you might assess and treat clients presenting with pain. Learning Objectives Students will: • Assess client factors and history to develop personalized therapy plans for clients with pain • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for pain • Evaluate efficacy of treatment plans for clients presenting for pain therapy • Analyze ethical and legal implications related to prescribing therapy for clients with pain To prepare for this Assignment: The Assignment Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. (Decisions have already been made. See decision results in the attached case study) You will be asked to make three decisions concerning the medication to prescribe to this client. Therapy for Clients With Pain and Sleep/Wake Disorders Paper. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest. I do not need you to tell me the treatment options available to you – I am very familiar with the cases. Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data). At each decision point, stop to complete the following: * Decision #1 Select what the PMHNP should do next: • You decided to start patient on Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day. (see attachment for result of decision#1) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the option to start with Gabapentin 300 mg at bedtime with weekly increases of 300 mg per day to a max dose of 2400 mg or Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter? • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Decision #2 Select what the PMHNP should do next: • You decide to continue current medication and increase the dose to 125 mg at HS this week continuing towards the goal dose of 200 mg daily. Therapy for Clients With Pain and Sleep/Wake Disorders Paper. The client will be instructed to take the medication one hour earlier than normal starting tonight and call the office in three days to report how his function is in the morning. (see attachment for result of decision#2) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either reduce Elavil to 75 mg at bed time by titrating the dose weekly while using Biofreeze or to reduce Elavil to 75 mg at bed time and add Neurontin 300 mg at bed time. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Decision #3 Select what the PMHNP should do next: • You decide to continue current medication and increase the dose to 125 mg at HS this week continuing towards the goal dose of 200 mg daily and counsel patient about healthy lifestyle then refer him to a lifestyle couch. (see attachment for result of decision#3) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either reducing Elavil to 100 mg a day and follow up in a month or continue Elavil 125 mg a day and start Qsymia 3.75 mg/23 mg tablet daily and titrate as required by package insert. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? Also include how ethical considerations might impact your treatment plan and communication with clients.

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Long-term Control and Quick Relief Medications for Asthma Patients

Long-term control asthma medications are used to decrease and prevent swelling within the airways and hence prevent triggering asthma attacks. They also prevent inflammation of the airway and prevent asthma symptoms. Long-control medications are appropriate for individuals having asthmatic symptoms three or above weekly or at night three or more times monthly (Laforent et al, 2016). Long-term control medications include:

Anti-inflammatory medications: They are useful in reduction and prevention of swelling within the airways and they consist of: inhaled corticosteroids these prevent airway swelling after exposure to asthma triggers. They also decrease mucus within the lungs and reduce mucus within the lungs (Alangari, 2014).  Examples include flunisolide, fluticasone and beclomethasone. On the other hand, inhaled cromolyn and nedocromil are mostly utilized in preventing asthma attacks. Examples include nedocromil sodium and cromolyn sodium.  Therapy for Clients With Pain and Sleep/Wake Disorders Paper.Bronchodilators are also long-term control asthma medications that are effective in muscle relaxation within and around the airways; this opens-up the airways (Lampkin et al, 2016). They include inhaled long-acting beta₂-agonists used in preventing nighttime symptoms by relaxing muscles in the tightened airways to reopen airways. Other examples of bronchodilators are sustained-release beta₂-agonist tablets and sustained-release theophylline. These prevent nighttime asthma symptoms. Tiotropium (inhaled) is an example of bronchodilator (Lampkin et al, 2016).

Leukotriene modifiers are long-term control asthma medications used in preventing asthma attacks. They are mostly used to prevent asthma symptoms triggered by aspirin allergic reactions. Examples include zileuton and zafirlukast. Lastly,  anti-IgE (omalizumab) are also long-term control asthma medications that decrease allergic reactions by removing free IgE; this prevents attachment of free IgE to allergens (Tashkin, 2016).

Quick-relief medications quickly relieve asthma symptoms by fast relaxing muscles within and around the airways; this opens-up airways. Quick-relief asthma drugs include inhaled anticholinergics and inhaled short-acting beta₂-agonists (Alangari, 2014). Inhaled anticholinergics work by blocking acetylcholine a chemical that stimulates contractions of muscles and increase mouth and lung secretions during an asthmatic attack. An example is ipratropium bromide. Short-acting beta₂-agonists work by helping relaxing of muscles within and around the tightened airways to reopen the airways. Examples include terbutaline, albuterol and pirbuterol (Alangari, 2014).

Long-term effects of both long-term and short-term corticosteroids include systemic effects like hypertension, suppression of growth especially in children, dermal thinning and diabetes. On the other hand, inhaled long-acting beta2-agonists have been shown to cause shakiness, increased heart beat and hypokalemia (Laforent et al, 2016).

Stepwise Approach to Asthma Treatment and Management

This form of approach integrates different care elements that include: assessment of severity to start treatment or assessment of control for therapy monitoring and adjustment; patient education; environmental control strategies and managing comorbid during each step; as well as medication selection (Dunn et al, 2017). The severity and asthma control determines the kind, quantity, as well as scheduling of medication. Treatment is increased (stepping up) as essential and reduced (stepping down) when possible. Stepwise approach aims to gain control as fast as possible and then reduce therapy to the least medication essential in maintaining control. It is recommended to begin with a more intensive therapy to ensure a more quick suppression of airway inflammation and therefore gain control promptly. Corticosteroids are the most reliably effective anti-inflammatory treatment for all age-groups at all care steps for persistent asthma. Corticosteroids are also the ideal first-line therapy that leads to improved asthma control (Bateman et al, 2015). Therapy for Clients With Pain and Sleep/Wake Disorders Paper.

Step 1 is recommended for treatment of intermittent symptoms of asthma and is appropriate for all age-groups. The recommended medications include short-acting beta-agonist, for example albuterol prn. If the patient used the treatment over two days weekly, the therapy should be taken as inadequate control and stepped up (Dima et al, 2016).

Step 2 is recommended for treatment of mild persistent asthma. The recommended therapies for all ages include low-dose inhaled corticosteroids and leukotriene blocker or cromolyn as the alternatives. However, for children aged between 0-4 years, a referral should be considered particularly if the diagnosis is uncertain. The alternative therapy should only be prescribed when the patient fails to tolerate the first-line treatment choice (Dima et al, 2016).

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Step 3 is recommended for moderate and severe asthma. For individuals aged 2 years and above, the recommended therapy is low-dose inhaled corticosteroid combined with long-acting beta agonist or single therapy of medium-dose inhaled steroid. For children aged between 5-11 years, the recommended therapy is low-dose inhaled corticosteroid together with long-acting beta agonist. For children aged between 0-4 years, the recommended therapy is medium-dose inhaled steroid and a referral to a specialist. In step 4, the therapy is used in moderate and severe asthma (Dima et al, 2016). In this step, just like in step 3, the dosage of inhaled steroids is elevated or LABA added or both depended on the asthma severity. For step 5 and 6, the patients are prescribed increased and high-dose of inhaled corticosteroids combined with long-acting beta agonist. In step 5 and 6, omalizumab is considered if allergies for patients aged above 12 years. In step 6, oral or chronic corticosteroids (normally prednisone) are deliberated (Dima et al, 2016).

For all ages, from step 4 to 6 an asthma specialist should be consulted. If allergic asthma, immunotherapy should be recommended.  For rescue medication, short-acting beta-agonist like albuterol should be administered depending on the symptom severity. Regular or using rescue medication increasingly may be an indication of an inadequate control and the necessity for stepping up treatment. For all steps, patient education and environmental controls should be provided (Dunn et al, 2017).  Therapy for Clients With Pain and Sleep/Wake Disorders Paper.

Significance of Stepwise Asthma Management to Disease Control

Stepwise approach to asthma management enables patients and healthcare providers to utilize written action plans in guiding patients on effective control asthma attacks or asthma exacerbations. Stepwise approach also enables healthcare providers to provide individualized care depending on the patient; therefore, the patients are able to handle any changes in their conditions and have treatment adjusted accordingly (Bateman et al, 2015). The capacity of patients to regulate their stepwise medication depending on their asthma severity enables patients to gain and maintain control of the disease process. Finally, stepwise approach in asthma management has been shown to be effective in prevention and management of asthma exacerbations (Bateman et al, 2015).

References

Alangari A. (2014). Corticosteroids in the treatment of acute asthma. Ann Thorac Med. 9(4), 187–192.

Bateman R, Becker A, Wong G, Soto M et al. (2015). A summary of the new GINA strategy: a roadmap to asthma control. European Respiratory Journal. 1(2).

Dunn N, Neff L & Maurer D. (2017). A stepwise approach to pediatric asthma. J Fam Pract. 66(5):280,282-286

Dima A, Bruin M & Ganse E. (2016). Mapping the Asthma Care Process: Implications for

Research and Practice. J Allergy Clin Immunol Pract. 4(5).

Laforent L, Manon B, Didier A, Ganse E & Marine G. (2016). Long-Term Inhaled Corticosteroid Adherence in Asthma Patients with Short-Term Adherence. J Allergy Clin Immunol Pract. 4(5), 890–899.

Lampkin S, Cheryl M, Maish W & John B. (2016). Asthma Review for Pharmacists Providing Asthma Education. J Pediatr Pharmacol Ther. 21(5), 444–471.

Tashkin D. (2016). A review of nebulized drug delivery in COPD. Int J Chron Obstruct Pulmon Dis. 1(11), 2585–2596.     Therapy for Clients With Pain and Sleep/Wake Disorders Paper.