Pain Management after Total Knee Arthroplasty
The Patient
The patient is a 54-year-old male who underwent total knee arthroplasty three weeks ago. The client complains of moderate pain despite receiving the recommended doses. As a result, he has a prescription of opioid analgesic oxymorphone to help relieve the pain. However, the client presents the side effects of using oxymorphone (opioid analgesic). They include constipation, sleepiness, and nausea and interfere with the patient’s recovery. When he suddenly stopped taking the opioid prescription, he experienced jittery nerves and insomnia.
Effects of Opioid Analgesics on Pain Pathway
Opioid prescription is a common practice in the Orthopedic Unit for the management of acute or severe postoperative pain. Analgesic effects of oxymorphone suppress both the sensory and affective dimensions of pain by altering the conscious perception of pain. Oxymorphone mainly depresses neuronal activities in the ventral posterolateral thalamus, anterior cingulate cortex, the somatosensory cortex, and medial dorsal thalamus resulting in a reduction of the fraction of responsive neurons as well as magnitude and duration of response (Whitener et al., 2018).
The Scope of Practice and Prescriptive Authority of FNP
A family nurse practitioner’s (FNP) scope of practice refers to the full range of practice privileges allowed by certification and licensure. The scope of practice incorporates the needs of the patient population in terms of assessment and treatment, including the limitations of practice. Different states vary in their definition of nurse practitioners’ (NPs) scope of practice (AANP, 2018). A majority of states give NPs authority to prescribe Schedule II controlled medications, while others limit the prescription of controlled substances or require both the signature of the NP and the collaborating physician (Varcarolis, 2016; AANP, 2018). Therefore, careful consideration is necessary before prescribing opioid to the patient.
Multimodal Pain Management
A multimodal pain management approach is the best way to reduce opioid use by the client. The approach requires the use of at least two different medications or methods to manage pain as opposed to using opioids alone (Goode et al., 2019). If successful, the multimodal approach will reduce opioid use and related complications. In this case, acetaminophen or gabapentin is the preferred supplementary pain medication. Furthermore, the use of multimodal pain management for patients undergoing total knee arthroplasty is gaining popularity (Goode et al., 2019).
Legal and Ethical Issues
One of the main ethical issues that arise is informed consent. The FNP must inform the patient all the relevant information about the proposed treatment interventions, including benefits, efficacy, and side effects. Before administration of any intervention, the patient must provide written informed consent, acknowledging that he is well informed of the treatment (Smith & Parkhouse, 2018). On the legal side, the FNP must ensure that the proposed interventions fall within the scope of practice (AANP, 2018).
Patient Education
The use of opioids requires additional educational efforts. A practitioner must educate their patients about the risks and benefits of all the treatments administered, especially when prescribing opioids. The best advice an FNP can give a patient is for them to take all the non-opioid pain medications as instructed and only consider taking opioid prescriptions if the pain persists after taking all other medications (Lee et al., 2019). Once the pain has reduced to tolerable levels, the patient should immediately stop taking the opioid. Informing patients about how to use opioids safely minimizes the risks of dependence.
References
American Association of Nurse Practitioners (AANP) (2018): State Practice Environment. Retrieved from https://www.aanp.org/advocacy/state/state-practice-environment
Goode, V. M., Morgan, B., Muckler, V. C., Cary Jr, M. P., Zdeb, C. E., & Zychowicz, M. (2019). Multimodal Pain Management for Major Joint Replacement Surgery. Orthopedic nursing, 38(2), 150.
Lee, J. S., Howard, R. A., Klueh, M. P., Englesbe, M. J., Waljee, J. F., Brummett, C. M., … & Dossett, L. A. (2019). The impact of education and prescribing guidelines on opioid prescribing for breast and melanoma procedures. Annals of surgical oncology, 26(1), 17-24.
Smith, A., & Parkhouse, J. (2018). Informed consent; legal and ethical considerations. Nursing And Residential Care, 20(4), 158-161.
Whitener, S., McEvoy, M. D., Shafer, S. L., & Flood, P. (2018). The Pharmacology of Intravenous Opioids. In Geriatric Anesthesiology (pp. 283-302). Springer, Cham.