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HPI:  A 78-year-old man who is TO UNDERGO a left above the knee amputation due to a limb abscess


· Peripheral artery disease for 18 years

· Cardiomyopathy

· BPH for 13 years

FH: Mother had osteoporosis; father had diabetes

SH: Lives with wife; has two grown children


· Aspirin 81mg daily

· multivitamin 1 daily

· pantoprazole (Protonix) (PPI) 40 mg daily

· tamsulosin (Flomax) 0.4 mg daily 

· atorvastatin 80 mg at bedtime

PAIN ASSESSMENT: Patient rates pain as 8 on a scale of 0 to 10

1. Based on the type of injury, what type of pain is this patient likely to experience?

Based on the patient having a surgical amputation, he would have acute pain that would be severe initially. Further, I would expect him to experience nociceptive pain as a result of the surgical injuries to bone and soft tissues, as well as neuropathic pain as a result of the “changes in peripheral axon properties and neuronal circuitry in both the peripheral and central nervous systems” (Kuffler, 2018). “This [amputation] leads to a complicated, mixed, form of pain and a highly varied array of different postoperative pain syndromes” (Neil, 2016).

2. What type of pain management regimen would you suggest in the postoperative period? Explain your answer.

I would expect that this patient will be experiencing acute, severe pain, so I would recommend that this patient be placed on an opioid for pain relief. Both morphine and hydromorphone are potent opioids that are reserved for severe pain (Chisolm-Burns et al., 2019). 

Because this patient will have had a surgical amputation, I believe that the best option for administration of the pain medication would be by PCA infusion pump. This would allow the provider to administer a pre-programmed dose of the analgesic and determine both a minimum dosing interval to ensure adequate pain coverage, as well as a maximum hourly dose, to help ensure that breakthrough pain can be treated while still safeguarding the client from overdose. 

For severe pain, the usefulness of nonopioids is limited; thus, I would not prescribe any at this time. Once the patient is through the postoperative period and ready to begin oral pain medications, I would re-evaluate his pain and determine whether the use of nonopioids could now be beneficial. 

With regard to the patient’s neuropathic pain, and possible phantom limb pain, I would start the client on gabapentin 300mg, po, 3 times per day, which could be titrated up to a maximum daily dose of 3600mg in divided doses. As Neil, M. (2017) reported:

Gabapentinoids have a good safety profile, few drug interactions, are well tolerated and have efficacy in both neuropathic and nociceptive pain. Although there is no conclusive evidence, a Cochrane review identified a ‘trend towards benefit’ from Gabapentin in the management of phantom pain.7 Increasingly compelling evidence is emerging regarding the use of Gabapentin, and Pregabalin in particular, for preventing chronic post-surgical pain. Combining these two strands of evidence indicates that it is reasonable to initiate therapy with a Gabapentinoid perioperatively, as the clinical condition allows, continuing after operation for as long as felt to be clinically necessary. (p. 111)


Following surgery, he was placed on morphine patient-controlled analgesia (PCA). 

He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

Current Meds:  

· Morphine PCA

· aspirin 81 mg daily 

· atorvastatin 80 mg at bedtime (Lipitor)

· multivitamin 1 daily

· gabapentin 100 mg three times daily

· pantoprazole 40 mg daily (PPI)

· tamsulosin 0.4 mg daily (for BPH)

· heparin 5000 units twice daily, until discharged home

He will be discharged to a skilled nursing facility for rehabilitation therapy. You would like to convert him to a combination preparation of hydrocodone and APAP for as-needed pain relief.

1. What dosing regimen would you suggest?

I would suggest that this client be prescribed Vicodin HP 10/300 scheduled po, every 4 hours, and 0.5 tablets of the Vicodin HP 10/300, available every 6 hours, po, as needed for breakthrough pain. At maximum scheduled and break-through dosing, the patient would be at a daily total of 80mg of hydrocodone and 2400mg of APAP, both which would be within a safe range for this client. If I had any concerns about respiratory depression, I could also offer the patient a prescription for self-administered naloxone.

2. What would your monitoring plan include for this patient?

I would monitor this client’s pain level to see if the prescribed dosing regimen provided adequate pain coverage for him. I would also want to monitor the client for side effects secondary to opioid administration including sedation, nausea, constipation, gastroparesis, vertigo, urticaria/itching, respiratory depression, or CNS irritability.

3. How would you assess pain response?

I would assess the client’s pain response by asking the patient to rate their pain level using the 0-10 Numeric Pain Intensity Scale or the Visual Analog Scale. In addition, while engaging with the client, I would assess for any non-verbal communication that the client might convey about his true pain status.

4. The patient is concerned about the redness and itching that he developed while on morphine. Would you document this as an allergic reaction?

I would document the pain and itching the patient was experiencing; however, I would not document it as an allergic reaction at this time, since itching and redness are well-known side effects of opioids. Because of the likely discomfort the client would be experiencing, I would prescribe either hydroxyzine 25-100mg po/IV, or diphenhydramine 25-50mg po/IM for him, and then frequently reassess the client to ensure that the redness and itching were resolving, and he was not having a true allergic reaction.

5. What other interventions or education may be necessary at this time?

Because opioids are constipating and this client will have limited mobility secondary to lower limb amputation, it will be important to start this patient on a stimulant laxative such as senna, 15mg, po, 1-2 times daily, for up to seven days (Medscape, 2021a), as well as a stool softener such as docusate sodium 250mg, po, once daily (Medscape 2021b), to prevent constipation. 


The patient was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.

Current Meds: 

· Aspirin 81 mg daily 

· atorvastatin 80 mg at bedtime

· multivitamin 1 daily

· gabapentin 100 mg three times daily

· pantoprazole 40 mg daily

· tamsulosin 0.4 mg daily

· heparin 5000 units twice daily until discharged home

· hydrocodone/acetaminophen 5/325 mg every 6 hours as needed for pain

Pain Assessment: Patient reports pain of 7 out of 10; worse with movement.

Physical therapy notes indicate the patient is unable to complete therapy goals due to complaints of pain.

1. Based on this information, what would you recommend to optimize pain control?

The client is not experiencing adequate pain control on the hydrocodone/acetaminophen 5/325, every 6 hours, as needed, because he reports that his pain is a 7 out of 10, which is considered severe pain. Thus, I would change him to a scheduled dose of opioid such as morphine. His daily limit would be 20mg prior to any reduction; however, since he’s having uncontrolled pain, I would not reduce the dose and instead I would just monitor him closely and ensure that naloxone was available should the patient experience any adverse effects such as respiratory depression. I would dose the morphine on a schedule of 5mg, po, every six hours. If tolerated, I would keep him on this dose, until his pain was better controlled. Hopefully in 24-48 hours the patient’s pain would be well controlled and we could then change his prescription to a scheduled opioid/non-opioid medication with approximately one-sixth of the total daily dosage reserved for breakthrough pain (Chisolm-Burns et al., 2019).

2. Prescribers play a critical role in prescription drug misuse and abuse prevention. What steps can be taken to identify signs of dependence and abuse and what education can you provide to the patient regarding the negative effects of medication misuse?

For providers to be able to identify signs of dependence and abuse in their clients, they need to ensure that they see the client frequently, so they can be assessed. Additionally, prescribers should ask about all medications that the patient takes and set recovery goals with the patient. Providers can also utilize evidence-based screening tools that assesses for non-medical use of prescription drugs, available on the National Institute on Drug Abuse (NIDA) website (NIDA, 2020). Providers should stay alert for clients who request frequent, unscheduled refills, or need sudden increases in their medication dosing (NIDA, 2020). 


The patient has been at the skilled nursing facility for 4 weeks and is making progress toward rehabilitation goals; however, he complains that his leg is throbbing and feels like pins and needles. 

As a result, he requests to rest several times during her therapy sessions. 

During unit rounds, his therapist inquires whether her previous pain medication should be reordered.

Pain Assessment: 4 out of 10

Current Meds: 

· Aspirin 81 mg daily

· atorvastatin 80 mg at bedtime

· multivitamin 1 daily

· gabapentin 100 mg three times daily

· pantoprazole 40 mg daily

· tamsulosin 0.4 mg daily

· heparin 5000 units twice daily until discharged home

1. What additional recommendations would you have at this time regarding pain management?

The type of pain that the client is describing is typical symptoms of neuropathic pain. The dose of gabapentin that the client is currently taking is sub-therapeutic and should be increased. Chisolm-Burns et al., (2019) report that the initial starting dose of gabapentin is typically 300mg, po, three times a day and can be titrated up to a daily maximum of 3600mg, in divided doses; however, The Mayo Clinic (2021) reports that dosing dose not usually exceed 1800mg per day (600mg three times per day). I would reassess the patient within a few days to evaluate whether the increased dose was effective. 

2. Are there any other therapeutic issues that should be addressed?

I don’t believe that the client still needs to be on heparin 5000 units twice a day, as he is now navigating rehabilitative therapy and is more ambulatory. Thus, the client is at lower risk for blood clot development based on immobility but is now at higher risk for a significant bleed secondary to a fall.


Chisolm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., Booskstaver, P. B. (2019). Pharmacotherapy: Principles & practice. McGraw Hill Education. 

Kuffler, D. P. (2018). Origins of phantom limb pain. Molecular Neurobiology, 55, 60-69.  https://doi.org/10.1007/s12035-017-0717-x

Mayo Clinic. (2021). Drugs and supplements: Gabapentin (oral route). https://www.mayoclinic.org/drugs-supplements/gabapentin-oral-route/proper-use/drg-20064011?p=1

Medscape. (2021a). Senna (OTC) https://reference.medscape.com/drug/senokot-exlax-regular-strength-senna-342030

Medscape. (2021b). Docusate (OTC) https://reference.medscape.com/drug/colace-dss-docusate-342012

National Institute on Drug Abuse. (2020). Misuse of prescription drugs research report. National Institute of Health.  https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/how-can-prescription-drug-misuse-be-prevented

Neil, M. (2016, March 1). Pain after amputation. British Journal of Anaesthesia, 16(3), 107-112.  http://doi.org/10.1093/bjaed/mkv028

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