Question

Scenario (students are invited to ask questions if they are unsure of what is being asked):

Nurse M. is caring for a 35 year old male client Tom admitted with right upper quadrant (RUQ) abdominal pain, nausea, and vomiting for the last 12 hours. You note petechiae on his arms, legs, and flank. He complains of (C/O) shortness of breath (SOB) and edema (swelling) in his extremities. When asked about medications patient Tom replies he has been using increasing doses of hydrocodone/acetaminophen (norco) when he determined the lidocaine patch (lidoderm) and the ibuprofen (motrin) 800mg twice a day was “not working “ for him for a back injury that occurred two months ago. He states on the date of injury he received morphine 5mg IV and that is the only thing that “worked” for him. He was unable to keep his last follow-up appointment with his physician. He states “the Dr wanted to perform a nerve block to numb the pain but there was NO way I was having a needle stuck in my back”

1. What further questions would you as the RN want to ask client Tom?

2. a) What do you perceive the immediate problem to be?  

     b) Secondary problem?

3. What lab tests will be ordered?

4. Morphine is used for acute pain and has what potential?

5. Are there any additional concerns regarding the use of the lidocaine patch (lidoderm) and also high doses of acetaminophen?

Answer 1

1.Further questions

a) Whether the hydrocodene was self prescribed?

b) If the answer to the first question is NO, then the next question is what is the initial dose of hydrocodene prescribed.

c) What is the current dosage of hydrocodene he is currently taking.

d) What is the duration between onset of symptoms and increasing the hydrocodene dosage.

2. a) The immediate problem seems to be in my first assessment an overdse of hydrocodene along with ibuprofen. Hydrocodene is an Mu opiod receptor agonist and is known to interact with other opiod receptors at higher doses. At higher dosages it is known to cause respiratory distress as evidenced by patient here in the form of shortness of breath. 10 % of patients also have adverse drug reactions with higher doses like nausea, vomitting, peripheral edema and pruritis. Ibuprofen should always be used with caution and for the shortest interval as possible especially for patients on hydrocodene. Drug interactions between the two will cause serious gastric disorders like ulcers, gastrointestinal bleeding and abdominal pain.

b) The secondary problem is an opiod dependency or addiction.

3. Lab tests to be ordered:

• complete renal function test
• liver function test
• complete hemogram
• circulating serum levels of opiod drug.
• stool examination - routine and occult blood
• Prothrombin time and Aptt

4. Morphine has addictive potential and increased risk of abuse. It is also a very good anallgesic, but must be used in cases of extreme caution due to its adverse effects and addictive potential.

5. Yes. Lido caine patch is a temporary solution and not indicated for long term usage. Also it does not relieve acute systematic pain and hence patients may be forced to increase dosage of other analgesics. Acetaminophen is alos indicated for mild to moderate grade pain and increased dosage is known to cause hepatotoxicity and renal damage. Prolonged usage is not recommended here.