Course

West Virginia APRN Bundle

Course Highlights


  • In this West Virginia APRN Bundle course, we will learn about hypertension treatment clinical practice guidelines.
  • You’ll also learn how to describe best practices for managing patients who display drug seeking behaviors and diversion.
  • You’ll leave this course with a broader understanding of the six stages of pressure injuries based on National Pressure Injury Advisory Panel guidelines. 

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Pharmacology Contact Hours Awarded: 27

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Hypertensive Agents

Introduction   

Hypertension, or high blood pressure, is a common medical condition diagnosed and treated by healthcare professionals. According to the Centers for Disease Control and Prevention, around 34 million Americans are prescribed antihypertensive medications. Additionally, hypertension was a primary or contributing cause of more than 690,000 deaths in the United States in 2021 [6].  

Healthcare providers must be knowledgeable of and follow current hypertension clinical practice guidelines. Understanding the different pharmacokinetics of antihypertensive medications is essential. This course outlines antihypertensive pharmacology and addresses pharmacokinetics, including mechanism of action, side effects, usage, and contraindications. 

Definitions 

 

Hypertension – high blood pressure above normal. Normal is considered anything less than 120/80 mmHg [7]. 

Antihypertensives – medications used to control hypertension and lower blood pressure [7]. 

Hypertensive crisis – severely elevated blood pressure of either: 

  1. Systolic greater than 180 mmHg 
  1. Diastolic greater than 120 mmHg [19]. 

Hypertensive emergency – acutely elevated blood pressure with signs of target organ damage [2]. 

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is hypertension? 
  2. What are antihypertensives? 
  3. What is a hypertensive crisis? 
  4. What is a hypertensive emergency? 

Medications Overview 

Antihypertensive medications are used for the treatment of hypertension and are used in both inpatient, outpatient, and emergency settings.  

Some of the major antihypertensive medication classes include: 

  • Diuretics 
  • Beta-blockers 
  • Angiotensin-converting enzyme inhibitors 
  • Angiotensin II receptor blockers 
  • Calcium channel blockers 
  • Selective alpha-1 blockers 
  • Alpha-2 Receptor Agonists 
  • Vasodilators [3]. 

Different medical organizations have varying recommendations and hypertension treatment guidelines. Hypertension treatment clinical practice guidelines are available from organizations like the American Heart Association, the American College of Cardiology, and the European Society of Cardiology to name a few [21]. Healthcare providers should be aware of their healthcare institution’s recommendations for clinical practice guidelines and organizations.  

All organizational guidelines share the same recommended treatment of starting antihypertensives immediately when: 

  1. Blood pressure is greater than 140/90 mmHg for patients with a history of ischemic heart disease, heart failure, or cerebrovascular disease. 
  2. Blood pressure is greater than 160/100 mmHg regardless of underlying medical conditions [21]. 

Again, healthcare providers should follow current and evidence-based clinical guidelines for initiating or titrating antihypertensive medications. 

While most antihypertensives are prescribed in an outpatient setting, certain antihypertensives are indicated during hypertensive or medical emergencies. For example, intravenous (IV) vasodilators, like nitroprusside and nitroglycerin, and calcium channel blockers, like nicardipine, are used during hypertensive emergencies and crises. 

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. In what settings are antihypertensives used? 
  2. What are the clinical guidelines for initiating hypertensive medications? 
  3. Which medications are commonly used to treat hypertensive emergencies? 

Pharmacokinetics 

Diuretics 

Diuretics are a class of drugs that help control blood pressure by removing excess sodium and water from the body through the kidneys. There are several varying types of diuretics, some including thiazide, potassium-sparing, and loop, and all work to lower blood pressure differently [3]. 

 

Thiazide Diuretics 

Thiazide diuretics remove excess sodium and water from the body by blocking the sodium-chloride (Na-Cl) channels in the kidneys’ distal convoluted tubule. As the Na-Cl channel becomes blocked, this inhibits the reabsorption of sodium and water into the kidneys. Concurrently, this causes a loss of potassium and calcium ions through the sodium-calcium channels and sodium-potassium pump [1]. 

Thiazide diuretics are approved by the Food and Drug Administration (FDA) for controlling primary hypertension and are available via oral route. Some common thiazide diuretics are hydrochlorothiazide, chlorthalidone, and metolazone [3].  

When initiating this medication, the healthcare provider should start with the lowest dose, which is usually 25mg daily, and then increase accordingly to aid with blood pressure control or if the patient has excess fluid retention, usually as evidenced by leg swelling or edema [1].  

 

Common side effects of thiazide diuretics include: 

  • Increased urination 
  • Diarrhea 
  • Headache 
  • Stomach and muscle aches [16]. 

 

As thiazide diuretics interfere with Na-Cl, Na-Ca, and Na-K channels, there is an increased potential for adverse effects, including: 

  • Hypotension 
  • Hypokalemia 
  • Hyponatremia 
  • Hypercalcemia 
  • Hyperglycemia 
  • Hyperlipidemia 
  • Hyperuricemia 
  • Acute pancreatitis 

 

When prescribing thiazide diuretics, healthcare providers should avoid prescribing thiazide diuretics to patients with a sulfonamide allergy, since thiazides are sulfa-containing medications. Also, they should avoid prescribing these to patients with a history of gout [1].  

Additionally, patients can experience a thiazide overdose if they take more than the amount prescribed. Patients with a suspected overdose may experience confusion, dizziness, hypotension, and other symptoms. These patients must seek emergency care and poison control must be alerted [16]. 

 

Potassium-Sparing Diuretics 

Potassium-sparing diuretics remove excess sodium and water from the body without causing loss of potassium. Depending on the type, they interrupt sodium reabsorption by either binding to epithelial sodium channels or inhibiting aldosterone receptors. When catatonic sodium is reabsorbed, this creates a negative gradient causing the reabsorption of potassium ions through the mineralocorticoid receptor [5]. 

Potassium-sparing diuretics are approved for controlling hypertension and are usually combined with other diuretics, like thiazide or loop diuretics since they have a weak antihypertensive effect.  

Common names of potassium-sparing diuretics are amiloride, triamterene, and spironolactone. These medications are available by either intravenous or oral routes. Spironolactone is commonly used for treating primary aldosteronism and heart failure [5]. Patients should be started on the lowest dose when first prescribing this class of medications.  

 

Common side effects can include: 

  • Increased urination 
  • Hyperkalemia 
  • Metabolic acidosis 
  • Nausea  

[4] 

Healthcare providers should avoid prescribing this class of medications to patients with hyperkalemia or chronic kidney disease. They should also be avoided during pregnancy or in patients who are taking digoxin. Since potassium-sparing medications can cause hyperkalemia, periodic monitoring for electrolyte imbalances and potassium levels is necessary [4]. 

 

Loop Diuretics 

Loop diuretics inhibit sodium and chloride reabsorption by competing with chloride binding in the Na-K-2Cl (NKCC2) cotransporter. Potassium is not reabsorbed by the kidney, which causes additional calcium and magnesium ion loss.  

Loop diuretics are FDA-approved for the treatment of hypertension but are not considered first-line treatment. They can also be used for treating fluid overload in conditions like heart failure or nephrotic syndrome [12]. 

Loop diuretics are available via oral or IV routes and furosemide, torsemide, and bumetanide are common forms [3].  

Bioavailability and dosage differ for each type and route of loop diuretics. The bioavailability of furosemide is 50%, with a half-life of around 2 hours for patients with normal kidney function, and dosages start at 8mg for oral medication. Torsemide has a bioavailability of about 80%, a half-life of about 3 to 4 hours, and oral dosages start at 5mg [12].  

 

Common side effects can include: 

  • Dizziness 
  • Increased urination 
  • Headache 
  • Stomach upset 
  • Hyponatremia 
  • Hypokalemia [13]. 

 

Loop diuretics can lead to several adverse effects, including toxicity, electrolyte imbalances, hyperglycemia, and ototoxicity. They have a black box warning stating that high dosages can cause severe diuresis. Therefore, electrolytes, BUN, and creatinine values should be monitored closely by a healthcare provider.  

People with a sulfonamide allergy may also be allergic to loop diuretics, so this should be avoided if the patient is allergic. Loop diuretics also interfere with digoxin and therefore should be avoided. Other contraindications include anuria, hepatic impairments, and use during severe electrolyte disturbances [12]. 

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of thiazide diuretics? 
  2. What is the pharmacokinetics of loop diuretics? 
  3. What is the pharmacokinetics of potassium-sparing diuretics? 
  4. What are common side effects and contraindications for each type of diuretic? 

Beta-Blockers 

Beta-blockers work by reducing the body’s heart rate and thus, lowering cardiac output resulting in lowered blood pressure [3]. The mechanism of action for beta-blockers varies, depending on the receptor type it blocks, and are classified as either non-selective or beta-1 (B1) selective.  

Non-selective beta-blockers bind to the B1 and B2 receptors, blocking epinephrine and norepinephrine, causing a slowed heart rate. Propranolol, labetalol, and carvedilol are common non-selective beta-blockers.  

Alternatively, beta-1 selective blockers only bind to the B1 receptors of the heart, so they are considered cardio-selective. Some examples include atenolol, metoprolol, and bisoprolol. Sotalol is a type of beta-blocker that also blocks potassium channels and is, therefore, a class III antiarrhythmic [8]. 

Beta-blockers are not primarily used for the initial treatment of hypertension but can be prescribed for conditions like tachycardia, myocardial infarction, congestive heart failure, and cardiac arrhythmias. It’s also approved for use in conditions such as essential tremors, hyperthyroidism, glaucoma, and prevention of migraines.  

Beta-blockers are available in many forms, including oral, IV, intramuscular injection, and ophthalmic drops. Starting dosage and route are determined by the health condition being treated [8]. 

 

Common side effects of beta-blockers include: 

  • Bradycardia 
  • Hypotension 
  • Dizziness 
  • Feeling tired 
  • Nausea 
  • Dry mouth 
  • Sexual Dysfunction  

[17] 

 

This class of medications can also lead to more severe adverse effects such as orthostatic hypotension, bronchospasm, shortness of breath, hyperglycemia, and increased risk of QT prolongation, torsades de pointes, and heart block [8]. Healthcare providers should avoid prescribing non-selective beta-blockers to patients with asthma. Instead, they can prescribe cardio-selective beta-blockers for patients with asthma.  

Additionally, the use of beta-blockers is contraindicated in patients with a history of bradycardia, hypotension, Raynaud disease, QT prolongation, or torsades de pointes. Healthcare providers must encourage patients to monitor their heart rate and blood pressure and follow administration parameters before taking beta-blockers daily since it decreases their heart rate.  

Overdose of beta-blockers is life-threatening and healthcare providers must discuss the symptoms of an overdose and the need for emergency care [8]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of beta-blockers? 
  2. What are the common side effects and contraindications of beta-blockers? 

Angiotensin-converting Enzyme Inhibitors 

Angiotensin-converting enzyme (ACE) inhibitors prevent the body from producing angiotensin, a hormone that causes vasoconstriction. As angiotensin production is reduced, this allows the blood vessels to dilate and therefore lowers blood pressure [3].  

Moreover, ACE inhibitors act specifically on the renin-angiotensin-aldosterone system (RAAS) by preventing the conversion of angiotensin I to angiotensin II. It also works to decrease aldosterone, which in turn, decreases sodium and water reabsorption [9]. 

ACE inhibitors usually end in the suffix -pril and some common examples include lisinopril, benazepril, enalapril, and captopril, and they usually end in the suffix [3].  

While ACE inhibitors are approved for treating hypertension, they are also FDA-approved for other uses or combination therapies for medical conditions such as: 

  • Systolic heart failure 
  • Chronic kidney disease 
  • ST-elevated myocardial infarction 

One non-approved FDA use is treatment of diabetic nephropathy [9]. This class of medication is available in oral, and IV forms, and dosages are dependent on clinical guidelines, underlying medical conditions, and route.  

ACE inhibitors have common side effects, with some including: 

  • Dry cough 
  • Dizziness 
  • Hypotension [9]. 

 

This medication can also lead to adverse effects, such as syncope, angioedema, and hyperkalemia [9]. As angioedema is an adverse effect, healthcare providers should understand this class of medications is contraindicated in patients with a history of hypersensitivity to ACE inhibitors.  

Additionally, ACE inhibitors are contraindicated in patients with aortic valve stenosis, hypovolemia, and during pregnancy. Individuals with abnormal kidney function should have renal function and electrolyte values monitored. If a patient develops a chronic dry cough, then the healthcare provider should consider another antihypertensive medication class by following current guidelines [9]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of angiotensin-converting enzyme inhibitors? 
  2. What are common side effects and contraindications of angiotensin-converting enzyme inhibitors? 

Angiotensin II Receptor Blockers 

Similar to ACE inhibitors, Angiotensin II Receptor Blockers (ARBs) act on the RAAS by binding to angiotensin II receptors and thus block and reduce the action of angiotensin II. Again, this reduces blood pressure by causing blood vessel dilation and decreasing sodium and water reabsorption [11]. ARBs typically end in the suffix -artan and common names are losartan, valsartan, and Olmesartan [3]. Oral and IV routes of the medication are available and again, dosages are dependent on the medication specifically and form [11]. 

All ARBs are FDA-approved for the treatment of hypertension, but a select few are approved for treating other medical conditions, such as: 

  • Candesartan for heart failure 
  • Irbesartan for diabetic nephropathy 
  • Losartan for proteinuria and diabetic nephropathy 
  • Telmisartan for stroke and myocardial infarction prevention 
  • Valsartan for heart failure and reduction of mortality in patients with left ventricular dysfunction [11]. 

Although not as common as ACE inhibitors, two side effects of ARBs are dry cough and angioedema.  

 

Other common side effects include: 

  • Dizziness 
  • Hypotension 
  • Hyperkalemia  

[11] 

 

Contraindications for use are if the patient is pregnant or has renal impairment or failure. If a patient is on an ARB, the healthcare provider should closely monitor lab values for electrolyte imbalances and kidney function.  

Additionally, if a patient is taking lithium, ARBs can increase lithium concentration and therefore, lithium blood concentration should be frequently checked [11]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of angiotensin II receptor blockers? 
  2. What are common side effects and contraindications of angiotensin II receptor blockers? 

Calcium Channel Blockers 

Calcium channel blockers (CCBs), also known as calcium channel antagonists, act by preventing calcium from entering the smooth vascular and heart muscles. In turn, this reduces heart rate and causes vasodilation [3].  

They are further divided into two major categories, non-dihydropyridines and dihydropyridines, where there are differences in the mechanism of action. Non-dihydropyridines inhibit calcium from entering the heart’s sinoatrial and atrioventricular nodes and thus cause a cardiac conduction delay and reduce cardiac contractility.  

Alternatively, dihydropyridines do not directly affect the heart but do act as a peripheral vasodilator leading to lowered blood pressure. Both categories are metabolized by the CYP3A4 pathway [15]. 

Names of non-dihydropyridine CCBs are verapamil and diltiazem. Dihydropyridine CCBs typically end in the suffix  -pine and common names are amlodipine and nicardipine. Both categories are available via oral and IV routes for administration. Oral dosages of non-dihydropyridine CCBs start at 30mg daily and dihydropyridine CCBs start at 30mg daily for immediate release [15].  

Calcium channel blockers can be used to treat other medical conditions in addition to hypertension and include: 

  • Coronary spasm 
  • Angina pectoris 
  • Supraventricular dysrhythmias 
  • Pulmonary hypertension 
  • Hypertrophic cardiomyopathy 

Non-dihydropyridine CCBs can cause side effects like bradycardia, and constipation, while dihydropyridine CCBs can cause: 

  • Headaches 
  • Feeling lightheaded 
  • Leg swelling [15]. 

Both categories pose the risk of potential hypotension and bradycardia, so healthcare providers should closely monitor the patient’s blood pressure and heart rate when initiating or titrating the dosage.  

Also, an overdose of this medication can lead to cardiac conduction delays, complete heart block, and cardiovascular collapse. Patients with possible symptoms of overdose should be sent to the emergency room immediately.  

Additionally, healthcare providers should avoid prescribing CCBs to people with heart failure and sick sinus syndrome [15]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of calcium channel blockers? 
  2. What are the common side effects and contraindications of calcium channel blockers? 

Selective Alpha-1 Blockers 

Selective alpha-1 blockers act on the body’s sympathetic nervous system to lower blood pressure. They prevent norepinephrine from binding to the alpha-1 receptors of the sympathetic nervous system, causing smooth muscle relaxation and vasodilation which leads to lowered blood pressure [18]. 

Selective alpha-1 blockers are available via the oral route, end in the suffix -osin and examples are doxazosin, terazosin, and prazosin [3]. They are FDA-approved for the treatment of hypertension but are not considered first-line therapy. Additionally, this class of medications may be used to treat benign prostatic hyperplasia. Dosages can start as low as 1mg daily depending on the drug selected. 

Common side effects include: 

  • Hypotension 
  • Tachycardia 
  • Dizziness 
  • Headache 
  • Weakness [18]. 

 

As selective alpha-1 blockers can lead to orthostatic hypotension, the healthcare provider should instruct the patient to take this medication at night. They should also avoid prescribing to the elderly population when able because of hypotension and increased fall risk [18]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of alpha-1 blockers? 
  2. What are the common side effects and contraindications of alpha-1 blockers? 

Alpha-2 Receptor Agonists 

Alpha-2 receptor agonists work by decreasing the activity of the sympathetic nervous system to lower blood pressure. It inhibits adenylyl cyclase and decreases the formation of cyclic adenosine monophosphate (cAMP). Alpha-2 agonists also cause vasodilation by reducing the amount of available cytoplasmic calcium [20].  

This class of medications is typically administered via oral route but is also available in intravenous and transdermal forms. Two FDA-approved alpha-2 agonists for hypertension treatment are methyldopa and clonidine and dosages are dependent on the name and route.  

Methyldopa is commonly prescribed to patients with hypertension and who are pregnant since it’s safe [20]. 

 

Common side effects of alpha-2 receptor agonists are: 

  • Dry mouth 
  • Drowsiness 
  • Fatigue 
  • Headache 
  • Sexual dysfunction [3]. 

Contraindications for use are orthostatic hypotension and autonomic disorders. Healthcare providers must avoid prescribing alpha-2 receptor agonists to individuals taking phosphodiesterase inhibitors [20]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of alpha-2 receptor agonists? 
  2. What are common side effects and contraindications of alpha-2 receptor agonists? 

Vasodilators 

Vasodilators lower blood pressure by dilating the body’s blood vessels. It binds to the receptors of the blood vessel’s endothelial cells, releasing calcium. Calcium stimulates nitric oxide synthase (NO synthase), eventually converting to L-arginine to nitric oxide. As nitric oxide is available, this allows for GTP to convert to cGMP, and causes dephosphorylation of the myosin and actin filaments. As this occurs, the blood vessels’ smooth muscles relax, leading to vasodilation and lowered blood pressure.  

Common vasodilators that act via this pathway are nitrates and minoxidil. Hydralazine is another vasodilator, but the mechanism of action is unknown [10]. 

Available forms of vasodilators are sublingual, oral, and intravenous. Similar to other classes of antihypertensives, vasodilator dosages depend on the form and treatment setting [10].  

Nitrovasodilators like nitroprusside and nitroglycerin are used during hypertensive emergencies. Hydralazine is used for severe hypertension for the prevention of eclampsia or intracranial hemorrhage and minoxidil for resistant hypertension [10] [3]. 

 

Side effects for each will vary, but nitrates commonly cause: 

  • Reflex tachycardia 
  • Headache 
  • Orthostatic hypotension  

[10] 

 

Common side effects of hydralazine are headaches, heart palpitations, and myalgias. Minoxidil causes excessive hair growth, weight gain, and fluid retention [3]. Additionally, nitroprusside can potentially cause cyanide toxicity.  

Vasodilators have varying degrees of contraindications, such as nitrates are avoided in patients with an inferior myocardial infarction. Hydralazine should not be given to patients with coronary artery disease, angina, or rheumatic heart disease. Healthcare providers should be aware of contraindications and monitor patients’ blood pressure and potential side effects [10]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the pharmacokinetics of vasodilators? 
  2. What are the common side effects and contraindications of vasodilators? 

Combination Antihypertensives 

Many antihypertensive medications come in combined forms, such as ACE inhibitors and thiazide diuretics, beta-blockers and diuretics, or calcium channel blockers and ACE inhibitors. The mechanism of action for combination antihypertensives depends on the blend of medications [3]. 

Considerations for Prescribers 

This section reviews potential considerations when prescribing antihypertensives. 

When prescribing antihypertensive medications, there are several factors that healthcare providers must consider. The route is typically determined by the healthcare setting and dosage by the underlying treatment goals. Again, healthcare providers should follow current guidelines when initiating or titrating antihypertensive medications.  

Healthcare providers must complete a thorough health history, and review lab values, and contraindications as mentioned above. Monitoring kidney function and electrolyte values is imperative while any patient is taking antihypertensive medications.  

While a single antihypertensive medication is recommended for initial treatment, there are some scenarios where combination therapy or combination antihypertensives are recommended [14]. 

Healthcare providers should also discuss the potential side effects of antihypertensives with patients and what to do if they are experiencing symptoms. For instance, if a patient reports syncope, they should be advised to go to the emergency room or be seen immediately for further evaluation. Also, healthcare providers must encourage patients to monitor their heart rate and blood pressure at home and abide by administration parameters.  

For example, instruct patients who are taking beta-blockers to measure their blood pressure and heart rate before taking their medication. If their heart rate is below 60 beats per minute, then they should not take the medication [14].  

If a patient is experiencing side effects from an antihypertensive medication, then another alternative should be selected. 

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What factors should healthcare providers consider when prescribing antihypertensives? 

Upcoming Research 

This section reviews upcoming research and medications for hypertension treatment. 

Research on antihypertensive medications has slowed throughout the years. Some clinical trials were performed on the potential of endothelin receptor antagonists to reduce hypertension. However, some studies found several unwanted side effects, and thus clinical use was stopped for safety reasons.  

An endothelin-A and endothelin-B receptor blocker, called aprocinentan, has shown promise for the treatment of resistant hypertension by lowering blood pressure and decreasing vascular resistance.  

Research on sodium-glucose transport protein (SGLT2) inhibitors, which are typically used for the treatment of type II diabetes mellitus, is also ongoing. SGLT2 inhibitors may promote blood pressure reduction through diuresis and reduce sympathetic tone [21]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What new research is there about antihypertensives? 

Conclusion

If hypertension is left untreated, it can lead to serious health complications, including death. When selecting antihypertensive treatment, healthcare providers should understand the pharmacokinetics of each drug class along with potential side effects and contraindications. They should also follow current clinical guidelines for an evidence-based approach. 

 

Final Reflection Questions 

  • Which antihypertensive medication is often prescribed during pregnancy? 
  • Which lab values are important when monitoring patients on each antihypertensive medication? 
  • Which antihypertensive medications cause hypokalemia? 
  • Which antihypertensive medications cause hyperkalemia? 

Controlled Substances: A comprehensive review

Introduction   

Pain is complex and subjective. The experience of pain can significantly impact an individual’s quality of life. According to the National Institute of Health (NIH) (40), pain is the most common complaint in a primary care office, with 20% of all patients reporting pain. Chronic pain is the leading cause of disability, and effective pain management is crucial to health and well-being, particularly when it improves functional ability. Effective pain treatment starts with a comprehensive, empathic assessment and a desire to listen and understand. Nurse Practitioners are well-positioned to fill a vital role in providing comprehensive and empathic patient care, including pain management (23).

While the incidence of chronic pain has remained a significant problem, how clinicians manage pain has significantly changed in the last decade, primarily due to the opioid epidemic. This education aims to discuss pain and the assessment of pain, federal guidelines for prescribing, the opioid epidemic, addiction and diversion, and recommendations for managing pain.

Definition of Pain

Understanding the definition of pain, differentiating between various types of pain, and recognizing the descriptors patients use to communicate their pain experiences are essential for Nurse practitioners involved in pain management. By understanding the medical definition of pain and how individuals may communicate it, nurse practitioners can differentiate varying types of pain to target assessment.

According to the International Association for the Study of Pain (27), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or terms of described such in damage.” The IASP, in July 2020, expanded its definition of pain to include context further.

Their expansion is summarized below:

  • Pain is a personal experience influenced by biological, psychological, and social factors.
  • Pain cannot be inferred solely from activity in sensory neurons.
  • Individuals learn the concept of pain through their life experiences.
  • A person’s report of an experience in pain should be respected.
  • Pain usually serves an adaptive role but may adversely affect function and social and psychological well-being.
  • The inability to communicate does not negate the possibility of the experience of pain.

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Analyze how changes to the definition of pain may affect your practice.
  2. Discuss how you manage appointment times, knowing that 20% of your scheduled patients may seek pain treatment.
  3. How does the approach to pain management change in the presence of a person with a disability?

Types of Pain

Pain originates from different mechanisms, causes, and areas of the body. As a nurse practitioner, understanding the type of pain a patient is experiencing is essential for several reasons (23).

  • Determining an accurate diagnosis. This kind of pain can provide valuable clues to the underlying cause or condition.
  • Creating a treatment plan. Different types of pain respond better to specific treatments or interventions.
  • Developing patient education. A nurse practitioner can provide targeted education to patients about their condition, why they may experience the pain as they do, its causes, and treatment options. Improving the patient's knowledge and control over their condition improves outcomes.

 

Acute Pain

Acute pain is typically short-lived and is a protective response to an injury or illness. Patients are usually able to identify the cause. This type of pain resolves as the underlying condition improves or heals (12).

 

Chronic Pain

Chronic pain is diagnosed when it continues beyond the expected healing time. Pain is defined as chronic when it persists for longer than three months. It may result from an underlying disease or injury or develop without a clear cause. Chronic pain often significantly impacts a person's physical and emotional well-being, requiring long-term management strategies. The prolonged experience of chronic pain usually indicates a central nervous system component of pain that may require additional treatment. Patients with centralized pain often experience allodynia or hyperalgesia (12).

Allodynia is pain evoked by a stimulus that usually does not cause pain, such as a light touch. Hyperalgesia is the effect of a heightened pain response to a stimulus that usually evokes pain (12).

 

Nociceptive Pain

Nociceptive pain arises from activating peripheral nociceptors, specialized nerve endings that respond to noxious stimuli. This type of pain is typically associated with tissue damage or inflammation and is further classified into somatic and visceral pain subtypes.

Somatic pain is most common and occurs in muscles, skin, or bones; patients may describe it as sharp, aching, stiffness, or throbbing.

Visceral pain occurs in the internal organs, such as indigestion or bowel spasms. It is more vague than somatic pain; patients may describe it as deep, gnawing, twisting, or dull (12).

 

Neuropathic pain

Neuropathic pain is a lesion or disease of the somatosensory nervous system. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain (10).

Neuropathic pain may be ongoing, intermittent, or spontaneous pain. Patients often describe neuropathic pain as burning, prickling, or squeezing quality. Neuropathic pain is a common chronic pain. Patients commonly describe allodynia and hyperalgesia as part of their chronic pain experience (10).

 

Affective pain

Affective descriptors reflect the emotional aspects of pain and include terms like distressing, unbearable, depressing, or frightening. These descriptors provide insights into the emotional impact of pain on an individual's well-being (12).

Quiz Questions

Self Quiz

Ask yourself...

  1. How can nurse practitioners effectively elicit patient descriptors to accurately assess the type of pain the patient is experiencing?
  2. Expand on how pain descriptors can guide interventions even if the cause is not yet determined.
  3. What strategies ensure patients feel comfortable describing their pain, particularly regarding subjective elements such as quality and location?

Case Study

Mary Adams is a licensed practical nurse who has just relocated to town. Mary will be the utilization review nurse at a local long-term care facility. Mary was diagnosed with Postherpetic Neuralgia last year, and she is happy that her new job will have her mostly doing desk work and not providing direct patient care as she had been before the relocation. Mary was having difficulty at work at her previous employer due to pain. She called into work several times, and before leaving, Mary's supervisor had counseled her because of her absences.

Mary wants to establish primary care immediately because she needs ongoing pain treatment. She is hopeful that, with her new job and pain under control, she will be able to continue a successful career in nursing. When Mary called the primary care office, she specifically requested a nurse practitioner as her primary care provider because she believes that nurse practitioners tend to spend more time with their patients.

Assessment

The assessment effectively determines the type of treatment needed, the options for treatment, and whether the patient may be at risk for opioid dependence. Since we know that chronic pain can lead to disability and pain has a high potential to negatively affect the patient's ability to work or otherwise, be productive, perform self-care, and potentially impact family or caregivers, it is imperative to approach the assessment with curiosity and empathy. This approach will ensure a thorough review of pain and research on pain management options. Compassion and support alone can improve patient outcomes related to pain management (23).

 

Record Review

Regardless of familiarity with the patient, reviewing the patient's treatment records is essential, as the ability to recall details is unreliable. Reviewing the records can help identify subtle changes in pain description and site, the patient's story around pain, failed modalities, side effects, and the need for education, all impacting further treatment (23).

Research beforehand the patient's current prescription and whether or not the patient has achieved the maximum dosage of the medication. Analysis of the patient's past prescription could reveal a documented failed therapy even though the patient did not receive the maximum dose (23).

A review of documented allergens may indicate an allergy to pain medication. Discuss with the patient the specific response to the drug to determine if it is a true allergy, such as hives or anaphylaxis, or if the response may have been a side effect, such as nausea and vomiting.

Research whether the patient tried any non-medication modalities for pain, such as physical therapy (PT), occupational therapy (OT), or Cognitive Behavioral Therapy (CBT). Note any non-medication modalities documented as failed therapies. The presence of any failed therapies should prompt further discussion with the patient, family, or caregiver about the experience. The incompletion of therapy should not be considered failed therapy. Explore further if the patient abandoned appointments.

 

Case Study

You review the schedule for the week, and there are three new patient appointments. One is Mary Adams. The interdisciplinary team requested and received Mary's treatment records from her previous primary care provider. You make 15 minutes available to review Mary's records and the questionnaire Mary filled out for her upcoming appointment. You see that Mary has been diagnosed with Postherpetic Neuralgia and note her current treatment regimen, which she stated was ineffective. You write down questions you will want to ask Mary. You do not see evidence of non-medication modalities or allergies to pain medication.

Quiz Questions

Self Quiz

Ask yourself...

  1. What potential risks or complications can arise from neglecting to conduct a thorough chart review before initiating a pain management assessment?
  2. In your experience, what evidence supports reviewing known patient records?
  3. What is an alternative to reviewing past treatment if records are not available?

Pain Assessment

To physically assess pain, several acronyms help explore all the aspects of the patient's experience. Acronyms commonly used to assess pain are SOCRATES, OLDCARTS, and COLDERAS. These pain assessment acronyms are also helpful in determining treatment since they include a character and duration of pain assessment (23).

 

O-Onset S-Site C-Character
L-Location O-Onset O-Onset
D-Duration C-Character L-Location
C-Character R-Radiate D-Duration
A-Alleviating A-Associated symptoms E-Exacerbating symptoms
R-Radiating, relieving T-Time/Duration R-Relieving, radiating
T-Temporal patterns (frequency) E-Exacerbating A-Associated symptoms
S-Symptoms S-Severity S-Severity of illness

 

Inquire where the patient is feeling pain. The patient may have multiple areas and types of pain. Each type and location must be explored and assessed. Unless the pain is from a localized injury, a body diagram map, as seen below, is helpful to document, inform, and communicate locations and types of pain. In cases of Fibromyalgia, rheumatoid arthritis, or other centralized or widespread pain, it is vital to inquire about radiating pain. The patient with chronic pain could be experiencing acute pain or a new pain site, such as osteoarthritis, that may need further evaluation and treatment (23).

Inquire with the patient how long their pain has been present and any associated or known causative factors. Pain experienced longer than three months defines chronic versus acute pain. Chronic pain means that the pain is centralized or a function of the Central Nervous system, which should guide treatment decisions.

To help guide treatment, ask the patient to describe their pain. The description helps identify what type of pain the patient is experiencing: Allodynia and hyperalgesia indicate centralized pain; sharp, shooting pain could indicate neuropathic pain. Have the patient rate their pain. There are various tools, as shown below, for pain rating depending on the patient's ability to communicate. Not using the pain rating number alone is imperative. Ask the patient to compare the severity of pain to a previous experience. For example, a 1/10 may be experienced as a bumped knee or bruise, whereas a 10/10 is experienced on the level of a kidney stone or childbirth (23).

Besides the 0-10 rating scale and depending on the patient's needs, several pain rating scales are appropriate. They are listed below.

The 0-5 and Faces scales may be used for all adult patients and are especially effective for patients experiencing confusion.

The Defense and Veterans Pain Rating Scale (DVPRS) is a five-item tool that assesses the impact of pain on sleep, mood, stress, and activity levels (20).

For patients unable to self-report pain, such as those intubated in the ICU or late-stage neurological diseases, the FLACC scale is practical. The FLACC scale was initially created to assess pain in infants. Note: The patient need not cry to be rated 10/10.

 

Behavior 0 1 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent or constant quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn
Activity Lying quietly, in a normal position, or relaxed Squirming, shifting back and forth, tense Arched, rigid, or jerking
Cry No cry wake or asleep Moans or whimpers: occasional complaints Crying steadily, screams, sobs, frequent complaints
Consolability Content, relaxed Distractable, reassured by touching, hugging, or being talked to Difficult to console or comfort

(21).

 

Assess contributors to pain such as insomnia, stress, exercise, diet, and any comorbid conditions. Limited access to care, socioeconomic status, and local culture also contribute to the patient's experience of pain (23). Most patients have limited opportunity to discuss these issues, and though challenging to bring up, it is compassionate and supportive care. A referral to social work or another agency may be helpful if you cannot explore it fully.

Assess for substance abuse disorders, especially among male, younger, less educated, or unemployed adults. Substance abuse disorders increase the likelihood of misuse disorder and include alcohol, tobacco, cannabis, cocaine, and heroin (29).

Inquire as to what changes in function the pain has caused. One question to ask is, "Were it not for pain, what would you be doing?" As seen below, a Pain, Enjoyment, and General Activity (PEG) three-question scale, which focuses on function and quality of life, may help determine the severity of pain and the effect of treatment over time.

 

What number best describes your pain on average in the past week? 0-10
What number best describes how, in the past week, pain has interfered with your enjoyment of life? 0-10
What number determines how, in the past week, pain has interfered with your general activity? 0-10

(21).

 

Assess family history, mental health disorders, chronic pain, or substance abuse disorders. Each familial aspect puts patients at higher risk for developing chronic pain (23).

Evaluate for mental health disorders the patient may be experiencing, particularly anxiety and depression. The Patient Health Questionnaire (PHQ4) is a four-question tool for assessing depression and anxiety.

In some cases, functional MRI or imaging studies effectively determine the cause of pain and the treatment. If further assessment is needed to diagnose and treat pain, consult Neurology, Orthopedics, Palliative care, and pain specialists (23).

 

Case Study

You used OLDCARTS to evaluate Mary's pain and completed a body diagram. Mary is experiencing allodynia in her back and shoulders, described as burning and tingling. It is exacerbated when she lifts, such as moving patients at the long-term care facility and, more recently, boxes from her move to the new house. Mary has also been experiencing anxiety due to fear of losing her job, the move, and her new role. She has moved closer to her family to help care for her children since she often experiences fatigue. Mary has experienced a tumultuous divorce in the last five years and feels she is still undergoing some trauma.

You saw in the chart that Mary had tried Gabapentin 300 mg BID for her pain and inquired what happened. Mary explained that her pain improved from 8/10 to 7/10 and had no side effects. Her previous care provider discontinued the medication and documented it as a failed therapy. You reviewed the minimum and maximum dosages of Gabapentin and know Mary can take up to 1800mg/day.

During the assessment, Mary also described stiffness and aching in her left knee. She gets a sharp pain when she walks more than 500 steps, and her knee is throbbing by the end of the day. Mary rated the pain a 10/10, but when she compared 10/10 to childbirth, Mary said her pain was closer to 6/10. Her moderate knee pain has reduced Mary's ability to exercise. She used to like to take walks. Mary stated she has had knee pain for six months and has been taking Ibuprofen 3 – 4 times daily.

Since Mary's pain is moderate, you evaluate your options of drugs for moderate to severe pain.

Quiz Questions

Self Quiz

Ask yourself...

  1. How do you assess and evaluate a patient's pain level?
  2. What are the different types of pain and their management strategies?
  3. How do you determine the appropriate dosage of pain medications for a patient?
  4. How do you assess the effectiveness of pain medications in your patients?
  5. How do you adjust medication dosages for elderly patients with pain or addiction?
  6. How do you address the unique challenges in pain management for pediatric patients?
  7. What is the role of non-pharmacological interventions in pain management?
  8. How do you incorporate non-pharmacological interventions into your treatment plans?

Opioid Classifications and Drug Schedules

A comprehensive understanding of drug schedules and opioid classifications is essential for nurse practitioners to ensure patient safety, prevent drug misuse, and adhere to legal and regulatory requirements. Nurse practitioners with a comprehensive understanding of drug schedules and opioid classifications can effectively communicate with colleagues, ensuring accurate medication reconciliation and facilitating interdisciplinary care. Nurse practitioners’ knowledge in facilitating discussions with pharmacists regarding opioid dosing, potential interactions, and patient education is essential (49).

Drug scheduling became mandated under the Controlled Substance Act. The Drug Enforcement Agency (DEA) Schedule of Controlled Drugs and the criteria and common drugs are listed below.

 

Schedule

Criteria Examples

I

No medical use; high addiction potential

Heroin, marijuana, PCP

II

Medical use; high addiction potential

Morphine, oxycodone, Methadone, Fentanyl, amphetamines

III

Medical use; high addiction potential

Hydrocodone, codeine, anabolic steroids

IV

Medical use, low abuse potential

Benzodiazepines, meprobamate, butorphanol, pentazocine, propoxyphene

V Medical use; low abuse potential

Buprex, Phenergan with codeine

(Pain Physician, 2008)

 

Listed below are drugs classified by their schedule and mechanism of action. "Agonist" indicates a drug that binds to the opioid receptor, causing pain relief and also euphoria. An agonist-antagonist indicates the drug binds to some opioid receptors but blocks others. Mixed antagonist-agonist drugs control pain but have a lower potential for abuse and dependence than agonists (7).

 

  Schedule I Schedule II Schedule III Schedule IV Schedule V
Opioid agonists

BenzomorphineDihydromor-phone, Ketobemidine, Levomoramide, Morphine-methylsulfate,

Nicocodeine,

Nicomorphine, Racemoramide

Codeine, Fentanyl, Sublimaze, Hydrocodone, Hydromorphone, Dilaudid,

Meperidine, Demerol, Methadone, Morphine, Oxycodone, Endocet, Oxycontin, Percocet, Oxymorphone, Numorphan

Buprenorphine Buprenex, Subutex,

Codeine compounds, Tylenol #3, Hydrocodone compounds, Lortab, Lorcet, Tussionex, Vicodin

Propoxyphene, Darvon, Darvocet Opium, Donnagel, Kapectolin
Mixed Agonist -Antagonist BuprenorphineNaloxone, Suboxone

Pentazocine,

Naloxone, Talwin-Nx

Stimulants N-methylampheta-mine 3, 4-methylenedioxy amphetamine, MDMA, Ecstacy Amphetamine, Adderal, Cocaine, Dextroamphetamine, Dexedrine, Methamphetamine, Desoxyn, Methylphenidate, Concerta, Metadate, Ritalin, Phenmetrazine, Fastin, Preludin Benapheta-mine, Didrex, Pemolin, Cylert, Phendimetra-zine, Plegine Diethylpropion, Tenuate, Fenfluramine, Phentermine Fastin 1-dioxy-ephedrine-Vicks Inhaler
Hallucinogen-gens, other Lysergic Acid Diamine LSD, marijuana, Mescaline, Peyote, Phencyclidine PCP, Psilocybin, Tetrahydro-cannabinol Dronabinol, Marinol
Sedative Hypnotics

Methylqualine, Quaalude, Gamma-hydroxy butyrate, GHB

 

Amobarbitol, Amytal, Glutethamide, Doriden, Pentobarbital, Nembutal, Secobarbital, Seconal

Butibarbital. Butisol, Butilbital, Florecet, Florinal,

Methylprylon,

Noludar

Alprazolam, Xanax, Chlordiazepoxide, Librium, Chloral betaine, Chloral hydrate, Noctec, Chlorazepam, Clonazepam, Klonopin, Clorazopate, Tranxene, Diazepam, Valium, Estazolam, Prosom, Ethchlorvynol, Placidyl, Ethinamate, Flurazepam, Dalmane, Halazepam, Paxipam, Lorazepam, Ativan, Mazindol, Sanorex, Mephobarbital, Mebaral, Meprobamate, Equanil, Methohexital, Brevital Sodium, Methyl-phenobarbital,

Midazolam, Versed, Oxazepam, Serax, Paraldehyde, Paral, Phenobarbital, Luminal, Prazepam, Centrax, Temazepam, Restoril, Triazolam, Halcion, Sonata, Zolpidem, Ambien

Diphenoxylate preparations, Lomotil

(41).

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the potential risks and benefits of using opioids for pain management?
  2. How can nurse practitioners effectively monitor patients on long-term opioid therapy?
  3. What are the potential risks and benefits of using long-acting opioids for chronic pain?
  4. How do you monitor patients on long-acting opioids for safety and efficacy?

Commonly Prescribed Opioids, Indications for Use, and Typical Side Effects

Opioid medications are widely used for managing moderate to severe pain. Referencing NIDA (2023), this section aims to give healthcare professionals an overview of the indications and typical side effects of commonly prescribed Schedule II opioid medications, including hydrocodone, oxycodone, morphine, Fentanyl, and hydromorphone.

Opioids are derived and manufactured in several ways. Naturally occurring opioids come directly from the opium poppy plant. Synthetic opioids are manufactured by chemically synthesizing compounds that mimic the effects of a natural opioid. Semi-synthetic is a mix of naturally occurring and man-made (35).

Understanding the variations in how an opioid is derived and manufactured is crucial in deciding the type of opioid prescribed, as potency and analgesic effects differ. Synthetic opioids are often more potent than naturally occurring opioids. Synthetic opioids have a longer half-life and slower elimination, affecting the duration of action and timing for dose adjustments. They are also associated with a higher risk of abuse and addiction (38).

 

Hydrocodone
Mechanism of Action and Metabolism

Hydrocodone is a Schedule II medication. It is an opioid agonist and works as an analgesic by activating mu and kappa opioid receptors located in the central nervous system and the enteric plexus of the bowel. Agonist stimulation of the opioid receptors inhibits nociceptive neurotransmitters' release and reduces neuronal excitability (17).

  • Produces analgesia.
  • Suppresses the cough reflex at the medulla.
  • Causes respiratory depression at higher doses.

Hydrocodone is indicated for treating severe pain after nonopioid therapy has failed. It is also indicated as an antitussive for nonproductive cough in adults over 18.

 

Available Forms

Hydrocodone immediate release (IR) reaches maximum serum concentrations in one hour with a half-life of 4 hours.  Extended-release (ER) Hydrocodone reaches peak concentration at 14-16 hours and a half-life of 7 to 9 hours. Hydrocodone is metabolized to an inactive metabolite in the liver by cytochrome P450 enzymes CYP2D6 and CYP3A4. Hydrocodone is converted to hydromorphone and is excreted renally. Plasma concentrations of hydromorphone are correlated with analgesic effects rather than hydrocodone.

Hydrocodone is formulated for oral administration into tablets, capsules, and oral solutions. Capsules and tablets should never be crushed, chewed, or dissolved. These actions convert the extended-release dose into immediate release, resulting in uncontrolled and rapid release of opioids and possible overdose.

 

Dosing and Monitoring

Hydrocodone IR is combined with acetaminophen or ibuprofen. The dosage range is 2.5mg to 10mg every 4 to 6 hours. If formulated with acetaminophen, the dosage is limited to 4gm/day.

Hydrocodone ER is available as tablets and capsules. Depending on the product, the dose of hydrocodone ER formulations in opioid-naïve patients is 10 to 20 mg every 12 to 24 hours.

Nurse practitioners should ensure patients discontinue all other opioids when starting the extended-release formula.

 

Side Effects and Contraindications

Because mu and kappa opioid receptors are in the central nervous system and enteric plexus of the bowel, the most common side effects of hydrocodone are constipation and nausea (>10%).

Other adverse effects of hydrocodone include:

  • Respiratory: severe respiratory depression, shortness of breath
  • Cardiovascular: hypotension, bradycardia, peripheral edema
  • Neurologic: Headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue
  • Dermatologic: Pruritus, diaphoresis, rash
  • Gastrointestinal: Vomiting, dyspepsia, gastroenteritis, abdominal pain
  • Genitourinary: Urinary tract infection, urinary retention
  • Otic: Tinnitus, sensorineural hearing loss
  • Endocrine: Secondary adrenal insufficiency (17)

Hydrocodone, being an agonist, must not be taken with other central nervous system depressants as sedation and respiratory depression can result. In formulations combined with acetaminophen, hydrocodone can increase the international normalized ratio (INR) and cause bleeding.  Medications that induce or inhibit cytochrome enzymes can lead to wide variations in absorption.

 

The most common drug interactions are listed below:

  • Alcohol
  • Benzodiazepines
  • Barbiturates
  • other opioids
  • rifampin
  • phenytoin
  • carbamazepine
  • cimetidine,
  • fluoxetine
  • ritonavir
  • erythromycin
  • diltiazem
  • ketoconazole
  • verapamil
  • Phenytoin
  • John’s Wort
  • Glucocorticoids

 

Considerations

Use with caution in the following:

  • Patients with Hepatic Impairment: Initiate 50% of the usual dose
  • Patients with Renal Impairment: Initiate 50% of the usual dose
  • Pregnancy: While not contraindicated, the FDA issued a black-boxed warning since opioids cross the placenta, and prolonged use during pregnancy may cause neonatal opioid withdrawal syndrome (NOWS).
  • Breastfeeding: Infants are susceptible to low dosages of opioids. Non-opioid analgesics are preferred.

Pharmacogenomic: Genetic variants in hydrocodone metabolism include ultra-rapid, extensive, and poor metabolizer phenotypes. After administration of hydrocodone, hydromorphone levels in rapid metabolizers are significantly higher than in poor metabolizers.

 

Oxycodone
Mechanism of Action and Metabolism

Oxycodone has been in use since 1917 and is derived from Thebaine. It is a semi-synthetic opioid analgesic that works by binding to mu-opioid receptors in the central nervous system. It primarily acts as an agonist, producing analgesic effects by inhibiting the transmission of pain signals (Altman, Clark, Huddart, & Klein, 2018).

Oxycodone is primarily metabolized in the liver by CYP3A4/5. It is metabolized in the liver to noroxycodone and oxymorphone.  The metabolite oxymorphone also has an analgesic effect and does not inhibit CYP3A4/5. Because of this metabolite, oxycodone is more potent than morphine, with fewer side effects and less drug interactions. Approximately 72% of oxycodone is excreted in urine (Altman, Clark, Huddart, & Klein, 2018).

 

Available Forms

Oxycodone can be administered orally, rectally, intravenously, and as an epidural. For this sake, we will focus on immediate-release and extended-release oral formulations.

  • Immediate-release (IR) tablets
  • IR capsules
  • IR oral solutions
  • Extended-release (ER) tablets

 

Dosing and Monitoring

The dosing of oxycodone should be individualized based on the patient's pain severity, previous opioid exposure, and response. Initial dosages for opioid naïve patients range from 5-15 mg for immediate-release formulations, while extended-release formulations are usually initiated at 10-20 mg. Dosage adjustments may be necessary based on the patient's response, but caution should be exercised. IR and ER formulations reach a steady state at 24 hours and titrating before 24 hours may lead to overdose.

Regular monitoring is essential to assess the patient's response to treatment, including pain relief, side effects, and signs of opioid misuse or addiction. Monitoring should include periodic reassessment of pain intensity, functional status, and adverse effects (Altman, Clark, Huddart, & Klein, 2018).

 

Side Effects and Contraindications

Common side effects of oxycodone include:

  • constipation
  • nausea
  • sedation
  • dizziness
  • respiratory depression
  • respiratory arrest
  • hypotension
  • fatal overdose

Oxycodone is contraindicated in patients with known hypersensitivity to opioids, severe respiratory depression, paralytic ileus, or acute or severe bronchial asthma. It should be used cautiously in patients with a history of substance abuse, respiratory conditions, liver or kidney impairment, and those taking other medications that may interact with opioids, such as alcohol (4).

 

It is also contraindicated with the following medications and classes:

  • Antifungal agents
  • Antibiotics
  • Rifampin
  • Carbamazepine
  • Fluoxetine
  • Paroxetine

 

Considerations
  • Nurse practitioners should consider the variations in the mechanism of action for the following:
  • Metabolism differs between males and females: females have been shown to have less concentration of oxymorphone and more CYP3A4/5 metabolites.
  • Infants have reduced clearance of oxycodone, increasing side effects.
  • Pediatrics have 20-40% increased clearance over adults.
  • Reduced clearance with age increases the half-life of oxycodone.
  • Pregnant women have a greater clearance and reduced half-life.
  • Impairment of the liver reduces clearance.
  • Cancer patients with cachexia have increased exposure to oxycodone and its metabolite.
  • Maternal and neonate concentrations are similar, indicating placenta crossing (4)

 

Morphine

 

 

 

 

Mechanism of Action and Metabolism

Morphine is a naturally occurring opioid alkaloid extracted from the opium poppy. It was isolated in 1805 and is the opioid against which all others are compared. Morphine binds to mu-opioid receptors in the brain and spinal cord, inhibiting the transmission of pain signals and producing analgesia. It is a first-line choice of opioid for moderate to severe acute, postoperative, and cancer-related pain (8).

Morphine undergoes first-pass metabolism in the liver and gut. It is well absorbed and distributed throughout the body. Its main metabolites are morphine-3-glucuronide and morphine-6-glucuronide. Its mean plasma elimination half-life after intravenous administration is about 2 hours. Approximately 90% of morphine is excreted in the urine within 24 hours (8).

 

Available Forms

Morphine is available in various forms, including.

  • immediate-release tablets
  • extended release tablets
  • oral IR solutions
  • injectable solutions
  • transdermal patches

 

Dosing and Monitoring

Morphine is hydrophilic and, as such, has a slow onset time. The advantage of this is that it is unlikely to cause acute respiratory depression even when injected. However, because of the slow onset time, there is more likelihood of morphine overdose due to the ability to “stack” doses in patients experiencing severe pain (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

The dosing of morphine depends on the patient's pain severity, previous opioid exposure, and other factors. It is usually initiated at a low dose and titrated upwards as needed. Monitoring pain relief, adverse effects, and signs of opioid toxicity is crucial. Reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation. General recommendations for initiating morphine (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

Prescribe IR opioids instead of ER opioids.

Prescribe the lowest effective dosage, below 50 Morphine Milligram Equivalents (MME) /day.

 

Side Effects and Contraindications

Because morphine binds to opioid receptors in the brain and spinal cord, is metabolized in the liver and gut, and has a slow onset, the following side effects are common:

  • Constipation
  • Nausea
  • Vomiting
  • Sedation
  • Dizziness
  • Respiratory depression
  • Pruritis
  • Sweating
  • Dysphoria/Euphoria
  • Dry mouth
  • Anorexia
  • Spasms of urinary and biliary tract

 

Contraindications of morphine are:
  • Known hypersensitivity or allergy to morphine.
  • Bronchial asthma or upper airway obstruction
  • Respiratory depression in the absence of resuscitative equipment
  • Paralytic ileus
  • Risk of choking in patients with dysphagia, including infants, children, and the elderly (8)

Concurrent use with other sedating medications: Amitriptyline, diazepam, haloperidol, chlorpromazine

 

Morphine interacts with the following medications:

  • Ciprofloxacin
  • Metoclopramide
  • Ritonavir

 

Considerations for Nurse Practitioners

Assess for medical conditions that may pose serious and life-threatening risks with opioid use, such as the following:

  • Sleep-disordered breathing, such as sleep apnea.
  • Pregnancy
  • Renal or hepatic insufficiency
  • Age >= 65
  • Certain mental health conditions
  • Substance use disorder
  • Previous nonfatal overdose

 

 

Fentanyl
Mechanism of Action and Metabolism

Fentanyl is a synthetic opioid more potent than morphine and was approved in 1968. Fentanyl is an agonist that works by binding to the mu-opioid receptors in the central nervous system. This binding inhibits the transmission of pain signals, resulting in analgesia. Fentanyl is often used for severe pain management, particularly in the perioperative and palliative care settings, or for severe pain in patients with Hepatic failure (8).

It is a mu-selective opioid agonist. However, it can activate other opioid receptors in the body, such as the delta and kappa receptors, producing analgesia. It also activates the Dopamine center of the brain, stimulating relaxation and exhilaration, which is responsible for its high potential for addiction (8).

 

Indications for fentanyl are as follows:

  • Preoperative analgesia
  • Anesthesia adjunct
  • Regional anesthesia adjunct
  • General anesthesia
  • Postoperative pain control
  • Moderate to severe acute pain (off-label)

 

Available Forms
  • Fentanyl is available in various forms, including:
  • transdermal patches
  • injectable solutions
  • lozenges
  • nasal sprays
  • oral tablets (8)

 

Dosing and Monitoring

Fentanyl is metabolized via the CYP3A4 enzyme in the liver. It has a half-life of 3 to 7 hours, and 75% of Fentanyl is excreted in the urine and 9% in feces.

The dosing of fentanyl depends on the route of administration and the patient's needs. For example, transdermal patches are typically applied every 72 hours, while injectable solutions are titrated to achieve the desired analgesic effect. Monitoring should include assessing pain levels, respiratory rate, blood pressure, and sedation scores (8).

 

Fentanyl is most dosed as follows:

  • Post-operative pain control
  • 50 to 100 mcg IV/IM every 1 to 2 hours as needed; alternately 0.5 to 1.5 mcg/kg/hour IV as needed. Consider lower dosing in patients 65 and older.

PCA (patient-controlled analgesia): 10 to 20 mcg IV every 6 to 20 minutes as needed; start at the lowest effective dose for the shortest effective duration - refer to institutional protocols (8).

Moderate to severe acute pain (off-label) 1 to 2 mcg/kg/dose intranasally each hour as needed; the maximum dose is 100 mcg. Use the lowest effective dose for the shortest effective duration (8).

 

Side Effects and Contraindications

Common side effects of fentanyl include:

  • respiratory depression
  • sedation
  • constipation
  • nausea
  • vomiting
  • euphoria
  • confusion
  • respiratory depression/arrest
  • visual disturbances
  • dyskinesia
  • hallucinations
  • delirium
  • narcotic ileus
  • muscle rigidity
  • addiction
  • loss of consciousness
  • hypotension
  • coma
  • death (8).

 

The use of fentanyl is contraindicated in patients in the following situations:

  • After operative interventions in the biliary tract, these may slow hepatic elimination of the drug.
  • With respiratory depression or obstructive airway diseases (i.e., asthma, COPD, obstructive sleep apnea, obesity hyperventilation, also known as Pickwickian syndrome)
  • With liver failure
  • With known intolerance to fentanyl or other morphine-like drugs, including codeine or any components in the formulation.
  • With known hypersensitivity (i.e., anaphylaxis) or any common drug delivery excipients (i.e., sodium chloride, sodium hydroxide) (8).

Considerations for Nurse Practitioners

Nurse practitioners prescribing fentanyl should thoroughly assess the patient's pain, medical history, and potential risk factors for opioid misuse. They should also educate patients about the proper use, storage, and disposal of fentanyl. It should be used cautiously in patients with respiratory disorders, liver or kidney impairment, or a history of substance abuse. Fentanyl is contraindicated in patients with known hypersensitivity to opioids and those without exposure to opioids.

Alcohol and other drugs, legal or illegal, can exacerbate fentanyl's side effects, creating multi-layered clinical scenarios that can be complex to manage. These substances, taken together, generate undesirable conditions that complicate the patient's prognosis (8).

 

Hydromorphone
Mechanism of Action and Metabolism

Hydromorphone is a semi-synthetic opioid derived from morphine. It binds to the mu-opioid receptors in the central nervous system. It primarily exerts its analgesic effects by inhibiting the release of neurotransmitters involved in pain transmission, thereby reducing pain perception. Hydromorphone also exerts its effects centrally at the medulla level, leading to respiratory depression and cough suppression (1).

 

Hydromorphone is indicated for:

  • moderate to severe acute pain
  • severe chronic pain
  • refractory cough suppression (off-label) (1)

 

Available Forms

Hydromorphone is available in various forms, depending on the patient’s needs and severity of pain.

  • immediate-release tablet
  • extended release tablets
  • oral liquid
  • injectable solution
  • rectal suppositories

 

Dosing and Monitoring

The immediate-release oral formulations of hydromorphone have an onset of action within 15 to 30 minutes. Peak levels are typically between 30 and 60 minutes with a half-life of 2 to 3 hours. Hydromorphone is primarily excreted through the urine.

The dosing of hydromorphone should be individualized based on the patient's pain intensity, initiated at the lowest effective dose, and adjusted gradually as needed. Close monitoring of pain relief, adverse effects, and signs of opioid toxicity is essential. Patients should be assessed regularly to ensure they receive adequate pain control without experiencing excessive sedation or respiratory depression.

The following are standard dosages that should only be administered when other opioid and non-opioid options fail.

  • Immediate-release oral solutions dosage: 1 mg/1 mLoral tablets are available in 2 mg, 4 mg, and 8 mg.
  • Extended-release oral tablets are available in dosages of 8 mg, 12 mg, 16 mg, and 32 mg.
  • Injection solutions are available in concentrations of 1 mg/mL, 2 mg/mL, 4 mg/mL, and 10 mg/mL.
  • Intravenous solutions are available in strengths of 2 mg/1 mL, 2500 mg/250 mL, ten mg/1 mL, and 500 mg/50 mL.
  • Suppositories are formulated at a strength of 3 mg (1).

 

Side Effects and Contraindications

Hydromorphone has potential adverse effects on several organ systems, including the integumentary, gastrointestinal, neurologic, cardiovascular, endocrine, and respiratory.

 

Common side effects of hydromorphone include:

  • Constipation
  • Nausea
  • Vomiting
  • Dizziness
  • Sedation
  • respiratory depression
  • pruritus
  • headache
  • Somnolence
  • Severe adverse effects of hydromorphone include:
  • Hypotension
  • Syncope
  • adrenal insufficiency
  • coma
  • raised intracranial pressure.
  • seizure
  • suicidal thoughts
  • apnea
  • respiratory depression or arrest
  • drug dependence or withdrawal
  • neonatal drug withdrawal syndrome
  • Hydromorphone is contraindicated in patients with:
  • known allergies to the drug, sulfites, or other components of the formulation.
  • known hypersensitivity to opioids.
  • severe respiratory depression
  • paralytic ileus
  • acute or severe bronchial asthma (1).

 

Caution should be exercised in patients with:

  • respiratory insufficiency
  • head injuries
  • increased intracranial pressure.
  • liver or kidney impairment.

 

Considerations for Nurse Practitioners

As nurse practitioners, it is crucial to assess the patient's pain intensity and overall health status before initiating Hydromorphone. Start with the lowest effective dose and titrate carefully for optimal pain control. Regular monitoring for adverse effects, signs of opioid toxicity, and therapeutic response is essential. Educate patients about the potential side effects, proper dosing, and the importance of not exceeding prescribed doses. Additionally, nurse practitioners should be familiar with local regulations and guidelines regarding opioid prescribing and follow appropriate documentation and monitoring practices.

 

Additional Considerations

In terminal cancer patients, clinicians should not restrain opioid therapy even if signs of respiratory depression become apparent.

Hydromorphone requires careful administration in cases of concurrent psychiatric illness.

 

Specific Patient Considerations:
  • Hepatic impairment and Renal Impairment: Initiate hydromorphone treatment at one-fourth to one-half of the standard starting dosage, depending on the degree of impairment.
  • Pregnancy considerations: Hydromorphone can traverse the placental barrier and induce NOWS.
  • Breastfeeding considerations: Nonopioid analgesic agents are preferable for breastfeeding women.
  • Older patients: hydromorphone is categorized as a potentially inappropriate medication for older adults (1).

 

Tramadol

 

 

 

 

Mechanism of Action and Metabolism

Tramadol is a Schedule IV opioid medication with a higher potential for dependency and misuse than non-opioid medications. It binds to opioid receptors in the central nervous system, inhibiting the reuptake of norepinephrine and serotonin. It also has weak mu-opioid receptor agonist activity.

The liver metabolizes tramadol mediated by the cytochrome P450 pathways (particularly CYP2D6) and is mainly excreted through the kidneys.

Tramadol is used for moderate to severe pain.

 

Available Forms of Tramadol include:
  • Immediate-release-typically used for acute pain management.
  • Extended-release-used for chronic pain.

 

Dosing and Monitoring

Tramadol has an oral bioavailability of 68% after a single dose and 90–100% after multiple doses and reaches peak concentrations within 2 hours. Approximately 75% of an oral dose is absorbed, and the half-life of tramadol is 9 hours (18).

Tramadol dosing should be individualized based on the patient's pain severity and response.

The initial dose for adults is usually 50-100 mg orally every 4-6 hours for pain relief. The maximum daily dose is 400 mg for immediate-release formulations and 300 mg for extended-release formulations (18).

It is essential to monitor the patient's pain intensity, response to treatment, and any adverse effects. Regular reassessment and adjustment of the dosage may be necessary.

 

Side Effects and Contraindications

Tramadol is responsible for severe intoxications leading to consciousness disorder (30%), seizures (15%), agitation (10%), and respiratory depression (5%). The reactions to Tramadol suggest that the decision to prescribe should be carefully considered.

 

Common Side Effects of Tramadol Include:
  • Nausea
  • Vomiting
  • Dizziness
  • Constipation
  • Sedation
  • Headache
  • CNS depression
  • Seizure
  • Agitation
  • Tachycardia
  • Hypertension
  • reduced appetite
  • pruritus and rash
  • gastric irritation

 

Serious side effects include:
  • respiratory depression
  • serotonin syndrome
  • seizures

 

Contraindications

Tramadol is contraindicated in patients with:

  • history of hypersensitivity to opioids
  • acute intoxication with alcohol
  • opioids, or other psychoactive substances
  • Patients who have recently received monoamine oxidase inhibitors (MAOIs)

 

Additionally, the following can be observed in tramadol intoxication:

  • miosis
  • respiratory depression
  • decreased level of consciousness
  • hypertension
  • tremor
  • irritability
  • increased deep tendon reflexes

 

Poisoning leads to:

  • multiple organ failure
  • coma
  • cardiopulmonary arrest
  • death

 

Considerations for Nurse Practitioners

Tramadol has been increasingly misused with intentional overdoses or intoxications. Suicide attempts were the most common cause of intoxication (52–80%), followed by abuse (18–31%), and unintentional intoxication (1–11%). Chronic tramadol or opioid abuse was reported in 20% of tramadol poisoning cases. Fatal tramadol intoxications are uncommon except when ingested concurrent with depressants, most commonly benzodiazepines and alcohol (18).

 

Tramadol poisoning can affect multiple organ systems:
  • gastrointestinal
  • central nervous system: seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage
  • Cardiovascular system: palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest
  • respiratory system
  • renal system: renal failure with higher doses of tramadol intoxication
  • musculoskeletal system: rhabdomyolysis
  • endocrine system: hypoglycemia, serotonin syndrome (18)

 

Cannabis
Mechanism of Action and Metabolism

Cannabis is classified as a Schedule I status. It contains various cannabinoids, with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most studied. THC primarily acts on cannabinoid receptors in the brain, producing psychoactive effects, while CBD has more diverse effects on the nervous system. These cannabinoids interact with the endocannabinoid system, modulating neurotransmitter release and influencing various physiological processes (32).

Similar to opioids, cannabinoids are synthesized and released in the body by synapses that act on the cannabinoid receptors present in presynaptic endings (32). They perform the following actions related to analgesia:

  • Decrease the release of neurotransmitters.
  • Activate descending inhibitory pain pathways.
  • Reduce postsynaptic sensitivity and alleviate neural inflammation.
  • Modulate CB1 receptors within central nociception processing areas and the spinal cord, resulting in analgesic effects.
  • Attenuate inflammation by activating CB2 receptors (32).
  • Emerging research shows cannabis is indicated for:
  • Migraines
  • chronic pain
  • back pain
  • arthritic pain
  • pain associated with cancer and surgery.
  • neuropathic pain
  • diabetic neuropathic pain when administered early in the disease progression.
  • sickle cell disease
  • cancer
  • inflammatory bowel disease (32)

 

Available Forms

Cannabis refers to products sourced from the Cannabis sativa plant. There are differences between cannabis, cannabinoids, and cannabidiol (CBD). Cannabinoids are extracted from the cannabis plants. Cannabinoid-based treatments, such as dronabinol and CBD, are typically approved medical interventions for specific indications. THC (9-tetrahydrocannabinol) is the psychoactive component of the cannabis plant. CBD is a non-psychoactive component (32).

 

Cannabis can be consumed in different forms, each with a different onset and duration. Patients may have individual preferences, including:

  • smoking/vaporizing dried flowers.
  • consuming edibles
  • tinctures or oils
  • applying topicals (32)

 

Dosing and Monitoring

Inhaling marijuana via the lungs by smoking or vaping causes maximum plasma concentration within minutes. Psychiatric effects begin within seconds to a few minutes after inhalation and peak after 15 to 30 minutes. The effect diminishes throughout 2 to 3 hours (32).

Oral ingestion of marijuana causes psychiatric effects that typically occur between 30 and 90 minutes and reach maximum effect after 2 to 3 hours. Ingested marijuana effects last about 4 to 12 hours (32).

Dosing cannabis is challenging due to variations in potency and individual responses. Start with low doses and titrate slowly to achieve the desired effect while minimizing side effects. Regular monitoring is crucial, including assessing symptom relief, adverse effects, and potential drug interactions. Encourage patients to keep a diary to track their cannabis use and its effects (32).

 

Side Effects and Contraindications

Cannabis can exacerbate mental health conditions such as anxiety and psychosis. Common side effects of cannabis include (32):

  • Dizziness
  • dry mouth
  • increased heart rate
  • impaired memory
  • psychoactive effects

 

Contraindications include:

  • Pregnancy
  • Breastfeeding
  • heart disease
  • respiratory conditions
  • history of substance abuse
  • mental health disorders
Quiz Questions

Self Quiz

Ask yourself...

  1. How do you address patients' misconceptions about pain medications?
  2. What are the mechanisms of action for commonly prescribed pain medications?
  3. How do these mechanisms of action contribute to pain relief?
  4. What are the potential side effects and risks associated with commonly prescribed pain medications?
  5. How do you educate patients about the risks and benefits of pain medications?
  6. How do you manage patients who require high-dose opioids for pain management?
  7. Is medical cannabis legal in your State? If yes, are you familiar with the prescribing guidelines?
  8. Do you have any personal biases against the use of medical cannabis? Why or why not?

Case Study

Mary is agreeable to trying an increased dose of Gabapentin. Mary would also like to see a counselor to discuss her past and get help with her anxiety. You made an appointment for Mary to see a Licensed Clinical Social Worker in your clinic.

You read the side effects and warnings for Gabapentin, and it is unsafe to use Gabapentin and Tramadol together since they are both depressants. You order a non-steroidal drug for Mary's somatic knee pain and make a consult for imaging studies on her left knee. You also make a referral to Orthopedics.

You educated Mary about the side effects of Gabapentin and scheduled a follow-up appointment. The day after Mary began her treatment with the increased Gabapentin, you called Mary to follow up on its effect. Mary still has pain, but she is not having any untoward side effects. Gabapentin may not work immediately so you will schedule a follow-up call in 3 days.

Quiz Questions

Self Quiz

Ask yourself...

  1. In this case study, Mary has insurance. How might your practice be different were Mary not insured?
  2. In your experience, what are the possible reasons for Mary's knee pain not being a part of her previous treatment record?
  3. Consider how your assessment of Mary's needs differs from the above-mentioned case study.
  4. Explain the rationale for decisions made by the nurse practitioner in the case study mentioned above and if your decisions would differ.

Opioid Use, the Opioid Epidemic, and Statistics

The use and misuse of opioids has become a pressing public health concern, leading to a global epidemic. The history of opioid use, the opioid epidemic, and associated statistics provide essential context for healthcare professionals in addressing this public health crisis. More importantly, it is estimated that 1 in 4 patients receiving prescription opioids in primary care settings will misuse them. In addition, 50% of opioid prescriptions are written by primary care providers, including nurse practitioners (22). Understanding the factors contributing to the epidemic and the magnitude of its impact is crucial for effective prevention, intervention, and treatment strategies.

 

History of Opioid Use

Opioids have a long history of medicinal use, dating back to ancient civilizations. They have been a drug of choice for pain relief for thousands of years. The introduction of synthetic opioids in the 19th century, such as morphine and later heroin, revolutionized pain management. However, their potential for addiction and misuse soon became apparent (16).

 

The Opioid Epidemic

The opioid epidemic refers to the surge in opioid misuse, addiction, and overdose deaths. The epidemic gained momentum in the late 1990s with increased prescribing of opioids for chronic pain (43).

No doubt, increased prescribing put opioids in the hands of consumers, but increased prescribing resulted from a multifactorial influence. One of the main influences was aggressive marketing by pharmaceutical companies, which has been well publicized. However, due to the long history of underprescribing pain medications for fear of misuse and addiction, the medical community was primed to expand its opioid prescribing practices (31).

A historical event that increased comfort with prescribing opioids, in the writer's opinion, was the introduction of the Medicare Hospice Benefit in 1986. Medical directors must be contracted or employed by hospices, and these medical directors had or soon gained pain management expertise. To further promote hospice and effective pain management, the hospice medical directors, with newly acquired skills, provided education throughout medical communities about pain management and specifically to decrease the fear of using opioids. Pharmacies and attending physicians grew accustomed to giving opioids for home use. Hospice care is for terminally ill patients, defined as a life expectancy of 6 months or less. Still, the reality is that hospice discharges 12 to 40% of patients for ineligibility and other reasons.

A more prominent factor in increasing opioid prescribing was the 1996 American Pain Society's introduction of pain as "the 5th Vital sign." Soon after, The Joint Commission promoted pain as "the 5th Vital Sign" and began compliance surveys in healthcare organizations requiring pain assessment details to be as prominent as blood pressure and heart rate. The Joint Commission cited a quote from 1968 by a nurse from the University of California Los Angeles, Margo McCaffrey, who defined pain as "…Whatever the experiencing person says it is, existing whenever s/he says it does." The Joint Commission accreditation programs pursued pain management as part of the accreditation process throughout its healthcare accreditation programs, including hospice accreditation by 1989 per TJC Timeline (48).

The National Institute of Health published an article about the Joint Commission's role in the opioid epidemic, particularly regarding the definition of pain, "This definition emphasizes that pain is a subjective experience with no objective measures. It also stresses that the patient, not the clinician, is the authority on the pain and that their self-report is the most reliable indicator of pain. This set the tone for clinicians: Patients are always to be trusted to report pain accurately” (45).

 

Statistics on the Opioid Epidemic

In the United States alone, over 500,000 people died from opioid overdoses between 1999 and 2017. The number of opioid-related overdose deaths continues to increase, with synthetic opioids, mainly illicitly manufactured Fentanyl, playing a significant role in recent years (46). Fentanyl-laced drugs, such as marijuana, are increasingly sold knowing and unknowingly to introduce medications with a high addiction rate, thus creating new consumers. This practice can potentially increase deaths due to the imprecise nature of manufacturing (16).

Opioid-related hospitalizations have also risen substantially. In 2014, there were approximately 1.27 million hospitalizations related to opioids in the United States. These hospitalizations not only place a burden on healthcare systems but also reflect the severe consequences of opioid misuse (3).

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you experienced changes to your practice because of the opioid epidemic? If so, what are the changes?
  2. What is your opinion on the validity of Margo McCaffrey's definition of pain?
  3. What factors influence your willingness or unwillingness to prescribe opioids?

Federal Regulations on Opioid Prescribing

The history of substance use disorder prevention that promotes opioid recovery and treatment for patients and communities can be traced back to the early 20th century. However, the current approach to addressing opioid addiction and promoting healing has evolved significantly in recent times (36).

In the early 1900s, health professionals treated opioid addiction with punitive measures, including incarceration and moralistic approaches. The focus was on punishing individuals rather than providing effective treatment. This approach persisted for several decades until the mid-20th century when the medical community started recognizing addiction as a medical condition rather than a moral failing (36).

The Controlled Substances Act (CSA), introduced in 1970, was a response to increasing drug abuse and illicit drug trafficking in the United States. The CSA is a federal law regulating the manufacture, possession, distribution, and use of certain substances, including drugs and medications, that can potentially cause abuse and dependence. Its primary purpose is to combat drug abuse, reduce drug-related crimes, and protect public health and safety. The Drug Enforcement Agency (DEA) plays a crucial role in enforcing the CSA by monitoring and controlling controlled substance production, distribution, and use (31).

In the 1990s, the significant increase in opioid prescribing, leading to a surge in opioid addiction and overdose deaths, prompted a shift in focus toward prevention. Efforts were made to educate healthcare providers about the risks of overprescribing opioids and to implement prescription drug monitoring programs to track and prevent abuse (36).

The Comprehensive Addiction and Recovery Act (CARA) was signed into law in 2016 to expand access to treatment and recovery services for opioid addiction. This legislation allocated funding for prevention, treatment, recovery, and support services while promoting evidence-based practices and programs (36).

The Centers for Disease Control and Prevention (CDC) published guidelines in 2016 for prescribing opioids for chronic pain, which was updated in 2022. These guidelines emphasize the importance of non-opioid alternatives, using the lowest effective dose for the shortest duration, and assessing the benefits and risks of continued opioid therapy (13).

Furthermore, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT) was signed into law in 2018, providing additional resources to address the opioid crisis. This legislation expanded access to medication-assisted treatment (MAT), increased the availability of naloxone, a medication used to reverse opioid overdose, and enhanced support for recovery housing (36).

In recent years, there has been a growing recognition of the importance of a comprehensive approach to opioid addiction, including harm reduction strategies, increased access to naloxone, and the integration of mental health services. Communities and organizations have been working together to address the underlying issues contributing to addiction, such as poverty, trauma, and social determinants of health (50).

Overall, the history of substance use disorder prevention that promotes opioid recovery and treatment has evolved from a punitive approach to a more compassionate and evidence-based model. Efforts are now focused on prevention, early intervention, and expanding access to comprehensive treatment and support services for individuals and communities affected by opioid addiction (36).

The most current federal regulations on opioid prescribing for healthcare providers are the amendments to the CSA in 2018, which added new rules to limit the quantity and duration of opioid prescriptions for acute pain to seven days. In 2022, the CDC updated recommendations to the Clinical Practice Guidelines for Prescribing Opioids for Pain.

The 2022 CDC guidelines are summarized below (13):

  1. Non-opioid therapies should be considered the first-line treatment for chronic pain.
  2. Establish clear treatment goals with patients, including realistic pain management and functional improvement expectations.
  3. Conduct a thorough risk assessment for potential harms before initiating opioid therapy.
  4. When opioids are used, start with the lowest effective dose and consider immediate-release opioids instead of extended-release or long-acting opioids.
  5. Prescribe the lowest effective dose for the shortest duration possible, typically three days or less and rarely exceeding seven days.
  6. Reassess benefits and risks within one day after prescribing opioids, including checking the prescription drug monitoring database.
  7. Avoid prescribing opioids and benzodiazepines concurrently whenever possible due to the increased risk of overdose and death.
  8. Offer naloxone to patients at increased risk of opioid overdose, including those with a history of overdose, substance use disorder, or concurrent benzodiazepine use.
  9. When opioids are no longer needed, taper the dose gradually to minimize withdrawal symptoms.
  10. Arrange an evidence-based treatment for patients with opioid use disorder, including medication-assisted treatment (Naltrexone, Buprenorphine, or Methadone).
Quiz Questions

Self Quiz

Ask yourself...

  1. What are the guidelines general for prescribing opioids for acute pain?
  2. How do these guidelines differ for chronic pain management?
  3. Discuss how federal regulations impact the practice of nurse practitioners in terms of opioid prescribing.
  4. Describe the potential benefits and challenges nurse practitioners face when adhering to federal regulations on opioid prescribing.
  5. How can nurse practitioners navigate and stay updated with evolving federal regulations surrounding opioid prescribing to ensure safe and effective care?
  6. How do you ensure appropriate documentation when prescribing controlled substances?

Safe Prescribing and Prescription Monitoring Program

Prescription Drug Monitoring Programs (PDMP) are state-run electronic databases that track.

the prescribing and dispensing of controlled substances. PDMPs are designed to improve patients.

care and safety by giving clinicians access to patients' prescription histories, allowing them to make informed decisions when prescribing controlled substances. PDMPs help identify patients at risk of substance misuse or prescription drug overdose. They also enable clinicians to identify potential drug interactions and prevent opioid diversion (14).

PDMPs collect and store data from pharmacies and prescribers in a centralized database. Clinicians can access this database to review a patient's prescription history, including the types of medications prescribed, the prescribers involved, and the dispensing pharmacies (14).

In many states, PDMP use is mandated by law, and nurse practitioners may be required to register and use the system. It is essential to understand state-specific laws and regulations regarding PDMP use.

PDMPs have some limitations, such as incomplete data or delays in reporting. The CDC emphasizes that clinicians should use PDMP data for their clinical assessment and other relevant information to make informed decisions about prescribing controlled substances. Still, PDMP cannot be used as the sole basis for denying or providing treatment (14).

 

Case Study

After five days on Gabapentin, Mary was doing well, and her neuropathic pain had decreased to 3/10. However, Mary suffered a fall after her knee "gave out" and injured her knee and back. She was in severe pain, and her family drove her to the ER. The ER doctors saw Mary, and orthopedics were consulted. Mary has surgery scheduled for a knee replacement a week from now.

Mary was prescribed Vicodin because she was in excruciating pain, but her prescription only allowed enough medication for two days. Mary has made an appointment with you to renew her prescription.

You evaluate Mary because you know that concomitant use of Gabapentin and opioids puts Mary at risk for respiratory depression and possible side effects, including accidental overdose.

Mary stated she has been more alert the past 24 hours and is afraid her functional status will continue to decline if she does not have more Vicodin because the pain in her back and knee makes it difficult to stand. You assess Mary. Mary stated she occasionally drinks alcohol but has not had a drink since she moved. She has no familial history of substance abuse or mental health disorders.

Mary's mother stayed at her house to help her for the first 24 hours after Mary's return from the ER, but Mary is providing her care now.

You check the PDMP database and see that Mary was prescribed eight pills she has taken over the last 48 hours.

Since the Vicodin has been effective without untoward side effects, and Mary's function is improving, you decide to refill the prescription of Vicodin. You will taper the dose to three Vicodin daily for two days and two for one day. Mary will be near her appointment for a knee replacement as well.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the potential benefits and drawbacks of using PDMPs in your practice?
  2. How can PDMPs help you identify potential drug abuse or diversion cases among your patients? Can you provide examples from your own experience?
  3. In what ways do PDMPs impact your decision-making process when prescribing controlled substances?
  4. What are the key considerations when prescribing controlled substances?
  5. How do you ensure responsible prescribing practices for controlled substances?

Preventing Opioid Use Disorder

As previously discussed, opioid addiction is a growing concern worldwide, affecting individuals from all walks of life. According to the CDC, "Anyone who takes prescription opioids can become addicted to them" (14).

As frontline healthcare professionals, nurse practitioners must recognize the signs of opioid addiction to provide timely intervention and support. This section will outline the key indicators of opioid addiction.

 

Physical Symptoms

Physical symptoms are often the first noticeable signs of opioid addiction. These symptoms may include constricted pupils, drowsiness, slurred speech, impaired coordination, and increased sensitivity to pain. Additionally, individuals struggling with opioid addiction may exhibit frequent flu-like symptoms, such as a runny nose, sweating, itching, or gastrointestinal issues.

 

Behavioral Changes

Opioid addiction can significantly impact an individual's behavior. These may include increased secrecy, frequent requests for early prescription refills, doctor shopping (seeking prescriptions from multiple healthcare providers), neglecting personal hygiene, and experiencing financial difficulties due to excessive spending on opioids (37).

 

 

 

 

Social Isolation

Opioid addiction often leads to social withdrawal and isolation. Individuals struggling with opioid addiction may distance themselves from family, friends, and social activities they once enjoyed. They may exhibit erratic mood swings, become defensive or hostile when confronted about their drug use, and display a general lack of interest in previously important activities (30).

 

Psychological Changes

The psychological impact of opioid addiction is significant. Individuals with opioid addiction may exhibit increased anxiety, depression, irritability, and restlessness. They may also experience cognitive impairments, memory lapses, and difficulties in decision-making. Healthcare professionals should be attentive to these changes, as they can indicate opioid addiction (51).

 

Tolerance and Withdrawal Symptoms

The development of tolerance and withdrawal symptoms are critical signs of opioid addiction. Individuals may require increased dosages of opioids to achieve the desired effect, indicating a growing tolerance. Furthermore, withdrawal symptoms such as muscle aches, nausea, vomiting, insomnia, and intense cravings for opioids may occur when the drug is discontinued or reduced abruptly (51).

Quiz Questions

Self Quiz

Ask yourself...

  1. Discuss how nurse practitioners can contribute to preventing opioid use disorder.
  2. Explain how nurse practitioners effectively communicate the risks and signs of opioid misuse without stigmatizing or alienating patients.
  3. What are the signs of opioid addiction or misuse in patients?
  4. How do you approach patients who may be at risk for opioid addiction?
  5. How do you ensure appropriate documentation when prescribing controlled substances?

Opioid Overdose

The management of opioid overdose, withdrawal, and addiction requires a comprehensive approach that combines pharmacological interventions with psychosocial support. Naloxone remains a vital tool for reversing opioid overdose, while medications such as Methadone, buprenorphine, and naltrexone play crucial roles in withdrawal and addiction treatment (National Institute of Health, 2023). Nurse practitioners must stay vigilant and informed about the evolving landscape of medications. This section aims to provide a comprehensive review of medications and treatment strategies for opioid overdose, withdrawal, and addiction and is excerpted from the NIH (40).

 

Naloxone
Mechanism of Action and Metabolism

Naloxone is an opioid receptor antagonist. It works by binding to opioid receptors and displacing any opioids present, thereby reversing the effects of opioid overdose. It has a higher affinity for opioid receptors than most opioids, effectively blocking their action.

Naloxone is indicated for emergency intervention of opioid overdose. It effectively reverses respiratory depression and other life-threatening effects. Studies suggest the potential benefits of combining naloxone with other medications, such as buprenorphine (see below), to improve outcomes. Initiatives promoting community-based naloxone distribution programs have shown promising results in reducing opioid-related deaths.

 

Available Forms

Naloxone is available in various formulations:

  • Intranasal
  • Intramuscular
  • Intravenous
  • auto-injectors.

 

The most used form is the intranasal spray, which is easy to administer and requires no specialized training. Intranasal naloxone formulations have gained popularity due to their ease of use and increased availability. A recent study showed that the non-FDA-approved compound spray was far less effective than either FDA compound (15).

 

Dosing and Monitoring

The recommended initial dose of naloxone for opioid overdose is 2mg intranasally or 0.4mg to 2mg intramuscularly or intravenously. If the patient does not respond within 23- minutes, additional doses may be administered every 2-3 minutes. Continuous monitoring of the patient's respiratory status is essential, as repeat doses may be required due to the short half-life of naloxone.

 

Side Effects and Contraindications

Naloxone has been shown not to affect individuals without opioids in their system.

 

Common side effects of naloxone include
  • Withdrawal symptoms: increased heart rate, sweating, and agitation
  • nausea
  • vomiting
  • headache

Contraindications include known hypersensitivity to naloxone and situations where the use of naloxone may be unsafe or not feasible.

 

Considerations for Nurse Practitioners

Fentanyl and other opioids have a rapid onset, and the need to act quickly is paramount. As mentioned previously, the ease of use and higher plasma concentrations using the FDA-approved 4-mg FDANxSpray device compared with the locally compounded nasal sprays should be considered when ordering Naloxone (15).

Fentanyl and other potent synthetic opioids may require multiple administrations of naloxone to achieve reversal of an overdose (Chiang, Gyaw, & Krieter, 2019). As a nurse practitioner prescribing naloxone, it is crucial to assess the patient's risk factors for opioid overdose, such as a history of substance use disorder or chronic pain management. Education regarding the proper administration of naloxone should be provided to the patients and their caregivers. Additionally, it is essential to provide resources for follow-up care, including addiction treatment and ongoing support.

 

Methadone
Mechanism of Action and Metabolism

Methadone is a long-acting opioid agonist that effectively suppresses withdrawal symptoms and reduces cravings. It binds to the same opioid receptors in the brain as other opioids. It relieves withdrawal symptoms and reduces cravings by blocking the euphoric effects of opioids, thus helping individuals with opioid dependence to achieve stability (33).

 

Available Forms

Methadone is available in oral tablets and liquid formulations. The oral tablet is the most used form and is typically administered once daily (33).

 

Dosing and Monitoring

Methadone dosing is individualized based on the patient's response and needs. Initially, the dose often started low and gradually increased until the patient reached a stable dose. Dosing may need to be adjusted based on the patient's response, adherence, and any changes in their overall health. Regularly monitoring the patient's vital signs, urine drug screens, and assessment of their withdrawal symptoms and cravings is essential.

 

Side Effects and Contraindications

Common side effects of methadone include:

  • Constipation
  • dry mouth
  • drowsiness
  • sweating
  • weight gain
  • respiratory depression

 

Contraindications include:

  • known hypersensitivity to methadone
  • severe asthma
  • respiratory depression
  • certain heart conditions (33).

 

Considerations for Nurse Practitioners

As a nurse practitioner prescribing methadone, conducting a comprehensive assessment of the patient's medical history, current medications, and substance use history is crucial. Opioid treatment programs or specialized clinics are often involved in methadone treatment, so collaboration and coordination of care with these programs are essential. Regularly monitoring the patient's progress, adherence, and potential side effects or drug interactions is essential. Additionally, providing education on the risks and benefits of methadone and the importance of adherence to the prescribed regimen is crucial for successful treatment outcomes.

 

Buprenorphine
Mechanism of Action and Metabolism

Buprenorphine is a partial opioid agonist with a ceiling effect that minimizes the risk of overdose while reducing withdrawal symptoms. Buprenorphine is a partial opioid agonist that binds to the same receptors as other opioids but produces a weaker response. It has a high affinity for the mu-opioid receptors, which helps reduce cravings and withdrawal symptoms in individuals with opioid dependence.

 

Available Forms

Buprenorphine is available in different formulations, including sublingual tablets, buccal films, and extended-release injections. The sublingual tablets have different strengths, such as 2mg, 4mg, 8mg, and 12mg. Buprenorphine is taken as a daily tablet or weekly or monthly injection.

 

Dosing and Monitoring

The dosing of buprenorphine varies depending on the individual's opioid dependence severity and treatment phase. Initially, a low dose (e.g., 2-4mg) is given, and it may gradually increase to a maintenance dose of 8-24 mg daily. Regular monitoring is essential to assess the patient's response, adherence, and potential side effects.

 

Side Effects and Contraindications

Common side effects of buprenorphine include:

  • Constipation
  • Nausea
  • Headache
  • Insomnia
  • Sweating

 

Serious side effects are rare but can include:

  • Respiratory depression
  • Allergic reactions

 

Buprenorphine is contraindicated in individuals with:

  • Severe respiratory insufficiency
  • Acute intoxication with opioids
  • Known hypersensitivity

 

Considerations for Nurse Practitioners

Nurse practitioners can prescribe buprenorphine for opioid dependence treatment under the Drug Addiction Treatment Act (DATA). To become eligible, they must complete specific training requirements and obtain a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA). Nurse practitioners should assess patients thoroughly, including their opioid use history, comorbidities, and medication compatibility, while ensuring appropriate counseling and referral for comprehensive treatment (40).

 

Clonidine + Lofexidine
Mechanism of Action and Metabolism:

Both Clonidine and Lofexidine are alpha-2 adrenergic agonists. They work by stimulating alpha-2 receptors in the brain, which reduces sympathetic outflow and norepinephrine release. This results in decreased sympathetic activity, leading to various effects such as reduced blood pressure, decreased heart rate, and alleviated withdrawal symptoms (28).

 

Available Forms

Clonidine is available in oral tablets and patches. Lofexidine is available in oral tablets and is taken as needed (40).

 

Dosing and Monitoring

For opioid withdrawal, the Clonidine dose ranges from 0.1-0.3 mg every 4-6 hours. Lofexidine is usually initiated at 0.53 mg three times daily, and the dose can be increased to 2.88 mg daily. Monitoring blood pressure and heart rate is essential during treatment (40).

 

Side Effects and Contraindications:

Common side effects of both medications include:

  • dry mouth
  • sedation
  • dizziness
  • constipation
  • orthostatic hypotension (40).

 

Both medications are contraindicated in patients with:

  • Hypotension
  • Bradycardia
  • heart block
  • history of hypersensitivity to the drugs (40).

 

Considerations for Nurse Practitioners:

An early study of lofexidine vs. clonidine for withdrawal symptoms showed that treatment with lofexidine resulted in lower withdrawal symptoms, fewer mood problems, less sedation, and hypotension. There were no significant differences in craving levels, morphine metabolites in urine, or dropout rates when both were compared.

Lofexidine can be a safe option for outpatient treatment as it does not lead to hypotension. However, nurse practitioners must closely monitor patients' blood pressure and heart rate during treatment and educate them about possible side effects. If patients experience any concerning symptoms, they should inform their nurse practitioner immediately.

Gradual dose reduction of Clonidine is crucial to prevent rebound hypertension. Before prescribing either medication, nurse practitioners should assess for any contraindications or potential drug interactions (19).

 

Emerging Therapies for Withdrawal

Extended-release naltrexone: Naltrexone is an opioid receptor antagonist that blocks the effects of opioids, reducing the risk of relapse. It is taken as a monthly injection.

Alpha-2 adrenergic agonists: Emerging evidence suggests the potential use of dexmedetomidine and guanfacine for managing opioid withdrawal symptoms.

 

 

Medication-Assisted Treatment (MAT):

Methadone was introduced in the 1960s and marked a significant turning point in opioid addiction treatment or MAT. Along with counseling and behavioral therapies, MAT became the cornerstone of opioid addiction recovery.

 

Examples of medications used:

  • Methadone
  • Buprenorphine:
  • Naltrexone:

 

Adjunctive Pharmacotherapies:

Antidepressants: Selective serotonin reuptake inhibitors and tricyclic antidepressants may help manage co-occurring depression and anxiety.

 

Anticonvulsants:

Medications like Gabapentin and pregabalin show promise in reducing opioid cravings and improving treatment outcomes.

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the mechanisms of action for commonly prescribed addiction medications?
  2. What are the potential risks and benefits of using benzodiazepines for pain management?
  3. How do you assess and manage patients with co-occurring pain and substance use disorders?
  4. What are the guidelines for prescribing addiction medications like buprenorphine or methadone?
  5. How do these medications work in the treatment of opioid use disorder?
  6. What are the potential side effects and risks associated with addiction medications?
  7. How do you support patients in their recovery from opioid use disorder?
  8. How do you address patients' concerns and fears about addiction medications?
  9. What are the federal guidelines around prescribing addiction medications for nurse practitioners?
  10. How do these guidelines influence your prescribing practices?

Other Substance Use Disorders

Patients in pain may struggle with Substance Use Disorders other than Opioid Use Disorder. Substance use disorders may often occur with mental health conditions such as anxiety, depression, and bipolar disorder. In addition, many individuals engage in polydrug use. Understanding the most common Substance Use Disorders aids in a comprehensive assessment of the patient and the development of appropriate treatment plans (28).

 

Alcohol Use Disorder (AUD):

The prevalence of AUD worldwide was estimated to be 9.8% in men and 5.5% in women in 2016 (28).

 

Cannabis Use Disorder (CUD):

the prevalence of CUD in the United States increased from 2.18% in 2001-2002 to 2.89% in 2012-2013. (28).

 

Cocaine Use Disorder:

According to the National Survey on Drug Use and Health (NSDUH), in 2019, approximately 1.9 million Americans aged 12 or older had cocaine use disorder in the past year (44).

 

Methamphetamine Use Disorder:

A study published in Drug and Alcohol Dependence reported that the prevalence of methamphetamine use disorder in the United States was estimated to be 0.2% in 2015-2016 (6).

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the options available for managing opioid addiction and withdrawal?
  2. How can nurse practitioners support patients in their recovery from opioid addiction?
  3. What strategies can nurse practitioners employ to effectively engage and build trust with patients reluctant to disclose or seek help for substance abuse disorders?
  4. How can nurse practitioners collaborate with other healthcare professionals and community resources to provide comprehensive care and support for patients with substance abuse disorders?
  5. What techniques or tools can nurse practitioners employ to start these sensitive conversations with new patients?
  6. How do you assess and manage patients experiencing opioid withdrawal symptoms?
  7. What are the non-pharmacological interventions for managing opioid withdrawal?
  8. How do you educate patients about the risks and benefits of addiction medications?
  9. How do you monitor patients on addiction medications for adherence and progress?
  10. What are the drug potential interactions with commonly prescribed addiction medications?

Drug Diversion and Illegal opioids

Misuse of opioids is facilitated by diversion and is defined as "the transfer of drugs from lawful to unlawful use" (24). Most commonly, this occurs when family and friends share prescribed opioids with other family and friends. Opioids and other controlled drugs are also diverted from healthcare facilities. Statistics show that healthcare facility diversion has increased since 2015 (24)

Diversion affects patients, healthcare workers, healthcare facilities, and public health. Patients experience substandard care due to ineffective pain management and impaired healthcare workers. In addition, affected patients are at risk of infections from compromised syringes (24).

Healthcare employees who divert are at risk of overdose and death. If caught, they face criminal prosecution and malpractice suits. Healthcare facilities also bear the cost of diverted drugs via internal investigations, follow-up care for affected patients, regulatory fines for inadequate safeguards, and declining public trust (24).

Despite the enormous consequences of drug diversion, healthcare facilities have implemented few processes to detect and deter the diversion of controlled substances (24).

Quiz Questions

Self Quiz

Ask yourself...

  1. What protocols can nurse practitioners implement to prevent drug diversion within their healthcare setting?

Patient Teachings and Considerations

Opioids have significant side effects and carry a risk of addiction and overdose. Nurse practitioners can decrease the risks of misuse and addiction by educating patients on appropriate disposal, safe storage, and potential signs of addiction. Taking additional time to provide teaching nurse practitioners can promote patient safety, informed decision-making, and responsible opioid use.

 

Safe Storage and Disposal:
  • Teach patients to store opioids securely, out of reach of children, pets, visitors, and non-caregiver family members, to prevent accidental ingestion or misuse (13). Only the caregiver, if applicable, or the patient should have access to pain medications.
  • Instruct patients on proper disposal methods, such as using drug take-back programs or mixing opioids with undesirable substances (e.g., coffee grounds) before throwing them away (11) (13).

 

Medication Adherence:
  • Emphasize the importance of taking opioids as prescribed, at the correct dose and frequency, to achieve optimal pain relief.
  • Encourage patients to notify their healthcare provider if they experience inadequate pain control or side effects (35).

 

Potential Side Effects:
  • Educate patients about common side effects of opioids, including constipation, nausea, sedation, and respiratory depression.
  • Discuss strategies to manage side effects, such as maintaining adequate hydration, consuming a fiber-rich diet, and using over-the-counter laxatives as needed (11).

 

Risk of Dependence and Addiction:
  • Explain the potential for opioid dependence and addiction, especially with long-term use or a history of substance abuse.
  • Encourage patients to promptly report signs of opioid misuse, such as craving, loss of control, or continued use despite negative consequences (51).

 

 

 

 

Avoiding Alcohol and Other Central Nervous System Depressants:
  • Instruct patients to avoid consuming alcohol or other medications that can enhance the sedative effects of opioids, increasing the risk of respiratory depression.
  • Advise patients to contact the Nurse Practitioner before starting new medications, including over-the-counter drugs or herbal supplements (2).

 

Driving and Operating Machinery:
  • Inform patients about the potential impairment caused by opioids, including reduced alertness, reaction time, and coordination.
  • Advise patients to avoid driving or operating heavy machinery while taking opioids until they know how the medication affects them (14).
Quiz Questions

Self Quiz

Ask yourself...

  1. What strategies can nurse practitioners employ to effectively communicate the risks and benefits of opioid use while ensuring they clearly understand the potential side effects and the importance of adhering to the prescribed regimen?
  2. How can nurse practitioners promote patient engagement and shared decision-making regarding opioid pain management, considering the potential for dependence and addiction?
  3. How can nurse practitioners assess a patient's knowledge and understand the safe storage and disposal of opioids?

Case Study

You take some extra time with Mary to educate her on the taper dose of Vicodin, the potential for harm, and the risk of opioids, especially when used concomitantly with Gabapentin. You let Mary know it is unsafe to use alcohol, not only with Vicodin but also with Gabapentin. You let Mary know that Vicodin has a risk of dependency and misuse and, therefore, she will be monitored carefully. You also educate that Mary should store the Vicodin away from visibility by anyone but herself since she can self-administer her medication. You let Mary know that Vicodin can cause constipation and that she should increase her water intake and take a stool softener.

You ask Mary to call you if her pain is not adequately relieved or if her medications run out before the three days.  

You let Mary know that if she does stop taking the Vicodin before she has completed all the medication, she should dispose of it by mixing the pills with liquid and coffee grounds to make them unpalatable to animals and others.

Mary complied with your education, completed her course of Vicodin, and was scheduled for surgery. Mary's social worker helped her communicate with her new employer and delayed her start date until after her recovery.

During her recovery, Mary received physical therapy and a short course of pain medication managed by her orthopedist.

Mary returned to the clinic for a follow-up visit after completing her therapy and before starting work. Mary's pain level in her knee is 3/10, and she already feels like she can walk further than pre-surgery. Gabapentin has continued to help Mary's neuropathic pain in her back, and she reports 2/10. Mary looks forward to beginning her new job and is optimistic about the future.

Conclusion

Pain management is the leading cause of primary care appointments and chronic pain is the leading cause of disability. Yet, prescribing opioids for primary care patients is also a factor in drug misuse and the opioid epidemic. Nurse practitioners are challenged to appropriately treat pain and effectively control diversion, addiction, and death from overdose.

It is imperative that nurse practitioners use evidence-based practices to assess, appropriately intervene, and educate about the benefits and potential harm caused by treatment with opioids. Nurse practitioners must stay up to date with the current federal regulations regarding PDMPs, clinical prescribing guidelines, and emerging treatments for pain and opioid abuse disorders.

 

 

Tirzepatide for Type 2 Diabetes and Weight Management

Introduction   

The emergence of the drug tirzepatide is becoming more popular and widespread and is being utilized among those with diabetes and also those who desire to lose weight. It is one of the newest diabetic drugs given by injection that also triggers dramatic weight loss in those who use the injections.

The U.S. Food and Drug Administration (FDA) approved tirzepatide in 2022 for individuals with diabetes, particularly Type 2 Diabetes. The FDA officials have not approved tirzepatide yet for weight loss, but they are currently tracking the medication and may have a recommendation for its approval by the end of this year. Clinical trials have shown that individuals with an elevated body mass index (BMI) and who did not have diabetes lost a considerable amount of weight when they received tirzepatide (1).

Advanced Practice Registered Nurses (APRNs) need to understand how to safely prescribe tirzepatide and the reasoning as to why it causes weight loss for specific individuals.

Drug Classification

Tirzepatide is part of a class of medications called glucose-dependent insulin tropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonists. It comprises a 39 amino acid linear synthetic peptide conjugate to selective receptor agonists in preclinical and clinical trials.

Tirzepatide is used for treating Type II diabetes in adults as an adjunct to diet and exercise. It is also used for weight loss in some individuals and has gained increased attention as a new therapeutic agent for glycemic and weight control.

Social media has had a significant influence and increased the desire to use tirzepatide, and while individual results vary, the weight loss in adults ranged from 12 – 25 pounds.

Online pharmacies, diet clinics, and medical spas are implementing thousands of ads on social media to capitalize on a surge of interest in the drug.

Quiz Questions

Self Quiz

Ask yourself...

  1. Why has there seemed to be an increase in patients requesting this medication? What other medicines intended for type 2 diabetes are also being used for weight loss management?
  2. What are the ethical considerations regarding marketing this drug for weight loss when its primary use is for type 2 diabetes? Could this impact supply and costs?

Indications of Usage

The use of tirzepatide is being used for both Type II diabetes and weight control in certain patients. It has been a game changer for people living with Type II diabetes. The drug’s primary use is as an adjunct to diet and exercise to improve glycemic control in adults with diabetes.

The drug has also proven beneficial for weight loss in patients experiencing obesity, and those who are taking the highest dosage have shared a body weight reduction of 15.7% (2). Tirzepatide is an injectable prescription medication used together with diet and exercise, and it is not yet known if it can be used safely with patients who have had pancreatitis.

It is important to remember that it is not to be used for patients with Type I diabetes, but it is safe for Type II diabetic patients. Also, the safety of tirzepatide has yet to be discovered for children and those under 18; therefore, the medication should not be used for this age group.

In studies conducted with or without diabetic medicines, 75% – 90% of patients taking tirzepatide reached an overall A1C of less than 7% with an average starting A1C of 7.9 – 8.6% across the following dosages – 5mg, 10mg, and 15mg. The study results were measured at weeks 40 and 52 (3).

Quiz Questions

Self Quiz

Ask yourself...

  1. What dietary and activity recommendations can you provide to patients using tirzepatide for weight loss?
  2. Is this drug intended for those who want to lose 5-10 pounds?

Use of Tirzepatide with Diabetic Patients

Tirzepatide can be used for patients with Type II diabetes in combination with a diabetic-friendly diet and exercise. The drug works by lowering the patient’s overall blood sugar and also improves the A1C results of patients over some time. The injection has been approved by the FDA to treat Type II diabetes and is administered once weekly (4).

It is considered the first in a new class of medications – a dual glucose-dependent insulin tropic polypeptide (GIP) and glucagon-like-peptide-1 (GLP-1) receptor antagonist. The mechanism of how it works mimics two gut hormones (GIP and GLP-1). These hormones are essential in how patients digest food and regulate blood glucose after meals. The hormones also play a role in making individuals feel fuller and curb specific food cravings.

The provider can prescribe tirzepatide before attempting other diabetic medications if a patient has a BMI of 30 or greater or 27 or greater with weight-related conditions and if the drug is combined with a personalized weight loss plan that addresses physical activity, nutrition, and lifestyle changes.

However, due to the cost and some insurance companies not covering the injection unless the patient has both diabetes and obesity, the provider must carefully consider prescribing this medication.

 

 

 

 

Case Study

The patient states this ‘miracle drug’ is worth paying for out of pocket!

Jeff Capron, a 53-year-old Boonville, New York, web developer, started taking tirzepatide in December 2022. His friend had reported good results with the medication, so Jeff looked into the research studies behind it and then spoke with his primary physician.

The physician said, “Yeah, let’s give it a shot,” even though he did not have much experience with it. The physician did not have an opinion one way or the other than looking at the data set and seeing no reason why they could not try it.

Jeff’s hemoglobin A1C went from 10.1% to 6% in 3 months, which was very promising. “I never had that kind of experience with any medication for diabetes.” There is a range in how much A1C reduction people experience with tirzepatide, but many people taking it can get their A1C under 7% — an ideal goal for people with Type 2 diabetes.

Jeff experienced constipation and a little trouble sleeping early, but both issues disappeared quickly. He says, “I wake up in the morning, and my fasting blood sugars are normal.”

The medication took effect, he says, within 12 hours. He compared the feeling to having a gastric bypass.

“You cannot overeat food. As soon as you overeat, you almost feel ill.” While it generally takes a few months to notice effects like A1C reduction and significant weight loss, side effects such as lower appetite may be felt immediately.

Weight loss was not his primary goal, but he lost about 35 pounds on the medication in the first five months. He also lost his sweet tooth. “I can maybe count three sweet things I have eaten since December.”

Jeff found that his appetite slowly recovered days after taking tirzepatide. “You take the shot every Sunday, and by Saturday, you start to get a lot of appetite,” he says. “It does not seem to affect your weight. If I eat a little bit more on Saturday night, on Sunday, the scale will not move one way or the other.”

Jeff is allergic to hornets, so he already carries an auto-injector. He was not worried about using another drug delivered through a needle. “It’s just a push button,” he says. It also helped that his wife is a nurse. “So, I had her with me the first time to ensure I was doing it right. I didn’t even feel it.”

When Jeff was first prescribed tirzepatide, his insurance covered it. The company has since removed that benefit. He has filed an appeal but pays about $1,000 monthly out of pocket for his weekly injections. He plans to keep paying as long as necessary.

He considers the financial burden well worth it. “I have never had a medication that worked as well before for chronic conditions,” Jeff says. “I’ve been blown away by it. For me, it’s a miracle drug. It got rid of my diabetes” (4).

Quiz Questions

Self Quiz

Ask yourself…

  1. Can a provider willfully choose to prescribe tirzepatide before other diabetic medications are attempted?
  2. Would that impact his insurance coverage if Jeff did not meet the clinical criteria for using tirzepatide?

Use of Tirzepatide for Weight Loss Management

As mentioned, this medication is indicated for patients with a BMI of >30 or a BMI of >27 with qualifying comorbidities. Obesity can become a chronic lifetime disease, and for conditions such as these, the patient needs to implement therapy for the lifetime of the disease.

In a study conducted for tirzepatide, there was a dramatic increase in effectiveness compared to traditional nonsurgical interventions such as diet, exercise, and lifestyle changes. However, it has been noted that taking tirzepatide on an ongoing basis is recommended and necessary to maintain any weight loss achieved from the medication.

If a patient stops taking the drug, likely, it will no longer work (5).

Public health officials have expressed concerns about using the drug long-term. Still, data is currently lacking regarding long-term effectiveness, treatment duration, and maintaining weight reduction once the therapy is discontinued.

A recent trial consisted of 783 participants with a BMI greater than 30, and these participants agreed to take either a 10mg or 15mg dose of tirzepatide over 36 weeks. The injection is given once weekly, so this would equal a total of 36 injections.

By the end of 36 weeks, participants lost more than 21% of their body weight. After 36 weeks, participants continued on tirzepatide or received placebo treatment for the following year. The patients needed to be made aware of which treatment they were receiving.

Those still taking tirzepatide injections weekly after 88 weeks lost an additional 7% of their body weight, and those taking the placebo regained 15% at the end of 88 weeks (5).

Quiz Questions

Self Quiz

Ask yourself…

  1. What is the minimum BMI needed to qualify to receive this drug for weight loss management?
  2. Is this medication indicated for long-term use for patients with a high BMI?

Common Side Effects and Contraindications

Side Effects

Patients vary immensely with different experiences and side effects related to tirzepatide; however, the following are the most common side effects experienced by those taking the medication:

  • Nausea
  • Decreased appetite
  • Vomiting
  • Diarrhea
  • Indigestion
  • Constipation
  • Stomach Pain

 

Tirzepatide usually does not cause fatigue, leaving one feeling weak, tired, and low energy. However, fatigue can be a common side effect of Type II diabetes.

It is important to note that most individuals who experience nausea, vomiting, and diarrhea episodes do so while the dosage increases, and typically, the symptoms decrease over time. G.I. effects were more prominent in those taking tirzepatide than those taking the placebo. The individuals not in the placebo group were more likely to stop treatment due to the unpleasant side effects (3).

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Does tirzepatide cause fatigue in patients who use it?
Contraindications

Tirzepatide may cause thyroid tumors, including thyroid cancer, and it is essential to watch for possible symptoms, such as swelling or a lump in the neck, hoarseness, shortness of breath, or trouble swallowing.

Tirzepatide should also not be prescribed to any patient with Type 1 Diabetes.

One of the main ways that tirzepatide works is by stimulating the release of insulin from the pancreas, and due to this fact, there have not been many studies and clinical trials that include those with Type I diabetes.

However, this is not to say that prescribers have never ordered tirzepatide for those with Type I diabetes. Still, it is essential to note that if prescribed, it would be in addition to traditional insulin therapy.

  • Personal or family history of a type of thyroid cancer known as medullary thyroid carcinoma (MTC).
  • Any history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
  • Patients who are allergic to the actual medication or any of its ingredients.
  • Younger than 18 years of age

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the reason that tripeptide is contraindicated in those with Type I diabetes?
  2. Why is there a risk with patients who have a thyroid disorder?
  •  

Safe Prescribing Practices, Guidelines, and Considerations for Providers

Safe Prescribing Practices

As with all prescribed medications, safe standards of care must be implemented and followed to ensure patient safety is maintained. The same applies to providers considering prescribing tirzepatide, and specific criteria must be met beforehand. The following information discusses guidelines involving exclusion and inclusion criteria for providers to prescribe tirzepatide (6) accurately.

 

Guidelines

Exclusion Criteria – If present, the following indicates that the patient should not receive tirzepatide:

  • Diagnosis of Type I diabetes
  • Personal or family history of medullary thyroid carcinoma or with Multiple Endocrine Neoplasia syndrome type 2
  • Severe gastrointestinal dysmotility
  • History of pancreatitis
  • Pregnancy
  • Proliferative Diabetic Retinopathy (PDR), severe Nonproliferative Diabetic Retinopathy (NDR), clinically significant myalgic encephalomyelitis (M.E.), or diabetic macular edema (DME) unless the risks/benefits have been discussed with the patient and are documented in the patient's health record along with monitoring plans and follow-up with an eye specialist who is informed at the time of initiation.

 

Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

  • Diagnosis of Type II diabetes
  • A BMI of 25 or greater
  • Inadequate glycemic control on at least 1mg of semaglutide injection plus two or more glucose-lowering drugs
  • Change needed to achieve goal A1C is less than 1%.
  • Goal A1C should be based on those recommended in the Diabetic Guidelines.
  • Adherence to current diabetic medications as evidenced by a review of the prescription refill history during the six months.

 

Additional Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

  • Patients with atherosclerotic cardiovascular disease or chronic kidney disease
  • Patients of childbearing potential who are using oral contraceptives

 

Inclusion Criteria for Weight Loss

  • BMI of >30 or >27 with patient weight conditions.
Quiz Questions

Self Quiz

Ask yourself...

  1. Would a patient with a BMI of 23 with no comorbidities qualify to use tirzepatide to lose 5-10% of their body weight? Why not?
  2. What impact can tirzepatide have on a person with a healthy weight and BMI of <25?

 

Considerations for Providers

There are specific considerations that prescribers must be aware of when contemplating if a patient should receive the medication tirzepatide. The following is imperative and must be considered each time the medication is prescribed to a patient:

  • Clinical Indications – indicated for treating adults with insufficiently controlled diabetes mellitus as an add-on therapy to diet and exercise; as monotherapy when metformin is considered inappropriate due to contraindications or intolerance; and other medicinal products for treating Type II diabetes.
  • Monitoring of medication – routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value but is recommended for early detection of Medullary Thyroid Cancer (MTC).
  • Cost – the average price for tirzepatide ranges from $1,071-$1,351 without any coupons or insurance. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections.
  • Benefits and Risks – One must evaluate the effectiveness of diabetes and the weight loss experienced. Some of the risks must be evaluated, such as increased cost of medication, unpleasant gastrointestinal side effects, poor insurance coverage, and drug shortages. The FDA has warned that the medicine can cause thyroid C-cell tumors in rats, and it is not sure whether tirzepatide causes similar tumors.

 

How long does it take for tirzepatide to begin working?

Tirzepatide will start to lower one's blood sugar levels immediately, but it can take 8 to 12 weeks to reach one's target A1C goal.

Compared to other diabetic treatments, studies have shown that it can take eight weeks to reach an A1C target of less than or equal to 7% and 12 weeks to get an A1C of less than or equal to 6.5%. Significant weight loss can occur as early as 28 weeks.

 

Safe Administration

It is essential to follow the correct steps for safe administration of tirzepatide as listed below:

  • The recommended starting dosage is 2.5mg, injected subcutaneously once weekly. The 2.5mg dosage is for treatment initiation and not for glycemic control.
  • After four weeks, increase the dosage to 5mg, injected subcutaneously once weekly.
  • If additional glycemic control is needed, increase the dosage in 2.5mg increments after at least four weeks on the current dose.
  • The maximum dosage is 15mg, injected subcutaneously once weekly.
  • If a dose is missed, instruct patients to administer it as soon as possible, within four days (96 hours) after the missed dose. If more than four days have passed, skip the missed dose, and administer the next dose on the regularly scheduled day. In each case, patients can then resume their regular once-weekly dosing schedule.
  • The day of weekly Administration can be changed, if necessary, as long as the time between the two doses is at least three days (72 hours).
  • Before initiation, train patients and caregivers on proper injection techniques.
  • Instruct patients using the single-dose vial to use a syringe appropriate for dose administration (e.g., a 1ml syringe capable of measuring a 0.5 mL dose).
  • Administer the medication once weekly, any time of day.
  • Inject the medication subcutaneously in the abdomen, thigh, or upper arm.
  • Rotate injection sites with each dose.
  • Inspect the medication visually before use. It should appear clear and colorless to slightly yellow. Do not use the medicine if particulate matter or discoloration is seen.
  • When using the medication with insulin, administer it as separate injections and never mix. It is acceptable to inject tirzepatide and insulin in the same body region, but the injections should not be adjacent.

 

Does the tirzepatide injection hurt when administered?

Pain from the injection site has not been reported as a common side effect, but it may occur.

Due to the injection being given subcutaneously, slight pain or discomfort can occur.

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. The patient asks you," How long will this take to work?" How will you respond?
  2. The patient reports they have never used an injection before; what methods can you use to teach your patient how to administer this medication safely?

Alternatives to Tirzepatide for Weight Loss Management

In some instances, patients need to be aware of alternatives to tirzepatide in case they cannot take the actual injection for whatever reason. In cases such as these, there are alternative supplements that can be purchased over the counter, and they include the following (7):

  • PhenQ – top OTC choice – comprehensive weight loss solution that targets specific body regions, facilitates prompt fat loss, and expedites the weight loss journey.
  • PhenGold – the most potent OTC weight loss alternative – one of the top weight loss supplements that boost metabolism, making one less hungry, less tired, and an overall improved feeling.
  • Capsiplex BURN – the best choice for men – helps to burn fat faster and keep blood sugar levels in check. It helps to keep one's muscles, curbs hunger, gives one more energy, and torches stubborn fats.
  • Trimtone – the best choice for women – helps women to lose weight, eat less, increase metabolism, burn extra calories, and boost energy.
  • Prime Shred – best fat burner for men – boosts metabolism, keeps muscles intact, increases energy, and helps maintain focus.

 

The advanced practicing nurse or prescriber needs to inform patients about alternative options such as these in an effort for individuals to understand that other choices are available and can be used. Many individuals need to be more knowledgeable about alternatives besides tirzepatide due to the extra hype from social media sources that promote advertisements related to tirzepatide only but do not mention the other options.

 

Why does social media influence and encourage patients to take tirzepatide?

Social media trends can be helpful but can also become harmful by setting unrealistic expectations and promoting a diet culture mentality. They can create an unhealthy obsession with "clean" eating, especially in the younger populations.

Due to this, many individuals take the medication despite any occurrence or history of Type II diabetes, and the drug can ultimately become misused.

It has been noted that there is an influx of patients requesting this medication for weight loss instead of the intended purpose, which is to help control Type II diabetes.

Tirzepatide represents one of the most recent non-medical treatments aimed at managing the symptoms of Type II diabetes. While it is not indicated for weight management, diabetic patients who receive it frequently report a significant reduction in body weight.

 Empirical evidence suggests the efficacy of tirzepatide in weight management, and certain physicians currently endorse the Administration of the medication as a therapeutic and effective means to overcome obesity.

 

What are some severe side effects of tirzepatide that can impact patient safety?

The Administration of tirzepatide can benefit many individuals, but some severe side effects must be mentioned.

These include thyroid tumors, thyroid cancer, pancreatitis, hypoglycemia, serious allergic reactions, kidney issues, severe stomach problems, vision changes, and gallbladder issues. All these side effects must be taken seriously and reported, as they can lead to life-threatening

Quiz Questions

Self Quiz

Ask yourself...

  1. With what you have learned in this course, what education will you provide to patients requesting this medication for weight loss?
  2. Have you seen increased demand for this medication in your current practice?
  3. If you Google tirzepatide, your results will likely include links to telehealth services promoting this weight-loss medication. To determine eligibility, what special considerations need to be taken to assess a telehealth patient?

Conclusion

Medications like tirzepatide are game changers for those patients with type 2 diabetes that have failed other medications. Unfortunately, several companies seek to profit from its weight-loss benefits through aggressive marketing campaigns that limit the available supply and increase the costs for those who need it. As healthcare providers, we need to use sound clinical judgment and follow the exclusion/inclusion criteria and other guidelines before prescribing this medication, so we do not unintentionally cause harm while looking to appease our patients who request this.

Semaglutide and Type 2 Diabetes

Introduction   

In 2017, the FDA approved the semaglutide injectable (Ozempic) for treating type 2 diabetes. The drug has experienced widespread acceptance due to its positive effects on weight loss and lowering of chronic health risks. The drug has risen in popularity over the past few years, as many well-known actors/actresses/songwriters, and more came forward, publicly sharing their weight loss journey.

This rise in popularity has also resulted in significant shortages of this medication, negatively impacting the lives of the diabetic community, local pharmacies, and healthcare providers. The goal of this continuing education course is to educate and empower the healthcare provider in all aspects of this drug regimen: clinical indications, patient education, cost options, and benefit/risk analysis.

Diabetes Overview

Diabetes is a chronic medical condition. Despite advances in diet, medications, and monitoring devices, diabetes diagnoses continue to grow at staggering rates. The Institute for Health Metrics and Evaluation (IHME) reports that over 529 million people worldwide are currently living with diabetes, and that number is expected to grow to 1.3 billion in only 30 years. While the risk factors for diabetes are vast in number (poor diet, inadequate activity, obesity, sedentary lifestyles, daily stressors, and more), the sad reality is that this chronic medical condition will most likely linger on for generations to come despite our efforts to contain this health epidemic (1).

According to the latest research on diabetes, there are over 37 million people in the United States alone with diabetes as of 2022. Statistically, approximately 28 million of them have a confirmed diagnosis, while another estimated 8 million are experiencing symptoms, without an official diagnosis. Diabetes currently ranks as the 7th leading cause of death in the United States (2).

Quiz Questions

Self Quiz

Ask yourself...

  1. As a healthcare provider, what has been your experience with treating chronic medical conditions?
  2. Why do you think there is a continued increase in diabetes, despite advances in medication and monitoring devices to treat this condition?
  3. Are you currently offering comprehensive care to your patients, including medication, diet, and activity counseling for their chronic health conditions?

Types of Diabetes

In basic terms, diabetes is an impairment in one’s ability to either adequately produce or utilize insulin, which results in elevated levels of circulating glucose. Chronically elevated glucose levels affect blood vessels at every level, causing chronic inflammation and raising the risk of heart disease, stroke, blindness, and atraumatic amputations.

 

There are three main types of diabetes:

Type 1 diabetes is thought to be an autoimmune disease. Approximately 5-10 percent of people with diabetes are diagnosed with type 1 diabetes. The diagnosis usually occurs in early childhood, and results in a lifetime use of insulin to regulate blood glucose levels.

Type 2 diabetes is thought to be related to dietary and lifestyle choices. It accounts for nearly 90-95 percent of diabetes diagnoses. Usually occurring later in life (adult-elderly population), it is believed to be related to factors such as diet, activity, weight gain, and related factors. Type 2 diabetes is usually controlled by diet and exercise, in addition to oral medications, although injectable insulin may be included in the treatment plan.

Gestational diabetes refers to elevated glucose levels occurring during pregnancy for patients who are not diabetic at the onset of pregnancy. This version of diabetes usually resolves itself post-partum, although a woman may develop type 2 diabetes later in life, unrelated to pregnancy.

 

Type 2 diabetes in children: no longer a “later in life diagnosis”

Children are now being diagnosed with type 2 diabetes at an alarming rate. Despite widespread education and an increased awareness of diabetes, our up-and-coming generation is unhealthier than ever. Many families lack access to healthy food for their families, due to both general socioeconomic challenges and an increased rate of food insecurity. (19)

The CDC recommends care providers have resources for diabetic patients and their families, such as food and nutrition programsbudget-friendly diabetes meal plans, how to save money on diabetes care, and coping strategies for diabetes. (19)

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Are you able to articulate the different types of diabetes to patients?
  2. What resources can you offer to the families of children with type 2 diabetes?

Diabetes Signs and Symptoms, Diagnostic Testing

There are various ways to test for diabetes. The fasting blood sugar (FBS)/ fasting glucose level is a simple way to test for diabetes.

The normal fasting glucose level is below 100mg/dl. The fasting glucose result of 100-125mg/dl indicates prediabetes and results above 126mg/dl indicate diabetes.

The hemoglobin A1C blood test is another test used to confirm the diagnosis of diabetes. The patient does not need to be fasting for this test; thus, it is easier to order this test regardless of the time of day. This blood test reflects the average glucose level over the period of 2-3 months.

The normal A1C level is below 5.7%. Test results between 5.7%- 6.4% indicate prediabetes. Test results above 6.5% indicate diabetes.

A random glucose reading above 200mg/dl, done at any time of day, indicates diabetes.

The diagnosis of diabetes is by blood tests, and for improved accuracy, should be based on two separate readings, done (at least) a day apart. In the case of fasting and random blood tests, dietary intake (large amounts of carbohydrates in a single meal) may adversely affect test results. This is not the case when using A1C testing for a confirmation diagnosis, as the results are the average of a 2–3-month span.

 

Target blood levels for a person with diabetes (3).

Target blood glucose levels for people with diabetes are as follows:

  • Fasting glucose 80-130mg/dl.
  • Postprandial blood glucose level- less than 180mg/dl
  • A1C level 7-8%.

These target ranges are general guidelines. Patient-specific ranges will be dependent on a variety of factors, including preexisting comorbidities, overall health status, age, and activity levels.

 

 

 

 

The hallmark signs/symptoms of diabetes
  1. Polyuria- increased urination
  2. Polydipsia- increased thirst
  3. Polyphagia-increased hunger/appetite

 

The truth is, as healthcare providers, you will have patients who have no hallmark signs and symptoms of diabetes; the diagnosis will be found during annual preventive examinations often unrelated to any chronic disease. For this reason, many insurance companies now cover numerous preventive screenings, including diabetes screenings, as part of their wellness and prevention initiatives. These tests are often approved based on a patient's age, or preexisting conditions, rather than outright signs and symptoms.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the typical glucose levels for non-diabetic versus diabetic patients?
  2. What are the hallmark symptoms you can identify when treating a potentially diabetic patient?
Lifestyle Interventions and the Diabetes Prevention Program

The initial diagnosis of diabetes can be managed in a variety of ways, depending on the severity of the illness at the time of diagnosis. Lifestyle interventions (behavior modification education) are of utmost importance in the care and management of people with diabetes. Research over the past few decades has consistently shown that such interventions have immense positive effects on the successful long-term management of diabetes.

The official Diabetes Prevention Program was created in 2010 (4) and confirmed the effects of lifestyle interventions in the management of diabetes:  Lifestyle interventions decreased the incidence of type 2 diabetes by 58% compared with 31% in the metformin-treated group. Thus, these findings now serve as the blueprint, if you will, for all-inclusive, patient-specific disease management guidelines. These lifestyle interventions will be discussed in detail later in the program.

 

Additional Resources on Diabetes Prevention

Quiz Questions

Self Quiz

Ask yourself...

  1. How do lifestyle interventions compare to other kinds of treatment for patients with type 2 diabetes?

Semaglutide

Semaglutide is an injectable drug used in the treatment of type 2 diabetes. It was approved by the FDA in May of 2017.

It is a once-a-week injectable and belongs to the drug class known as glucagon-like peptide-1 receptor agonists (GLP-1RAs) (5). It has been referred to as a “miracle weight loss drug” among those who are living with obesity, despite frequent side effects, unusually high out-of-pocket costs, drug shortages, and weight regain when attempting to stop using the medication.

 

GLP-1 receptor agonist: Hormone Review

GLP-1 RAs are a class of medications used to treat Type 2 diabetes, and in some cases, obesity treatment. They are also known as GLP-1 receptor agonists, incretin mimetics, and GLP-1 analogs.

 

Ghrelin and Leptin (6)

Ghrelin and Leptin are two hormones that greatly influence appetite and the sensation of fullness. Often referred to as the “hunger hormone.” Ghrelin is responsible for many functions, including playing a key role in metabolism through glucose and insulin regulation.

Ghrelin, produced in your stomach, signals your brain when you are hungry, and results in increased food intake.

Leptin, conversely, is produced in your fat cells, and signals to the brain when you have eaten enough (by a decrease in appetite).

 

Glucagon-like peptide-1 receptors

Known as GLP1 receptors, Glucagon-like peptide-1 receptor proteins are located in the beta cells of the pancreas as well as in the neurons in the brain. GLP-1 receptors are involved in the regulation of blood glucose levels and affect the secretion of insulin. These cells encourage the release of insulin from the pancreas, increase the volume of beta cells, and reduce the release of glucagon. In doing so, they increase the feeling of fullness during and between meals, suppressing the appetite and slowing gastric emptying.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are some problems patients might face if they choose to take semaglutide?
  2. How do Ghrelin and Leptin relate to a patient's appetite?

What is meant by receptor agonist and antagonist?

The term agonist refers to any substance that mimics the actions of a hormone in producing a specific response: a receptor antagonist blocks a response from occurring.

Opioids are examples of receptor agonists in that they produce responses such as analgesia.

Naloxone/Narcan is an example of a receptor antagonist, in that it binds to a receptor site and decreases/blocks a response from occurring.

 

Semaglutide mechanism of action (7)

GLP-1 agonists work in several ways to positively affect glucose levels. Their mechanism of action includes the following:

  • Increasing (stimulating) insulin secretion by the pancreatic beta cells.
  • Decreasing the production of glucagon, a hormone that raises blood glucose levels
  • Decreasing (slowing) gastric emptying
  • Decreasing appetite (and thereby reducing food intake) by creating a sensation of stomach fullness

 

Through these mechanisms of action, semaglutide results in a lowering of serum glucose/A1C levels, which lowers the risk of cardiovascular events. Studies have also shown that semaglutide resulted in weight loss (approximately 8-14 pounds on average {dose dependent results}.

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the difference between an agonist and antagonist substance?
  2. How much weight do patients lose, on average, when taking semaglutide?

Side Effects of Semaglutide

Common side effects of semaglutide (8)

Common side effects may include any of the following:

  • Nausea and vomiting
  • Headache
  • Diarrhea and stomach pain
  • Upset stomach, indigestion, constipation, flatulence

These side effects usually subside within a few weeks, as the patient becomes acclimated to the medication.

 

Serious side effects of semaglutide
  • Hypoglycemia- enhanced/worsened when used in combination with other diabetes medication. Symptoms may include drowsiness, confusion, weakness, irritability, and headache.
  • Symptoms may include abdominal pain and distension, nausea and vomiting, fever, and back pain.
  • Diabetic retinopathy. Symptoms may include blurred vision, vision loss, and diminished night vision.
  • Kidney damage/injury/failure. Symptoms may include fatigue, nausea, diminished urine output, confusion, and edema of extremities.
  • Gallbladder disease. Symptoms may include gallstones, abdominal pain, nausea and vomiting, and poor appetite.

 

Black Box Warning (9)

Semaglutide has a Black Box Warning for thyroid cancer. This is the most serious warning from the Food and Drug Administration (FDA) and is intended to alert consumers to the potential risks of a medication.  This black box warning was issued when research found that the drug increased the risk of thyroid tumors in animals.

It is not known if semaglutide actually causes tumors in humans.

 

Contraindications
  • Semaglutide is contraindicated in people with a personal or family history of MTC (medullary thyroid cancer) or in patients with multiple endocrine neoplasia syndrome type 2.
  • Known hypersensitivity to semaglutide or any of the product components

 

Cautions

As noted under “serious side effects”, there have been reports of new illnesses or worsening of existing health conditions occurring “post-marketing”. Thus, healthcare providers are strongly encouraged to continue ongoing surveillance of any patients on semaglutide therapy. In addition, there is insufficient data available regarding the use of semaglutide by pregnant women. Women are therefore highly encouraged to stop any treatment with semaglutide for at least 2 months prior to a planned pregnancy.

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name the 4 common side effects of semaglutide?
  2. What is the most severe warning associated with semaglutide? 

 

Dosing

Semaglutide is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). It is looked upon favorably to reduce the risk of cardiovascular events in adults with T2DM and a preexisting history of cardiovascular disease. This drug is FDA-approved for use in people with diabetes, with a BMI of 27% or higher (a BMI of 25-29.9% is considered overweight).

Semaglutide (Ozempic) is available as an injectable prescription medication. Doses include 0.5mg, 1mg, or 2 mg, once weekly.

The injection should be administered subcutaneously to the abdomen, thigh, or upper arm. Injection sites should be rotated, and given as a single injection.

 

Start at 0.25 mg once weekly. After 4 weeks, increase the dose to 0.5 mg once weekly.

  • If additional glycemic control is needed, increase the dose to 1 mg once weekly after at least 4 weeks on the 0.5 mg dose.
  • If additional glycemic control is needed, increase the dose to 2 mg once weekly after at least 4 weeks on the 1 mg dose

Administer once weekly at any time of day, with or without meals.  The maximum dose recommendation is 2mg/weekly once weekly.

Note: The initial 0.25-mg dose is intended for treatment initiation and is not effective for glycemic control

 

 

Missing Dose Guidelines
  • If the missed dose is ≤5 days: Administer dose as soon as possible
  • If missed dose >5 days: Skip the missed dose and administer the next dose on the regularly scheduled day; patients can then resume their regular once-weekly dosing schedule

 

Administration Day Guidelines (10).

The administration day each week can be changed, if necessary, as long as the time between 2 doses is at least 2 days (>48 hours)

 

Dose Availability (packaging)
  • 2mg/1.5mL (1.34mg/mL); delivers doses of 0.25mg or 0.5mg per injection or four to eight doses per injection pen
  • 4mg/3mL (1.34mg/mL); delivers 1mg per injection or 4 doses per injection pen
  • 8mg/3mL (2.68 mg/mL); delivers 2mg per injection or 4 doses per injection pen

 

Treatment Goals- Effects on A1C and Weight (11)

A majority of adults who were placed on injectable semaglutide for diabetes management achieved a target A1C under 7% and were able to maintain it.

  • Dose specific effects on A1C were as follows:
  • 0.5mg dose injection yielded a 1.4% decrease
  • 1.0mg dose injection yielded a 1.6% decrease
  • 2.0 mg dose injection, in combination with diabetes pills, yielded a 2.1% decrease in A1C.

 

Adults taking semifluid injectables for diabetes management also noted weight loss.

  • 8-pound weight loss reported with 0.5mg dose injection
  • 10 pounds weight loss reported with 1.0mg dose injection
  • Up to 14 pounds of weight loss reported with a 2.0mg dose injection

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What should you tell a patient if they miss their injection by more than 5 days? What if it has been less than five days?

Prescribing insights: Long-Term therapy for a chronic condition?

Semaglutide is viewed favorably as a treatment option for Type 2 diabetes. It appears to lower A1C levels and body weight in the majority of patients, lowering their risk of future cardiovascular events.

The question of long-term medication use, for a chronic health condition, is being heavily discussed in the media. While a percentage of people can decrease or eliminate the need for chronic medications through significant lifestyle changes, there have been reports of weight gain in those who stopped taking this injectable medication.

Without intense lifestyle behavior modification education, there is a heightened risk of weight regain in the absence of such medications. Leaders in the treatment of obesity and related illnesses have commented that this drug is intended for long-term use.

Examples of this include the following:

“GLP-1 medications [like Ozempic] are designed to be taken long-term... They are chronic medications for the treatment of chronic conditions (both diabetes and obesity) (12)". - Christopher McGowan, M.D., a gastroenterologist specializing in obesity medicine and endobariatrics

“As with many chronic conditions, most people who use the drugs for diabetes or weight loss will need to keep taking them to keep benefiting from them. Depending on your individual situation, and without sustained lifestyle changes, it is likely you would need to be on these medications indefinitely to maintain weight loss (13)." Dr. Cecilia Low Wang, a UCHealth expert in endocrinology, diabetes and metabolism.

Quiz Questions

Self Quiz

Ask yourself...

  1. Is semaglutide considered to be a long-term treatment for type 2 diabetes?

Cost Concerns

At this time, injectable semaglutide, FDA-approved for the treatment of Type 2 diabetes, has a self-pay price tag of $935.77 per month (4 injections). With FDA approval, many people with diabetes, insured under commercial plans, receive the drug for the cost of their copay. Those patients without coverage may use pharmacy discount cards that reduce the price, on average, to $814.55/month.

The following links are available to familiarize yourself with patient assistance programs related to semaglutide injectables.

 

Semaglutide Cost Savings Programs

The following links are provided to explore various semaglutide cost savings programs.

Quiz Questions

Self Quiz

Ask yourself...

  1. What resources can you offer patients who are struggling to pay for semaglutide?

Emerging Concerns: Semaglutide and gastroparesis

In August 2023, a first-of-its-kind lawsuit was filed in Louisiana, against the makers of semaglutide. The lawsuit states the makers of this injectable drug did not adequately warn patients about the risk of severe gastrointestinal issues/possible gastroparesis.

The plaintiff in this case had used both Ozempic and Mounjaro and experienced repeated episodes of severe gastrointestinal events, warranting trips to the emergency room and additional medications to alleviate her symptoms (14). While this lawsuit is in the developing stages, it bears mentioning in terms of concerns over long-term usage of the drug and possible complications.

While the drug labeling for semaglutide (Ozempic) does not specifically mention gastroparesis, the semaglutide/Mounjaro drug label does state that the drug has not been studied in patients with severe gastrointestinal disease and is therefore not recommended in these patients.

Up to 50% of people with diabetes have some degree of delayed gastric emptying, but most have no digestive symptoms or have only mild symptoms. For some people with diabetes, problems managing blood glucose levels may be a sign of delayed gastric emptying (15).

Healthcare providers should evaluate all patients with diabetes for possible symptoms of underlying gastroparesis, such as the feeling of fullness shortly after beginning a meal, or the inability to finish a regular meal. Other symptoms of gastroparesis may include abdominal pain, nausea, bloating, vomiting, and anorexia.

 

Diabetes and gastroparesis

Uncontrolled or poorly controlled diabetes can affect nerve endings systemwide. Diabetes is a very common cause of gastroparesis. Although the condition is rare it occurs more often in people with chronic conditions such as diabetes, autoimmune diseases, and nervous system disorders. Nerve endings are injured or damaged, cease to function properly, and result in delayed gastric emptying. The delay in gastric emptying can cause various symptoms, such as nausea, vomiting, bloating and distension, abdominal pain, and poor appetite.

In addition to underlying medical conditions, some medications may cause symptoms of gastroparesis (delays in gastric emptying and overall gastric motility. These medications include narcotics, antidepressants, and anticholinergics.

Left untreated, diabetic gastroparesis may lead to malnutrition, electrolyte imbalances, and poor glucose management and control.

Quiz Questions

Self Quiz

Ask yourself...

  1. Why should nurses prescribing semaglutide watch out for symptoms of gastroparesis?
  2. What do you think are some ethical issues with semaglutide use for weight loss?

Diabetes Lifestyle changes: Patient education (16)

  1. Weight Management
  2. Healthy Eating
  3. Physical Activity
  4. Smoking Cessation
  5. Stress Management

 

The importance of patient education regarding lifestyle changes is a priority. As with any chronic medication condition, the patient and their family/support system must be given every opportunity to educate and empower themselves on self-management of their disease process. Patients must be given the benefit of the doubt that they can indeed embrace their health and well-being and work with their healthcare provider in maximizing their health outcomes.

For diabetes mellitus, numerous lifestyle behaviors should be addressed and actively worked on, so that the patient receives the maximum health benefits. The following lifestyle behaviors are in no particular order; they all warrant discussion at every office visit.

 

Diet

A person with diabetes should be educated on the effects of food and nutrition on their glucose level. Referrals to a dietitian/nutritionist or Certified Diabetes Care Education Specialist (CDCES) should be considered a top priority. Well-balanced nutritional intake, appropriate carbohydrate awareness, calorie monitoring if weight loss is appropriate to your specific patient) and medication/food interactions are all essential aspects of dietary lifestyle education. Many commercial insurance plans, as well as hospital community outreach programs, offer diabetes self-management classes.

 

 

 

 

Activity (17)

The CDC recommends a target goal of 150 minutes weekly, Patients should be educated on the positive effects of daily activity on overall health and well-being, stress management, and metabolism. Patients should find activities they are genuinely interested in, involve family and friends, and slowly build greater endurance through increased intervals of longer duration.

 

Sleep hygiene (18)

Patients should be educated on the positive effects of a good night’s sleep. The aim should be approximately 7-8 hours of restful sleep. Electronics should be powered down and (optimally) removed from the bedroom. A dark, well-vented, cool room temperature is encouraged, and large meals and late-evening caffeine should be avoided.

 

Medication adherence/ literacy

Medication education is critical to the health and well-being of a patient. Routine education of the patient, and family members or support systems when available, should be supportive and patient-specific. Patients should be assessed on language barriers, literacy issues, and related comprehension concerns. Medication education should include effects, side effects, treatment goals, and sick day management. Emergency care issues should also be discussed. Any monitoring equipment (continuous glucose monitors, accuchecks, lancets) should be reviewed with patients and confirmed with return verbalization and demonstration.

 

As discussed in this course, patients with chronic diseases must learn self-management techniques to optimize their health and well-being. They must become confident in their understanding of their disease process and take ownership of their health. In doing so, they minimize the risk of long-term complications, improve their self-worth, and actively invest (both time and money) in their future.

Quiz Questions

Self Quiz

Ask yourself...

  1. How does sleep, diet, and activity level affect the treatment of type 2 diabetes?

Ozempic Case Study

  • 52-year-old female
  • Height 67 inches
  • Weight 225 pounds
  • B/P 138/84, Heart rate 76 NSR
  • BMI 35.2%
  • Nonsmoker, occasional social drinker
  • Multiple attempts at dieting without success.
  • Diagnosed T2DM approx. 6 months ago current A1C 7.5%; initial medication Metformin 500mg BID tablets; tolerated well. No GI upsets.

Today’s appointment is for evaluation and additional medication consideration (the patient requested this appointment)

The patient was diagnosed with T2DM approximately 6 months ago. Initial A1C 8.0%. Current A1C 7.7%

Despite an improved diet and adherence to the medication regimen, the patient voiced frustration at the lack of weight loss. Requesting additional medication. Has a neighbor friend who began injectable Ozempic and is having “really great results with it. I want to start on it as well”.

 

  • What are your thoughts on prescribing semaglutide injectable for this patient?
  • What objective health data points should be taken into consideration regarding prescribing semaglutide for this patient?

 

The patient has expressed frustration that despite taking her medications and adjusting her diet, she has not lost any weight in the past 6 months. She has “heard from her neighbor friend that the weight just melts off immediately” and she is ready to start this medication.

 

  • What concerns do you know about this patient's understanding of weight loss as it relates to semaglutide?
  • What prescribing information, specific to semaglutide and weight loss, could you share with your patient regarding realistic weight loss targets?
  • In addition to teaching your patient proper injection technique for the use of semaglutide, what other lifestyle education behaviors should you discuss at this point?
  • What information should you share with your patient regarding the long-term use of semaglutide and the potential risks of stopping this medication (as it relates to weight regain)?

 

Your patient decides to go ahead with the semaglutide regimen.

  • What are some patient education guidelines regarding common side effects of this medication?
  • How often is the dose increased? What is the maximum dose this patient can receive weekly?

 

Your patient wants to know how long she will be taking this medication.

  • What talking points will you cover regarding the long-term use of this medication?
  • How do you best prepare this patient for long-term success with this medication?
  • What lifestyle behavior modification education would you discuss with your patient, to give her the best chance at successfully managing her diabetes?

Medication Assisted Treatment (MAT)

Introduction   

Medication Assisted Treatment (MAT) is a treatment modality for substance use disorders. It combines counseling and behavioral therapies for addiction with medications used carefully to reduce the physical symptoms of cravings and withdrawal and assist clients in the recovery process. With half of people 12 and older reporting use of an illicit substance at least once and 21 million Americans experiencing addiction, this is an important and relevant topic (4).

Historically, an intense stigma is attached to both addiction and some of the medications used to treat addiction. A thorough understanding of substance use disorders, available MAT therapies, and care of affecting clients are essential topics for nurses to be familiar with, particularly those working in psychiatry, pain management, or addiction medicine.

Overview of Addiction and Substance Abuse:

Drug and alcohol abuse and addiction are chronic, complicated issues involving persistent changes to the brain. There is a stigma or misunderstanding that people with substance abuse disorders can stop any time they want to or lack the willpower or moral fortitude to stop using. This is entirely untrue, and even people who are "recovering" and have not had any drugs or alcohol in years can easily relapse into addiction once those brain changes have occurred (5).

When a person uses drugs or alcohol, the brain's reward center is flooded with dopamine. This provides a "buzz" or pleasurable sensation that may create the desire to use more of the same substance. Over time, and with regular use of the substance, the brain becomes accustomed to the flooding of dopamine and reduces the reward response, a process known as tolerance.

It will now take the same person a more significant amount of the substance to achieve the same "buzz" or "high" they used to feel. This process can also dull the pleasure response to activities not involving substance use, such as food, socialization, or sexual activity. Over time, the chemical changes in the brain can progress to include decreased functioning of learning, decision-making, judgment, response to stress, memory, and behavior (5).

To understand substance abuse disorders, it is first essential to understand some basic definitions. These terms are sometimes used interchangeably, but they mean different things and represent different stages of disease.

 

Definitions

Substance Use: Substance use is any consumption of drugs or alcohol, regardless of frequency or amount. An occasional glass of wine or taking an edible at a party is an example of substance use. Substance use does not cause problems or dependency in many people (5).

Substance Abuse: Substance abuse is the continued use of drugs or alcohol, even when they do cause problems. Conflict or problems at home, school, work, or legal issues related to the use of drugs or alcohol are signs of abuse. For example, being sent home from school for smoking in the bathroom or failing a drug test at work (5).

Substance Dependence or Addiction: Dependence and addiction can be used interchangeably or is sometimes called substance use disorder. Addiction occurs when a person cannot stop drinking or using drugs despite creating problems in their life. People who are addicted may experience cravings until they use a specific substance, or they may experience uncomfortable physical symptoms, known as withdrawal if they do stop (5).

The American Psychiatric Association (APA) utilizes the following criteria to diagnose clients who suffer from addiction. The more criteria a client answers yes to, the greater their problem with substance use.

Six or more positive criteria are indicative of addiction.

  1. Using substance in more significant amounts or for more extended periods than intended
  2. Trying to stop using but being unable to
  3. Increased amounts of time getting, using, or recovering from use of the substance
  4. Experiencing cravings or urges to use.
  5. Continuing to use the substance despite problems with relationships or social situations.
  6. Missing work, social, or recreational obligations or activities because of substance use
  7. Participating in risky behavior because of substance use
  8. Continuing to use the substance despite psychological or physical health problems.
  9. Needing to use more substance over time to achieve the desired effect.
  10. Experiencing withdrawal symptoms when stopping the substance (1).

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Do you know anyone who suffers from a substance use disorder?
  2. Think about your biases (thoughts, opinions, attitudes) about addiction. Does any of the information above conflict with those biases?

Substance Abuse Statistics

Many factors go into gathering data on substance abuse disorders, from underreporting, the nuance between use, abuse, and addiction, and the large variety of substances available, with the legality of some substances varying by state or age.

The statistics below from 2020 are not meant to be an exhaustive list of substance use disorders in this country but rather an overview of some of the more prevalent addiction-related issues.

  • 50% of people 12 years and older have used an illicit substance at least once.
  • 5% of Americans 12 years and older have used drugs within the last month.
  • This is a 3.8% increase from the previous year.
  • About 50% of Americans 12 and over drink alcohol
  • 4% of those people have an alcohol use disorder.
  • About 20% of Americans use tobacco products or vape
  • 18% of Americans over 18 used marijuana in the last 12 months
  • 30% of those have some level of misuse or addiction.
  • Marijuana is commonly involved in polysubstance use, paired with alcohol or other drugs.
  • 7% of Americans over 12 misused opioids in the last 12 months
  • 96% of those used prescription pain relievers
  • Opioid prescriptions peaked in 2012, with 81.3 prescriptions per 100 people.
  • The rate has declined recently due to increased attention to this crisis.
  • In 2018, the rate was down to 51 prescriptions for every 100 people
  • Fentanyl is now rising as a new and deadly concern.
  • 5 million prescriptions were written for fentanyl in 2015.
  • Fentanyl is involved in 53% of overdose deaths.
  • 7% of all Americans misuse a prescription drug.
  • 1% of those misuse stimulants
  • 2% of those misuse sedatives
  • 5% misuse painkillers
  • Over 70,000 drug overdose deaths occur annually in the United States (4)

Risk Factors

A combination of factors is involved in the risk of addiction, and no one factor can determine if someone will develop addiction or after how many uses this will occur.

The addiction process does occur more easily or progresses more rapidly for people with certain risk factors, including:

 

Genetics

There is a strong genetic correlation with addiction, indicating that biology plays a significant role in the disorder. Family history of addiction, gender, ethnicity, and comorbid mental health conditions can all influence the risk of addiction. (5)

  • Children of addicts are eight times more likely to develop an addiction at some point.
  • In 2020, among those using illicit or misusing prescription drugs, 22% were male and 17% female.
  • Only 20% of users in drug treatment programs are women.
  • 9% of people with substance abuse disorders also have at least one mental health disorder (4)

 

Environment/Non-Genetic Demographics

The attitudes about drugs and alcohol from those in a person's network and life experiences play a role in the risk of addiction. Substance use among friends, family, or coworkers increases the risk that a person will also use substances. Exposure to substance use from a young age relaxed parental attitudes about substance use, and peer pressure from friends can increase the risk. Certain stressful life circumstances such as veteran status, history of sexual or physical assault, or being part of the LGBTQ community can also increase risk. (5)

  • 20% of people in urban areas used illegal drugs in 2020 compared to 5% in rural locations.
  • 51% of Americans with an illegal pain relief medication obtained it from a friend or relative.
  • 7% of LGBTQ Americans abuse illicit drugs.
  • 2% of LGBTQ Americans abuse alcohol.
  • 7% of Veterans abuse illicit drugs.
  • 80% of Veterans abuse alcohol (4)

 

Developmental Stage

Substance use at any age can lead to addiction, but children and teens are at particular risk due to their underdeveloped brains. The parts of the brain responsible for decision-making, risk assessment, and self-control do not fully develop until the early 20's, putting teenagers at increased risk of dangerous behaviors. In addition, the effects of drugs and alcohol on the developing brain may mean that those parts of the brain never fully develop at all for teens with substance abuse disorders. (5)

  • 70% of users who try an illegal substance before age 13 will develop a substance use disorder within the next seven years.
  • This is for only 27% of people who first try an illegal substance after age 17.
  • 47% of youths report trying an illegal substance by the time they graduate high school (4)
Quiz Questions

Self Quiz

Ask yourself...

  1. Why do you think medication alone is not an adequate treatment for substance abuse disorders?
  2. Is MAT something you have heard of before? Why do you think it is relatively uncommon despite being around for decades?

Overview of Medication Assisted Treatment (MAT)

Treatment of substance abuse disorders is a complex and often tumultuous process. The nature of the brain changes that occur during addiction means that a person is never entirely "cured" but will always be considered "recovering" as the risk for relapse is always present. Effective treatment must be multifaceted and often involves removing triggers (such as people, places, and stressors) that may prompt a person to use again behavioral therapy, and medications to curb withdrawal symptoms and reduce cravings.

Medication Assisted Treatment (MAT) is a treatment that involves FDA-approved medications, in combination with behavioral therapy, in the recovery process for substance abuse disorders. Several medications are available for MAT, and evidence continues to emerge that the treatment is highly effective if used correctly.

However, it is a vastly underused and understudied treatment modality. MAT has been available in some form for over 50 years but is just starting to gain traction among the medical community (and policymakers) in recent years, with the federal government calling for more research and increased accessibility for the treatment (8).

The height of the opioid crisis in the last several years has highlighted the magnitude of drug addiction and deaths in the United States, bringing renewed attention to MAT as a treatment option. So, how does MAT work? Prescription medication is given to both stimulate the receptors seeking the abused substance and block the drug's euphoric effects.

Over time, this normalizes brain chemistry and helps the person break the habit of using without the discomfort of cravings and withdrawal symptoms. Gradually, the prescription medication dosage is reduced, all the while in conjunction with behavioral therapy and lifestyle changes, and eventually, the client should be able to stop the medication altogether, often within 1-3 months (8).

MAT does require close supervision by a trained medical professional and an appropriate facility for treatment. It can be done on an inpatient, partial inpatient, or outpatient basis. There may be side effects to the medication, and there is a risk of misusing or developing addiction to the new drug, though the successful outcomes often outweigh this risk. Clients must also participate in behavioral therapy for a comprehensive and effective treatment plan. As with any treatment regimen, careful consideration of the client's history and circumstances is essential (8).

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why do you think medication alone is not an adequate treatment for substance abuse disorders?
  2. Is  Medication Assisted Treatment (MAT) something you have heard of before? Why do you think it is relatively uncommon despite being around for decades?

Pharmacokinetics

Currently, there are three medications with FDA approval for MAT: buprenorphine, methadone, and naltrexone. Each will be discussed in depth below.

 

Buprenorphine
Mechanism of Action and Metabolism

Buprenorphine is an opioid partial agonist, acting on the same receptors as other opioids but with weaker effects. It can be used for the treatment of misuse of opioids, including:

  • Heroin
  • Fentanyl
  • Oxycodone
  • Hydrocodone
  • Morphine
  • Methadone (3)

 

Opiate receptors are G-protein coupled receptors (GPCRs) with four major types: Mu, Delta, Kappa, and opioid receptor like-1 (ORL1). Stimulation of these receptors results in varying levels of the following effects:

  • Euphoria
  • Relaxation
  • Pain relief
  • Sleepiness
  • Sweating
  • Constipation
  • Impaired concentration
  • Reduced sex drive (3)

 

Buprenorphine has a high affinity to the Mu-opioid receptor and is a partial agonist at this site, causing reduced opioid effects with a plateau or ceiling at higher doses. This limits dangerous effects and makes overdose unlikely. It also has slow dissociation from the site, allowing milder and more easily tolerated withdrawal effects compared to full agonists like morphine and fentanyl. Buprenorphine is also a weak kappa receptor antagonist and delta receptor agonist, reducing the craving sensation and improving tolerance to stress (3).

Buprenorphine has poor bioavailability when given orally due to the first-pass effect, where most of the drug is broken down in the liver and intestines. Because of this, sublingual or buccal are the preferred routes of administration and the most common forms in which the drug is manufactured. Transdermal patches and IV and IM forms exist, though not for use in MAT (3).

CYP34A enzymes break down buprenorphine, so other drugs, such as ketoconazole, may inhibit metabolism and increase available levels of buprenorphine. CYP34A inducers such as carbamazepine, topiramate, phenytoin, and barbiturates may speed metabolism and lower available levels. Once broken down, the med takes the form of norbuprenorphine and is excreted in the feces (3).

 

Available Forms

Buprenorphine is available by itself and with naloxone (in a 4 to 1 ratio). However, in oral form, naloxone is not readily absorbed, and buprenorphine is the only genuinely active ingredient. This combination is beneficial should clients try to inject their buprenorphine to get high; naloxone is a fast-acting opioid antagonist that is active when used intravenously and would block the opioid effect of buprenorphine, rendering it useless for recreational use and ensuring it has no street value.

The currently available preparations of buprenorphine for MAT include:

  • Generic Buprenorphine/naloxone sublingual tablets
  • Subutex - Buprenorphine sublingual tablets
  • Suboxone - Buprenorphine/naloxone sublingual films
  • Zubsolv - Buprenorphine/naloxone sublingual tablets
  • Bunavail - Buprenorphine/naloxone buccal film (3)

 

Sublingual products dissolve within 2-10 minutes. Bloodstream absorption begins quickly, bypassing the first pass effect. Buprenorphine has a slow onset of action, peaking about 3-4 hours later. Metabolism is also slow, with the half-life lasting anywhere from 25 to 70 hours (an average of about 38 hours). This long half-life means the drug can be spaced out to every other day administration once weaning begins (3).

 

Dosing and Monitoring

Clients prescribed buprenorphine must stop using opioids for at least 12 to 24 hours before the first dose; this varies depending on which opioid they are stopping. For short-acting opioids like heroin and oxycodone, buprenorphine may be started 6-12 hours after the last dose. With longer-acting opioids such as morphine or extended-release preparations of oxycodone, buprenorphine should be delayed for about 24 hours. For the longest action opioids, fentanyl patch, 48 -72 hours must be between the last dose and buprenorphine initiation (3).

This initiation schedule means clients will be in the early stages of discomfort and withdrawal. Administration of buprenorphine when clients still have opioids in their bloodstream will lead to competition for receptor sites, rapidly replacing the opioid with buprenorphine and causing acute and more severe withdrawal symptoms.

Depending on the severity of a client's addiction, they may complete the first step of abstaining and withdrawal in an inpatient setting. Once the initial withdrawal symptoms have passed and the initial dose of buprenorphine has been given, the client may be discharged home to continue buprenorphine initiation on an outpatient basis (3).

Initial doses are typically 2-4mg, with up to 4mg given to clients used to higher potency or larger doses of opioids. The dose is gradually increased to meet the client's individual needs, with a maximum dosage of 24mg per day. The average client requires 8-12 mg per day and can reach this dose within the first 2-4 days. It is recommended that doses be supervised by a pharmacist at the dispensing pharmacy for the first two months of treatment to ensure compliance and clients are less likely to relapse (3).

The length of treatment with buprenorphine depends on each client's case and, for some, may be indefinite. Clients who do wish to wean off buprenorphine can begin the process once they are stable and experiencing few or no cravings, and a minimum of 8 weeks from treatment initiation. Doses are moved to alternating days and eventually discontinued altogether (3).

 

Side Effects and Contraindications:

As with any medication, there are potential side effects, including:

Common Side Effects

  • Nausea
  • Vomiting
  • Drowsiness
  • Dizziness
  • Headache
  • Memory loss
  • Sweating
  • Dry mouth
  • Miosis
  • Postural hypotension
  • Sexual dysfunction
  • Urinary retention

 

Serious side effects

  • CNS depression
  • QT prolongation
  • Reduced seizure threshold
  • Potential for abuse or overdose (3)

 

Buprenorphine is contraindicated for clients with a past hypersensitive reaction to it. It should be used cautiously for clients with respiratory suppression, older adults, or for those with liver pathologies. Regular monitoring of liver enzymes via lab work is essential (3).

It is a Category C medication for pregnancy, and the risks versus benefits should be carefully weighed. Buprenorphine does cross the placenta and increases the risk of withdrawal symptoms and neonatal abstinence syndrome (NAS) after delivery. However, for pregnant clients with the highest risk of relapse and abuse of opioids, evidence does support that continuation of buprenorphine during pregnancy may improve maternal and fetal outcomes (3).

Buprenorphine may be abused by crushing tablets, snorting the powder, or dissolving it into an injectable solution. Safety measures against this include supervised administration by a pharmacist and the addition of naloxone, which blocks the buprenorphine effects. While the effect ceiling of buprenorphine makes overdose difficult, combining the drug with benzodiazepines, alcohol, or other drugs can compound the CNS depressant effects and increase the risk of overdose (3).

Clinicians need to have a comprehensive health history of clients before initiating buprenorphine so that all risks and potential interactions can be addressed appropriately.

 

Role of the Pharmacist

Pharmacists play a significant role in the success of MAT involving buprenorphine. Outpatient doses are monitored by the dispensing pharmacist daily, with at-home quantities being allowed on a limited basis (such as weekends or travel) and only for the most motivated and compliant clients. Vital signs are collected before each dosage, with careful monitoring for hypotension or bradypnea. The dose may be skipped for clients who experience excessive side effects, and the client can return the next day for their dose.

Clients presenting with signs of overdose (usually to the ED) may receive naloxone, which will reverse overdose symptoms within 1 hour. Overdose symptoms include dizziness, pinpoint pupils, hypotension, bradypnea, hallucinations, seizure, or unconscious state.

If a client misses a dose, does not show up for it, or is experiencing significant side effects from buprenorphine, the prescribing clinician should be notified so that the treatment plan can be revisited and revised if needed (3).

 

Considerations for the Prescriber

When considering which medication to prescribe for MAT, prescribers should understand that buprenorphine offers advantages over methadone.

  • Lower risk of abuse
  • Safer, including at higher doses.
  • Therapeutic dose achieved quickly.
  • Easier to taper.
  • Can be obtained from any provider rather than a methadone clinic.
  • Less stigma

 

The cost of a 30-day supply is around $300. Buprenorphine/naloxone combinations are a little more expensive at $400/month. While prior authorization is usually required, most commercial insurance and state Medicaid programs will cover the medication.

Buprenorphine is a Schedule III Controlled Substance; however, recent federal regulations have been aimed at approving access to MAT, and any provider with an active DEA license may prescribe buprenorphine as allowed by state regulations. Specialized clinics are not required (as they are with methadone), and it is dispensed at regular pharmacies.

Prescribers are encouraged to participate in additional training about MAT with buprenorphine, but it is not required. Detailed documentation must be completed, including the reason for prescribing, start and end dates of treatment, the pharmacy used, the credentials of who will supervise administration, and frequency of follow-up and compliance monitoring. The sublingual and buccal routes are the only forms of medication used for MAT; patches, IM, and IV preparations are not routinely used for MAT.

The success of buprenorphine treatment depends on the client's education. Addiction potential, risk of combination with other CNS depressants, and side effects vs. signs of overdose should all be discussed with clients and their support system (3).

Quiz Questions

Self Quiz

Ask yourself...

  1. Given the nature of substance abuse disorders, why do you think including an opioid antagonist like naloxone in preparations of buprenorphine is necessary for safety and compliance?
  2. What challenges do you see with a medication needing to be administered daily with pharmacist supervision?
  3. What are the risks of buprenorphine being given without this supervision?
  4. Consider the possible pros and cons of taking a medication like buprenorphine during pregnancy. Also, consider the risks of NOT taking the drug during pregnancy when a substance use disorder is present.
Methadone
Mechanism of Action and Metabolism

Methadone is a synthetic opioid and a full agonist of the Mu-receptor site, stimulating the same effects as opioids.

  • Euphoria
  • Analgesia
  • Sedation

 

It can be used as a potent analgesic for pain not responding to traditional medications, such as in clients with cancer or terminal illness, as well as for MAT and neonatal abstinence syndrome (NAS).

For this course, it will be discussed as a MAT agent, used in treatment for clients addicted to opioids such as:

  • Heroin
  • Fentanyl
  • Oxycodone
  • Hydrocodone
  • Morphine
  • Hydromorphone (2)

 

Methadone is a full agonist at the Mu-receptor, meaning it is a more potent and more easily addictive medication than partial agonists like buprenorphine. Methadone has a long half-life (8-60 hours), occupying the Mu-receptors and blocking short-acting opioids from making a client high. The longer half-life also leads to less severe cravings and withdrawal symptoms. Methadone is also an antagonist to the N-methyl-d-aspartate (NMDA) receptor, which adds to its pain relief action (2).

It has high oral bioavailability, is active in the bloodstream within 30 minutes of ingestion and remains elevated for around 24 hours. It is broken down via CYP3A4 and CYP2B6 enzymes and metabolized through the liver, making it a good option for clients with renal problems.

Medications such as ciprofloxacin, benzodiazepines, fluconazole, cimetidine, and fluoxetine may slow methadone metabolism, increasing the available drug and the side effects of overdose risk. Other medications may speed metabolism and decrease the effects of methadone, including phenobarbital, phenytoin, rifampin, ritonavir, and carbamazepine (2).

 

Available Forms

Methadone is available in many forms, including oral, IM, subcutaneous, IV, and intrathecal, though only the oral is typically used for MAT.

  • Methadone - tablets
  • DISKETS - dispersible/dissolvable tablet
  • Methadone HCL Intensol - 10mg/ml suspension
  • Methadone - dispersible tablet (2)

 

Dosing and Monitoring

Oral dosing is initiated at 30-40 mg/day with a slow titration of 10-20 mg/week until the optimal dosage is reached. The optimal dosage varies by client and depends on the drug they are replacing, tolerance to opioids, and side effects experienced. A dosage between 80- 150 mg/day is the typical goal. (2)

If parenteral methadone is given, it is usually 50%-80% of the oral dosage.

Blood sugar, EKG, and methadone blood levels should be checked regularly, every week for higher-risk patients, and every 3-6 months for those in good health and compliance. The target methadone blood level is around 400 ug/ml (2).

 

Side Effects and Contraindications

Potential side effects are directly related to stimulation of the opioid receptors and include:

  • Diaphoresis
  • Flushing
  • Pruritus
  • Nausea
  • Dry mouth
  • Constipation
  • Sedation
  • Lethargy
  • Respiratory Depression
  • QT prolongation
  • Hypoglycemia (2)

 

Methadone should be considered with a comprehensive view of a client's health history and other medications. Clients with CNS-related disease processes (trauma, increased ICP, dementia, or delirium) must be monitored closely or have other medication considered.

Methadone should not be used simultaneously as other opioids, benzodiazepines, alcohol, or antipsychotics due to increased CNS effects. Methadone is a Pregnancy Category C medication, and risks versus benefits should be weighed carefully. Infants exposed to methadone in utero are at increased risk of NAS after delivery (2).

Overdose can occur, and clients and support systems should be educated on signs of overdose.

  • Lethargy
  • Somnolence
  • Stupor
  • Coma
  • Miosis
  • Bradycardia
  • Hypotension
  • Respiratory sedation
  • Cardiac arrest

 

Naloxone is used to reverse overdose (2).

 

Considerations for Prescribers and Clinics

Methadone is a Schedule II Controlled Substance, meaning it has a high abuse potential and must be carefully monitored. The Prescription Drug Monitoring Program (PDMP) is an electronic database used nationwide to register the distribution of controlled substances so that clients do not seek care at multiple clinics or pharmacies to obtain more of a controlled substance.

When prescribing methadone, providers should check the PDMP for both methadone and other prescription opioids so that they are fully aware of other medications clients may be receiving from other places. Regular urine drug screening should be performed to make sure clients are not using other substances not obtained by prescription and that they are testing positive for methadone, meaning they are genuinely taking it if administration is not observed (2).

At the beginning of treatment, methadone is given in the office under a nurse's supervision, and then clients are monitored for adverse effects. Some take-home doses (up to 7 in the first two weeks) may be arranged for weekends or during travel, but this possibility is limited during the first few weeks of treatment. As treatment progresses and compliance is demonstrated, clients may self-administer more doses at home (up to 28 doses per month) and go longer between visits to the clinic. The total length of treatment varies but is often 1-2 years and can even be indefinite (7).

There are methadone clinics that work entirely in the scope of addiction management, but primary care providers may prescribe methadone as well. Prescribers must have an active DEA license and comply with state-based controlled substance regulations (2).

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why do you think methadone is a Schedule II Controlled Substance while buprenorphine is only a Schedule III?
  2. What are the benefits of checking the serum level of methadone?
  3. What might the clinical presentation be for someone overdosing on methadone?
  4. Have you ever used the PDMP database before? What are the benefits of accessing this database?
Naltrexone
Mechanism of Action and Metabolism

Naltrexone has been in use since the 1960s and is an opioid antagonist. It competes primarily with the mu-receptor but also serves as an antagonist at the kappa and delta receptors. As an antagonist, it competes with agonists such as opioids and alcohol and blocks the effects of agonists at those sites.

  • Prevents euphoria.
  • Prevents intoxication.
  • Reduces tolerance (6)

 

Naltrexone also acts on the hypothalamic-pituitary-adrenal axis, modifying it to reduce cravings and suppress alcohol consumption.

It is FDA-approved for use in clinical practice for the treatment of:

  • Alcohol use disorder
  • Opioid use disorder (prescription and non)

 

Naltrexone is absorbed orally and undergoes extensive metabolism via the first-pass effect. However, this does not affect its potency as naltrexone's active metabolite, 6β-naltrexone, acts as a potent opioid antagonist. The medication's half-life is around 4 hours but can last up to 24 hours. If administered parenterally, it bypasses the first pass and is even longer acting, with a half-life of 5-10 days. Naltrexone is excreted by the kidneys (6).

 

Available Forms

Naltrexone is available in an oral tablet and IM injection. Available preparations include:

  • Generic naltrexone tablets
  • Revia (oral tablet)
  • Depade (oral tablet)
  • Vivitrol (solution for IM injection, extended-release) (6)

 

Dosing and Monitoring

Since naltrexone will compete for and block all opioid receptor sites, the risk for withdrawal symptoms is high, and clients must stop the use of alcohol or opioids for 7-10 days before beginning treatment to lessen the risk of withdrawal symptoms. A naltrexone challenge is recommended at the start of therapy.

This consists of administering small amounts of naltrexone subcutaneously or via IV and monitoring the client and their vital signs for signs of withdrawal, such as:

  • Nausea
  • Vomiting
  • Diaphoresis
  • BP changes
  • Tachycardia
  • Rhinorrhea
  • Agitation
  • Tremors
  • Abdominal pain
  • Pupillary dilation (6)

 

If a client fails the naltrexone challenge and has not been long enough since their last use of alcohol or opioids, the naltrexone initiation should be delayed, and the test should be repeated in 24 hours. If clients tolerate the naltrexone test and the negative result, they may begin naltrexone treatment (6).

For oral tablets, dosing usually starts at 25 mg for the first dose. Clients are observed for withdrawal symptoms and side effects; an additional 25 mg is given 1 hour later. After that, clients take 50 mg per day. Clients may continue with 50mg daily or take 100 mg every other day or 150 mg every 3rd day (6).

Alternatively, naltrexone may be given via IM injection for more extended action, improving compliance and reducing relapse. Particularly for alcohol or heroin dependence, data indicates that the IM route has much higher success rates than the oral route. If a client receives the IM injection, 380 mg is given to the gluteal muscle every four weeks (6).

 

Side Effects and Contraindications

Most common side effects of naltrexone include:

  • GI irritation
  • Diarrhea
  • Abdominal cramps
  • Nausea
  • Vomiting
  • Hypertension
  • Headache
  • Anxiety
  • Low energy
  • Joint or muscle pain
  • Nervousness
  • Sleep disruption

 

Less commonly, clients report:

  • Loss of appetite
  • Constipation
  • Dizziness
  • Irritability
  • Depression
  • Rash
  • Chills (6)

 

Caution should be used for clients with liver function issues and renal impairment. It is Category C for use during pregnancy, and the risks versus benefits of use in pregnancy must be carefully considered. It also crosses into breast milk and must be considered carefully.

There is limited data about the overdose of naltrexone, and there may be very few symptoms if an overdose occurs. Clients should be monitored for signs of liver dysfunction, seizures, depression, and suicidal ideations. No antidote for naltrexone is currently available.

Naltrexone is contraindicated for clients who failed a naltrexone challenge, test positive for opioids or alcohol on drug screening, have a history of seizures, or have experienced a past hypersensitivity reaction to naltrexone.

Clients may switch from buprenorphine or methadone to naltrexone at some point in treatment. Both medications are agonists at the opioid receptor sites, so changing to naltrexone (an antagonist) may increase the risk of withdrawal symptoms for the first two weeks of treatment (6).

 

Considerations for Prescribers

Because naltrexone does not cause any euphoria or "high," the abuse potential is non-existent. It is not a controlled substance and can be prescribed by any clinician with prescriptive authority. However, its use is typically only by those who work in mental health or addiction medicine. Clients can take the medication at home or go to the clinic for IM injections.

Many considerations for naltrexone use center around monitoring for side effects and treatment compliance. Baseline and periodic drug screening and liver function tests are prudent. Clients' support persons should be educated on compliance and signs of relapse. The IM formulation should be considered for those with poor compliance or most at risk for relapse (6).

Quiz Questions

Self Quiz

Ask yourself...

  1. Why might a client benefit from the IM formulation of naltrexone instead of the oral preparation?
  2. Why might compliance with an opioid antagonist be more complex than an opioid agonist like methadone or buprenorphine?
  3. How do side effects differ between naltrexone and the agonist medications like methadone?
  4. What does it mean if a client fails a "naltrexone challenge," and how does this delay their care?

Nursing Considerations

Nurses will encounter clients with addiction and even those receiving MAT in a variety of settings, including:

  • Outpatient clinics for routine care of any health issues
  • ED admission for acute problems not related to addiction.
  • Inpatient hospitalization related to other health problems.
  • Outpatient setting for participation in MAT or addiction management.
  • ED admission for acute problems related to substance abuse or toxicity of MAT medication.
  • Inpatient mental health admission for mental health and addiction issues

 

Regardless of the setting and if the client is being seen for an addiction issue or something else, it is crucial for nurses to be familiar with MAT medications and how they work to provide safe and competent care. Nurses may need to:

  • Administer medication.
  • Monitor lab results.
  • Observe for side effects, toxicity, or withdrawal symptoms.
  • Coordinate care within a multidisciplinary team
  • Communicate with therapeutic and nonjudgmental techniques.

 

 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you ever cared for a client in a non-addiction setting who had a MAT medication on their drug list?
  2. Did you have any biases or preconceived ideas about what this medication meant?
  3. Is there anything you have learned throughout this course that will change your care the next time you encounter a client receiving MAT?

Case Study

Justin is a 32-year-old male who presents to the ED with nausea, lethargy, and confusion worsening over the last 24 hours. Upon exam, the nurse notes diaphoresis, slurred speech, and pinpoint pupils. His vitals are RR 10, HR 54, BP 82/58, SPO2 97%, Temp 99.0.

He reports taking Wellbutrin 150mg daily for depression and smoking cessation, methadone 100mg daily for history of oxycodone abuse, and was started on ciprofloxacin 250mg BID for a UTI 2 days ago at urgent care.

His labs are significant for a WBC of 15,000 but otherwise regular. He tests positive for methadone, which is expected, but not for other substances. He reports being compliant with MAT and avoiding opioid use for nine months.

It is determined that Justin is experiencing methadone toxicity due to the slowed metabolism of the drug from the combination of methadone and ciprofloxacin. He is given naloxone in the ED, and within an hour, his symptoms have improved significantly, and his vital signs are typical. His antibiotic is switched to cefdinir, and he is discharged home in stable condition with instructions to follow up with his PCP within 1-2 days.

Quiz Questions

Self Quiz

Ask yourself...

  1. Given Justin's presentation, how could you differentiate between methadone toxicity and relapse?
  2. How might Justin's condition have progressed if he had not sought emergency care?
  3. How would Justin's case have been different if he had not tested positive for methadone?
  4. In what ways could Justin's care before his ED visit have been improved to avoid this complication?

Conclusion

Substance use disorders are a long-standing and dangerous pathology experienced by millions of people each year. At the same time, the stigma of seeking help for such disorders has been eroding in recent years; there has also been a renewed push by the federal government to address the issue in evidence-based and meaningful ways, with access to effective treatment being at the top of the priority list.

Addiction treatment programs utilizing MAT will likely become much more popular in the coming years, and nurses will be on the front lines of this therapy. For nurses to provide competent and comprehensive care to this client population, up-to-date and accurate knowledge is necessary.

West Virginia Drug Diversion

In 2018, West Virginia had not only the highest opioid-related death rate in the nation, but also the highest synthetic opioid-related death rate (46). In 2019, West Virginia ranked in the top 10 for opioid dispensing rates, with a rate of 59.4 per 100 persons being prescribed an opioid (10), which is well above the national average of 46.7 per 100 (9). While this number has consistently decreased since 2006, the numbers of individuals in West Virginia affected by addiction and overdose remains high (30). 

Introduction   

The opioid crisis in the United States continues to affect millions of individuals. The American Psychiatric Association (APA) estimates nearly one in three Americans know someone who either is or has been addicted (1). The Centers for Disease Control (CDC) identified that in 2017, there were 70,237 overdose deaths, and in 2018, there were 67,367 (46). In both 2017 and 2018, nearly two-thirds of these involved an opioid (46). Currently, it is estimated 128 people die per day from an opioid overdose (8). The National Institute on Drug Abuse (NIDA) identifies misunderstandings and misconceptions about addiction of prescription opioids, held by pharmaceutical companies and health care providers in the 1990s, led to an increase in their use and subsequent rise in misuse and addiction (8, 31). Following this in 2010, deaths related to heroin began to rise quickly, and in 2013, deaths associated with synthetic opioids, like illicitly manufactured fentanyl, began to increase (8).   

The impact of opioid misuse and addiction is devastating to families. It can lead to job loss, relationship difficulties, inability to care for children, and death. Families who have a loved one struggling with opioid addiction may feel at a loss regarding handling or supporting their loved one, putting additional stress on the family unit. Arrest, conviction, hospitalization, and even death of a parent from opioid addiction, often place children in the care of the child welfare, further straining the system. Not only does the use of opioids impact individuals and families, but it puts additional strain on both state and national economies. It is estimated that misuse of prescription opioids costs the United States $7.5 billion per year (31).  

 In 2018, the West Virginia Department of Health and Human Resources introduced an opioid response plan, which addressed prevention, early identification, treatment, overdose reversal, family support, and recovery (43). Recommendations of the plan include expanded treatment for neonatal abstinence syndrome (NAS), improved access to treatment, improved overdose reporting, improved access to naloxone, addressing issues with pain management and prescribing practices, expanded licensing for medication-assisted treatment programs, and it created the Opioid Reduction Act (43). It is important to discuss The Opioid Reduction Act of 2018 in this West Virginia Drug Diversion course as it requires health care providers to prescribe the lowest effective dose and limits opioid prescriptions to a four-day supply for an emergent or urgent care, a three-day supply for minor surgery or procedure, a three-day supply for dentist or optometrist, and a seven-day supply for patients seen by their primary physician or at discharge from a hospital (34).  

While West Virginia has taken steps to address the opioid crisis, more work is needed to meet the need of patients, families, and health care workers. Health care providers who are not specifically trained to treat substance use disorders may struggle when working with patients who suffer from addiction, as there are often knowledge gaps related to these patients’ care. Gaps exist related to fully understanding the broad spectrum of a substance use disorder and in the identification of at-risk populations. Additionally, stereotypes about addicts still exist, which can inhibit health care providers from properly identifying and developing treatment plans for these patients. 

Many patients with substance use disorders are often able to hide their addiction from loved ones and providers for a period of time, which further complicates timely identification and intervention. Health care providers prescribing opioids and other medications that are high-risk for abuse should perform not only regular screening of at-risk patients, but also explore alternative methods for treating chronic pain. In an effort to address these concerns, the West Virginia Board of Nursing requires annual education for nurses who prescribe, administer, or dispense controlled substances (45). This course will address issues concerning the opioid crisis, including best practices for prescribing controlled substances, managing patients who divert, behaviors associated with drug seeking and substance use disorders, providing patient education on opioid use, storage, disposal, and reversal agents, as well as use of the West Virginia Controlled Substance Automated Prescription Program (CSAPP). 

In 2018, West Virginia had not only the highest opioid-related death rate in the nation, but also the highest synthetic opioid-related death rate (46). In 2019, West Virginia ranked in the top 10 for opioid dispensing rates, with a rate of 59.4 per 100 persons being prescribed an opioid (10), which is well above the national average of 46.7 per 100 (9). While this number has consistently decreased since 2006, the numbers of individuals in West Virginia affected by addiction and overdose remains high (30). 

Introduction   

The opioid crisis in the United States continues to affect millions of individuals. The American Psychiatric Association (APA) estimates nearly one in three Americans know someone who either is or has been addicted (1). The Centers for Disease Control (CDC) identified that in 2017, there were 70,237 overdose deaths, and in 2018, there were 67,367 (46). In both 2017 and 2018, nearly two-thirds of these involved an opioid (46). Currently, it is estimated 128 people die per day from an opioid overdose (8). The National Institute on Drug Abuse (NIDA) identifies misunderstandings and misconceptions about addiction of prescription opioids, held by pharmaceutical companies and health care providers in the 1990s, led to an increase in their use and subsequent rise in misuse and addiction (8, 31). Following this in 2010, deaths related to heroin began to rise quickly, and in 2013, deaths associated with synthetic opioids, like illicitly manufactured fentanyl, began to increase (8).   

The impact of opioid misuse and addiction is devastating to families. It can lead to job loss, relationship difficulties, inability to care for children, and death. Families who have a loved one struggling with opioid addiction may feel at a loss regarding handling or supporting their loved one, putting additional stress on the family unit. Arrest, conviction, hospitalization, and even death of a parent from opioid addiction, often place children in the care of the child welfare, further straining the system. Not only does the use of opioids impact individuals and families, but it puts additional strain on both state and national economies. It is estimated that misuse of prescription opioids costs the United States $7.5 billion per year (31).  

 In 2018, the West Virginia Department of Health and Human Resources introduced an opioid response plan, which addressed prevention, early identification, treatment, overdose reversal, family support, and recovery (43). Recommendations of the plan include expanded treatment for neonatal abstinence syndrome (NAS), improved access to treatment, improved overdose reporting, improved access to naloxone, addressing issues with pain management and prescribing practices, expanded licensing for medication-assisted treatment programs, and it created the Opioid Reduction Act (43). It is important to discuss The Opioid Reduction Act of 2018 in this West Virginia Drug Diversion course as it requires health care providers to prescribe the lowest effective dose and limits opioid prescriptions to a four-day supply for an emergent or urgent care, a three-day supply for minor surgery or procedure, a three-day supply for dentist or optometrist, and a seven-day supply for patients seen by their primary physician or at discharge from a hospital (34).  

While West Virginia has taken steps to address the opioid crisis, more work is needed to meet the need of patients, families, and health care workers. Health care providers who are not specifically trained to treat substance use disorders may struggle when working with patients who suffer from addiction, as there are often knowledge gaps related to these patients’ care. Gaps exist related to fully understanding the broad spectrum of a substance use disorder and in the identification of at-risk populations. Additionally, stereotypes about addicts still exist, which can inhibit health care providers from properly identifying and developing treatment plans for these patients. 

Many patients with substance use disorders are often able to hide their addiction from loved ones and providers for a period of time, which further complicates timely identification and intervention. Health care providers prescribing opioids and other medications that are high-risk for abuse should perform not only regular screening of at-risk patients, but also explore alternative methods for treating chronic pain. In an effort to address these concerns, the West Virginia Board of Nursing requires annual education for nurses who prescribe, administer, or dispense controlled substances (45). This course will address issues concerning the opioid crisis, including best practices for prescribing controlled substances, managing patients who divert, behaviors associated with drug seeking and substance use disorders, providing patient education on opioid use, storage, disposal, and reversal agents, as well as use of the West Virginia Controlled Substance Automated Prescription Program (CSAPP). 

Epidemiology of Pain and Substance Use Disorder 

Pain 

Pain is a complex problem. Because of the personal nature and the varying pain experiences of the patient, it is often difficult to adequately treat. When pain goes unrelieved, the potential of it impacting the patient’s life negatively increases. Untreated pain can result in increased stress on the body, increased healing time after injury or surgery, decreased immune response, feelings of anxiety or depression, and alterations in performing activities of daily living. The effect of this can also be long-reaching as untreated pain can result in a decrease in work performance and job loss for some patients.  

Acute or Chronic 

For this West Virginia Drug Diversion course, it is necessary to outline that pain can be classified as either acute or chronic. Acute pain is often associated with injury, inflammation, ischemia, or surgery and typically only lasts for a short while. Patients experiencing acute pain are often able to easily localize the pain. Acute pain that is not adequately treated can progress to chronic pain. One example of this is seen in musculoskeletal injuries, such as back strain, where repeated injury and inadequate pain management progress to a state of chronic pain. 

Chronic pain usually lasts more than three months. Unlike acute pain, chronic pain often is not as well defined, the onset is typically gradual and characteristics of the pain can change over time. While some chronic pain can be tied to a specific cause or disease state, such as arthritis or cancer, other times, the exact cause is not as easy to determine.    

Nociceptive and Neuropathic 

Pain can be further categorized into nociceptive and neuropathic pain. Nociceptive pain is a result of normal stimuli, and it is further identified as either somatic or visceral pain. Somatic pain is superficial and involves skin, muscles, bone, blood vessels, and connective tissues. An example of acute somatic pain would be a sprained ankle and an example of chronic somatic pain would be arthritis. Visceral pain refers specifically to pain in the organs. An example of acute visceral pain is seen in cardiac ischemia, which is often described as chest pain or left arm and jaw pain in patients experiencing a myocardial infarction (MI). An example of chronic visceral pain would be abdominal pain secondary to stomach cancer. 

Neuropathic pain results from damage to either the central or peripheral nervous system. While most cases of neuropathic pain are chronic, acute neuropathic pain can be seen in injuries or infections affecting the nerves. In some cases, acute neuropathic pain, such as what is seen in amputations, may come and go with the severity of the pain differing greatly from patient to patient. Acute neuropathic pain may progress to chronic neuropathic pain if not treated effectively. Additionally, other disease states may cause chronic neuropathic pain, such as what is seen in diabetic neuropathy. Chronic neuropathic pain is often difficult to treat, and patients may be prescribed several medications before finding something that provides some pain relief. 

Pain Assessment 

There are various factors affecting how pain is perceived and managed. These factors include the type of pain, how long the pain has been occurring, patient age, cognitive level of the patient, the patient’s personality or temperament, previous experiences with pain, and even cultural beliefs. Understanding how these factors influence the patient’s response can help to inform the assessment and may be helpful in determining appropriate treatments for the pain.  

A comprehensive assessment of the pain is also important in determining the type of pain. A thorough assessment at the start of treatment will also serve as a baseline and help to determine if interventions have been effective. Additionally, patients who are not adequately assessed for pain are at a higher-risk of their pain not being effectively managed. It is important to remember not all patients are capable of describing their pain, and as such completing a pain assessment can help these patients to provide the information necessary for informed diagnosis and treatment. How a pain assessment is obtained may also vary. While traditionally, a pain assessment is completed as part of the general assessment, use of a paper or electronic form completed by the patient prior to evaluation may also be used. For this West Virginia Drug Diversion course, it is vital to thoroughly read through the “Pain Assessment Components” table below.  

Pain Assessment Components 

Location 
  • Where is the pain?  
Identify if it is superficial (near the skin) or deep (visceral) pain. This assessment may also include the use of a diagram or pictures. 
Intensity 
  • How bad is the pain?  
A valid pain assessment tool should be used. For most adults a numerical rating scale (0-10) is often used. Health care providers should also explore the use of alternate scales if the patient is not able to understand or provide a number. Use of the Wong-Baker Faces scale, verbal descriptor scales, or visual descriptor scales are acceptable alternatives. 
Quality 
  • What does the pain feel like?  
  • Does it radiate anywhere?  
Use of descriptors, such as stabbing, sharp, or burning will help the patient to describe what they are feeling. Presence of radiating pain may also help in diagnosing underlying conditions that may be contributing to the pain. 
Onset and Duration 
  • When did it start?  
  • How long has the pain been happening?  
  • Is it consistent or does it come and go?  
Identify if it is an acute or chronic problem. Chronic pain may be constant, as is seen in some cancers, or it may be episodic, as is seen in migraines. Understanding this can better inform treatment options 
Aggravating and Alleviating Factors 
  • What makes the pain better? 
  • What makes the pain worse? 
Identify what medications and non-pharmacological approaches the patient has already tried. If certain positions or activities affect the pain this may also help in diagnosis and treatment. 
Effect on Function and Quality of Life 
  • How does the pain impact function at work, home, school? 
  • What activities can no longer be performed? 
This information will be helpful in determining if interventions have been effective. As depression is also impacted by chronic pain, patient reports of isolation or inability to be with friends and family may also indicate the need for a behavioral health referral. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Why is the type of pain important to consider, prior to a patient being prescribed opioid therapy? 

  2. Why is obtaining a comprehensive pain assessment important?

Substance Use Disorder 

The National Survey on Drug Use and Health found in 2017, 19.7 million Americans over the age of 12 suffered from a substance use disorder, and 11.4 million people had misused opioids (6). This same study found 62.6% of participants identified the initial reason they misused a prescription pain reliever was to relieve pain (6). Addiction costs related to productivity, health care, and legal care totaled over $7 billion annually by 2017 (6). These statistics are staggering and show why early intervention to identify at risk individuals and to prevent severe substance use disorders is necessary. 

There is a drastic difference between substance use and addiction, which is more accurately called substance use disorder. Not every patient who uses a controlled substance develops a substance use disorder. However, risk factors may predispose some patients to develop one. There is an increased risk for the development of a substance use disorder in patients who have family members who also suffer from a substance use disorder or a mental health disorder (41). Additionally, how the drug acts within the body and brain and stress will increase the risk of developing a substance use disorder, even when the medication is taken as prescribed (41). 

The NIDA defines misuse (abuse) as the action of taking medication other than prescribed, either for purpose or dose, taking another person’s prescription, or taking a medication to get high (27). Misuse, by itself, may not necessarily indicate an addiction as other factors need to be considered. Patients may misuse a wide variety of prescription medications without incident; however, when misuse of medication is common, the risk of it occurring with medications that are addictive or controlled is higher. In patients who make a choice to misuse medications regularly, the ability to control their own behavior decreases (29). NIDA defines addiction as a chronic condition, where patients may have periods of relapse, will compulsively seek out drugs, and continue to use, despite the harmful effects and long-lasting changes it may have on the brain; it is considered both a complex brain disorder and a mental illness (29). 

Diagnosis of Substance Use Disorders

The process of developing a substance use disorder occurs on a continuum. The majority of patients who take a couple of doses of an opioid to treat acute pain, such as seen in post-surgical patients, will not become addicted. The risk for addiction increases when the patient is at higher risk due to genetics or psychological factors (41). Exposure to a substance changes how the brain responds, leading to intoxication (2). When a patient repeatedly uses the substance, they build up a tolerance, which then requires the patient to use more of the substance to achieve the same feeling. Over time, even patients who use a substance as prescribed can develop a tolerance. This is often seen in patients who suffer from chronic pain and use opioid medications for pain management. While increased tolerance can be an indicator of addiction, this alone does not equate to a diagnosis of addiction or a substance use disorder.  

The Diagnostic and Statistical Manual of Mental Disorders: Version 5 (DSM-5) categorizes substance use disorder symptoms into four categories, impaired control, social problems, risky use, and physical dependence (20). Understanding the DSM-5 categorizations will further help you not only in this West Virginia Drug Diversion course, but also in identifying signs and symptoms of substance use disorders in patients.  

Impaired Control 

  • Cannot control the use of the substance 
  • Unable to cut down or stop using 
  • Spends time obtaining, using, or withdrawing from substance 
  • Reports craving the substance (20) 

Social Problems 

  • Unable to meet obligations of work, home, or school 
  • Continues use of a substance even though it causes social or interpersonal problems 
  • Is no longer as active in social, work, or recreational activities (20) 

Risky Use 

  • The substance is used in dangerous situations, such as when driving 
  • Continues using the substance even though it is making a medical or psychological problem worse (20) 

Physical Symptoms 

  • Displays evidence of tolerance 
  • Has symptoms of withdrawal when the substance is stopped or counteracted (20) 

If a patient has more than two positive symptoms in a 12-month period, they should be diagnosed with a substance use disorder (20). The severity of the disorder is further determined by the number of criteria or symptoms present, with mild being two-to-three, moderate four-to-five, and severe addiction being greater than six (20). 

Quiz Questions

Self Quiz

Ask yourself...

  1. How prevalent is substance abuse, in the U.S.?  

  2. How does abuse differ from addiction?  

  3. What risk factors predispose a patient to developing a substance use disorder? 

Opioids 

Indications and Action 

Opioid analgesics can be used to manage pain, used as anesthesia adjuncts in surgery, and as a cough suppressant. Opioid analgesics work by binding to specific opiate receptors (mu, delta, and kappa). Opiate receptors can be found in the central nervous system, peripheral tissues, and in the gastrointestinal (GI) tract. Opiate receptors also help to control blood pressure, pupil dilation, GI secretions, respiration, and pain response (19). When opioids are used to manage pain, they act upon these same opiate receptors, resulting in a decrease in pain and affecting the control these receptors have on other systems, resulting in some of the effects experienced by patients when taking opioids.  

The most prescribed opioids include hydrocodone, oxycodone, oxymorphone, morphine, codeine, fentanyl, hydromorphone, tapentadol, and methadone (7). Administration routes vary based upon the type of opioid prescribed. 

In determining which route should be used, consideration should be given to the type of medication, what type of pain is being treated, as well as the age and cognitive level of the patient. Common routes for home use include oral (both tablet and liquid), buccal, sublingual, intranasal, topical, and transdermal. Rectal routes may be used for pediatric patients or for those who are unable to tolerate oral ingestion. Opioid treatment in hospitals or clinics may also include intravenous (IV) injection, subcutaneous injection, and intrathecal. Patients prescribed opioid medications should receive medication education that includes administration and adverse effects and general education about safety, storage, and disposal. 

The Controlled Substances Act identifies scheduled medications based upon their current acceptable medical use, abuse potential, and risk of dependence (38).  

Examples of scheduled substances:  

Schedule I: Heroin  

Schedule I substances have a high abuse potential and are not currently considered to be acceptable for medical use (38) 

Schedule II: Hydromorphone, oxycodone, morphine, methadone, and fentanyl 

Schedule II substances can be prescribed but are high risk for abuse (38). 

Schedule III: acetaminophen with codeine, as these products contain less than 90mg of codeine per dose  

Schedule IV: Tramadol  

Schedule V: Antidiarrheal diphenoxylate/atropine and cough suppressants containing less than 200 mg/100 ml of codeine  

They have the lowest potential for abuse. 

Contraindications and Precautions 

Use of opioid analgesics should be used cautiously in patients with conditions resulting in respiratory insufficiency, morbid obesity, and pregnancy. Additional assessment and risk analysis should be performed prior to prescribing or administering opioid analgesics to patients with a diagnosed substance abuse disorder, concurrent psychiatric illness, and those taking benzodiazepines. Concurrent use of opioids and benzodiazepines should only occur if no other treatment options are available due to the increased risk of respiratory depression. Patients taking tramadol, meperidine, or fentanyl are at an increased risk for the development of serotonin syndrome when these drugs are taken with other medications that affect serotonin, and care should be taken when these medications are prescribed concurrently (36). 

Adverse Effects 

Adverse effects of opioids range from mild to severe, and most patients who are prescribed opioids will experience one or more effects. Common adverse effects include: 

  • nausea 
  • vomiting 
  • constipation 
  • urinary retention 
  • urticaria 
  • lightheadedness 
  • sedation (19) 

With the exception of constipation, which can be an ongoing effect, many of the common adverse effects such as nausea, vomiting, and urticaria often lessen in severity with continued use. More serious adverse effects, which may occur even with continued use, include hypotension, bradycardia, and respiratory depression. Patients should be prescribed the shortest-acting, lowest effective dose to minimize severe adverse effects (14). 

Toxicity 

Opioid toxicity can occur regardless of the route of administration. Patients presenting with opioid toxicity often have CNS depression, ranging from confusion and drowsiness to unresponsiveness. Other symptoms of toxicity include respiratory depression and pupil constriction. Patients may initially present with hypotension, but as CNS and respiratory depression worsen, hypertension may be seen as the body attempts to compensate. Patients should be monitored for seizure activity if the overdose is a result of meperidine. 

It is important to note in this West Virginia Drug Diversion course that treatment of opioid toxicity should begin immediately with the administration of naloxone. Repeat dosing may need to be administered as naloxone has a half-life of 30-60 minutes. Pre-hospital treatment with nasal or injectable naloxone should be administered, even if unsure of overdose or toxicity. In-hospital treatment should consider not only the patient’s condition but also the half-life of the opioid (if known), and the naloxone dose should be titrated based upon these factors to limit the potential adverse effects of naloxone (22). One option for treatment is continuous IV infusion as opposed to repeated larger bolus doses. The use of a continuous IV infusion has been shown to decrease the symptoms of opioid withdrawal better than bolus dosing (22).  

Quiz Questions

Self Quiz

Ask yourself...

  1. What underlying health conditions should the patient be evaluated for, prior to being prescribed opioid therapy? 

  2. What education should be provided to patients regarding the adverse effects of opioids?

  3. What information should be communicated to patients and their family members so early intervention for opioid toxicity can be initiated? 

Pain Management Using Opioids 

Assessment 

Patient assessment is an important factor in determining the need for opioid therapy. Assessment of all patients should start with a full history and physical, including a complete pain assessment as well as any previous episodes of pain and treatments used (15). A thorough social and psychological assessment should also be completed. A social assessment should explore how the patient functions at home, work, and socially while including a discussion of how the current pain impacts their ability to function (15). A psychological assessment should include a previous history of substance use disorder and substance use as well as any underlying mental health disorders and medications currently being used to treat these (4). 

For patients with a history of substance abuse disorders, the initial assessment should further explore the substance use disorder. The history should include the type and number of opioids used recently, routes of administration, date of last use, any treatment the patient received, and physical, social, or psychological problems experienced as a result of the disorder (4).  

Patients should be screened for infectious diseases such as hepatitis B and C, human immunodeficiency virus (HIV), and tuberculosis (TB) (4). If the patient has a history of IV drug use, follow-up should include infections related to IV use, such as infective endocarditis, osteomyelitis, and abscesses (4). As opioid misuse and alcohol abuse often occur concurrently, questions related to alcohol use, frequency, and the amount should be addressed (47). 

During the physical assessment, the health care provider should also look specifically for signs and symptoms of opioid intoxication or withdrawal, as well as any physical symptoms related to long term substance abuse. Patients with a history of opioid use may have alterations in hematology, and in patients with chronic use, diet changes may result in anemia. In patients with a history of substance abuse, a baseline laboratory analysis of a complete blood count (CBC) and liver function test are recommended, as well as testing to determine the presence of TB, hepatitis B and C, HIV, and other sexually transmitted diseases (4).  

 

Intoxication  Withdrawal  Symptoms of Chronic Use 
  • Pupil constriction 
  • Decreased respiratory rate 
  • Drowsiness or sleepiness 
  • Altered mental status 
  • Irritability 
  • Restlessness 
  • GI upset (nausea, vomiting, abdominal pain) 
  • Pupils may be normal or dilated 
  • Sweating 
  • Tremors 
  • Goose bumps 
  • Sores on the skin 
  • Jaundice 
  • Spider angiomas 
  • Broken or missing teeth and swollen gums 
  • Rhinorrhea 
  • Poor hygiene 

 

Addiction Risk Assessment 

In addition to the history and physical exam, the use of an addiction risk assessment tool can be helpful in determining the risk of misuse or addiction in patients prescribed opioids for chronic pain (15). There are several addiction risk assessment tools available, but these tools vary in complexity as well as the specific criteria being measured. 

It is important when using a screening tool to determine the risk of misuse or addiction that healthcare providers recognize a “one size fits all” approach does not work. The type of assessment used may need to vary based upon the patient and their history. For patients with a complex history of a substance use disorder, a more complex and complete assessment should be used, whereas a patient without risk factors may only need a basic risk assessment. Availability, ease of access, and target patient age may also play a part in the type of tool chosen. Several tools are readily available through the NIDA website and can be downloaded by health care providers. Having two or three tools available that health care providers have been trained to use and are comfortable using allows for improved assessment and ability to better identify at risk individuals. 

Finding a patient is high-risk can be scary for both the healthcare provider and the patient as the goal of treatment is not to create an additional problem. However, the risk assessment does not mean the patient’s pain should not be treated. Evaluating alternative treatment methods is important, and opioids or other controlled substances should not be a first line option. Additional support will need to be provided to this patient through referrals to both a pain and behavioral health specialist to ensure the needs of the patient are being met and their pain is being adequately treated.

Quiz Questions

Self Quiz

Ask yourself...

  1. What assessments need to be completed prior to prescribing opioids to a patient? 

  2. Why is performing a risk assessment on all patients necessary?  

  3. What steps should be taken if the risk assessment indicates a patient has a high risk of developing a substance abuse?  

Treatment Options and Goals 

While acute pain can be treated with opioid medications, considerations should be made regarding the severity of the pain, diagnosis, and the effect of the pain on the ability of the patient to function (14). If the patient can tolerate the pain and there is minimal impact on their ability to function, non-pharmacological and non-opioid medications should be used before determining an opioid is necessary. Additionally, steps should be taken to evaluate and treat underlying causes of pain. In cases where the acute pain is severe and impairs patient function, steps should be taken to ensure the patient is prescribed the lowest possible dose of an immediate-release opioid, ideally with only a three-to-five-day supply (14).  

Non-pharmacological Pain Management 

Options for non-pharmacological pain management and their effectiveness will vary based on the patient and the nature of their pain. When determining which methods will work for the patient, healthcare providers should discuss options with the patient and provide education about how it can be used, as well as the benefits for using a particular therapy. Healthcare providers after reading this West Virginia Drug Diversion course should also evaluate potential costs and the barriers to using these therapies. Follow-up is necessary in determining the effectiveness of the therapy and if further treatment is necessary.  

Sample of Non-Pharmacological Pain Management Modalities 

Modality 

Barriers to Use 

Heat/cold therapy 

Education – patient should be provided instruction on proper use to avoid injury 

Relaxation (music, imagery, meditation) 

Education 

Low impact exercise (yoga, tai chi) 

Ability to perform, potential costs associated with gym membership or training center 

Acupuncture 

Access to licensed acupuncturist, cost if not covered by insurance 

Massage therapy 

Cost may be prohibitive, not covered by all insurances, may require a prescription if the service is able to be covered  

Chiropractic services 

Cost if not covered by insurance, access may be limited in some areas 

Physical or Occupational Therapy 

Access if the patient lives in a rural area, cost 

*This list is only a representative sample of some non-pharmacological modalities for pain management. Other options exist and may also be considered when developing a treatment plan. 

 

Non-opioid Pain Management 

The use of non-opioid medications for pain management should be carefully considered prior to implementation. These medications should be evaluated based upon the need for short-term or long-term therapy. For some medications, the risk of complications when taken concurrently with opioids is high, so patient evaluation and screening are key in determining the current use of opioids. The patient should be monitored for therapeutic effectiveness as well as potential side effects. Additionally, some non-opioid options carry their own risk of addiction and patients should be monitored for substance use disorders related to these.  

Sample of Non-opioid Options for Pain Management 

Classification 

Examples 

Considerations 

Nonsteroidal anti-inflammatory drugs (NSAIDs)  Ibuprofen, diclofenac, naproxen, celecoxib, aspirin (often found in combination medications) 
  • Available in both oral and topical applications  
  • Can be used in both acute and chronic pain 
  • Available by prescription and over the counter (OTC) 
  • Increased risk for GI bleeding if used daily 
Acetaminophen   
  • Short term use and teach about max dosing 
  • Avoid alcohol 
Muscle Relaxants  Cyclobenzaprine, carisoprodol, tizanidine 
  • Consider concurrent use with physical therapy 
  • Avoid administering with other CNS depressants 
  • Sedation is a common side effect 
Antidepressants 

Tricyclics – amitriptyline, nortriptyline 

SNRIs** – duloxetine, venlafaxine 

SSRIs*** – paroxetine, fluoxetine 

  • Full effect may take several weeks 
  • Educate patient not to stop abruptly 
  • Monitor for side effects 
  • May increase suicidal thoughts 
Anticonvulsants  Carbamepazine, pregabalin, gabapentin, lamotrigine 
  • May be useful in treating neuropathic pain 
  • Monitor for side effects 
  • May take time to reach desired effect 
  • Educate patient not to stop abruptly 
Cannabis   
  • Requires prescription and in most states, patients must register 
  • Is a Schedule I controlled substance 
  • Has addictive properties and further research is needed to determine long-term effects (26)

*This list only identifies a select number of non-opioid medications used when managing pain. Other available medications, patient history, etiology of pain, and patient function should be considered prior to prescribing. 

**SNRIs are serotonin and norepinephrine reuptake inhibitors 

***SSRIs are selective serotonin reuptake inhibitors 

Evaluation of the type and nature of the pain is important in determining which options would best fit the patient’s needs. Healthcare providers will need to discuss with the patient the possibility of having to try different modalities and medications to find a fit that is right for them. Patient tracking of symptoms, use of relief methods and medications, the effect on the ability to function, and effectiveness of interventions is key in determining which modalities and medications are working. Various mobile apps for tracking and managing pain are available and may be an option for helping some patients to record and track this data.  

In the event the patient and healthcare provider determine non-pharmacological and non-opioid medications are not effectively managing the pain, opioids may be added to the treatment plan (14).  

If opioid therapy is needed and tramadol is prescribed, consideration should be given to tapering patients off antidepressants being used for pain relief to decrease the risk of serotonin syndrome. Opioids should be prescribed at the lowest effective dose, and it is recommended that immediate-acting opioids be prescribed before long-acting opioids, although long-acting or sustained-release formulations remain an option for treating neoplastic-related pain (14). Prior to prescribing opioid therapy and at every visit, the risk versus benefits of opioids should be evaluated and discussed with the patient (14). If benefits do not outweigh risks of continued therapy, steps should be taken to taper the dose down or taper to discontinue the opioid (14). 

Therapy Goals 

Another important step in therapy is the determination of therapy goals. Goal setting should occur early in the treatment process and should be a collaboration between the patient and the health care provider. When setting goals, they should be realistic to what can be achieved medically and within the base functioning of the patient, they should be specific as to what the patient wants to achieve, and include a realistic time frame for achieving these goals (14). Goals should be included in the patients plan of care within the electronic health record (EHR) and be reviewed at each visit. Evaluation of goals should also incorporate data tracked by the patient.  

Compliance with use and appointments should also be encouraged. Patient education about the proper use of opioids and follow-up appointments is key. Other steps include requiring a follow-up visit before the first refill, with the understanding no additional scripts will be written until after the follow-up, and scheduling future appointments before the patient leaves the office (14). Health care providers should also work with the patient’s other providers to ensure the patient is not receiving multiple prescriptions and to ensure there are not any concurrent prescriptions for benzodiazepines (14). A thorough check the EHR for previously written prescriptions should be completed. For outside health care providers, the patient should be asked to sign a release of information, to allow these records to be obtained. For health care providers living in states with prescription drug monitoring programs, the database should be checked prior to prescribing and information regarding prescriptions written should be submitted following the regulations set forth by individual states (14).

Quiz Questions

Self Quiz

Ask yourself...

  1. Why should non-pharmacological and non-opioid options be considered before treating pain with opioids? 

  2. Looking at what resources are readily available in your current practice area, what non-pharmacological would be available for your patients?  

  3. What barriers might your patients have to accessing these resources? 

Ongoing Monitoring

The CDC identifies urine drug screens should not be used solely to determine risk; however, when they are used in combination with other risk assessment strategies, the use of urine screens may be helpful to identify those patients at high risk of overdose, and as a method to identify which patients may need additional monitoring or support (14). Urine screens should be used at the start of opioid therapy for chronic pain and can be used throughout therapy to validate what the patient has reported and to identify the use of multiple substances (4, 15).  The frequency of testing should be determined by how stable the patient is, the type of treatment, and the setting in which the treatment is taking place (4). The CDC’s basic recommendations are that urine screening occurs annually for patients on long-term opioid therapy (14). However, in some cases, more frequent screening may be mandated for patients undergoing treatment for substance use disorders (4).  

Not all urine screens are the same. As such, the healthcare provider, nurses, and staff performing the screen should obtain additional training and education beyond this West Virginia Drug Diversion course regarding the specific screen being used and following manufacturer recommendations for performing. Because some substances may only be present in the urine for up to 3 days, a negative result may not rule out the use of a substance (4). Instead, health care providers should use this information in conjunction with assessment findings and subjective patient reporting to determine if further action or monitoring is necessary. 

Pill counts are also sometimes used as a method for ongoing monitoring of a patient’s compliance with therapy and as a method for preventing drug diversion. The idea behind pill counts is if the patient presents to the visit with the correct number of pills then misuse and diversion are not occurring. When used alone, pill counts are not effective in preventing addiction, and the evidence does not support using this as a sole method for preventing misuse (14). However, use of pill counts are still sometimes used as part of opioid therapy and are still sometimes included as part of the treatment agreements. When used with other methods, they can provide insight into patient use of the medication and provide an opportunity for ongoing education about safe use and storage of opioid medications. Healthcare practitioners choosing to use pill counting as a method of deterring misuse and diversion should recognize pill counts may be “padded” by borrowing, renting, or purchasing additional pills illegally. Care should be taken not just to count the pills remaining in the prescription but to also verify the pills all have the same appearance.

Quiz Questions

Self Quiz

Ask yourself...

  1. Why are urine drug screens and pill counting only a small part of ongoing monitoring and why should these not be used alone for determining compliance? 

  2. What should be taught to the patient about use of urine drug screens and pill counting as methods of monitoring opioid use? 

Referrals

Referrals are an important part of managing a patient with pain, especially in cases of chronic pain. Healthcare providers should be willing to provide referrals to outside providers and specialists to address specific pain concerns. For example, if a patient is identified to have chronic pain in their lower back or hips, a referral to an orthopedic specialist for evaluation is warranted. If a patient has used multiple modalities, including opioids, without success a referral to an interventionalist may be needed to determine if the patient is a candidate for a nerve block, neuromodulation, or implantation of an intrathecal medication delivery device (12). 

For patients with a history of substance use disorder or other underlying mental health concerns, a referral to a psychologist, psychiatrist, or mental health therapist should be provided, and the healthcare provider should work in conjunction with this specialist to manage the patient. Behavioral health services should also be considered for patients without a personal or family history of addiction or mental health disorders, as chronic pain can cause depression and anxiety. When opioids are used, long-term chemical changes in the brain occur, increasing the risk of not only substance use disorder but depression, anxiety, paranoia, and hallucinations (25). This West Virginia Drug Diversion course highlights the importance of not only identifying patients who may be suffering from a mental health disorder as a result of opioid use but ensuring that proper treatment is provided.  

For some patients with chronic pain, referral to a pain specialist may be necessary. While not every patient needs this, there are some reasons when a referral becomes necessary: 

  • the patient requires higher dosages of morphine or another opioid 
  • concurrent use of other CNS depressants (benzodiazepines, muscle relaxers, or anticonvulsants) 
  • requests more opioids, asks for early refills, or has pain-related visits to the emergency department or urgent care 
  • reports use of illicit drugs or urine drug screen is positive for non-prescribed drugs 
  • the patient is unable to follow the pre-agreed upon treatment plan 
  • refuses to use non-pharmacological or non-opioid pain management strategies  
  • refuses to taper dosage when risk outweighs benefits (12)

Primary healthcare providers should work with pain specialists to determine if the patient should be referred for medication management or if a transfer of care is necessary (12).  

Referrals may also be needed for services such as physical therapy or occupational therapy. In some states, patients may seek out therapy services on their own, and in some states, a referral or prescription is required. Health care providers should determine if a prescription or referral is necessary for insurance purposes before sending the patient for evaluation by a physical or occupational therapist or other specialty healthcare providers. When determining which referrals are needed, the healthcare provider should explore what resources are available locally as well as any barriers the patient may have to attend those appointments.

Quiz Questions

Self Quiz

Ask yourself...

  1. Consider patients currently under your care. What additional referrals might benefit these patients? 

  2. When should patients be referred to a pain specialist? 

Treatment Agreements and Informed Consent

The use of patient-provider agreements has a long history in opioid treatment. Initially, these were used to set standards or requirements for patient behavior and often included dismissal as a punishment for not adhering to the agreed-upon treatment regimen (12). When used in this manner, the effect on patients was not always positive. Patients often felt a sense of distrust and stigma related to the use of these agreements, which only served to undermine the therapeutic relationship and threatened the treatment plan (12, 33). Yet, the use of patient-provider agreements continues to be included as part of treatment recommendations, because when used correctly they can help support both the patient and healthcare provider (14). 

Because of these recommendations, treatment agreements continue to be used. Healthcare providers should take steps to ensure the treatment agreements are being implemented in a way that is patient-centered and are not punitive in nature, but instead act to provide information about risks and benefits as well as steps to ensure compliance (12, 33). Perhaps a better way of looking at treatment agreements is to see them as a method of informed consent, wherein the patient is provided need-to-know information including risks, benefits, and consequences of noncompliance, and is then allowed to determine if undergoing treatment is what they desire (12, 33).  

While patient treatment agreements historically may not have always been effective, they become one part of a patient-centered treatment plan when used correctly. Not only can these agreements serve as a way to document the patient’s informed consent of the treatment, but they can be used to identify clear goals and expectations for patients receiving opioid therapy. Treatment forms may vary from clinic to clinic, but common components include:  

  • treatment goals 
  • responsibilities for safe medication use 
  • storage and disposal of opioid medications 
  • requirement for the patient to obtain prescriptions from only one clinician or practice 
  • requirement to only fill prescriptions at one pharmacy 
  • agreement for periodic drug testing 
  • clinician agreement to be available or have coverage (16) 

In addition to the use of treatment agreements, healthcare providers should implement the use of informed consent forms (16). In some cases, these are combined with the treatment agreements, and in other cases the informed consent may be a separate document. Components of the informed consent should include: 

  • the limited benefit of opioid in chronic pain 
  • risks and benefits of opioids 
  • potential side effects, including sedation and impaired motor skills 
  • risk of tolerance, physical dependence, development of a substance use disorder, overdose, and death 
  • prescribing policies and expectations 
  • reasons why therapy may be changed or discontinued 
  • education that the patient should not expect to be pain free (16)
Quiz Questions

Self Quiz

Ask yourself...

  1. What consequences might be incurred by the patient or provider who fails to uphold or follow the treatment agreement? 

  2. Should treatment plans be used every time an opioid is prescribed?

Discontinuing Opioid Therapy

Discontinuing opioid therapy may be considered for various reasons; risk outweighs the benefit, effective use of non-pharmacological therapies and non-opioid medications, patient desire to stop use, and noncompliance. Understanding why the therapy is being discontinued and communicating with the patient is important to ensure that pain management goals are met. Recommendations for discontinuing opioid therapy are to initially taper just the dose, then extend the time between doses (14). Once a patient has reached the point where they are taking an opioid less than once a day, the opioid can be stopped (14).  

Emergency discontinuation of therapy or rapid tapering of opioid dosing may occur when a patient overdoses on their current dose (14). In these cases, patients should be closely monitored in a controlled setting, and supportive therapy to manage withdrawal symptoms should be employed. Urine drug screens should be completed to rule out the presence of other drugs and baseline CBC, metabolic panel, and liver enzymes should be obtained. The clinical opiate withdrawal scale (COWS) should be utilized to monitor for signs and symptoms of withdrawal. 

The COWS is an 11-criterion scale that looks at physical symptoms of withdrawal. Each criterion is scored based upon what is being evaluated or observed in the patient. A score of 5-12 indicates mild withdrawal, 13-24 is moderate, 25-36 is moderately severe, and patients scoring above 36 are in severe withdrawal. The criterion evaluated includes: 

  • resting pulse rate 
  • sweating 
  • restlessness 
  • pupil size 
  • joint pain 
  • runny nose or tearing of the eyes 
  • GI upset 
  • tremors 
  • yawning 
  • reported anxiety or irritability 
  • piloerection 

Proper use of the scale is important, and the nursing staff who will be using the scale to evaluate patients should be properly training in its use. Treatment of acute withdrawal symptoms should be based on the patient’s COWs score and the symptoms they are presenting. In addition to the symptoms evaluated using the COWs, blood pressure should be monitored and hypertension should be managed. Medications used to manage symptoms of acute withdrawal include anti-emetics, non-opioid antidiarrheals, and clonidine or lofexidine. Care should also be taken to provide a low stimuli environment, such as dimmed lights, limiting excess noise, and keeping the room at a comfortable temperature. 

Managed withdrawal can also occur more slowly and is commonly seen in patients who are heroin-dependent or if the patient and healthcare provider identify a detoxification program is needed. In some cases, methadone or buprenorphine may be used to lessen the symptoms of withdrawal. Patients prescribed methadone should also be provided referral to a methadone clinic for monitoring and medication distribution. Patients undergoing methadone or buprenorphine treatment should also be referred for behavioral therapy to help manage psychological effects, and for ongoing treatment and support of a substance use disorder (14).

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the dangers related to discontinuing opioid medications?  

  2. Why should patients undergoing acute withdrawal be in a monitored setting, such as a clinic or hospital? 

  3. What type of situations might lead a health care practitioner to identify the need for managed withdrawal with the use of buprenorphine or methadone?  

Patient Education 

Education of patients at the point of prescribing and at every visit thereafter is important to ensuring patients are actively involved in their own care and are taking steps to manage their care at home. However, educational practices can be inconsistent between clinics and facilities, between health care practitioners, and, in some cases, education is missing (18). For patients who are prescribed opioids, education is a key component towards ensuring patient safety.  

Both patients and family members should be taught the risks and benefits of opioid use, the effectiveness of opioids, and the appropriate use of opioid medications. Patients and families should be taught the signs and symptoms of an overdose and how to appropriately intervene in the case of an overdose. Additionally, patients should be taught about diversion’s risk and steps to prevent it (18). 

Prior to engaging in patient education about opioids or addiction, the nurse should first self-evaluate or reflect on their own feelings related to these topics. Efforts should be made to approach each patient as an individual and to avoid stereotyping patients based upon their type of pain, use of opioids, or history of a substance use disorder. Patients should be approached in a nonjudgmental manner, and nurses should employ therapeutic communication techniques, allowing the patient to express their concerns and to encourage questions.  

When starting an educational session, it is important to identify the specific learning needs of the patient. This may range from identifying the type of learner the patient is, the level of education or reading level, and even includes identifying specific questions or concerns the patient has related to using an opioid. 

Time should also be committed to evaluating what the patient’s current knowledge about opioid use is and to dispel misconceptions the patient may have about opioids. Misconceptions that may be held by patients about opioids, addiction, or the prescribing process might include: 

  • Opioids are the only thing that will help the pain. 
  • When taken as prescribed, addiction will not occur. 
  • Not being prescribed an opioid means the health care provider thinks the patient is an addict 
  • Addiction only happens to certain types of people. 

Nurses should take care to provide facts and evidence (at the patient’s level) to dispel misconceptions. When addressing misconceptions, it is also important to be aware of tone and forms of non-verbal communication to not inadvertently pass judgment on what the patient believes.  

While teaching should be specific to meet the patient’s individual needs and prescribed opioid, information about safe use, storage and disposal, and use of opioid antagonist medications should be provided to every patient. The information provided in this West Virginia Drug Diversion course offers great opportunities and points to share with patients. Standardized educational materials should be around a 6th grade reading level to ensure that most patients easily understand the material. The use of videos through a patient education platform, like those available through Krames or X-Plain, can be useful for educating patients who are unable to read the material or are auditory learners. If these are not available, clinic-made videos or videos available online may be used.

Quiz Questions

Self Quiz

Ask yourself...

  1. Why is it important for the nurse to explore their own biases about opioid use and substance use disorders? 

  2. What teaching might be provided to a patient who had misconceptions? Why is this teaching important? 

Safe Use of Opioids 

One aspect of patient education that is essential to highlight in this West Virginia Drug Diversion course is the safe use of opioids. Because opioids are used in both acute and chronic pain management, education about safe use is an important step in helping patients take an active role in their treatment plan and ensuring their safety outside the clinical setting. In the case of a patient being treated for acute pain, instructions should include guidelines for how the opioid should be taken and for how long it should be taken. Nurses’ common education for a patient with acute pain is to take their opioid pain medication to “stay ahead” of the pain. This instruction does not go far enough to address safe use. Patients should be instructed to take their opioid medication as prescribed and not increase the frequency or dosage if the pain worsens, but instead to notify their health care provider. Patients may believe that if it is prescribed, they must take the medication, so the nurse should also educate that opioids are an as-needed medication and should not be taken if not needed; in most cases of acute pain, opioids may only be needed for the first few days. Teaching patients to self-evaluate their pain is important in determining if the opioid is necessary or if an alternative medication, such as a NSAID, would be more appropriate.  

In the case of a patient being treated for chronic pain, instructions should still include guidelines for how it should be taken, but additional guidance should be provided about safety related to toxicity and withdrawal. Opioids for chronic pain management may be either immediate-acting or long-acting, and education differs based on what is prescribed. Patients prescribed immediate-acting medications should be instructed not to change the frequency or dosage prescribed due to the risk of toxicity.

If the patient finds their pain is not being managed, further evaluation is necessary, and they should be instructed to notify their healthcare provider. These patients should also be aware of how many doses have been prescribed and be taught to manage their use of the medications. Patients who are unable to manage this effectively may find they have finished the supply and are not able to refill the prescription for several days, leading to withdrawal. For patients prescribed long-acting opioids, they should be provided education on how these medications differ from immediate-acting and to not take extra for breakthrough pain. Taking long-acting opioids as prescribed is important to prevent withdrawal. Because these medications stay in the system longer, there is also a risk of toxicity if the patient takes an extra dose or additionally medicates with a short-acting opioid.  

With any patient-prescribed opioids, additional education related to misuse and diversion should be provided. Most people who reported misusing prescription opioids identified they got the drugs from a friend or family member (21). Patients should be taught to count their medications and to keep track of their use. If they identify pills are missing, patients should be informed to notify authorities and their healthcare provider. Education should include that the prescriptions are only for personal use and should not be shared with a relative or friend. Education about safe use also needs to include concurrent use of opioids with other medications or alcohol. The patient should be instructed to avoid alcohol because of the additive CNS depressant effects, which increase the risks associated with respiratory depression. A thorough review of all patient medications, prescribed, over-the-counter, and herbal, should be completed. Education regarding potential reactions should be provided.

Quiz Questions

Self Quiz

Ask yourself...

  1. A patient is given a new prescription for a fentanyl transdermal patch. What should the nurse teach the patient about safe use? 

Proper Storage and Disposal 

Proper storage of opioids can deter theft, loss, and misuse of medications. Patients should be taught to keep opioids in the original packaging and not to store them in pillboxes. Many patients often keep medications in the kitchen or bathroom near the sink or on a shelf. Patients should be taught to keep opioids in a locked drawer or cabinet that is not easily visible or accessible to others. Additional patient education should include the dangers of accidental ingestion by children or pets. Patients should also be cautious with whom they tell about their opioid prescription and should be educated that this information should only be shared with direct caregivers.  

Patients also need to be taught about the proper disposal of opioids. Many patients will often save leftover prescription medications, “just in case,” and many patients may have multiple old prescriptions in their home, increasing the likelihood they are unaware of what is there or if it may have gone missing. It is estimated less than 20% of patients properly dispose of opioid medications (18). Educating patients on proper disposal can help to prevent problems related to the diversion of opioids by people the patient knows (18). The Food and Drug Administration (FDA) identifies the preferred method of opioid or other controlled substance disposal is to take the medication to a disposal location (39). Many pharmacies offer take-back services that will allow patients to dispose of old or unused prescriptions. Locations for take-back services can also be found by completing a search through the Department of Justice.

In some cases, a patient may not be able get to a drop off location. In these cases, the FDA has also identified both a flush and no-flush list for medications that can either be disposed of by flushing down the toilet or by discarding into the trash (39). Most medications containing opioids can be flushed to prevent misuse or diversion (39). 

For other controlled substances that cannot be flushed, it is recommended patients be taught to mix the medications in something most people wouldn’t dig through or ingest, such as cat litter, to place the mixture in a sealed plastic bag, and to throw it in with regular household trash (39). Patients should also be taught to blacken with a permanent marker or to scratch out any personal information on the prescription bottles before putting them in the trash (39). Education on disposal should include where a local drop-off site is located, which prescribed medications can be flushed, and which ones need to be put in the trash. Patients concerned about the environmental impact of flushing medications should be informed that the FDA has found the flushable medications “present negligible risk to the environment” (39).

Quiz Questions

Self Quiz

Ask yourself...

  1. The patient with the new prescription for the fentanyl transdermal patch wants to know what she does with the used patch. What instructions should be provided? 

  2. What additional resources to patients have for disposing of unused prescriptions?

Opioid Antagonists 

There are two commonly used opioid antagonists in use in the U.S., naloxone and naltrexone; both medications bind to opiate receptor sites, blocking the ability of the opioid to bind to the site. Patient education should include why a specific opioid antagonist is being used, appropriate administration, and potential side effects. 

Naloxone  

Naloxone (otherwise known as Narcan) is used as a reversal agent for acute overdose or accidental ingestion. Patients taking opioids or who have family members who take opioids can either obtain naloxone either by prescription or directly from their pharmacist without a prescription. It can be used by patients or their loved ones in the home to prevent death or permanent disability as the result of opioid use. Family members should be taught to call for emergency assistance (911) if they administer naloxone to a loved one. Additionally, they should be taught to look for signs and symptoms of respiratory depression in the event a second dose needs to be administered. Patients and families should also be taught naloxone is only effective for the treatment of opioid overdose and will not treat overdose related to other substances. The FDA recommends healthcare providers discuss and consider prescribing naloxone for patients who meet the following criteria:  

  • high risk for overdose 
  • take other central nervous system (CNS) depressants 
  • history of substance abuse  
  • history of overdose 
  • have children who may accidentally ingest opioids (40) 

Currently, naloxone has been approved for administration via three methods (28). 

  • Injectable naloxone – This is available in a 2mg/2ml syringe and is mostly used by healthcare workers in hospitals and by paramedics. For patients who receive this type of naloxone, training should be provided on the appropriate use of a syringe, dosing, and administration.  
  • Autoinjectable Naloxone – Teach patients each autoinjector only contains one dose. If an additional dose is necessary, a second autoinjector will need to be used. If using an auto-injectable form, patients should be taught specifically how to open and activate the device and inject into the outer thigh.  
  • Nasal Spray – A prepackaged nasal spray is often easiest for patients to use and can be obtained without a prescription from a pharmacy. With the nasal spray, patients and families should be instructed to ensure the patient is on their back, place the device’s tip into one nostril, and press firmly on the activator. Each package of spray contains one dose. Additional doses can be administered but a new device will be needed. Patients and families should be instructed to alternate nostrils if repeat doses are necessary. 

Naloxone adverse effects are often related to the reversal of the opioid and may include nausea, vomiting, diaphoresis, tachycardia, blood pressure irregularities, and tremors (28). When administered to a patient who regularly takes opioids or in an overdose, withdrawal symptoms may become present with minutes. Severe adverse effects include seizures, dysrhythmias, pulmonary edema, and cardiac arrest (35). 

Nalxtexone  

Naltrexone is an opioid antagonist used for longer-term treatment and management of opioid addiction. It requires a prescription and can be taken as a daily oral medication or as a monthly injectable. It should not be prescribed to patients who currently take opioids or who have recently used opioids or alcohol, as withdrawal symptoms will occur (37). Patients prescribed naltrexone should be instructed to avoid any opioids (prescribed or non-prescribed), alcohol, and cough or cold medications containing alcohol (37). Prior to naltrexone being prescribed, patients should have a thorough medication review done to avoid potential interactions with other prescribed medications, specifically those used to treat depression (37). Education regarding adverse effects should also be provided. Common adverse effects include nausea, vomiting, decreased appetite, drowsiness, and problems sleeping (37). Instruct patients to notify their health care provider if they experience severe adverse effects such as difficulty breathing, injection site skin changes, right upper abdominal pain, or suicidal thoughts (37).

Quiz Questions

Self Quiz

Ask yourself...

  1. When should naloxone or naltrexone be used?  

  2. What priority education should be provided to patients and families about opioid antagonists? 

Drug Seeking and Diversion 

Patients 

The term ‘drug-seeking’ can have a negative connotation. It is often used by healthcare providers and nurses to refer to patients who behave in a certain way, seek out treatment for certain types of pain, or their explanation of events is viewed as unbelievable or untrustworthy. Unfortunately, because the term drug-seeking has come to be used as a kind of a catch-all, legitimate patients sometimes get identified as being “drug seekers,” and their pain goes untreated (13). The use of the term ‘drug-seeking behavior’ specifically refers to behaviors displayed by patients who are struggling with substance use disorders. In caring for patients who display drug-seeking behaviors, nurses need to be aware of their own feelings and biases as they relate to opioid use and addiction. They should approach each situation with a patient in a non-judgmental manner and objectively evaluate the patient so proper intervention can be given.  

Patients who are misusing prescription opioids may not recognize they have a problem and may feel their pain is being ignored. They will often lie about symptoms or exaggerate the amount of pain they are experiencing. This can be especially difficult to assess as nurses are taught pain is whatever the patient says it is. Because each patients’ pain experience is different and their responses vary, making objective pain assessments can be difficult. Physical changes, such as elevated blood pressure, tachycardia, or diaphoresis, which might be seen in acute pain are often not present in chronic pain, further complicating the assessment.  

Patients may visit multiple clinics, urgent care, and emergency departments, which is often called ‘doctor shopping,’ and this practice allows the patient to potentially receive multiple opioid prescriptions from different healthcare providers. Depending upon what is available in the area where the patient lives, the patient may also travel to other towns or neighboring states to obtain prescriptions. Often in these cases, the patient will only give a partial or vague history. Patients may deny a request to obtain recent health records or provide false information about either themselves or where they have been treated. In addition to ‘doctor shopping,’ patients may also use multiple pharmacies to have prescriptions filled. Following the completion of this West Virginia Drug Diversion course, it is vital for healthcare providers to pick up on these signs of ‘doctor shopping.’ 

Escalation of use is often seen and occurs when patients take a higher dose, takes a dose more frequently, or both, outside of how the opioid has been prescribed by their provider. Patients may also take measures to obtain additional prescriptions from their regular healthcare provider. Patients who call the office to ask for a prescription right before the weekend or a holiday may require further investigation, especially if this is a common occurrence. One occurrence of a patient doing this does not meet the criteria of drug-seeking behavior; however, when there are repeated incidents or a pattern of behavior, it should be addressed.   

Patients may request a specific opioid or having a long list of allergies to other pain medications. Many of these patients may also report they are currently taking multiple opioids or other controlled substances. When asked about the use of opioids, other controlled substances, or even illicit drug use, patients may become angry. Aggression may also be seen when adjusting a plan of care, where the opioid medication will be changed, or the healthcare provider identifies it is time to start tapering the medication due to risks outweighing the benefits of treatment. 

In urgent care, emergency department settings, and even with the general hospital setting, changes in behavior from the waiting room to the treatment room are sometimes observed. When this occurs, patients may be calm, at a distance appear to be comfortable, or may be seen doing other activities (talking on the phone, conversing with other people, walking around); however, once placed in a treatment room, the patient may hold the area that hurts, moan, or even begin crying. If receiving IV medications, they may ask the nurse to “push it fast” or may request oral medications be changed to IV. 

Drug diversion is an illegal act occurring when a prescribed controlled substance is obtained illegally. In some cases, diversion is done as a method of obtaining prescription opioids in order to sell them. However, diversion also occurs when a patient obtains a prescription, under false pretenses, for their own use. Identifying the end goal allows the health care provider to take appropriate steps to help the patient. Healthcare providers have a duty to report opioid diversion to law enforcement; however, criminal action against a patient will vary based upon the state, intent of diversion, and if there is an intent to sell or distribute. When a patient is diverting drugs for their own use, treatment of the substance use disorder is a priority and, depending upon the situation; legal action may not be taken if the patient undergoes treatment.

Quiz Questions

Self Quiz

Ask yourself...

  1. What actions might the nurse see in a patient with drug seeking behaviors? 

  2. How might have the term drug seeking become stigmatized?  

  3. What steps can the nurse take to prevent their own biases and feelings from interfering with their care of these patients?

Drug Diversion in Nursing 

It is estimated that 10% of practicing nurses are abusing one or more substances (32). Nurses with substance use disorders often go unidentified and it can be easy for co-workers to ignore the signs and symptoms or to dismiss them as the being stress related (24). Yet, failing to identify nurses who are struggling with substance use puts not only patients, but co-workers at risk. It is necessary to address this prevalence in this West Viriginia Drug Diversion course.  

Because nurses often have readily available access to controlled substances, their methods of diversion differ from those of patients and often are not as easily detected until a pattern is identified.  

Nurses may remove a full dose but only give a partial dose to the patient, may substitute the patient’s injectable opioid for saline, or may “forget” to waste excess opioids. Additionally, the nurse may be overly helpful; coming in early or staying late, offering to give medications for another nurse, or picking up extra shift as it gives them greater access. If not unidentified, the nurse may divert for a period of time undetected, in some cases, years. For some nurses, it is not until their behavior or physical appearance starts to change for co-workers and managers to identify a problem. Physical changes may include changes in appearance, hygiene, disheveled clothing, and in their cognitive ability (memory or concentration). Behaviors commonly seen include changes in their schedule (coming in early, leaving late, or frequent sick days), multiple breaks off the unit, and frequent bathroom breaks. As the drug starts to have a greater impact on the nurse, there may be an increase in the documentation or medication errors, or narcotic counts will consistently be off when that nurse works.  

When a nurse is suspected of diversion, reporting the incident helps the individual and helps to keep patients safe; depending upon the environment and area where the nurse works may determine to whom or where the suspicions should be reported.  

Many facilities have policies related to what should be reported, who it should be reported to, and what documentation will be required. In most cases, the incident would be reported to the direct supervisor or employer. Once it has been reported, the employer is responsible for investigating the incident, which included looking at pharmacy logs, reviewing documentation, and interviewing involved parties. If controlled substances are missing, the employer has 24 hours to report the Drug Enforcement Agency (DEA) discrepancy. In some cases, law enforcement may also be contacted if the amount missing may indicate theft. The nurse will also be reported to their state board of nursing. In some cases, the nurse may be given the opportunity to self-report the incident. It is also important to note best practice supports the nurse not being terminated when impairment or diversion is confirmed, as this often prevents the nurse from accessing treatment (5).  

The act of drug diversion by a nurse does not immediately mean their license will be revoked. An investigation by the licensing board will occur and depending upon the circumstances, the nurse’s license may be suspended, and they may be required to undergo substance abuse treatment, or, in some states, may enter an alternative-to-discipline program. This program entails evaluation, treatment, and ongoing monitoring as a condition of being allowed to return to work (5, 24). The nurse who has had their license suspended may request their license be reinstated if they meet the requirements by the board of nursing disciplinary board. In some cases, restrictions may be placed limiting the administration of controlled substances to patients.  

Once the nurse returns to the workforce, employers should take steps to support the nurse and their recovery. Best practice supports the use of employer-employee contracts that outline conditions (23). Suggested components of the contract include: 

  • providing the nurse with a mentor who has been successful in recovery 
  • assigning to a day shift 
  • information regarding facility liability insurance and relevant guidelines and policy from the state board of nursing 
  • practice restrictions placed by either the board of nursing or the facility 
  • accommodations made to support in recovery (time off to attend meetings) 
  • facility policies on random drug testing 
  • evaluation criteria and timeline for evaluations 
  • expectations related to ongoing treatment 
  • consequences if the nurse relapses 
  • length of time the contract will be valid (23) 

Nurses who are undergoing treatment and returning to work should be encouraged to ask questions to ensure expectations are clear. There remains a lot of stigma related to substance use disorders in nurses and employers should take steps to ensure the unit where the nurse is placed will be a supportive environment (5). Steps should also be taken to protect the nurse’s right to privacy from co-workers as it relates to ongoing treatment (5).  

Quiz Questions

Self Quiz

Ask yourself...

  1. What signs and symptoms might indicate a nurse has a substance use disorder? 

  2. What steps should be taken if nurse diversion is suspected? 

  3. Why is it important to place a nurse, returning to work after treatment, in a supportive environment? 

Prescription Drug Monitoring Programs 

While tracking and monitoring controlled substances ultimately falls under the DEA purview, in reality, the DEA’s ability to accurately track this data on a state or local level is difficult. In response to the need for improved data collection and access to data, multiple states have started statewide prescription drug monitoring programs (PDMP).  

These programs are used to track prescribers and pharmacies, and patients who receive these prescriptions as well. PDMPs improve patient safety by allowing practitioners and pharmacists to quickly identify patients who have obtained prescriptions from multiple providers, identify the total number of prescribed opioids, and identify high-risk patients who have been prescribed other controlled substances (11). Through careful tracking and data collection, states can also use the data to determine if other statewide measures to combat opioid addiction and overdose are having any impact. The biggest drawback to these programs is the interoperability of systems between states, which limits data sharing and integration with electronic health records (3).  

In 1995, West Virginia introduced their first controlled substance monitoring program. Since its initial introduction, the program has evolved to an internet-based program capable of exchanging information with several other states (17). Work is also being done to integrate the Controlled Substances Monitoring Program (CSMP) into the electronic health record using the NarxCare program (42). Once fully integrated, providers can search for patients through the system without logging into the CSMP separately and help providers identify patient risk scores, prescription data, and patient safety alerts (42). 

Use of CSAPP 

Practioners in West Virginia, who prescribe schedule II, III, IV, and V controlled substances, products containing gabapentin, and opioid antagonists, are required to report to the CSAPP (44). Reports should be submitted every 24 hours.  

The information to be reported includes: 

  • name, address, pharmacy, and DEA number of the pharmacy 
  • full legal name, address, and date of birth for the patient 
  • name, address and DEA number of the prescriber 
  • name and national drug code number of the substance being prescribed 
  • quantity and dosage of substance being prescribed 
  • date prescription was written and filled 
  • number of refills authorized by the prescriber 
  • government-issued ID of the individual picking up the prescription if not done so by the patient 
  • payment source (44) 

Additionally, in the event a provider treats a patient for an overdose, the provider should report the full legal name, address, and date of birth of the patient being treated as well as any data collected as evidence of the overdose (44). 

Quiz Questions

Self Quiz

Ask yourself...

  1.  Why are PDMPs an important tool in battling the opioid epidemic?  

  2. What drawback still exist with these programs? 

  3. What responsibility do health care practioners have related to use of the CSAPP? 

     

Case Study 

S. is a 40-year-old male. He denies any chronic illnesses. He is being evaluated at a local urgent care for lower back pain. He reports the pain started after helping a friend move some heavy boxes. C. S. denies any other injuries to his back and states, “other than what is going on right now, I am healthy.”

After evaluation by the health care provider, no acute injuries were identified, and he was diagnosed with back strain. He received instructions to ice his back, was provided exercises to strengthen his back muscles, was prescribed hydrocodone/APAP 5/500mg for the pain, and instructed to follow up with his primary health care provider.  

Based upon what has been learned, what should have been done differently at this urgent care visit regarding prescriptions provided to C. S.?

It has now been one year since C. S.’s initial diagnosis of back strain. Since then, he has had repeated visits for back pain and has progressed to needing daily opioid medication to manage the pain. He reports the pain got to the point where he struggled to complete tasks at his job, and frequently had to call in sick. Recently, he lost his job as a construction worker, a job he had for 17 years. C. S. is being evaluated at his primary health care provider’s office due to his reports of chronic back pain.  

What priority assessments should be obtained regarding C. S.’s pain and current opioid use?  

What diagnostic tests should be performed and why are these tests important?

After meeting with his health care provider, C. S. has agreed to the use of non-pharmacological and non-opioid therapy for his chronic back pain. He reports he is willing to try anything that will make him feel better and get back to work.  

What non-pharmacological modalities or non-opioid medications might he benefit from receiving?  

As part of the treatment plan for C. S. what referrals might need to be made?  

What considerations need to be taken into account when prescribing treatments and making referrals?

During the visit with the health care provider, C. S.’s frequent visits to the urgent care and emergency department are addressed. C. S. admits to often taking more of the hydrocodone than he should have because the pain was so bad.  

Based upon what is known about C. S., what type of ongoing monitoring should be used? 

Why is this monitoring the best choice for C. S.?

S. has agreed to the proposed treatment plan but he also expresses he is worried his family and friends will only see him a drug addict. He expresses concern that because of his opioid use he won’t be able to go back to work. 

What should the nurse include in the teaching plan for C. S?  

Summary 

Pain is a complex process that differs for each patient and is not always easily treated. A thorough assessment is necessary to determine the type of pain present. This assessment also serves to aid in diagnosis and as a baseline for determining the effectiveness of prescribed interventions. For patients with pain, who are using opioids, there is a risk of developing tolerance and dependence upon the drug, resulting in the development of a substance use disorder—previously known as an addiction, substance use disorders are now recognized by the APA and are further categorized in the DMS-5. This important step has helped to further awareness of the problem among health care providers and provides clear guidelines for the diagnosis of the disorder.  

The CDC has identified best practice guidelines to prescribing opioid therapy: 

  • Implement non-pharmacological and non-opioid medications before using opioids for pain 
  • Identify realistic goals addressing both pain and level of function 
  • Educate patients on both the risks and benefits of opioid therapy 
  • Prescribe immediate-release and the lowest effective dose for patients who need opioid therapy 
  • When prescribing opioids for acute pain, only prescribe what the patient will need for three days 
  • Regularly evaluate risk versus benefit and taper dosage or discontinue if benefits do not outweigh the risks 
  • Evaluate risk factors for misuse and addiction 
  • Use PDMP data to inform decision-making and identify patients at high risk for overdose. 
  • Implement urine drug screening at initiation of therapy and annually 
  • Avoid prescribing both opioids and benzodiazepines 
  • Offer treatment for patients with substance use disorder (14) 

When non-pharmacological and non-opioid options have been attempted without success, opioid therapy remains an option for pain management. Patient education related to opioid use should focus on the medication being prescribed and address both administration and adverse effects. Additional education related to the safe use of opioids, storage and disposal, and the use of opioid antagonists should also be provided.  

The incidence of substance use disorder is the U.S. remains high, even in light of steps taken by federal and states governments to address the problem. The cost of addressing opioid misuse takes a heavy toll on the healthcare system and both state and federal budgets, but these pale in comparison to the impact on patients and families who are suffering under the heavy burden of substance use disorders. Everyday patients and their families are affected by opioids and feel the impacts of joblessness, broken families, and death from overdose as result of the opioid epidemic. Measures taken by the state of West Virginia have raised awareness of the problem and have helped address concerns related to prescribing and access, but the work is not done; this West Virginia Drug Diversion course is just one step in the right direction. Continuing education about prescribing, administering, and dispensing controlled substances is essential to help curb over-prescribing and to help identify patients at risk of substance use disorders, so early intervention can be provided. Likewise, patient education is needed to ensure patients are taught the skills to safely use opioids to manage their pain and to be prepared to take an active role in their treatment plans.  

Constipation Management and Treatment

Introduction   

In the realm of healthcare, where every aspect of patient well-being is meticulously tended to, constipation is a condition that often remains in the shadows. Often dismissed as a minor inconvenience, constipation is a prevalent concern that can have significant repercussions on the health and comfort of hospitalized and long-term care patients (8).  

Imagine a scenario where a middle-aged patient, recently admitted to a hospital for a non-related condition, is experiencing discomfort due to constipation. Despite the patient's hesitation to bring up this seemingly "embarrassing" topic, a skilled nurse takes the initiative to initiate an open conversation.  

By actively listening and empathetically addressing the patient's concerns, the nurse alleviates the discomfort and also plays a crucial role in preventing potential complications. This scenario exemplifies the pivotal role that nurses play in the comprehensive management of constipation. 

Envision a long-term care facility where an elderly resident's mobility is limited, leading to a sedentary lifestyle. As a result, this individual becomes more susceptible to constipation, which could potentially lead to more severe issues if left unattended. Here, the nurse's expertise in identifying risk factors and tailoring interventions comes into play.  

By suggesting gentle exercises, dietary adjustments, and adequate hydration, the nurse transforms the resident's daily routine, ensuring a healthier digestive tract and enhanced overall well-being. 

Through the above scenarios, it becomes evident that constipation is not merely a minor inconvenience but a legitimate concern that warrants attention. As the first line of defense in patient care, nurses are uniquely positioned to identify, address, and holistically prevent constipation.  

Nurses possess the knowledge and skills to create a profound impact on patient lives by acknowledging and addressing this issue. This course aims to equip nurses with an in-depth understanding of constipation, enabling them to be proactive vigilant advocates for patient comfort, bowel health, and overall well-being. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What role do nurses play in constipation management? 
  2. Name one lifestyle factor that can contribute to constipation. 

Epidemiology  

To truly comprehend the significance of constipation in healthcare settings, it's essential to grasp its prevalence and impact. Statistics reveal that constipation holds a prominent spot in healthcare challenges, with up to 30% of patients in hospitals and long-term care facilities experiencing this discomfort (4). This means that in a unit with 100 patients, nearly a third of them might be grappling with constipation-related issues.  

Even though constipation transcends demographics, elderly patients, who are a substantial part of long-term care settings, are more susceptible to constipation due to factors like decreased mobility, altered dietary habits, and medication use. Understanding this demographic predisposition is crucial for nurses as it guides their vigilance in recognizing and managing constipation among this vulnerable group. By unraveling its prevalence and its penchant for affecting diverse patient groups, nurses can step into their roles armed with knowledge, ready to make a tangible difference in patient lives. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What percentage of patients in hospitals and long-term care facilities experience constipation?  

Etiology/Pathophysiology  

Embarking on the journey to comprehend constipation's root causes and underlying mechanisms offers a fascinating glimpse into the intricate workings of the digestive system. The digestive system is a well-orchestrated symphony where even a slight disruption can lead to a discordant note, constipation being one such note.  

Constipation arises from an intricate interplay of factors. Lifestyle choices, such as physical inactivity, dietary habits, and even medication use, can disturb the symphony of digestion. These disruptions impact the stool's consistency, its journey through the intestines, and the efficiency of water absorption.  

 

Some examples of how lifestyle choices can cause constipation include the following: 

  • The digestive tract, like a finely tuned instrument, requires regular movement to maintain its rhythm and balance. Without physical activity to nudge food along, its journey through the digestive process slows down, potentially leading to constipation. 
  • Mismanagement of water absorption in the colon can also contribute to constipation. Excess absorption of water in the colon can turn the stool hard and dry, making it a formidable challenge to pass.  
  • When fiber is lacking in the diet, stool encounters resistance and sluggishness, akin to a symphony losing its guiding rhythm. This lack of fiber can lead to constipation, underscoring the importance of dietary choices in maintaining a harmonious digestive process (10). 

 

Understanding the above dynamics empowers nurses to decode the origins of constipation and tailor interventions that restore the harmonious rhythm of the digestive orchestra. Just as a conductor guides a symphony to its crescendo, nurses can orchestrate the path to relief and comfort for patients grappling with constipation. 

Signs and Symptoms  

Constipation's signs and symptoms are the stars that guide nurses toward effective management. Infrequent bowel movements, excessive straining, abdominal discomfort, and bloating are like constellations, revealing the narrative of digestive imbalance. 

Recognizing the constellation of signs and symptoms becomes the compass guiding nurses toward effective care. Just as a seasoned sailor navigates by the stars, nurses navigate constipation's landscape by deciphering the cues that patients present. 

Research by Anderson and Brown (1) reveals that patients grappling with constipation often experience infrequent bowel movements as a telltale sign. Nurses, armed with this insight, recognize that infrequent bowel movements warrant vigilant assessment and timely interventions. 

Excessive straining, much like tugging at sails in adverse winds, emerges as another hallmark of constipation (6). Patients' tales of discomfort during bowel movements point to an underlying imbalance. Nurses adeptly interpret this discomfort as a call for action, initiating strategies that ease the passage of stool and restore harmony to the digestive symphony. 

Discomfort serves as an indicator of the digestive system's struggle to find its equilibrium. Nurses, like skilled navigators, probe further, discerning the nuances of the discomfort to tailor interventions that address its root cause (11). 

Bloating is another symptom. Research by Smith and Williams (9) illuminates the link between constipation and bloating. This connection heightens nurses' vigilance, prompting them to delve into patients' experiences and offer relief from the discomfort. 

Pharmacological/Non-Pharmacological Treatment 

Constipation management encompasses a harmonious blend of pharmacological and non-pharmacological strategies. Just as a symphony thrives on a balanced ensemble, nurses can orchestrate a symphony of relief and comfort by selecting the right interventions for each patient's unique needs. Through this holistic approach, nurses play a pivotal role in restoring the digestive symphony to its harmonious rhythm. 

 
Pharmacological 

As nurses step into the realm of constipation management, they encounter a diverse array of strategies that can harmonize the digestive symphony. Picture a pharmacist's shelf adorned with an assortment of medications, each with a specific role in alleviating constipation. 

Fiber supplements work by increasing stool bulk and promoting regular bowel movements. They're gentle and mimic the natural process, ensuring a harmonious flow. 

Osmotic laxatives introduce more water into the stool, creating a balanced blend of moisture, preventing dry and challenging stools, and facilitating movement.  

Stimulant laxatives stimulate bowel contractions, hastening the stool's journey through the digestive tract. They're like the energetic beats that invigorate a symphony, leading to a rhythmic and effective passage. 

Lastly, stool softeners ensure that the stool is neither too hard nor too soft, striking the perfect balance. They act by moistening the stool, making it easier to pass without straining. By introducing this harmony, stool softeners contribute to patient comfort. 

 
Non-pharmacological 

Beyond the realm of medications lies an equally vital avenue: non-pharmacological interventions. Nurses can craft a holistic care plan, carefully considering dietary adjustments and lifestyle modifications as the foundation. Examples of non-pharmacological interventions include the following: 

A diet rich in fiber guides the stool's journey with ease. Nurses can educate patients on incorporating fruits, vegetables, and whole grains, ensuring a harmonious flow through the intestines. 

Engaging in regular physical activity not only stimulates bowel movements but also enhances overall well-being. Nurses can encourage patients to integrate movement into their routines, contributing to a dynamic and efficient digestive process. 

Relaxation techniques play a vital role in constipation management. Nurses can provide guidance on techniques like deep breathing or gentle abdominal massages that soothe the digestive tract, facilitate a smoother passage, and transform discomfort into relaxation. 

Quiz Questions

Self Quiz

Ask yourself...

  1. How does fiber-rich food aid in preventing constipation? 
  2. What are the four main types of pharmacological treatment for constipation? 

Complications 

Constipation complications can disrupt the symphony of health. Nurses, armed with knowledge and interventions, become conductors of comfort, guiding patients toward a harmonious journey free from discomfort and dissonance. Through their skilled care, nurses harmonize the symphony of patient well-being, preventing complications and promoting relief. Examples of complications include the following. 

 

Hemorrhoids 

These are swollen blood vessels around the rectal area that cause pain, itching, and even bleeding during bowel movements. Nurses can educate patients about preventive measures, such as adequate fiber intake, staying hydrated, and avoiding straining during bowel movements. 

 

Anal Fissure 

This is a small tear in the anal lining that can cause pain and bleeding, disrupting daily life. Nurses can gently guide patients toward hygiene practices and proper self-care, restoring comfort and preventing further disruption. 

 

Fecal Impaction 

Here, the stool accumulates, creating an obstruction that can be likened to an unexpected pause in flow. This impaction causes severe discomfort and can even lead to bowel obstruction. Nurses should be attentive to patients at risk of fecal impaction, promptly intervening with measures such as stool softeners, gentle digital disimpaction, and regular bowel assessments.  

 

Rectal Prolapse 

This protrusion of the rectal lining is a disruptive problem that not only causes physical discomfort but also emotional distress. Nurses can empower patients by educating them about the importance of managing constipation and preventing rectal prolapse.  

 

Nausea and Vomiting 

The buildup of waste and toxins can trigger these unsettling symptoms. Nurses should be vigilant, recognizing these cues as a sign of digestive imbalance. Collaborating with healthcare teams, nurses can address the underlying constipation, restoring harmony and alleviating discomfort. 

 

Bowel Obstruction 

This is a medical emergency. Patients experience severe abdominal pain, bloating, and the inability to pass stool or gas. Nurses should be well-equipped to recognize these symptoms and act swiftly, seeking immediate medical intervention.  

Quiz Questions

Self Quiz

Ask yourself...

  1. What is a potential complication of untreated constipation that involves swollen blood vessels around the rectal area? 
  2. What are two potential symptoms of constipation-related nausea and vomiting? 
  3. When should nurses suspect a bowel obstruction in a patient with constipation? 

Prevention  

Prevention is composed of dietary choices, hydration, exercise, and lifestyle awareness. Nurses, as conductors of preventive care, guide patients toward a harmonious journey of well-being. By embracing preventive measures, patients become active participants in the symphony of their health, ensuring that the digestive rhythm remains soothing and uninterrupted. Sample preventive measures include the following: 

 

Dietary Adjustments 

Nurses can educate patients about the importance of incorporating fiber into their diets. Picture a patient's plate adorned with vibrant fruits, vegetables, and whole grains — these fiber-rich choices act as the brushstrokes that create a smooth flow through the digestive system.  

 

Hydration 

Like the gentle spray that keeps a garden vibrant, staying adequately hydrated ensures the digestive landscape remains fluid and inviting. Nurses can encourage patients to drink sufficient water, allowing the stool's journey to be as effortless as the water's flow.  

 
Exercise 

Nurses can guide patients in incorporating regular physical activities like brisk walks, or gentle stretching into their daily routines, creating a rhythm that enhances bowel motility and overall well-being. Movements, much like instrument tuning before a performance, prepare the digestive system for optimal function.  

 

Lifestyle Awareness 

Nurses can educate patients about the importance of timely bowel movements and creating a comfortable environment for digestion. Patients can cultivate their well-being by avoiding prolonged periods of sitting and adopting healthy toileting habits.  

 

Patient Education 

Nurses can provide insights into the importance of fiber-rich foods, hydration, and movement. By empowering patients with knowledge, nurses equip them with the tools needed to prevent constipation and maintain digestive well-being.   

Quiz Questions

Self Quiz

Ask yourself...

  1. What is the importance of dietary adjustments in preventing constipation? 
  2. How does hydration impact constipation prevention? 
  3. What is the role of exercise in preventing constipation? 

Nursing Implications 

Nurses are instrumental in managing constipation and improving patient outcomes. Nurses should be skilled in assessing patients for constipation risk factors, communicating effectively about symptoms, and tailoring interventions to individual patient needs. Collaborating with other healthcare professionals to develop comprehensive care plans is essential. Examples of useful nursing skills include: 

 

Holistic Assessment 

Nurses are vigilant observers, attuned to the nuances of patient well-being. Like skilled detectives, nurses delve into patients' histories, medications, and lifestyles, identifying constipation risk factors. Holistic assessments allow nurses to understand the unique backdrop against which constipation may unfold. Armed with this knowledge, nurses can tailor interventions that resonate with each patient's needs (12). 

 
Effective Communication 

Envision a nurse as a skilled communicator, bridging the gap between patient concerns and medical insights. Like a translator, nurses help patients express their symptoms and experiences, ensuring nothing gets lost in translation. Effective communication not only nurtures trust but also facilitates accurate assessment, enabling nurses to identify constipation-related cues and initiate timely interventions (14). 

 

Collaboration with Multidisciplinary Teams 

Consider a care setting where the patient's well-being is a collective effort, much like an orchestra composed of diverse instruments. Nurses collaborate with physicians, dietitians, physical therapists, and other healthcare professionals to ensure a harmonious approach to constipation management. This interdisciplinary collaboration ensures that each note of patient care resonates in unison, creating a symphony of comprehensive well-being (7). 

 

Patient-Centered Care Plans 

Imagine nurses as architects of care plans, designing blueprints that reflect patients' unique needs and preferences. Just as architects tailor a building to its occupants, nurses craft patient-centered care plans that incorporate dietary preferences, lifestyle routines, and individualized interventions. This tailored approach ensures that patients feel heard and empowered in their constipation management journey (13). 

 

Education and Empowerment 

Envision nurses as educators, empowering patients with knowledge that transforms them into active participants in their care. Much like a guide, nurses navigate patients through the maze of constipation management strategies, ensuring clarity and understanding. By imparting information about dietary choices, hydration, exercise, and self-care, nurses equip patients with the tools needed to harmonize their digestive well-being (2). 

 
Continuous Monitoring and Evaluation 

Imagine nurses as diligent conductors, continuously assessing the rhythm of constipation management. Just as a conductor listens to every note, nurses monitor patients' responses to interventions, ensuring their effectiveness. Regular evaluation allows nurses to fine-tune strategies, ensuring that the symphony of constipation management remains harmonious and effective (5). 

 

Compassionate Support 

Envision nurses as compassionate companions on the patient's constipation management journey. Like trusted friends, nurses offer emotional support, addressing patients' concerns and fears with empathy. This compassionate approach fosters a sense of security and trust, enabling patients to navigate the challenges of constipation with resilience and a sense of camaraderie (3). 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. How can nurses contribute to patient-centered care plans for constipation management? 
  2. What is the significance of effective communication in constipation management? 
  3. Why is continuous monitoring and evaluation important in constipation management? 

Conclusion

Constipation is a significant concern that impacts the comfort and well-being of hospitalized and long-term care patients. Nurses' proactive role in identifying, managing, and preventing constipation is essential for promoting patient health. By employing a combination of pharmacological and non-pharmacological interventions, nurses can significantly enhance patient comfort and quality of life.  

Envision nurses as educators who share the symphony of knowledge with patients, empowering them to become proactive partners in their well-being. With insights about dietary choices, hydration, exercise, and relaxation techniques, patients become active participants in the harmony of their digestive health. 

Think of nurses as vigilant observers, continuously assessing the rhythm of constipation management, listening to every note, monitoring patient responses, and adjusting interventions to ensure a harmonious and effective approach.  

Finally, visualize nurses as compassionate companions on the constipation management journey. They offer unwavering support, much like friends sharing the weight of challenges. This compassionate presence fosters trust, comfort, and a sense of unity, creating a symphony of emotional well-being alongside physical relief. 

As this course concludes, let us remember that constipation management is not just about alleviating discomfort but about orchestrating a symphony of care that encompasses every aspect of the patient’s experience.  

By blending knowledge, empathy, and skill, nurses elevate constipation management from a routine task to a transformative experience. With this newfound understanding, nurses are prepared to guide patients toward a harmonious symphony of relief, comfort, and overall well-being. 

 

 

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are some societal misconceptions or stereotypes about people with spinal cord injuries? 
  2. What are some learning gaps among nurses regarding caring for people with spinal cord injuries? 
  3. How well does the healthcare system accommodate people with spinal cord injuries?

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  


Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

 

Trauma 
  • Vehicle accidents: Accounts for 40% of all cases [2] 
  • Falls: Accounts for 32% of all cases [2] 
  • Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
  • Sport-related accidents: Accounts for 8% of all cases [2] 

 

Medical Conditions 
  • Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
  • Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
  • Post-Polio: Damage to the central nervous system caused by a virus [1] 
  • Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
  • Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
  • Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
  • Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
  • Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

 

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

 

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one function of the spinal cord? 
  2. What is one way to prevent spinal cord injuries in any group? 
  3. Why do you think injuries caused by medical conditions are least likely to occur in the U.S.? 
  4. Why do you think the first year of care after the injury is the most costly?

Think about someone you know (or cared for) who had a spinal cord injury. 

  1. Did they have total or partial loss of feeling and movement to the extremities? 
  2. What comorbidities or complications did they have associated with the injury? 
  3. In what ways did the injury affect their overall quality of life?

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

  • Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
  • Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
  • Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
  • Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

 

Injury Level 
  • Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
  • Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

 

Impairment 
  • Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
  • Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

 

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

 

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why might a person with a disability experience mental distress? 
  2. In what type of spinal cord injury does a person lose all sensation and mobility below the waist? 
  3. Why are people with spinal cord injuries at risk for pressure injuries? 
  4. How can spinal cord injuries affect a person’s personal relationships? 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Quiz Questions

Self Quiz

Ask yourself...

Think about a time you assisted with bowel or bladder management in someone with a spinal cord injury. 

  1. What types of activities were included in their bowel or bladder regimen? 
  2. What challenges did you encounter during bowel or bladder care? 
  3. What difficulties did they express to you about managing their bowel or bladder program? 
  4. In what ways did you assist them in managing their own bowel or bladder program?

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

 

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one role of the brain in bowel and bladder function? 
  2. Which type of bowel dysfunction occurs in thoracic-level spinal cord injuries? 
  3. In which type of bowel dysfunction might a suppository be most effective? 
  4. In which type of bladder dysfunction does the bladder lose muscle tone? 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Quiz Questions

Self Quiz

Ask yourself...

Think about your experiences with patients with spinal cord injuries and their family or caregivers. 

    1. How knowledgeable was the patient about their bowel or bladder care? 
    2. In what ways were the family or caregiver involved in the plan of care? 
    3. Did the family or caregiver have any learning gaps that needed to be addressed? 
    4. What difficulties did the family or caregiver express to you about their role? 

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

 

Questions the nurse can ask the patient: 
  • What does your typical diet consist of? 
  • How much fluid do you drink on a daily basis? 
  • How often do you have a bowel movement or urinate? 
  • Do you schedule your bowel movements with assistance from medications? 
  • Are there certain body positions or things you do to help you pass stool more easily?
  • How often do you use an intermittent urinary catheter for bladder relief? 
  • How much time do you spend on your bowel and bladder regimens? 
  • Do you care for all of your elimination needs or does someone help you? 
  • How does your bowel and bladder dysfunction affect your quality of life? 

 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

 

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

 

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

 

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

 

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

 

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

 

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Quiz Questions

Self Quiz

Ask yourself...

  • What is one question a nurse can ask a patient to obtain a bowel and bladder history? 
  • How can nurses help patients with spinal cord injuries start or modify a bowel or bladder regimen? 
  • When might a colostomy be indicated for a patient with a spinal cord injury? 
  • What type of referral might be ordered for a patient with a spinal cord injury who has bowel or bladder dysfunction?

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

Pressure Injury Prevention, Staging and Treatment

Introduction   

When hearing the term HAPI, what comes to mind? The fact is, HAPI may not necessarily generate happy thoughts. Hospital-acquired pressure injuries (HAPIs) are a significant problem in the U.S. today. In fact, pressure injuries in general – whether acquired in a hospital or not – are a global problem.

Many articles have noted that staging and differentiating pressure injuries can be overwhelming for nurses [9]. The purpose of this course is to equip learners with the knowledge needed to reduce pressure injuries, resulting complications, financial risk, and associated death. The information in this course will serve as a valuable resource to nurses from all specialties and backgrounds.

What is a pressure injury?

The National Pressure Injury Advisory Panel (NPIAH) defines pressure injuries as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device” [17]. Pressure injuries can present as intact or opened skin and can be shallow or deep. Pressure injuries can be quite painful for patients and may require extensive treatment.

Prior to 2016, pressure injuries were termed “pressure ulcers.” However, since ulcer implies “open skin,” the NPIAH changed it to “pressure injury” as the skin is not always open with some of these injuries [22][25].

 

What causes a pressure injury to develop?

Pressure 

Intense and/or prolonged pressure on the patient’s skin and/or tissue can cause compromised blood flow and decreased sensation [7]. This can occur when patients lay or sit on a bony prominence for an extended period of time [16].  

Bony prominences are areas where you can easily feel a bone underneath the skin or tissue when palpating. These can include the heels, hips, elbows, and tailbone. Approximately two-thirds of all pressure injuries occur on the hip and buttocks area [7]. 

 
Friction and Shear 

Friction and shear often happen when patients slide down in bed, for example, when the head of the bed is raised. Although “friction and shear” are often used together, there is actually a difference between the two.  

While friction occurs when skin is dragged across a coarse surface (leading to surface-level injuries), shearing occurs when internal bodily structures and skin tissue move in opposite directions (leading to deep-level injuries) [10]. Shearing is often associated with a type of pressure injury called deep tissue injury (occurring in the deeper tissue layers rather than on the skin’s surface) [10].

 

[24] 

 

What are risk factors for developing a pressure injury? 

There are numerous risk factors for pressure injuries – some of which may not be directly related to the skin. These risk factors can be categorized as either intrinsic factors (occurring from within the body) or extrinsic (occurring from outside of the body) [2][13]. 

 

Intrinsic Risk Factors 

- Poor skin perfusion (e.g., peripheral vascular disease or smoking) 

- Sensation deficits (e.g., diabetic neuropathy or spinal cord injuries) 

- Moist skin (e.g., urinary incontinence or excessive sweating) 

- Inadequate nutrition (particularly poor protein intake) 

- Poor skin elasticity (e.g., normal age-related skin changes) 

- End of life/palliative (leads to organ failure including the skin) 

- Limited mobility (i.e., bedridden, or wheelchair-bound) 

 

Extrinsic Risk Factors 

- Physical and chemical restraints (leads to limited mobility) 

- Undergoing a procedure (laying down for extended periods of time) 

- Length of hospital stay (for HAPIs) 

- Medical devices (can lead to medical device-related pressure injuries)

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the most common areas for pressure injuries to develop? 
  2. What is the major difference between friction and shear? 
  3. What is one reason why elderly adults are at an increased risk for developing a pressure injury? 

Statistical Evidence 

This section will cover pressure injury statistics both globally and nationally. This section will also cover the impact pressure injuries have on healthcare.

What is happening on a global scale? 

In a global study, researchers found that the prevalence (all cases) and incidence (new cases) of pressure injuries in 2019 were 0.85 million and 3.17 million, respectively – numbers that have decreased over time [23][25]. Numbers were disproportionately high in high-income North America, Central Latin America, and Tropic Latin America [25]. Numbers were lowest in Central Asia and Southeast Asia. The report revealed that although numbers are high overall, they are much lower than what they were predicted to be, which may be attributed to better prevention and treatment initiatives.

What is happening nationally? 

In the U.S., 2.5 million people develop pressure injuries each year [1]. This number does not account for the many people trying to manage pressure injuries on their own at home (i.e., when family acts as the caregiver).  

HAPIs in particular are a growing problem. The most recent data on hospital-acquired conditions in the U.S. shows that from 2014 to 2017, HAPIs increased by 6% (647,000 cases in 2014 to 683,000 in 2017) [6]. Each year 60,000 patients in the U.S. die as a direct result of pressure injuries [1]. 

How do pressure injuries impact healthcare? 

Pressure injuries can be quite costly to the healthcare system. These injuries can lead to persistent pain, prolonged infections, long-term disability, increased healthcare costs, and increased mortality [1].  

In the U.S., pressure injuries cost between $9.1 - $11.6 billion per year [1]. These injuries are complex and can be difficult to treat [7]. Often requiring an interdisciplinary approach to care, the costs of one pressure injury admission can be substantial. Individual care for patients with pressure injuries ranges from $20,900 to $151,700 per injury [1]. Not to mention, more than 17,000 lawsuits are related to pressure injuries every year [1].  

Due to the significant impact that these injuries have on healthcare, prevention and accurate diagnosis is imperative.

Quiz Questions

Self Quiz

Ask yourself...

  1. What are possible contributing factors to the increase in HAPIs in the U.S.? 
  2. What are some factors that may contribute to the high costs of pressure injuries in healthcare settings?

Staging and Diagnosis 

The section will cover the staging, varying types, and diagnosis of pressure injuries.  

 

What is the difference between wound assessment and staging? 

Pressure injury staging is more than a basic wound assessment. Wound assessment includes visualizing the wound, measuring the size of the wound, paying attention to odors coming from the wound, and lightly palpating the area on and/or around the wound for abnormalities. Pressure injury staging, however, involves determining the specific cause of injury, depth of skin or tissue damage, and progression of the disease.  

 

What are the six stages of pressure injuries? 

According to NPIAP guidelines, there are six types of pressure injuries – four of which are stageable [14]. 

 

[16] 

 

Stage 1 

In Stage 1 pressure injuries, there is intact skin with a localized area of non-blanchable erythema (pink or red in color), which may appear differently in darkly pigmented skin. Before visual changes are noted, there may be the presence of blanchable erythema or changes in sensation, temperature, or firmness. Stage 1 pressure injuries do not have a purple or maroon discoloration (this can indicate a deep tissue pressure injury). 

 

Stage 2 

In Stage 2 pressure injuries, there is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent an intact or opened serum-filled blister. Fat (adipose) and deeper tissues are not visible. Granulation tissue, slough (soft moist material, typically yellow or white), and eschar (hard necrotic tissue, typically black in color) are not present. Stage 2 injuries cannot be used to describe wounds associated with moisture-only, skin chaffing, medical adhesives, or trauma. 

 

Stage 3 

In Stage 3 pressure injuries, there is full-thickness loss of skin, in which fat is visible in the injury, and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be noted. The depth of tissue damage is dependent on the area of the wound. Areas with a significant amount of fat can develop deep wounds.  

Undermining (burrowing in one or more directions, may be wide) and tunneling (burrowing in one direction) may be present. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury, not a Stage 3. 

 

Stage 4 

In Stage 4 pressure injuries, there is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound. Slough and/or eschar may be visible. Rolled wound edges, undermining, and/or tunneling are often present. The area where the wound is present will determine the depth. As with stage 3 pressure injuries, if slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury. 

 

Unstageable 

In unstageable pressure injuries, there is full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is covered by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.  

 

Deep Tissue Injury 

In deep tissue pressure injuries (also termed: deep tissue injuries or DTIs), there is intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.  

Pain and temperature changes often precede skin color changes. Discoloration may appear differently in darker-pigmented skin. The injury may resolve without tissue loss or may worsen quickly and open up, revealing the actual extent of tissue injury. Deep tissue pressure injuries should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.  

Quiz Questions

Self Quiz

Ask yourself...

  1. How do basic wound assessments differ from pressure injury staging? 
  2. What is the main difference between a Stage 1 pressure injury and deep tissue injury? 
  3. What is one structure you might see in a Stage 4 pressure injury wound bed that you would not see in any other pressure injury?

What are other types of pressure injuries? 

Mucosal Membrane Pressure Injury 

Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. For example, a wound on the inside of a nostril from a nasogastric tube would be considered a mucosal membrane pressure injury. Due to the anatomy of the tissue, mucosal membrane pressure injuries cannot be staged [18]. 

 

Medical Device-Related Pressure Injury 

Medical device-related pressure injuries, often associated with healthcare facilities, resulting from the use of devices designed and applied for diagnostic or therapeutic purposes [15]. The resulting pressure injury typically conforms to the pattern or shape of the device which makes identification easier. The injury should be staged using the staging system.  

 

Hospital Acquired Pressure Injury (HAPI) 

While the general hospital setting places patients at a 5% to 15% increased risk of developing a pressure injury (HAPI), patients in the intensive (or critical) care unit in particular have an even higher risk [17]. Critical care patients typically have serious illnesses and conditions that may cause temporary or permanent functional decline. There is also evidence that pressure injuries in this setting can actually be unavoidable.  

The NPIAP defines “unavoidable” pressure injuries as those that still develop after several measures by the health provider have been taken. These measures include when the provider has (a) evaluated the patient’s condition and pressure injury risk factors, (b) defined and implemented interventions consistent with standards of practice and the patient’s needs and goals, and (c) monitored and evaluated the impact of interventions [20]. There are certain situations in which a critical care patient may have a higher risk of developing unavoidable pressure injuries.  

In one study of 154 critical care patients, researchers found that 41% of HAPIs were unavoidable and those who had a pressure injury in the past were five times more likely to develop an unavoidable pressure injury during their stay [20]. The study also found that the chance of developing an unavoidable HAPI increased the longer patients stayed in the hospital – a 4% risk increase each day.  

Quiz Questions

Self Quiz

Ask yourself...

  1. What type of pressure injury can be caused by nasogastric tube use? 
  2. What is it about critical care patients that places them at a high risk for HAPIs? 
  3. In what situation is a pressure injury considered unavoidable?

How are pressure injuries diagnosed? 

Diagnosing a pressure injury is done by simply staging the injury. The health provider may stage the injury or rely on the nurse’s staging assessment before giving the final diagnosis and initiating treatment. There are tests that may be ordered to help identify the early stages of a developing injury.  

For example, subepidermal moisture assessment (SEM) scanners may help to identify tissue changes early on in patients with darker skin tones [8]. Tests may also be ordered to determine the extent of the damage, disease, or infection caused by a pressure injury. A magnetic resonance imaging test (MRI) can be used to determine if the infection in a stage 4 pressure injury has spread to the bone. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are some problems that can occur if a pressure injury is not staged correctly?  
  2. What is one reason a provider would order an MRI of a pressure injury?

Prevention and Treatment 

This section will cover various strategies that can be used to prevent and treat pressure injuries. 

 

What are some ways to prevent pressure injuries? 

Preventing pressure injuries takes more than just one nurse repositioning a patient every two hours. It involves a combination of strategies, protocols, and guidelines that facilities can implement across various departments, specialties, and care team members. The NIAPH recommends the following prevention strategies [19]. 

 

Risk assessment 

Facilities should use a standardized risk assessment tool to help identify patients at risk for pressure injuries (i.e., the Braden or Norton Scale). Rather than using the tool as the only risk assessment strategy, risk factors should be identified by other means (for example, by gathering a detailed patient history).  

Risk assessments should be performed on a regular basis and updated as needed based on changes in the patient’s condition. Care plans should include risk assessment findings to address needs. 

 

Skin Care 

Monitoring and protecting the patient’s skin is vital for pressure injury prevention. Stage 1 pressure injuries should be identified early to prevent the progress of disease. These include looking at pressure points, temperature, and the skin beneath medical devices.  

The frequency of assessments may change depending on the department. Ideally, assessments should be performed upon admission and at least once daily. Skin should also be cleaned promptly after incontinence episodes. 

 

Nutritional Care 

Tools should be used that help to identify patients at risk for malnutrition. Patients at risk should be referred to a registered dietician or nutritionist. Patients at risk should be weighed daily and monitored for any barriers to adequate nutritional intake. These may include swallowing difficulties, clogged feeding tubes, or delays in intravenous nutrition infusions. 

 

Positioning and mobilization 

Immobility can be related to age, general poor health, sedation, and more. Using offloading pressure activities and keeping patients mobile overall can prevent pressure injuries. Patients at risk should be assisted in turning and repositioning on a schedule. Pressure-relieving devices may be used as well. Patients should not be positioned on an area of previous pressure injury. 

 

Monitoring, training, and leadership 

Current and new cases of pressure injuries should be documented appropriately and reported. All care team members should be educated on pressure injury prevention and the importance of up-to-date care plans and documentation.  

All care team members should be provided with appropriate resources to carry out all strategies outlined. Leadership should be available to all care team members for support (this may include a specialized wound care nurse or wound care provider). 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one reason why a patient at risk for pressure injuries would be weighed daily? 
  2. What are two ways to prevent pressure injuries in a patient with limited mobility?

How are pressure injuries treated? 

There is no one way to treat a pressure injury. Management of pressure injuries involves a specialized team of care providers and a combination of therapies that aim to target underlying factors and prevent complications [7]. Depending on the stage of the wound and skin risk factors, providers may order specific types of treatments.  

Some pressure injury treatments may include the following [7]. 

- Wound debridement – a procedure in which necrotic tissue is removed from a wound bed to prevent the growth of pathogens in the wound, allowing for healing 

- Antibiotic therapy (topical or systemic) 

- Medicated ointments applied to the wound bed (e.g., hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal) 

- Nutritional therapies (e.g., referrals to dieticians) 

- Disease management (e.g., controlling blood sugar in diabetes) 

- Pain medications 

- Physical therapy (to keep the patient active) 

Quiz Questions

Self Quiz

Ask yourself...

  1. In what way does debridement help to heal a pressure injury? 
  2. What non-nursing care team member may be consulted for a patient with a pressure injury?

The Nurse’s Role 

The section will cover the nurse’s role in preventing pressure injuries and the progression of disease.  

 

What is the nurse’s role in pressure injury prevention? 

Based on NPIAH guidelines, the Agency for Healthcare Research and Quality (AHRQ) – an agency that monitors pressure injury data for the U.S. – breaks down quality initiatives for preventing pressure injuries in a three-component care bundle [2].  

A care bundle is a combination of best practices that when used together, can lead to better patient outcomes [2]. The care bundle includes skin assessments, risk assessments, and care planning. Nurses should follow the guidelines listed under each component. 

Standardized pressure injury risk assessment 

- Use risk assessment tools and processes to identify patients at risk 

- Do not rely on tools only, use your own judgment as well (tools are meant to guide the assessment) 

- Update risk scores at least once daily and if patient’s condition changes 

- Document findings in the medical record 

- Communicate findings to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

 

Comprehensive skin assessment 

- Identify any pressure injuries that may be present 

- Determine whether there are other areas of skin breakdown or factors that may predispose the patient to develop a pressure injury (e.g., moist skin) 

- Identify other skin issues 

- Perform assessments at regular intervals 

- Document findings in the medical record 

- Communicate findings to other staff involved in care so that appropriate changes can be reported (e.g., informing the nursing assistant) 

- Ask colleague to confirm findings for accuracy (i.e., two-nurse skin checks) 

 

Care planning and implementation to address areas of risk 

- Create care plans that include each skin risk factor (e.g., nutrition, mobility, and moisture) 

- Update care plans as often as needed if there are any changes in the patient’s condition 

- Evaluate whether care plan was effective by assessing patient response to interventions 

-  Individualize care plans for each patient based on risk assessment scores and other observed risks 

- Identify patient learning needs and implement teaching as needed 

- Document care plan in the medical record 

- Communicate care plan to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why should nurses avoid relying solely on standardized assessment tools? 
  2. Why is documentation important when performing a skin assessment? 
  3. What pressure injury information should nurses communicate during handoff report?

How can nurses prevent medical device-related pressure injuries?

The NPIAP outlined best practices to prevent medical device-related pressure injuries in various settings including general care, long-term care, critical care, and pediatric care [20]. The following strategies apply across all settings. 

- Choose the correct size of medical device for the individual. 

- Cushion and protect the skin with dressings in high-risk areas (e.g., nasal bridge). 

- Inspect the skin under and around the device at least daily (if not medically contraindicated).  

- Rotate sites of oximetry probes.  

- Rotate between O2 mask and prongs (if feasible).  

- Reposition devices (if feasible).  

- Avoid placement of device over sites of prior or existing pressure injury OR directly under the patient.  

- Be aware of edema under the device and the potential for skin breakdown. 

- Change rigid C-collar to softer collar when medically cleared (for critical care settings).

Quiz Questions

Self Quiz

Ask yourself...

  1. How can nurses prevent a pressure injury from developing on the ear of a patient who wears a nasal cannula?

How can nurses identify pressure injuries in patients with darker skin tones? 

Research suggests that it may be difficult to note early changes that can lead to the development of a pressure injury in patients with darker skin tones – for one, blanching may not be as visible [8]. This places the patient at a greater risk for the advancement of disease as early identification may be challenging.  

In order to appropriately identify pressure injuries in patients with darker skin tones, nurses should use unique strategies. The NIPAH offers these recommendations for nurses to help accurately identify pressure injuries in this group [8]. 

 

Identification tips 

- Clean the suspected area beforehand 

- Compare the area to surrounding unaffected areas 

- Compare the area to the opposite laterality if possible (i.e., right versus left elbow) 

- Compare the area to unaffected areas in a different location (i.e., upper back versus chest) 

- Look for differences in skin tautness 

- Look for shining skin changes 

- Palpate for changes in skin temperature 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one way to identify pressure injuries in patients with darker skin tones? 

How can nurses quickly differentiate between pressure injury stages? 

Correct staging of pressure injuries is vital as treatment is determined by the extent of damage, disease, or infection. First and foremost, wounds should be gently cleaned prior to staging as drainage or debris can be mistaken for fat or bone within the wound bed [14].  

Nurses can quickly differentiate between stages by asking these simple easy-to-understand starter questions. A more detailed assessment should follow. 

- Stage 1 versus Stage 2: Is the skin intact? 

Rationale: The skin is always intact in Stage 1. The skin is always open in Stage 2 (or there may be an intact blister present). 

- Stage 2 versus Stage 3: Is the wound bed pink or beefy red? 

Rationale: The wound bed is pink or beefy red in Stage 2. In Stage 3, the wound bed has structures within that may be discolored. 

- Stage 3 versus Stage 4: Does the wound bed contain soft or firm structures? 

Rationale: The wound bed contains softer structures in Stage 3. The wound bed contains firmer structures in Stage 4.* 

- Unstageable versus Stageable: Is any part of the wound bed hidden? 

Rationale: The wound bed is not entirely exposed in an unstageable. The wound bed is exposed in a stageable that is open. 

- Intact DTI versus Stage 1: Is the discoloration light or dark? 

Rationale: The discoloration is dark in a DTI. The discoloration is much lighter in Stage 1. 

- Open DTI versus Stage 2: Is the discoloration in or around the wound bed dark? 

Rationale: There is dark discoloration in or around the wound bed in an open DTI. In stage 2, the discoloration is much lighter (if even present). 

 

*Nurses should familiarize themselves with the appearance of the various structures that may be present in a wound like fat, fascia, bone, tendon, ligament, etc. Most importantly, nurses should consult the wound care team or health provider if a stage cannot be determined. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why should nurses clean a wound prior to staging? 
  2. What should nurses do if unsure how to stage a pressure injury?

What should patients know? 

Facilities can use the NIAPH prevention strategies to devise teaching plans for patients [19]. Nurses should educate patients and families/caregivers on risk factors, signs and symptoms, prevention tips, and the importance of following through with treatment.  

Nurses should also teach patients to advocate for their own health in order to avoid progression of disease. Here are important tips to teach at any point during the patient’s stay. These tips can apply to nurses working in a variety of settings. 

- Tell the nurse or provider of your medical conditions (needed to identify risk factors) 

- Tell the nurse or provider if you notice any numbness or tingling in your body (potential risk for sensory deficits) 

- Tell the nurse or provider if you have a loss of appetite or trouble eating (potential risk for malnutrition) 

- Clean yourself well after using the restroom (maintains skin integrity) 

- Tell the nurse or provider if you need to use the restroom or need help with cleaning yourself (maintains skin integrity) 

- Tell the nurse right away if you have an incontinence episode (maintains skin integrity) 

- Take all prescribed medications (may include necessary antibiotics or wound-healing medications) 

- Reposition yourself in bed often or tell the nurse if you need help doing so (reduces immobility risk) 

- Tell the nurse or provider if you notice a new discolored area on your skin, or an open area (potential new or worsening pressure injury) 

- Tell the nurse or provider if you notice any changes to your wound (potential worsening pressure injury) 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one pressure injury prevention tip nurses can teach hospitalized patients? 
  2. What signs or symptoms should nurses teach the patient to report?

Quality Improvement 

This section will cover the quality improvement measures in place to reduce pressure injuries. 

What is a pressure injury quality improvement initiative? 

Quality improvement involves setting goals (or initiatives) and standards of care. The goal of quality improvement is to improve patient outcomes at a systematic level where everyone involved is on the same page.  

Although possibly unaware, all care team members are involved in quality improvement. Nursing leaders design, manage, and evaluate program initiatives. Staff nurses and other care team members follow protocols that are often developed from these initiatives.  

The Pressure Injury Prevention Program is a guide designed by the AHRQ to help health facilities implement a structured pressure injury prevention initiative based on quality improvement [12]. Facilities can use the guide as a training toolkit to implement a new quality improvement program [5].  

 

Initiative Goals: 

- Reduced pressure injury rates 

- Reduced adverse events related to pressure injuries 

- Reduced costs associated with pressure injuries 

- Reduced lawsuits related to pressure injuries 

 

Ways facilities can implement a prevention program: 

- Address the overall objectives of the prevention program 

- Identify the needs for change and how to redesign practice 

- Develop goals and plans for change 

- Use the NIAPH pressure injury prevention recommended practices 

- Establish comprehensive skin assessment protocols 

- Standardize assessments of pressure injury risk factors 

- Incorporate risk factors into individualized care planning 

- Establish clear staff and leadership roles 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one reason why a health facility would start or update a pressure injury prevention program? 
  2. When pressure injury rates are reduced, what else can health facilities expect to improve as well?

What are some pressure injury quality measures? 

Quality measures are tools that measure a system’s healthcare goals and/or ability to provide high-quality care [11]. In simple terms, quality measures are specific ways that systems (governments, states, organizations, etc.) can show how they are making progress in meeting goals. The AHRQ highlights the following three ways the U.S. measures its progress.  

 

Number of HAPIs 

The AHRQ measures the number of HAPIs per year. The most recent data is from 2014 to 2017 [6].

 

Year  Number of HAPIs 
2014  647,000 
2015  700,000 
2016  677,000 
2017  683,000 

 

Rate of HAPIs per admission 

The AHRQ measures the number of HAPIs per admission related to age groups. The number is measured as a “rate,” meaning the number of HAPIs per 1,000 hospital admissions. The most recent evidence is from 2017 [4]. 

 

Age group  Number of HAPIs per 1,000 admissions 
18 – 39   0.38 
40 – 64   0.63 
65 – 74   0.74 
75 and over  0.71 

 

Costs of HAPIs 

Another quality measure is HAPI costs. While the AHRQ does not measure costs of HAPIs every single year, the most recent data is from 2017 [3].  

 

Year  Cost of HAPIs per patient 
2017  $8,573 – $21,075 

 

Deaths related to HAPIs 

Patient mortality rates related to HAPIs are a quality measure (calculated per 1,000 pressure injury cases). The most recent data is from 2017 [6]. 

 

Year  Number of deaths per 1,000 pressure injury cases 
2017  2.42 – 5.06  

  

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one way a health facility can show its progress in preventing pressure injuries? 
  2. What patient age range do you think has the most pressure injury rates? Age 65 to 74 or age 75 and over?

Conclusion

 Pressure injuries are complex conditions that can lead to poor patient outcomes and a burdened healthcare system. The best strategy in the care of patients with pressure injuries or those at risk is prevention.  

However, preventing these injuries involves more than individual nurses taking specific steps. Prevention of pressure injuries involves a team effort from all members of the care team and a systemic plan for improvement.

 

Negative Pressure Wound Therapy (Wound Vac)

Introduction   

Negative pressure wound therapy (NPWT), also known as a wound vac, can be a powerful tool in combatting acute and chronic wounds. It relies on generating a negative pressure on the surface of a difficult wound to promote wound healing.

The goal of this course is to develop an understanding of mechanism of action of NPWT, discuss appropriate nursing assessment of these wounds, evaluate adjunct treatment options and troubleshooting support tips.

We will review basic concepts of the integumentary system and the normal wound healing process to support the rationale of NPWT.

Definition

Negative pressure wound therapy (NPWT) is the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue in an effort to enhance wound healing (4). The idea of applying negative pressure therapy is that once the pressure is lower around the wound, the gentle vacuum suction can lift fluid and debris away and give the wound a fighting chance to heal naturally.

NPWT has a long and interesting history. The idea of suctioning fluid from wounds as therapy is not a new concept. The process was first called “cupping” and was described in Ebers Papyrus around 500 BC; historians tell us that a form of wound suction was used around 1000 BC in China, 600 BC in Babylon and Assyria, and in 400 BC by Greeks who heated copper bowls over wounds to remove blood and fluids (5).

Modern medicine has built upon a very old concept. Thankfully, nurses have a slightly easier tool in NPWT devices than heating copper bowls.

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name the various methods of wound treatments that you have encountered?
  2. Do you recognize how negative pressure can create suction?

Indications for Use 

Negative pressure wound therapy is widely used for the management of both acute and chronic wounds. This therapy is helpful for a broad range of wounds, from pressure ulcers to closed surgical incisions.  

The system is now implemented routinely for open wounds, such as open fractures, fasciotomies, diabetic foot ulcers, and infected wounds. Delayed wound healing and difficult wounds are seen more commonly in elderly patients and those with comorbidities (1).  

It’s important to review the basic anatomy of our integumentary system, types of wounds, and barriers to healing to understand the usefulness of NPWT. 

 

Basic Anatomy of Integumentary System 

Our integumentary system is considered the body’s largest organ. Our skin acts as a shield against heat, light, bacteria, infection, and injury. Other functions include body temperature regulation, storage of water and fat, sensory function, prevention of water loss, and a basic storage compartment for the organs (6).  

 

The skin is made up of 3 layers. Each layer has unique functions: 

  1. Epidermis 
  1. Dermis 
  1. Subcutaneous fat layer (hypodermis) 

 

The epidermis is the thin outer layer of our skin, it contains squamous cells, basal cells, and melanocytes (gives skin its color). The dermis is the middle layer of skin, it contains blood vessels, hair follicles, sweat glands, nerves, lymph vessels, fibroblasts, and sebaceous glands (6). It is important to remember that the dermis contains nerves and nerve receptors. 

The subcutaneous fat layer is the deepest layer of skin and is made up of a network of collagen and fat cells; this layer conserves the body's heat and protects the body from injury by acting as a shock absorber (6).

This design was created on Canva.com on September 28, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

 

Types of Wounds 

Negative pressure wound therapy is primarily used to treat complex wounds that are non-healing or at risk of non-healing. It is also indicated for acute wounds when the wound cannot be closed due to the risk of infection, active infection, skin tension, or swelling (7).  

Closure or skin grafting of acute wounds, such as open fractures or burns, are at high risk for infection due to microorganisms becoming trapped in the soft tissue leading to abscess development.  

 

Examples of possible wounds to apply NPWT (1):  

  • Diabetic foot ulcers 
  • Bed sores 
  • Skin graft fixation  
  • Burns 
  • Crush injuries 
  • Sternal/abdominal wound dehiscence  
  • Fasciotomy wounds 
  • Animal bites 
  • Frostbite 

 

Barriers to Healing 

Age 

  • Increased risk of tearing and shearing due to thinning of epidermis and decrease in elastin 
  • Phases of healing are prolonged 
  • Increased risk of dehiscence as the dermis has slower contractility 
  • Skin more susceptible to bacterial growth and infections as pH becomes more neutral with age  

 

Co-morbidities 

  • Cardiopulmonary Disease 
  • Oxygen-transport pathways are affected 
  • O2 necessary for wound healing 
  • Diabetes Mellitus 
  • High glycemic levels predispose patients to infection 
  • Microvasculature and neuropathic components of DM increase the risk for impaired healing  
  • Poor glycemic control can increase the risk of ulceration and delayed healing 
  • Immune-suppressing conditions (Cancer, HIV, immunosuppressive therapy, immunosuppression syndrome) 
  • Inflammatory phase (immunology) is impaired 
  • Increased risk for infection 

 

Impaired Perfusion and Oxygenation 

  • Peripheral Vascular Impairment 
  • Proper perfusion is required for growth of new tissue and immunological responses of the tissue. 
  • Arterial insufficiency (blood flow to extremities) leads to necrosis or lack of response to edema. 

 

Neurological Impairment  

  • Peripheral neuropathy 
  • Complication related to DM, alcoholism, chemotherapy 
  • Loss of neuronal signaling and transmission 
  • Loss of the sensory ability to recognize and react to sensations of touch, pressure, temperature, pain. Example: patient leaving foot on hot surface because there was no pain sensation, leading to burn wound. 
  • Spinal cord injury 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Are you familiar with the layers and components that make up the integumentary system?
  2. Have you ever cared for a patient with a chronic wound?
  3. What are some ways the elderly population is at higher risk for prolonged wound healing?

Mechanism of Action 

The mechanism of action is dependent on applying negative pressure, which is below atmospheric pressure, to the wound. This pressure allows the gentle vacuum suction to lift fluid and exudate away from the wound to enhance healing (3).  

The vacuum is gentle because powerful suction would remove newly formed tissue as well. The mechanism of action is not only in removing fluid and debris from the tissue, but the pressure causes stimulation of the growth of granulation tissue at a macroscopic and microscopic level.  

The porous foam shrinks in size with the application of negative pressure and exerts strain on the wound bed, which leads to macro- and micro-deformation of the wound (3). Microdeformation is simply a term used to describe microscopic tissue cell reactions. This reaction can be compared to a battery jump-start of a car; the stimulation causes the battery to engage. 

NPWT systems consist of a sterile foam sponge, a semi-occlusive adhesive cover, a fluid collection system or canister, and a suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam and the wound is sealed with adhesive tape to make it airtight, and the machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg (1). 

 


 

This design was created on Canva.com on October 1, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Proper application of the NPWT is important for the mechanism of action to be effective. Research supports that NPWT is effective at creating a stable wound environment, reduces inflammation and bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis (1).  

Imagine you want to plant a garden in a swampy location, you would first need to divert the water and algae from the land, cover it with a greenhouse with consistent heat and pressure, and cultivate the soil for optimal growth. Similarly, NPWT creates the most ideal conditions possible for tissue regeneration.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name the components of NPWT?
  2. Have you ever applied a wound vac dressing?
  3. Are you familiar with the other semipermeable materials that serve as a filter?

Contraindications 

NPWT would be contraindicated for the following: 

  • Wounds involving untreated osteomyelitis. 
  • Wounds that have exposed blood vessel 
  • Wounds with exposed nerves, anastomotic sites, or organs 
  • Wounds including open joint capsules 
  • Malignant wounds 
  • Wounds with necrotic tissue; it is recommended to excise first 

 

The following wounds could benefit from NPWT, but caution should be given (5): 

  • Wounds with visible fistula 
  • Wounds with exposed bone or tendon 
  • The bone or tendon should be isolated from direct pressure  
  • Patient with clotting disorders or that are taking anticoagulants, due to an increased risk of bleeding. 
  • Compromised microvascular blood flow to the wound bed. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Can you think of reasons a malignant, cancerous wound should not have NPWT?
  2. Have you ever dressed a wound prior to or following debridement?

Assessment 

A focused assessment should be done for patients with NPWT devices in place, both on the machine settings, the dressing, and the wound itself. Thorough documentation of the wound is essential to see the progression of wound healing. 

 

Suction Device Settings: 

  • Continuous or intermittent 
  • Pressure Setting: Range of pressure settings from -40mmHg to -200mmHg, which can be tailored for different types of wounds (7). This is set by the medical provider. 

 

Laboratory assessment is meaningful in wound care. Labs can be used to assess oxygenation or indicators of infection (6). 

 

Dressing Assessment 

The appearance of the NPWT and dressing should be clean, dry, intact, and sealed. The tubing should not be twisted or kinked, and the clear adhesive dressing should not be wrinkled or overlapping. Please see below an example of the appropriate appearance of a dressing. 

 

Wound Assessment: 
  • Anatomic location 
  • Type of wound  
  • Degree of tissue damage 
  • Description of wound bed 
  • Wound size 
  • Wound edges and surrounding skin 
  • Signs of infection 
  • Pain 

 

Anatomical Location  

Anatomical terms and numbering should be used to make sure the location of each wound is documented. Patients often have more than one wound, so the treatment needs to be specified for each wound.  

 

Wound Base 

Assess the color of the wound base. Healthy granulation tissue appears pink and moist due to the new capillary formation. The appearance of slough (yellow) or eschar (black) in the wound base should be documented and communicated to the health care provider (1).  

This tissue may need to be removed to optimize healing. If any discoloration or duskiness of the wound bed or wound edges are identified, the suction should initially be reduced or switched off (7).  

 

Type and Amount of Exudate 

Assess the color, thickness, and amount of exudate (drainage) The amount of drainage from wounds is categorized as scant, small/minimal, moderate, or large/copious.  

Terms are used when describing exudate: sanguineous, serous, serosanguinous, and purulent (6).  

  • Sanguineous: fresh bleeding  
  • Serous: Clear, thin, watery plasma 
  • Serosanguinous: Serous drainage with small amounts of blood noted 
  • Purulent: Thick and opaque. The color can be tan, yellow, green, or brown. This is an abnormal finding and should be reported to a physician or wound care provider. 

 

Wound Size  

Wounds should be measured on admission, wound vac dressing changes, or as needed for abnormal events. Many healthcare facilities use disposable, clear plastic measurement tools to measure the area of a wound.  

Consistent measurement is vital to the assessment of wound healing. 

  • Measure the greatest length, width, and depth of the wound in centimeters 
  • Examples of wound classification tools: 
  • NPUAP staging system for pressure injuries 
  • Payne-Martin classification system for skin tears 
  • CEAP (clinical, etiologic, anatomic, and pathophysiology) system for venous ulcers 

 

Tunneling or Undermining 

Tunneling is when a wound has moved underneath the skin, making a “tunnel.” The depth of tunneling can be measured by gently inserting a sterile, cotton-tipped applicator into the tunnel and noting the length from the wound base to the end of the tract (7). Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge.  

 

Healing Process 

It is important to recognize the entire process of normal wound healing. There are four phases of wound healing: hemostasis, inflammatory, proliferative, and maturation (6).  

Hemostasis begins immediately after injury, involving platelet aggregation and activation of clotting factor (6). A platelet “plug” is formed as fibrinogen converts to fibrin and binds to itself. Vasoconstriction occurs at this time, decreasing blood loss and allowing clot formation.  

The inflammatory phase begins right after the injury and the injured blood vessels leak and cause localized swelling. The swelling, warmth, pain, and redness present during this stage of wound healing are related to the release of white blood cells, growth factors, nutrients, and enzymes to help control bleeding and prevent infection (6).  

The proliferative phase of wound healing involves “rebuilding” with new tissue made up of collagen and extracellular matrix; granulation tissue is built stronger with proper oxygen and nutrients.  

Key nursing knowledge: Dark granulation tissue can indicate infection, ischemia, or poor perfusion. The maturation phase of wound healing is when collagen is remodeled, aligns along tension lines, water is reabsorbed so the collagen fibers can lie closer together and cross-link, and the wound fully closes (1). 

There are three types of wound healing: primary intention, secondary intention, and tertiary intention.  

Primary intention means that the wound healing is supported by sutures, staples, glue, or otherwise closed so the wound heals beneath the closure (6).  

Secondary intention must happen when the edges of a wound cannot be approximated, or “brought together,” so the wound heals with the production of granulation tissue from the bottom up (6).  

Wounds that heal by secondary intention are at higher risk for infection, so contamination prevention is essential. Pressure ulcers are an example of wounds that heal by secondary intention.  

Tertiary intention refers to a wound that needs to remain open, often due to severe infection. Wounds with secondary and tertiary intention have longer healing times (2). 

Alternatives when NPWT fails 
  • Hyperbaric Oxygen Therapy (HBOT): 
  • HBOT is a treatment in which the wound is exposed to pure oxygen in a pressurized chamber to enhance wound healing (3). 

 

  • Bioengineered Tissue:  
  • Skin grafting or bioengineered tissue to promote tissue growth and healing.  
  • Skin grafts are considered as a treatment option if a wound is so large that it can’t close on its own. In this procedure, skin is taken from another part of your body – usually your thigh – and transplanted onto the wound (2). 
  • Some grafts are made from human cell products and synthetic materials. Studies have shown that these increase the chances of poorly healing venous leg ulcers closing faster. (2) 
  • Electrical Stimulation Therapy:  
  • Electrical stimulation therapy applies electrical currents to stimulate wound healing and tissue generation (4). It may be used to treat chronic wounds or pressure ulcers. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Have you ever cared for a patient with a wound that was unable to be stitched or sutured?
  2. Can you describe the importance of thorough, descriptive documentation of multiple wounds?
  3. Can you think of barriers to the normal wound healing process?

Adjunct Treatment Options 

When selecting an adjunctive therapy for wound management, the patient's medical history, overall health, co-morbidities, ambulation status, psychosocial aspects, environmental factors, and the specific needs of the wound should all be considered. Each patient is unique, and an individualized care plan is the goal.  

Treatment of the underlying contributing disorder will be essential. For example, a patient with uncontrolled diabetes that has led to poor circulation can benefit from glycemic control.  

Take a look at the larger, holistic picture. It can be helpful for the healthcare team to create a concept map of problems that contribute to the wound. 

 

Topical Agents and Dressings 

Various creams, ointments, or dressings can promote wound healing and prevent infection. One example is silver-based products, which are commonly used in reducing bacterial burden and treating wound infection (4). 

 

Nutrition Therapy for Wound Healing 

Patients with wounds would benefit from nutrition consultation and ongoing support.  

Nutrients from foods help the body build and repair tissue and fight infection. An increase in calories and protein is important, as well as blood sugar control for diabetics.  

Vitamins C, D, B-6, B-12, folate, and others aid in repairing tissues (6). Minerals such as iron, magnesium, calcium, zinc, and others support the cardiovascular system making sure cells have enough oxygen, the nervous system, and immunological function (6). 

 

Compression Therapy 

Compression therapy uses pressure to reduce swelling and improve blood flow to the wound. There are common compression devices or stockings available. It is frequently used to treat venous leg ulcers (6). 

 

Hyperbaric Oxygen Therapy (HBOT) 

HBOT can also be used as an adjunct treatment in which the patient breathes pure oxygen in a pressurized chamber to increase the amount of oxygen in the blood, which enhances wound healing (3). 

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you ever provided patient education on how nutrition impacts the immune system and wound healing?

Troubleshooting Tips 

You may encounter complications with the wound dressing or the wound vac equipment. The most common complications associated with NPWT are pain, bleeding, and infection (7).  

The wound therapy relies on an adequate seal similar to a regular vacuum, so a loss of suction can result in ineffective treatment. If loss of seal occurs, the nurse should assess the seal around the wound dressing and note if the transparent adhesive sealant tape has either been misapplied or has come off due to poor contact with the underlying skin.  

A loss of suction could also result from incorrect placement of the suction drain tube, loss of battery power, blockage of the suction drain tube, or if the suction device is full of output (7). Sometimes the location of the wound leads to difficulty in keeping the dressing seal in place; for example, the abdomen or near joints, so movement can misplace the dressing and break the seal. Patient education is key to maintaining proper suction. 

 

Troubleshooting Tips: 

  • Confirm the machine is on and set to the appropriate negative pressure. 
  • Make sure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure. 
  • Assess the negative pressure seal and check for leaks. 
  • Check for kinks in the tubing and make sure all clamps are open. 
  • Avoid getting the machine wet. 
  • Assess the drainage chamber to make sure it is filling correctly and does not need changing. 
  • Address alarm issues: 
  • Canister may be full 
  • Leak in the system  
  • Low/dead Battery 
  • The device should not be turned off for more than two hours without ordered discontinuation. 
  • If the device is off, apply a moist dressing and notify the provider immediately. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name reasons the NPWT device may sound an alarm?
  2. Can you think of barriers to proper suction? (ex: kinks in tubing, full canister, etc.)

Case Study 

Mr. Smith is a 59-year-old male presented to his primary care provider and referred to general surgery; diagnosed with lymphedema and multiple, copiously draining ulcerations on the left lower extremity.  

The patient presented with lymphedema and multiple ulcerations on the left lower extremity with copious amounts of drainage. This is an ongoing, worsening issue for over 8 months and has failed to respond to compression, foam dressings, or hydrocolloid dressing.  

The hospitalist has ordered surgical consultation, who scheduled debridement of the wounds and application of a wound vac following the procedure; Negative pressure wound therapy (NPWT) orders in place.  

 

CHIEF COMPLAINT: "The sores on my feet are draining more and I can no longer go to work because my boots do not fit on my foot.” He also reports a loss of appetite, chills, and loss of sensation to his left lower extremity.  

HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old truck driver who has previous medical history of DM Type II, hypertension requiring use of anti-hypertensive medication, and hyperlipidemia (non-compliant with medication regimen). He takes NSAIDS as needed for back and joint pain and was recently started on a daily baby aspirin by his PCP for cardiac prophylaxis. He denies alcohol intake. He reports smoking a pack of cigarettes per day. 

PHYSICAL EXAMINATION: Examination reveals an alert and oriented 59-YO male. He appears anxious and irritated. Vital sips are as follows. Blood Pressure 155/90 mmHg, Heart Rate 120/min - HR Thready - Respiratory Rate - 20 /minute; Temperature 98.0  

ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. Wound: 3 cm x 2 cm x 1 cm wound to lateral LLE. Wound base is dark red with yellow-green drainage present. Removed 4 x 4 dressing has a 5 cm diameter ring of drainage present. The surrounding skin is red, warm, tender to palpation, and with a dusky appearance to the entire LLE.  

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals a regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak. A positive Stemmer sign was noted and palpable pedal pulses with mild symptoms of venous insufficiency were noted. 

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are present.

Quiz Questions

Self Quiz

Ask yourself...

  1. Discuss abnormal findings noted during History & Physical Examination. 
  2. Evaluate additional data to obtain possible diagnostic testing, treatment, nursing interventions, and care plans. 
  3. Discuss how the patient’s comorbidities may be attributed to prolonged wound healing. 
  4. What suction settings would the nurse expect to be ordered?

Conclusion

Hopefully, upon completion of this course, you feel empowered and curious about the use of negative pressure wound therapy (NPWT). Wound vacs can be a powerful tool in combatting acute and chronic wounds, it is a well-documented concept throughout history.

The nurse should be knowledgeable on the integumentary system makeup and types of wounds this therapy is indicated for. The mechanism of action of NPWT is critical knowledge when assessing the healing of a wound. Adjunct treatment options and troubleshooting support tips are also meaningful in the care of patients with NPWT.

Nutritional Interventions to Promote Wound Healing

Introduction   

The medical field is an ever-evolving and constantly changing arena. Advances in technology and an increased understanding of how the body works have produced newer and better procedures and techniques in healing. These initiatives, as innovative as they may be, still depend on the body’s ability to heal itself as the foundation of the recovery process.  

In turn, the body needs proper nutrition to support the healing process within itself. Nutrition is often overlooked by nurses even though it is arguably the most critical aspect of physical healing. 

Factors That Impact Wound Healing 

Wound healing is a complex process. There are a myriad of factors that impact the body’s ability to heal and recover from an injury. Comorbidities, genetic disorders, medications, and, in some cases, disease treatments (chemotherapy, radiation, steroids, etc.) can all have the potential to slow, change, or interfere with normal wound healing (2). For this course, we will discuss a few of the more common factors that nurses will undoubtedly come across during their practice. 

 

Diabetes 

It is estimated that this growing, global disease will impact forty million people by the year 2030. It has been proven that diabetes is responsible for more than one hundred changes in wound healing.  

These alterations have been seen across all four phases of wound healing. Platelet activation, epithelialization, collagen deposition, and granulation tissue formation are among the alterations that take place with diabetes. Worsening renal function/failure and peripheral vascular disease as a result of diabetes also affect the wound-healing process (2). 

 

Renal Failure 

Though most patients who have chronic kidney disease or renal failure also have multiple comorbidities that cause the renal problem, renal failure does, independently, bring a risk of diminished wound healing. Tissue edema, delayed granulation, chronic inflammation, and decreased vessel formation are all ways that renal failure impacts wound healing.  

Hemodialysis, a life-sustaining treatment of chronic renal failure, adds fuel to the fire when it comes to risks of diminished wound healing. Protein and water-soluble vitamins and nutrients are lost through the dialysis process. This includes zinc and iron and will lead to deficiencies in these needed nutrients. Further, patients on hemodialysis and patients who receive a kidney transplant as treatment for renal failure are both at higher risk for developing infections (2).  

 

 

 

 

Smoking 

Smoking causes multiple alterations within the body at the molecular level that affect normal wound healing. Vasoconstriction caused by smoking worsens wound ischemia. The highly documented negative impact that smoking has on wound healing has led physicians to decline some elective surgeries due to the risk of poor wound healing (2). 

 

Infection 

It is not fully understood how infection alters wound healing. It is believed to be a multifactorial process that has a range of properties that can be progressive in nature; infection-necrosis-sepsis-death. The bacteria create an environment where the collagen that repairs the injured tissue is destroyed (2). 

 

Obesity 

Obesity complicates virtually every disease process including normal wound healing. Wound healing complications due to obesity include increased rates of infection, hematomas, and dehiscence. Local hypoxia is also a complication that impacts wound healing (2). 

 

Age 

Aging also has an impact on wound healing. During the aging process, the skin loses elasticity, thickness, and water content. There is also a decrease in the skin’s blood vessels as it ages, reducing the capacity for oxygenation and nutrients. Wound closure becomes slower with aging; by age forty, the amount of time for an identical wound to heal doubles from age twenty. After the age of fifty, dermal collagen decreases by one percent per year (2). 

 

Malnutrition 

Malnutrition or undernutrition has a variety of effects on wound healing. Good nutrition is essential for proper wound healing and the overall recovery of the body after an injury.  

Malnutrition can lead to the loss of immune function which will affect the body’s response to infection. With malnutrition, the skin becomes thin and frail thus more apt to develop wounds. Pressure wounds are also more likely as fat deposits over pressure points become depleted. The lack of energy during malnutrition leads to immobility, increasing the possibility of wounds. Collagen synthesis is also decreased (5).

Quiz Questions

Self Quiz

Ask yourself...

  1. Name three factors that can affect wound healing. 
  2. How does age and aging impact wound healing?
  3. What are two ways that malnutrition impacts wound healing?

Phases of Wound Healing 

Once again, wound healing is a complex process. From a simple pin prick to a stage-four decubitus ulcer, the wound healing process itself remains the same. The body will go through the four phases of wound healing to repair the damage.  

 

Hemostasis 

The first phase of wound healing is hemostasis. Whether by surgery or trauma, the body attempts to achieve hemostasis at the time of the injury. The intrinsic and extrinsic coagulation cascades are activated by the body.  

Vasoconstriction takes place while platelet aggregation occurs to form a fibrin clot. This is all in an effort of the body to stop the bleeding to bring about hemostasis. As the platelets arrive at the site of injury, cytokines and growth factors are released by the platelets to initiate the inflammation process (3) (4) (5). 

 

Inflammation 

Inflammation is the second phase of wound healing. It starts once hemostasis has been re-established. During this phase, the previous vasoconstriction reverses and the vessels dilate.  

This brings blood to the injury site along with neutrophils, macrophages, monocytes, and other inflammatory cells. Phagocytosis is initiated and the wound is cleansed by the removal of bacteria. The wound site will swell and there may be some restrictions in mobility to the affected area (3) (5). 

 

Proliferation 

Phase three is proliferation. In this phase, rebuilding of the wounded tissue begins. The number of fibroblasts increases and begins to build a collagen network and prepare the wound base for new granulation tissue.  

At the same time, new blood vessels are created; a highway for oxygen and nutrients to be supplied to the site. By the end of this phase, the foundation will have been laid for full epithelialization (3) (5). 

 

Remodeling 

The final phase of wound healing is remodeling. Epithelialization is in full swing once granulation tissue has filled the wound. This process stimulates skin integrity restoration.  

Scar tissue is formed as proteins such as collagen and elastin along with keratinocytes are produced. The wound closes and begins to strengthen and appear “normal”; it may take a couple of years for the site to return to its fully functional pre-injured status (3). 

Quiz Questions

Self Quiz

Ask yourself...

  1. How many phases of wound healing are there? 
  2. Name all the phases of wound healing in order.
  3. What happens during the proliferation phase of wound healing?

How Does Nutrition Impact Healing? 

Nutrition is, perhaps, the most important underlying aspect of wound healing. The mechanism of wound healing and the role nutrition plays in that process is very complex.  

Adding nutritional interventions to the wound healing care plan is generally low cost and will increase the probability of a full recovery. Nutrition is essential for all phases of the healing process. It is the foundation of wound healing.  

The malnourished patient will have difficulty progressing through the wound healing phases. Proper nutrition will also help prevent wounds such as pressure ulcers from developing in the first place.  

Understanding which nutrients are needed through the phases of wound healing will help to devise a nutritional plan of care. Energy is required in all the phases of wound healing and is only made possible through proper nutrition (3). 

Quiz Questions

Self Quiz

Ask yourself...

  1. In what phase of wound healing is proper nutrition essential?  

Common Deficiencies 

Nutrients and proteins are the building blocks of life. They are needed for growth, maintenance, and healing of the body. Many types of nutrient deficiencies greatly impact the healing process. Here, we will discuss some of the more common nutrient deficiencies. 

 

Iron 

Iron plays a key role in the synthesis of hemoglobin. Hemoglobin delivers oxygen throughout the body; oxygen is required through all phases of wound healing. Iron deficiencies can lead to anemia and decreased tissue perfusion. An iron deficiency will also affect protein synthesis, macrophage function, and overall wound strength (3) (6). 

 

 

 

 

 

Vitamin A 

When it comes to wound healing, vitamin A quickens collagen synthesis and the overall inflammatory phase. A deficiency in vitamin A decreases collagen production, epithelization, and tissue granulation (9). 

 
Vitamin B 

There are eight vitamins included in the vitamin B complex. Each of the eight vitamins has its own daily recommended intake. Vitamin B promotes cell proliferation and promotes normal metabolism. In the presence of a wound, some dietitians promote doubling the daily recommended intake of the B vitamins (3). 

 

Vitamin C 

Vitamin C (ascorbic acid) assists with iron absorption. It is also essential in the process of collagen formation. Without vitamin C, the immune response cannot take place as needed. There are many sources of vitamin C readily available for everyday consumption (6). 

 

Zinc 

Zinc is used through all phases of the wound-healing process. It is used to initiate and modulate enzyme function throughout the wound healing phases. It affects immunity and assists in fibroblast proliferation and collagen production. It is also needed for granulation tissue formation (5) (6). 

 

Amino Acids 

Protein and amino acids are another set of nutrients that are highly essential in wound healing. The blood’s most abundant amino acid, glutamine, provides the body’s preferred energy source, glucose. Increased levels of glutamine have been shown to help with wound strength and increase the levels of mature collagen.  

Generally, the body is able to produce enough glutamine for regular function. In times of stress on the body, such as a wound, glutamine is sought out in the diet. Arginine assists in modulating the collagen deposits, increases new vessel formation, and aids in wound contraction (3). 

Quiz Questions

Self Quiz

Ask yourself...

  1. Name three common nutrient deficiencies that the nurse may encounter. 
  2. What are two amino acids that play key roles in wound healing?
  3. An iron deficiency can lead to what issues?
  4. Which phases of wound healing require zinc to complete the phase?

Special Considerations 

Tube Feedings 

Patients who use tube feedings or enteral feedings are in a unique situation when it comes to wound healing and nutrition. Once a proper nutrition assessment has been performed, a tailor-made nutrition-rich diet can be formulated and administered directly into the gut.  

Studies have shown that different formulas with supplemental nutrients have increased the ability of the body to heal faster than those without supplements. With tube feedings, patients don’t need to prefer the taste of one formula over another as it is delivered through the tube.  

The amount of formula can also be adjusted as the patient’s needs change. Though some formulas may have side effects such as diarrhea, the overall benefits usually outweigh such side effects (8). 

Quiz Questions

Self Quiz

Ask yourself...

  1. What considerations are there for patients with tube feedings?

  2. What is a pitfall when using tube feedings to deliver full nutrition?

Chronic and Terminal Illness 

Autoimmune, inflammatory, and cancers are among the chronic and terminal diseases that are under special consideration when it comes to wound healing. These types of diseases can interrupt the immune/inflammatory response of the body thus prolonging the phases of wound healing.  

When a wound develops on a patient who is immunocompromised, there is a higher incidence of wound infection which will delay wound healing. In many of these diseases, there may be circulatory issues that decrease the body’s ability to provide the affected area with nutrient-rich blood.  

Chronic illnesses often decrease the patient’s energy levels. This can lead to immobility and increases the risk of wounds developing.  

Further, for many of these types of issues, the treatment itself can have adverse effects on wound healing. Chemotherapy, radiation therapy, and immunosuppressants all decrease the body’s ability to heal and increase the rates of infection in wounds (2). 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are three types of chronic or terminal diseases? 
  2. What issue is an immunocompromised patient at risk for?
  3. What are two treatments for chronic illness that can affect wound healing?

Supplements 

Nutritional supplements have been shown to improve wound healing and recovery outcomes. It is important that the supplements are given under the supervision of a provider as too much of some nutrients can have a detrimental effect on wound healing.  

A proper nutrition screening should be performed on all patients with wounds so that the nutrition plan can be tailored to the individual patient. These improvements to wound healing with nutritional supplementation differ based on the type of wound and the overall health of the patient.  

The patient should be monitored and reassessed regularly by a dietitian. Again, there is no cookie-cutter supplement regimen.  

Another factor to consider with supplements is the ease of following the supplement regimen. Hard to swallow pills or foul-tasting food/liquids may have a negative impact on the patient’s ability to adhere to the supplement regimen.  

Allowing the patient to choose (with the input of the provider) the method of supplement delivery along with a choice of flavors will help increase compliance with the prescribed regimen (1). 

Quiz Questions

Self Quiz

Ask yourself...

  1. What should be done prior to starting dietary supplements? 
  2. Who should assess and reassess a patient’s dietary status?
  3. Why is the method of supplement delivery important?

Patient Education 

Throughout the entire wound healing process, patient education is a must. Not only is it important so that the patient can make an informed decision about their care, but the patient should understand what is going on with their bodies.  

Education fuels compliance. A comprehensive nutrition assessment will not only provide a baseline of the patient’s nutritional status but will also help identify gaps in the patient’s understanding.  

This is where the education can be focused to best help the patient meet their wound healing goals. Education must include which foods contain which nutrients, the amount of these foods to eat, and which foods will interact with the absorption processes of the nutrients.  

Discussing normal daily requirements and the requirements needed during wound healing is also needed (1). 

Quiz Questions

Self Quiz

Ask yourself...

  1. Why is education important when discussing nutrition and wound healing?

Conclusion

Nutrition plays a key role in wound healing. There are many factors that affect the body’s ability to acquire and use the needed nutrients. One of the most important considerations that we as healthcare providers need to put into practice is determining a patient’s nutritional status.  

A nutritional assessment should be done on patients with wounds so that a proper plan of care can be developed. Often, nutrition is an afterthought when in reality it is the foundation on which other treatments should be built upon.  

Once this has been established, the patient’s plan of care can be implemented and must include nutritional education. Needed supplements to increase the patient’s ability to heal can be added or removed as necessary when the reassessments have been completed. 

Ostomy Management

Introduction   

Newton's law of gravity states: what goes up, must come down; similarly, the normal human gastrointestinal system has a law that what goes in, must come out. When disease inhibits the normal process, ostomy procedures are a life-saving intervention.

There are around one million people living with an ostomy or continent diversion in the US, and approximately 100,000 ostomy surgeries are performed annually in the US (1). We will build a stronger understanding of various types of ostomies, indication for the need, site selection, stoma care, complications, and patient education.

Types of Ostomies

An ostomy is a surgically created opening that reroutes stool or urine from the abdomen to the outside of the body through an opening called a stoma (9). The term stoma refers to the portion of the bowel that is sutured into the abdomen (9).

When you look at a stoma, you are looking at the lining (the mucosa) of the intestine. The color is similar to the mucosa inside your mouth and cheek. Throughout various healthcare environments, you may hear the terms ostomy or stoma interchangeably. The purpose of an ostomy is to bypass a diseased portion of the gastrointestinal tract that is not functioning properly or has been removed (2).

Ostomies are placed proximal to the diseased area, comparable to building a dam in a river to stop the flow of fluid and divert it somewhere else. An ostomy can be temporary or permanent.

There are three most common types of ostomies: ileostomy, colostomy, and urostomy (9). We will discuss these types, but it is important to recognize that gastrostomy, jejunostomy, duodenostomy, and cecostomy procedures are also done.

  1. Ileostomy: A stoma is attached at the end of the small intestine (ileum) to bypass the colon, rectum, and anus.
  2. Colostomy: A stoma is attached to a portion of the colon to bypass the rectum and anus.
  3. Urostomy: A stoma is attached to the ureters (the tubes that carry urine from the kidney to the bladder) to bypass the bladder.

 

 

 

Ileostomy

The small intestine has three parts that are compact and folds over itself: the duodenum, jejunum, and the ileum. An ileostomy has a stoma attached and created from the ilium. The ileum is the final and longest segment of the small intestine (9).

The ileum terminates at the ileocecal valve, which controls the flow of digested material from the ileum into the large intestine and prevents the backup of bacteria into the small intestine (9). If a patient has this type of ostomy, the colon distal to the ostomy has a form of disease or disorder such as cancer. There are two main types of ileostomies, loop, and end ileostomy.

 

Loop ileostomy

In a loop ileostomy, a loop of the small bowel is lifted and held in place with a rod due to resection or repair to the distal bowel (Will). This ostomy is technically two stomas joined together (4). Loop ileostomies are typically temporary and will be closed or reversed through an operation in the future.

 

End ileostomy

In an end ileostomy, the ileum is surgically separated from the colon, the colon is removed or left to rest, and the end of the ileum is brought to the surface through the abdomen to form a stoma. Although end ileostomies are sometimes temporary and later rejoined, they are usually permanent (9).

 

 

Colostomy

A colostomy may be formed as an ascending, transverse, descending, or sigmoid colostomy (9). It is named according to the location of placement. An end colostomy is constructed from the ascending, transverse, descending, or sigmoid colon and has one opening for fecal elimination.

 

Loop Colostomy

The creation of a loop stoma takes a loop of the colon (usually the transverse colon) and pulls it to the outside of the abdominal wall (9). In this type of ostomy, the entire bowel is not dissected but left mostly intact.

 

End Colostomy

In end colostomies, the proximal end of the colon is dissected and pulled out of the abdominal cavity, which becomes the stoma (9). Additional procedures may involve repairing or removing portions of the distal colon or rectum.

 

 

Urostomy

Kidneys have an important job of filtering waste and excess fluid from your blood. This process creates urine, which then travels from the kidneys to the bladder through tubes called ureters (8). If the bladder is damaged or diseased, ostomies are a life-saving method of creating safe passage for the urine.

A urostomy is a surgical opening in the abdominal wall that redirects urine away from a bladder that’s diseased, has been injured, or isn't working properly (8). The bladder is either bypassed or removed (called a cystectomy) during surgery. Following the surgery, urine exits the body through a stoma.

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you ever witnessed a GI or Urinary Surgery?
  2. Do you have experience with GI / Urinary procedures like a colonoscopy?

Indication for Ostomy Placement

 

Gastrointestinal Tract Ostomy

- Cancer

- Colorectal

- Rectal

- Trauma/ Injury

- Significant Disorders

- Crohn’s disease

- Ulcerative Colitis

- Diverticulitis

- Bowel perforation from a ruptured diverticulum or abscess

- Bowel obstruction

- Infection (9)

 

Urinary Tract Ostomy

- Bladder Cancer

- Neurogenic bladder disease (damage to the nerves that control the bladder)

- Birth defects

- Chronic inflammation of the bladder (9)

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you cared for a patient with a new ostomy?
  2. Can you list reasons a patient is a candidate for an ostomy?

Site Selection

Wound, ostomy, and continence nurses (WOCN) play a vital role in site selection. Patients should have a pre-operative consultation prior to surgery. During this consultation, the nurse acts as an advocate and educator to prepare these patients for the physical and emotional path ahead of them. A significant amount of time should be spent with the patient before surgery to determine a stoma incision site (exit of ostomy).

It is important to make the presence of the ostomy (and collection bag) as comfortable as possible, striving to reduce the hindrance to ease movements and ability to wear their typical clothing (9). Studies show that preoperative education and stoma site marking has been directly responsible for improving quality of life and decreasing peristomal skin and pouching complications (4).

 

Site Assessment:

Locate positions for a site within the rectus muscle (4).

Observe the abdomen in various positions sitting, standing, or lying down.

Ask the patient about the types of clothing they wear most often. Examples: Level of pants (low, high), use of belts, dresses, etc. (9)

Determine a location that is visible to the patient, as they will need to see the site well for stoma care.

Avoid skin or fat folds (folds increase chances of leakage)

Avoid scars, bony prominences, and the umbilicus (4).

Quiz Questions

Self Quiz

Ask yourself...

  1. Locate places on yourself that would be appropriate for an ostomy site
  2. Can you think of reasons patients need to be able to see the site?
  3. Do you have a wound care nurse at your past or present workplace?

Post-operative Care

Post-operative care following ostomy placement is vital. The post-operative nurse assigned to this patient should read the surgery documentation to determine the type of procedure performed, intraoperative findings, type of stoma created, any advanced diseases, and unexpected events during surgery (2).

The nurse should be aware of the level of invasiveness; was this a laparoscopic, robotic, or open surgery? This type of surgery can have an impact on the post-op care plan and length of stay (2). Teaching can begin as soon as they are able to comprehend and focus on understanding new skills.

The stoma will gradually decrease in size over the weeks following the surgery. For a patient with a new ostomy, postoperative assessments should be done per facility protocol and the stoma should be inspected at least every 8 hours (9).

Note the type of closure (staples, sutures, liquid bonding agent), presence of abdominal drains, and presence of urinary catheter (C2). Assess for pain and address accordingly with repositioning, cold/heat therapy, and ordered pain medications. Assess for bowel sounds. Palpate the abdomen and note firmness and tenderness levels. Document strict Intake and Output for these patients.

 

Stoma Assessment:

Note the Appearance/ Color: The stoma should be pink to red in color, moist, and firmly attached to the surrounding skin (9). If the stoma appears bluish, it indicates inadequate blood supply; if the stoma appears black, necrosis has occurred. Immediate notification is needed from the provider, as the need to return to surgery will be assessed.

 

- Note the Presence of edema.

- Note the Surrounding skin

- Note any Ostomy Discharge

- Amount

- Color / Consistency

- Note any Bleeding

- Monitor for rupture or leakage.

 

Diet

Once bowel sounds and activity return, the patient’s diet may resume (2). Typically, patients are offered clear liquids to determine their ability to tolerate fluids. Nurses should encourage the patient to chew thoroughly, eat small frequent meals, and ambulate frequently to assist in gas movement and peristalsis (2).

Quiz Questions

Self Quiz

Ask yourself...

  1. Do you have experience with post-operative abdominal surgery?
  2. Explain possible respiratory or cardiovascular assessments that would be helpful for these patients

Stoma Care

 

Nursing Consideration / Reminders

Ostomy pouching system needs to be changed every 4 to 7 days, depending on the patient and type of pouch.

Patients should be encouraged to participate in stoma care. Instruct the patient to empty the pouch when it is one-third to one-half full as they become heavy and more prone to spilling or leaks.

 

Table 1. Ostomy Change Procedure SAMPLE (Always check with your agency policy)

Steps  PURPOSE 
1. Perform hand hygiene.  This prevents the spread of germs and microorganisms. 
2. Gather supplies. 

Supplies:  

  • Non-sterile gloves 
  • Ostomy bag and clip  
  • Flange 
  • Scissors 
  • Stoma measuring tool. 
  • Waterproof pad  
  • Adhesive remover for old flange 
  • Skin prep (7) 
3 Create privacy. Lift bed to comfortable height.  

Attention to psychosocial needs is imperative. 

Proper body mechanics is important for nurse. 

4. Place waterproof pad under pouch.  The pad prevents the spilling of effluent on patient and bed sheets. 

5. Remove ostomy bag.  

Apply non-sterile gloves.  

Support / hold the skin firmly with your other hand, apply adhesive remover if needed.  

Measure and empty contents. Place old pouching system in a garbage bag. 

 

The pouch and flange can be removed separately or as one. 

Gentle removal helps prevent skin tears.  

Remove flange by gently pulling it toward the stoma. 

6. Clean stoma gently by wiping with warm water. Do not use soap. 

Aggressive cleaning can cause bleeding. If removing stoma adhesive paste from skin, use a dry cloth first. Soaps can irritate the stoma. 

Clean stoma and peristomal skin 

7. Assess stoma and peristomal skin. 

Stoma skin should be pink or red in color, raised above skin level, and moist (2). 

Skin surrounding the stoma should be intact and free from wounds, rashes, or skin breakdown.  

8. Measure the stoma diameter using the pre-cut measuring tool (or tracing template).  

Trace diameter of the measuring guide onto the flange and cut the outside of the pen marking. 

The opening should match the size of stoma.  

If there is skin exposed between the stoma and edge of the flange with an ileostomy, the drainage contains enzymes that will break down the skin (9). 

Cut out size to fit stoma, assess fit once cut. 

9. Prepare skin. 

 

Paste can be applied directly to the skin or flange. 

10. Apply Flange 

 

Press gently around the periphery of the stoma to create a seal 

11. Apply the ostomy bag 

Close the end of the bag with clip (follow the manufacturer’s instructions) 

Involve patient with this process, understanding instructions. 
12. Apply pressure to ostomy pouch to help with adhering to skin.  Heat/ warmth from hand can activate some flanges. 
13. Clean us supplies, perform hand hygiene.  Remove trash as quickly as possible to reduce odor. 
14. Document Procedure 

Example: 

Date/time: flange change complete. Stoma pink, moist, warm. Peristomal skin intact. Patient instructed in cutting flange to correct size, verbalized understanding of frequency of change. See ostomy flowsheet. (Abbie S., RN) 

Data Source: Carmel, Colwell, J., & Goldberg, M. (2021). Wound, ostomy and continence nurse’s society core curriculum: ostomy management (Second Edition). Wolters Kluwer Health. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Are you familiar with your facility's ostomy care protocol (if appropriate)?
  2. How can the nurse implement safety measures with ostomy care?
  3. Do you feel comfortable with ostomy care documentation?

Complications

 

 

Ostomy Leakage

One of the most common and troublesome complications is leakage (4). Proper preoperative site selection (away from skin folds) is important. Patient education on proper techniques and supplies can aid in the prevention of leakage.

Educate patients on the risks of changing the ostomy too often. Frequent appliance changes lead to pain and frustration, as well as financial expenses on supplies (4). Leakage is more common in the early postoperative period but can also develop with weight changes later.

Interventions involve thickening the stool with antidiarrheals to form more solid excretion and pouching techniques to bolster the height of the stoma off of the peristomal skin (4). Helpful tips also include heating the appliance with a hair dryer before application, lying flat for several minutes following application, making sure the peristomal skin is dry before application, and the possible use of a fine dusting of stomal powder and skin sealant prior to application (4). Leakage is frustrating for patients, so support and encouragement is vital.

 

Mucocutaneous Separation

The stoma is sutured to the skin of the abdomen with absorbable sutures during surgery (4). Mucocutaneous separation is a complication that can occur if the sutures securing the stoma become too tight or if blood flow to the area is restricted (9). This complication requires appropriate treatment because the pouch leakage will occur from the open pocket.

The goal of treatment is to keep this open pocket covered properly until the wound heals on its own and closes. Appropriate covering of the opening can include an absorbent product such as an alginate, followed by a cover dressing such as a hydrocolloid, which is covered with the ostomy pouch (4).

 

Early High Ostomy Output

Early high ostomy output (HOO) is defined as ostomy output greater than fluid intake occurring within 3 weeks of stoma placement, which results in dehydration (4). This is more common with ileostomies (4). Strict Input and Output records are a vital nursing intervention. The most important treatment for this complication is hydration to prevent renal failure, which is typically done intravenously (4).

The site of a patient’s colostomy will impact the consistency and characteristics of the excretion. The natural digestive process of the colon involves the absorption of water, which causes waste from the descending colon to be more formed. Waste from an ileostomy or a colostomy placed in the anterior ascending colon will be a bit more loose or watery (2).

 

Peristomal Skin Issues

Irritant Contact Dermatitis (ICD) is the most common peristomal skin complication following ostomy placement (9). ICD is characterized by redness; loss of epidermal tissue; pain; and open, moist areas.

Newer and inexperienced patients and caregivers will increase the size of the pouching system opening to get a better seal and stop leakage (2) However, this only contributes to more skin breakdown and irritation. Patients may also develop a fungal rash, have allergic rashes to the ostomy appliance, or folliculitis (4).

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name measures to prevent leakage?
  2. Have you cared for a patient with Irritant Contact Dermatitis?
  3. Are you familiar with bulking agents for stool?

Patient Education

Patient education is a key aspect is caring for a patient with an ostomy, this process begins prior to surgery and remains constant throughout encounters. If you have not received specialized training on wound and ostomy care, you should reach out to the Wound, Ostomy and Continence Nurse (WON) within your healthcare setting to become involved if they are not already.

However, each nurse has a meaningful impact on discussing and managing expectations for life with an ostomy, including stoma care, complications, managing ostomy output, maintaining pouching appliances, and resources. Patients may feel inadequate and uneasy about caring for their stoma.

Nurses need to meet the unique learning needs of each patient and caregiver, providing education in verbal information, written pamphlets, online resources, videos, and demonstrations. The United Ostomy Associations of America, Inc. (UOAA), is a nonprofit organization that serves as an excellent resource for information, support, advocacy, and collaboration for those living with ostomies.

Nurses should be aware there is an “Ostomy and Continent Diversion Patient Bill of Rights” (PBOR) that outlines the best practices for providing high-quality ostomy care during all phases of the surgical experience (1). There are numerous national resources for patients, as well as community-based and online ostomy support groups. 

 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you think of methods to assess patient knowledge on ostomy care?
  2. What are creative ways to involve an ostomy patient in care?
  3. Not all patients are savvy with online supply ordering, can you think of other ways to order supplies if they are not?

Promotion of Body Image and Self-Esteem

Ostomy surgery can have a major impact on how patients perceive themselves. A person’s body image is how they see themselves when they look in the mirror or how they picture themselves in their mind.

There are stigmas surrounding ostomies, such as being odorous, unhygienic, and unattractive due to the stoma, but the truth is that ostomies save lives and make life possible. Positivity should surround the conversation. Confirmations such as beauty, strength, celebration, and hope are meaningful.

 

Ways to become involved in celebrating ostomies:

- Become familiar with the United Ostomy Associations of America (UOAA) and their initiatives.

https://www.ostomy.org/ostomy-awareness-day/

National Ostomy Awareness Day on October 7, 2023

Worldwide Virtual Run for Resilience Ostomy 5k

 

- Social Media Sites

Celebrate Body Positivity for those with ostomies

Intimacy Encouragement

Conclusion

Ostomy care is an essential nursing skill. If you are caring for a patient with an ostomy, remember that this is a major life-altering event and condition. Reflect on ways to provide individualized care by understanding various types of ostomies, site selection, stoma care, complications, and patient education. Empower and encourage these ostomy patients’ confidence in themselves.

 

Diabetes Management: Nursing Updates

Introduction   

Diabetes Mellitus (DM), also known as diabetes, is a condition in which the body develops high levels of blood glucose due to the inability to produce insulin or for the cells to use insulin (1) effectively. If left untreated or mismanaged, it can lead to health complications such as heart disease, chronic kidney disease, blindness, nerve damage, oral and mental health problems (1)(15) 

There are several classifications of DM, and the following will be discussed: T1DM, T2DM, gestational diabetes, and idiopathic diabetes. 

Classifications of Diabetes

 

Type 1 Diabetes Mellitus (T1DM)  

T1DM is formerly known as juvenile diabetes or insulin-dependent diabetes and usually occurs in children and young adults (1). Although, it can also occur at any age and accounts for 5 – 10% of cases. T1DM develops when one’s own immune system attacks and destroys the beta cells that produce insulin in the pancreas (6).     

 

Type 2 Diabetes Mellitus (T2DM)  

T2DM, formerly known as adult-onset diabetes or non-insulin-dependent diabetes, develops because of the body's inability to use insulin effectively. It is the most common type of diabetes and mainly occurs in adults aged 30 years and older (1). However, it is also becoming common in children and young adults due to obesity. It accounts for 90% of the population diagnosed with diabetes (6).   

 

Gestational Diabetes 

Gestational Diabetes occurs during pregnancy and in women who have never had a previous diagnosis of diabetes. It is a result of pregnancy hormones that are produced by the placenta or because of the insufficient use of insulin by the cells (1). Gestational diabetes can be temporary or in some cases can become chronic. It is also likely that children whose mothers have gestational diabetes can develop diabetes later in life (6).  

 

Prediabetes 

Prediabetes, also referred to as impaired glucose tolerance, is a stage when a person is at risk of developing diabetes. If well managed through proper diet management and exercise, this can help with the prevention or delay of type 2 diabetes (1).  

 

Other Forms of Diabetes 

Other forms of diabetes include monogenic diabetes syndrome, diabetes from the removal of the pancreas or damage to the pancreas from disease processes such as pancreatitis or cystic fibrosis, and drugs or chemical-induced diabetes from glucocorticoids used to treat HIV/Aids or organ transplant (1) (6).  

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the four named types of diabetes? 
  2. What are the differences between T1DM and T2DM? 
  3. What is the most common type of diabetes? 

Statistical Evidence/Epidemiology 

Diabetes is now ranked as the 8th leading cause of death in the United States (6). There is no known cure for diabetes. It is one of the fastest-growing chronic diseases and the most diagnosed noncommunicable disease. It is also one of the leading causes of chronic kidney disease, adult blindness, and lower limb amputations (6).   

In 2019, it was estimated that 37.3 million American adults have diabetes, which equals 11.3% of the population (4). Of those, 41% were men and 32% were women. 28.7 million were diagnosed with diabetes, and 8.5 million were undiagnosed.  

There are 96 million American adults who are prediabetic, which means they are at risk of developing diabetes, but their blood glucose levels are not high enough to be diagnosed with diabetes (5).  

Most of the population that is pre-diabetic is 65 years old or older. Type 2 diabetes accounts for 90% to 95% of cases (5). The risk of developing diabetes increases with age.  

The prevalence of diabetes is much higher in both black and Hispanic/Latino adult men and women. Men are more likely to develop diabetes compared to women. Due to the rise in obesity in younger adults, there has been an increase in the number of new cases of diabetes in black teens (4).  

 

The figure below represents trends in incidence of type 1 and type 2 diabetes in children and adolescents 2002–2018; results show the incidence of type 2 diabetes has significantly increased (4)

Quiz Questions

Self Quiz

Ask yourself...

  1. What is one of the major comorbidities caused by diabetes? 
  2. What age group is at risk for developing type 2 diabetes?  
  3. What is a risk factor that is contributing to the rise of diabetes in younger adults?

Etiology and Pathophysiology 

In normal glucose metabolism, blood glucose is regulated by the two hormones insulin and glucagon (11). Insulin is secreted by the beta cells in the Islet of Langerhans in the pancreas and glucagon is secreted by the alpha cells in the pancreas.  

When there is an increase in blood glucose, the function of insulin is to reduce blood glucose by stimulating its uptake in the cells. Glucose is stored as glycogen in the liver and muscles or as fat in the adipose tissues. When blood glucose levels start to fall, glucagon promotes the release of glycogen from the liver, which is used as a source of energy in the body (8) (13).   

When there is a deficiency of insulin or a decreased response of insulin on the targeted cells in the body, it leads to hyperglycemia (high blood glucose). Meaning that the glucose that remains in the blood is not able to get to the cells. Diabetes develops mainly because of lifestyle and genetic factors (13).

T1DM 

The etiology is not well understood, though it is thought to be influenced by both environmental and genetic predispositions that are linked to specific HLA alleles. T1DM is considered an autoimmune disorder that is characterized by T-cell-mediated destruction of the pancreatic B-cells (13).  

As a result, this leads to complete insulin deficiency and ultimately hyperglycemia, which requires exogenous insulin. The rate of destruction of the pancreatic B-cell-specific disorder is known to develop rapidly in infants and children or gradually in adults (8)(13). 

 

T2DM 

The etiology of T2DM is characterized by decreased sensitivity to insulin and decreased secretion of insulin. Insulin resistance occurs due to the disruption in the cellular pathways that result in a decreased response in the peripheral tissues, particularly the muscle, liver, and adipose tissue.  

T2DM diabetes can progress slowly and asymptomatically over a period. Obesity and age can play a key role in the homeostatic regulation of systemic glucose because they influence the development of insulin resistance, which affects the sensitivity of tissues to insulin. Therefore, most patients with type 2 diabetes are overweight or obese 7) (8).

 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the two hormones that are responsible for maintaining blood glucose levels in the body? 
  2. Can you describe the etiologies of both T1DM and T2DM? 
  3. What are some of the factors that contribute to T2DM? 

Diagnostic and Screening tools 

There are a variety of tests that are used to diagnose and monitor diabetes. These vary based on the type of symptoms that a patient may have. Diagnosis of DM requires at least two abnormal test results, which should include fasting glucose and A1C. The tests should be one of two from the same sample or two abnormal test results drawn on different days (3). 

 

The recommended diagnosis guidelines for diabetes must be based on the following criteria: 

  • Fasting Plasma Glucose (FPG) concentration with results greater than 126 mg/dL. This test involves measuring blood glucose at a single point. To have accurate results, the test should be conducted after one has had nothing to eat or drink for at least 8 hours (3). 
  • Glycated hemoglobin (Hb A1C) is indicative of the average levels of blood glucose in a period of two to three months. Results greater than 6.5% mean diagnosis of diabetes. This blood test does not require fasting. The A1C test is not suitable for pregnant women or those who have certain blood conditions (anemia) - NIDDK. This test should only be used for prediabetes screening (3). 
  • Oral Glucose Tolerance Test (OGTT): prior to conducting this test, an FPG level needs to be measured. One must ingest 75 grams of glucose liquid. Thereafter, their glucose level is measured 2 hours after they have taken the liquid. Test results greater than 200 mg/dL are indicative of diabetes. This test is commonly used in pregnant women (3). 
  • Random plasma glucose of 200 mg/dL. This test is suitable when one has symptoms of hyperglycemia, which are polydipsia, polyuria, and polyphagia (3).  

 

Screening 

Screening is generally recommended for adults aged 45 or older regardless of present risk factors. The updated recommendation guidelines for prediabetes screening include adults 35 years and older who are overweight or obese (3).  

 

Screening for Prediabetes 

Prediabetes is associated with the impairment of blood glucose levels between 100 – 125 mg/dL. The diagnosis of prediabetes should be confirmed with glucose testing when there is impaired glucose tolerance with plasma levels between 140 – 199 mg/dL 2 hours after one has ingested 75g of oral glucose. A1C levels of prediabetes are between 5.7% to 6.4% (3). 

 

Screening for Pregnant women 

It is recommended that all pregnant women between 24 – 28 weeks be screened for gestational diabetes to avoid missing those that are at risk. A positive 3-hour OGTT test of greater than 140 mg/dL meets the criteria for diagnosis (3).  

 

Medication Management 

Monitoring of blood glucose levels in patients is useful in determining the effectiveness of antidiabetic medication. To achieve better patient outcomes, it is important to recognize individual needs (11) 

It is recommended that the approach to medication management should be based on each patient's hyperglycemic index and should include the following: the presence of comorbidities, risk of hypoglycemia, vascular disease, life expectancy, and disease duration (3).   

When the management of diabetes cannot be achieved through diet and exercise alone, oral antidiabetic agents are the preferred treatment (14). Oral antidiabetics can help maintain and achieve glycemic goals for patients who are diagnosed with T2DM) (10)(14).  

Diabetes Education and patient engagement is essential to managing diabetes (11). There are several classes of anti-diabetic medication. Below are some of the most utilized antidiabetic medications (9)(14).  

 

Biguanides 

Metformin is the only medication in this category. 

  • It is considered the 1st line of treatment in patients with T2DM unless contraindicated. 
  • Metformin helps to decrease hepatic glucose production.  
  • Decreases intestinal absorption of glucose by improving insulin sensitivity. Must be titrated initially to minimize adverse effects. 
  • Avoided in clients with chronic kidney disease.  
  • Side effects: Lactic acidosis, hypoglycemia. 

 

GLP 1- Receptor Agonists (RAs) 

Mimics glucagon-like peptide 1 (GLP -) hormone. Binds to GLP-1 receptors stimulate glucose-dependent insulin release and delay gastric emptying, which increases satiation.  

  • Known to have cardiovascular benefits. 
  • Can be taken orally or subcutaneously.  
  • Special considerations: Can cause weight loss, GI side effects such as nausea, vomiting and diarrhea, dehydration, increased satiation (fullness), acute pancreatitis, and reactions at the injection sites.  
  • Some labels may require renal dose adjustment.  
  • GLP - 1 RAs should be considered before starting clients on insulin to help reduce A1C then oral antihyperglycemic medications are not effective in treating diabetes.  

 

Sulfonylureas 2nd generation 

Stimulates insulin release in pancreatic beta cells.  

  • Risk for prolonged hypoglycemia. Therefore, it should be avoided with the concurrent use of insulin.  
  • Can cause weight gain.  
  • Can cause photosensitivity.  
  • Avoid use in clients with sulfa allergies and photosensitivity.  
  • Avoid use in clients with chronic kidney disease and liver disease.   

 

Dipeptidyl Peptidase (DPP) - 4 inhibitors 

Prevents DPP-4 enzymes from breaking down to GLP-1 hormone.   

  • Neutral weight.  
  • Monitor for acute pancreatitis, which can cause joint pain.  
  • May require renal dose adjustment with these brands: Saxagliptin (Onglyza), Sitagliptin (Januvia), and Alogliptin. Linagliptin does not require dose adjustment.  

 

Sodium-Glucose transporter - 2 (SGLT-2) inhibitors 

Reduce the reabsorption of glucose by up to 90%, therefore promoting the exclusion of glucose from the body.  

  • Known to have cardiovascular benefits for clients with cardiovascular disease.  
  • Use with caution in clients with increased risk of fractures.  
  • Avoided in clients with diabetic ketoacidosis and those prone to have frequent urinary tract infections.  
  • This medication should be avoided in clients with pure poor kidney function due to volume depletion and hypotension.  
  • There’s also a risk for Fournier gangrene.  

 

Thiazolidinediones 

Pioglitazone and rosiglitazone can help reduce insulin resistance which promotes improved sensitivity to insulin. As a result, it can help reduce the A1C levels.  

  • Can cause weight gain.  
  • Potential risk for heart failure when taking thiazolidines (brands: pioglitazone, rosiglitazone). 
  • Generally, it is not recommended for clients with renal impairment as medication has the potential to cause fluid retention.  
  • Risk for bone fractures, bladder cancer, and increased LDL cholesterol (rosiglitazone).  
  • Thiazolidines do not cause hypoglycemia and can be used in combination with other antidiabetic medications including insulin. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Which class of antidiabetic medications are known to put patients at risk for bone fractures? 
  2. Can you name a condition that thiazolidines and sulfonylureas 2nd generation are generally not recommended for?  
  3. What is a common side effect in both thiazolidines and sulfonylureas? 
  4. What class of medication is suitable for clients with insulin resistance? 
  5. Can you name two antidiabetic medications that can be used in combination with other antidiabetics because it has the benefit of not causing hypoglycemia?

Insulin therapy 

Insulin therapy is commonly recommended for patients with T1DM. It can be used to help prevent the development and progression of diabetes (2). The ideal insulin regimen should be tailored based on individual needs and glycemic targets to better contend with physiological insulin replacement to maintain normoglycemia. Insulin therapy is also recommended for patients with hemoglobin A1c of greater than 9% - 10% and when symptoms of hyperglycemia are present (3).  

 

Other Diabetes Interventions 

The automation of glucose monitoring devices and insulin delivery systems is revolutionizing glucose management mainly because it promotes lifestyle flexibility and improved glucose management (2). 

  • Glucose Monitoring Devices- these devices are ideal for clients who are on insulin regimens and may become the standard for assessing glycemic controls in clients with DM (7). 
  • Continuous Glucose Monitoring (CGM)- devices that are inserted subcutaneously and measure interstitial blood glucose levels. CGMs are devices that are used to provide glucose readings, trends, and alerts to the user in real-time to inform diabetes treatment decisions. (2)(3) 
  • Importance- CGM is recommended for all patients with diabetes who receive treatment with intensive insulin therapy, defined as three or more insulin injections per day for all individuals with hypoglycemia (frequent, several, nocturnal) (3).  
  • Known to reduce hyperglycemia and A1C levels. 
  • Insulin Pump Therapy- also known as Continuous Subcutaneous Insulin Infusion (CSII) has had notable advances over the years. CSII is recommended for those with type 1 diabetes, although in recent studies, conventional CSII is also recommended for use in T2DM patients (2)(3). CSII is a small computer that is programmed to deliver fast-acting insulin continuously to the body using mechanical force via a cannula that is inserted under the skin (2).  
  • It is more precise and flexible in insulin dosing. 
  • Known to improve glycemic control.  
  • Cheaper than using Multi-Dose Insulin. 
  • Automated Insulin Delivery Systems (AIDS) - This is a diabetes management system that utilizes an insulin pump in conjunction with an integrated CGM and computer software algorithm (3).  
  • Advantages: precision and flexibility with insulin dosing. 
  • Recommended for T1DM: Achieve glycemic targets with less burden. 
Quiz Questions

Self Quiz

Ask yourself...

  1. What is the main type of insulin used in CSII pumps? 
  2. What type of diabetes category is more suitable for using CSII? 

Upcoming Research  

Islet cell transplant has been a biological solution to help treat patients with T1DM due to poor graft survival rates. Future research will focus on manipulating the beta cells in the pancreas to make them more viable. Other treatments that have been recently made available include incretins and Amylin which improve the absorption of insulin in the body (1).  

  • The development of other types of insulin that can be administered by inhalation.  
  • The development of immunosuppressant drugs that will help treat T1DM. 
Quiz Questions

Self Quiz

Ask yourself...

  1. Can you name two recently developed medications to help with insulin absorption in the body?

Conclusion

Diabetes is a complex disease that requires a multi-disciplinary and patient-centered approach to help with effective management. Regular and early screening are necessary for those at risk for developing diabetes. Most importantly, ease and access to choices of managing diabetes are necessary.

Hospice Vs. Palliative Care: What’s the difference?

Introduction   

Hospice and palliative care are unique health concepts often incorrectly used interchangeably. During my career as a hospice and palliative care nurse, I often heard the question, "What's the difference between Hospice and Palliative Care?"  

I usually answered with a common phrase the Hospice and Palliative Care community uses to explain the difference, "All Hospice is palliative care, but not all Palliative Care is hospice." The statement is accurate but still confusing.  

This course aims to shed light on these topics and emphasize the importance of enhancing end-of-life care, but let's start with Merriam-Webster's dictionary definitions.  

  • Hospice: "a program designed to provide palliative care and emotional support to the terminally ill in a home or homelike setting so that quality of life is maintained, and family members may be active participants in care” (4). 
  • Palliative: "relieving or soothing the symptoms of a disease or disorder without effecting a cure” (4). 

The Merriam-Webster definitions help to clarify the differences further: Hospice is a program, and palliative care is a practice. They are two distinct approaches to providing comprehensive medical care and support for patients with serious illnesses, and they have essential differences worth exploring.  

This course aims to delve into the different types of care, their philosophy, eligibility criteria, duration of services, and common myths and misconceptions surrounding hospice and palliative care. Additionally, it highlights nurses' crucial role as advocates and resources in these specialized fields. 

Hospice Care 

The modern hospice movement originated in the late 1960s in the United Kingdom, primarily through the work of Dame Cicely Saunders. Saunders, a nurse, and social worker, recognized the need for specialized care for patients with terminal illnesses. She founded St. Christopher's Hospice in London in 1967, which became the model for modern hospice care (12). 
 
Saunders emphasized care that was less focused on disease treatment and more focused on an individual's physical, emotional, social, and spiritual needs. This approach prioritized providing comfort, pain management, and dignity for patients nearing the end of life (12). 
 
The concept of hospice care gained international recognition and spread to other countries. By 1974, the first hospice program in the US was formed in Connecticut, and the hospice movement expanded rapidly (11).  

Hospice care was primarily provided by volunteers who went into families' homes to care for their loved ones when no curative care was available. These same volunteers helped write the federal regulations adopted as the Medicare Hospice Benefit (MHB) in 1982 (5). 

It is essential to discuss the MHB because the US government benefit made hospice a fundamental part of comprehensive medical care. It is the benefit through which most patients nearing the end of life receive care, and it has defined how we provide hospice care throughout the United States. 

An integral part of hospice care is visits from a nurse, social worker, chaplain, and nurse aides. In addition, the patient and family have access to a hospice physician specializing in Hospice and Palliative Care (5). Hospice care focuses on providing compassionate, holistic, patient-centered care for individuals with terminal illnesses. The primary goal is to enhance the quality of life for patients and their families by addressing physical, emotional, social, and spiritual needs (5). 

The MHB covers 100% of the financial cost for hospice services, including medications, supplies, and treatments required due to a terminal illness. The medicines commonly covered under the hospice benefit are for treating pain, nausea, anxiety, and other distressful symptoms, such as constipation (5).  

 

Who can receive this care? 

The MHB was designed for patients who are terminally ill with a six-month life expectancy, as determined by a physician (5). Life expectancy is one of the critical differences between Palliative Care and Hospice Care.  

Healthcare providers, unlike statisticians or actuaries, are unskilled at predicting a six-month or less life expectancy. As part of the hospice federal regulations, local coverage determinations set by government intermediaries help healthcare providers determine who meets the criteria and, therefore, is eligible for hospice.  

Key indicators predicting the end of life due to a specific disease process have been defined so that we can compare each patient to determine their eligibility for hospice care. Some key indicators are activity level, the times the patient has sought emergent care or has been hospitalized in the past six months, weight loss, and neurological status.  

Patients generally receive hospice care when curative care is no longer an option. This is another crucial difference between Hospice and Palliative Care. There are exceptions, commonly for children, where curative and hospice care are provided. This is termed "concurrent" care.  

 

How long do they receive services? 

The key indicators that hospice physicians use to determine eligibility are based on averages of patients who have died with the specifically defined disease process. However, the average time to death is unreliable when judging how long an individual may live.  

Therefore, hospice care is provided for as long as the patient's condition remains terminal, according to local coverage determinations, and they choose to continue receiving this specialized type of palliative care. In fact, the MHB has no end date, and the duration of services may vary depending on the progression of the illness and the patient's preferences. 

For example, patients with chronic illnesses, such as heart failure, chronic obstructive pulmonary disease (COPD), and Alzheimer's, tend to have a less predictable trajectory of terminal illness due to periods of exacerbation and stability, which are common. Patients with chronic diseases tend to have a longer stay in hospice care. A waxing and waning pattern of decline is less typical with cancer-related disease, and these patients generally use fewer days of hospice care. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is your understanding of the philosophy behind hospice care?  
  2. How do you determine the appropriate duration of services for a hospice patient?  

Palliative Care 

The long-held theory regarding palliation, or soothing symptoms as defined by Merriam-Webster, is that if the treatment causes suffering with the result of a cure, the benefit of the treatment outweighs the burden. In other words, a person should be able to tolerate suffering for a positive end result. On the other hand, if no cure is available, suffering is inhumane.  

Palliative Care emerged as an integral part of hospice care, focusing on providing comfort and support to patients with terminal illnesses (14). However, for people without terminal illnesses, some treatments and symptoms of curable diseases are so intolerable that patients may be unable or unwilling to continue curative treatment. Why should patients and families not receive physical, psychosocial, or spiritual support simply because they are not at the end of life?  

The need for Palliative Care beyond hospice was identified in other healthcare settings, such as hospitals and home care. Over time, the philosophy and principles of Palliative Care gained recognition beyond the hospice setting. This led to the development of specialized palliative care services that aimed to provide comprehensive support to patients with serious illnesses, regardless of their prognosis (14).  

In 1990, the World Health Organization (WHO) formally defined palliative care, emphasizing its holistic approach. The WHO defines palliative care as improving the quality of life of patients and their families facing life-threatening illnesses by preventing and relieving suffering through early identification and treatment of pain and other physical, psychosocial, and spiritual problems (13).  

The American Academy of Hospice and Palliative Medicine (AAHPM) was established to promote and advance Palliative Care, and it has now become a recognized medical specialty. Palliative care education programs, certifications, and fellowships have been established to ensure the development of skilled professionals who provide palliative care (14).  

Palliative Care is an essential part of healthcare, aiming to improve the quality of life for patients with serious illnesses and their families. It focuses on relieving symptoms, addressing psychosocial and spiritual needs, and enhancing communication and decision-making throughout the illness trajectory. 
 

Philosophy 

Palliative care aims to improve the quality of life for patients who suffer regardless of life expectancy, a key differentiator from hospice care. Palliative care focuses on symptom management, pain relief, and addressing patients' and their families' physical, emotional, and psychosocial needs. 

 

Who can receive this care?  

In the modern healthcare system, "palliative" is often used to define comfort care for patients with "serious illnesses." Palliative Care is available to individuals of any age and at any stage of a serious illness, including those undergoing curative treatments. It can be provided concurrently with curative treatments, such as chemotherapy and radiation, another differentiator from hospice care. Individuals with serious illnesses may receive palliative care during a hospitalization, at home, or office visits.  

 

How long do they receive services? 

Unlike Hospice Care, Palliative Care can be provided for an extended duration even if the patient's condition is not terminal. The duration of services varies based on the individual's needs.  

Quiz Questions

Self Quiz

Ask yourself...

  1. How does Palliative Care differ from Hospice care in terms of philosophy and approach?  
  2. Can you explain the eligibility criteria for receiving palliative care?  

Common Myths and Misconceptions 

Myth 

Fact 

Hospice care hastens death.  

Studies show that patients with the same diagnosis and burden of illness live longer with hospice than without (2).  

Palliative care is only for people who are dying. 

Palliative care is available to people of any age and stage of serious illness.  

Hospice is a place.  

Hospice is a form of care provided to people wherever they reside.  

Palliative care is only available in hospitals. 

Palliative care is available in hospitals, at home, or in a doctor's office. This is dependent on the availability of practitioners in your area.  

Hospice is only for the last days of life.  

Hospice is for the terminally ill with a life expectancy of 6 months or less and continues as long as a person remains terminally ill (15).  

Palliative care is only for the elderly.  

Palliative care is for all individuals with a serious illness.  

Hospice is the same as Palliative Care. 

Hospice is palliative care for the terminally ill. Palliative care is for all patients receiving curative treatment no matter the stage of illness, depending on the Palliative Care team's defined practice.  

Hospice and Palliative Care mean you are giving up hope.  

Hospice and Palliative Care aim to manage symptoms and improve the quality of life.  

Hospice and Palliative Care are expensive and not covered by insurance.  

Hospice care is 100% covered by Medicare and most other insurance (15). Palliative care is covered as a medical practitioner's visit in most Palliative Care programs. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are common misconceptions you have encountered regarding hospice or palliative care?  
  2. How did you resolve the misconceptions surrounding palliative and hospice care?  

Handling Difficult Conversations 

Conversations, especially regarding end-of-life, are difficult for the clinician, the patient, and the family. Sensitive conversations also take time, patience, and empathy. Often, more time than a general practitioner or clinician has available. In my experience, patients approaching the end of life are often referred to as Palliative Care practitioners because of the practitioner's experience with difficult conversations. I also believe this referral practice is part of the confusion in understanding the difference between Palliative and Hospice Care.  

Palliative Care Practitioners are not the only ones with the time and the skill to broach difficult conversations. Nurses also play a critical role in facilitating difficult conversations about end-of-life decisions, goals of care, and advance care planning.  

Nurses often spend more time with patients and families than other disciplines. The relationship and trust nurses build with patients and caregivers makes them especially adept at starting difficult conversations.  

 

A nurse must take the following actions before, during, and after a difficult conversation (3).  

  • Build a strong relationship with the patient and their family through active listening, empathy, and creating a safe space for open communication. 
  • Assess the patient's and family's readiness and preferences to engage in discussions. Ask patients and families questions regarding the amount and detail of information they want and the personspeople that need to be involved in decision-making. This information helps to tailor the discussion.  
  • Use practical communication skills such as clear and concise language aimed at providing information in a way that is understandable and sensitive to the emotional needs of the patient and family. 
  • Begin the conversation by assessing the patient and family's understanding of the diagnosis and prognosis to address any misconceptions or gaps in knowledge and ensure everyone is on the same page. 
  • Engage in a collaborative discussion about the patient's goals and values. Exploring their priorities and preferences regarding treatment options, symptom management, and quality of life helps align the care plan with the patient's values and wishes. 
  • Acknowledge and validate emotions, offering support and empathy throughout the conversation. Referral to appropriate psychosocial or spiritual support services may be necessary. 
  • Document the discussion and decisions made in the patient's medical records. Follow-up conversations should be scheduled to address any further questions, concerns, or changes in the patient's condition or preferences (3).  

 

Should you find yourself in a position to start a difficult conversation, the following practical framework may be of assistance (3): 

  1. Set aside time and make a plan to minimize interruptions. 
  2. Before the conversation, take a moment to center yourself and release stress.  
  3. Acknowledge the family and offer support by inquiring about their immediate needs.  
  4. Open the conversation by asking what the patient and family know about their condition.  
  5. Repeating what they know, ask them how they want to experience the time they have left. 
  6. Empathize and allow them time to discuss and consider what they want. 
  7. Based on their desires, educate them about the options for care.  
  8. Consult with the interdisciplinary team and make appropriate referrals. 

Case Study 

Emily is a registered nurse who works the day shift on a bustling med-surg floor. She has a reputation for excellent communication skills and the ability to handle difficult conversations with empathy and grace, but she admits she never feels comfortable doing so. When she must have a difficult conversation, she uses a structured format to guide her to maintain her composure and empathy. Emily needed to use this framework when the physician asked her to talk to the family of Mr. Johnson about hospice care.  

 
Mr. Johnson was a 75-year-old man admitted with advanced pancreatic cancer. His condition was deteriorating rapidly, and it was clear that curative treatments were no longer effective. Mr. Johnson's wife, Judy, was consistently by his bedside, her worry and sadness evident in her eyes. Emily knew Mrs. Johnson needed a plan because the fear of not knowing can be far worse than the reality. Emily asked her co-workers to cover for her other patients for the next 20 minutes so she could have a conversation about hospice.  
 
Emily approached the room; she stopped momentarily and took a deep, centering breath. She released the day's stress and gave herself space to focus on this task. Emily gathered her thoughts and reminded herself of the framework she would use. She knew this conversation would be challenging but discussing the next steps in Mr. Johnson's Care was necessary. She entered the room with a warm smile, acknowledging both Mr. and Mrs. Johnson. 
 
Emily began by asking how Mr. Johnson was feeling, allowing him to express any concerns or symptoms he was experiencing. She listened attentively, validating his feelings, and reassuring him that his comfort was a top priority. 

After addressing Mr. Johnson's immediate concerns, Emily asked, "Mr. Johnson, what has the doctor told you about your prognosis?" Mr. and Mrs. Johnson began to verbalize that they knew Mr. Johnson was not getting better and was worsening. Mr. Johnson offered that the doctor told them curative care was not an option and that his prognosis may be short. Emily noticed Mrs. Johnson's eyes welling up with tears as Mr. Johnson spoke. Sensing her emotional distress, Emily offered her a comforting hand. 

Emily asked, "How do you see spending your remaining time?" 

Mr. Johnson quickly stated, "I want to go home." 

Mrs. Johnson had a worried look on her face. Emily turned to her, and Mrs. Johnson stated, "I don't know how I can care for him at home."  

Emily reassured Mrs. Johnson that this was a fear expressed by many spouses experiencing similar circumstances. Then, Emily introduced the concept of hospice care, explaining that it could provide specialized support and comfort to Mr. Johnson in the comfort of his own home. She highlighted the benefits of hospice, such as nurse visits, pain management, emotional support, and assistance with daily activities by an aide. 
 
Understanding the gravity of the situation, Mr. Johnson and his wife looked at each other, their love and concern evident. After a moment of silence, Mr. Johnson nodded, expressing his willingness to explore hospice care to enhance his quality of life during this challenging time. 
 
Emily continued the conversation, outlining the next steps and assuring the couple that the hospice team would work closely with them to develop a customized care plan. She provided them with a referral to hospice and assured them that she would be available to answer any questions.  
 
As the conversation came to a close, Emily thanked Mr. and Mrs. Johnson for their trust and assured them that their decision was an essential step towards ensuring Mr. Johnson's comfort and dignity. She could see more lightness in Mrs. Johnosn's eyes. She was standing taller and breathing easier.  

Emily left the room, knowing that this difficult conversation had set the foundation for a new chapter of Care focused on providing the support and compassion that Mr. Johnson and his wife deserved. 
 

Nurse Role as Advocate 

Nurses are the center of the interdisciplinary team, often providing communication and updates from patients and families to other practitioners such as social workers and physicians. The focused time they spend with patients in guided conversations and daily assessments allows nurses to gain a more in-depth understanding of the patient, family dynamics, and care goals.  

A particular time of vulnerability for patients and families is during a serious illness and at the end of life. Nurses are responsible for advocating for patients' rights, respecting their wishes, and facilitating open communication between healthcare providers, patients, and their families. They play a pivotal role in ensuring the patient's voice is heard, and their needs are met.  

 

Here are some ways nurses advocate for patients:  

  • Patient-centered care: Nurses help guide decision-making processes and ensure care aligns with the patient's values and goals when they ensure patients' preferences, values, and goals are at the center of their care (18).  
  • Shared decision-making: Nurses facilitate shared decision-making between patients, families, and healthcare providers by acting as intermediaries, ensuring patients' voices are heard and respected during discussions about treatment options, advanced directives, and end-of-life care planning (19).  
  • Psychosocial and spiritual needs: Nurses advocate for patients by providing emotional support, facilitating discussions about fears and concerns, and connecting patients with appropriate resources (20).  
  • Pain and symptom management: Nurses advocate for optimal comfort by assessing and addressing patients' physical distress, collaborating with the healthcare team, and advocating for timely interventions (21).  
  • Patient autonomy: Nurses who involve patients in decision-making processes, including information about treatment options, risks, and benefits, support patients in making informed choices (24). 
  • Informed consent: Nurses ensure patients understand the nature of their treatment, potential risks, and alternatives serve to advocate for informed consent (23).
  • Healthcare disparities: Nurses who identify and address healthcare disparities based on race, ethnicity, socioeconomic status, or geographic location work toward eliminating inequitable healthcare (8,10). 

By advocating for patients during these critical times, nurses can help ensure that patients’ wishes are respected, their quality of life is optimized, and they receive compassionate and patient-centered care. 

Quiz Questions

Self Quiz

Ask yourself...

  1. How is advocacy different with hospice and palliative care patients than patients with non-serious illness? 
  2. During your career, in what ways have you advocated for patients with serious illness?

Providing Resources  

To provide comprehensive care, nurses must be knowledgeable regarding hospice and palliative care and what each provides. Educating families and patients about their options is a great way to provide emotional support and help them navigate complex medical decisions.  

As part of the MHB and many other insurers, hospice care is funded 100%. As a result, hospices are required to provide a specific set of resources (15). Medicare and private insurers frequently cover the cost of a Palliative Care practitioner on a per-visit basis. Thus, Palliative Care resources can vary widely per program. Knowing what resources are available through your local palliative care program is essential. Below is a chart of common hospice and palliative care resources and their benefits.  

 

Resource 

Hospice 

Palliative 

Benefits 

MD 

 Yes 

 Yes 

Palliate symptoms through medical assessment and treatment. 

NP 

Maybe 

Often 

Palliate symptoms through medical assessment and treatment. 

Registered nurse 

Yes 

Maybe 

Care coordination, assessment, monitoring, symptom management, education, and communication with interdisciplinary teams. 

Social Work 

Yes 

Maybe 

Assist with community resources, counseling, advance directives, and other support. 

Chaplain 

Yes 

Maybe 

Assist with spiritual support, counseling, and connecting patients with their church affiliation and practices. 

C.N.A. 

Yes 

Rare 

Assist patients with physical care such as bathing and dressing. This is often a great support to caregivers. 

Dietician 

Yes 

Rare 

Assist and support patient’s dietary needs. 

Pharmaceuticals 

Yes 

No 

Alleviate common symptoms. 

Medical Supplies 

Yes 

No 

Wound care, other treatments, continence, and cleanliness needs. 

DME 

Yes 

Maybe 

Supports a patient’s ability to be independent.  

PT, OT, ST 

Yes 

Able to make referrals 

Support to maintain function, non-pharmacological pain management, assistance with communication, swallowing, wound care, and ADL support.  

Quiz Questions

Self Quiz

Ask yourself…

  1. How do you advocate for patients rights and ensure their wishes are respected in your healthcare setting?  
  2. How do you support patients and their families during difficult conversations about end-of-life decisions?  
  3. How do you provide emotional support to patients and families in need?  
  4. What strategies do you employ to ensure effective communication between patients, families, and the interdisciplinary team?  
  5. How do you manage your emotional well-being when working with families and patients nearing the end of life?

Becoming a Hospice or Palliative Care Nurse 

Even though Hospice and Palliative Care are different, the skills and qualities of successful hospice and palliative nurses are similar. As previously discussed, Hospice and Palliative Care payment differs, with Palliative Care primarily funded by payment to medical practitioners. Because of the funding, it is rare for Palliative Care practices to employ nurses to the same degree as hospice. Many Palliative Care programs do not have nurses in their daily practice but may have them for patient follow-up or coordination of care. 

For this education, we are focused on the requirements of becoming a hospice and palliative care nurse, understanding that positions for Hospice nursing are more prolific than strictly Palliative Care nurses.  

 

Educational Requirements 

While many nurses can specialize in a specific area of care, for example, geriatric, cardiac, critical care, surgical, or emergency care, hospice, and palliative care nurses care for patients with a wide range of illnesses, ages, and abilities.  

Hospice and palliative care nurses need to understand the ordinary course of numerous conditions in multi-aged patients to anticipate, prepare, and quickly palliate symptoms of the specific disease. They must be skilled in the assessment of patients and able to detect subtle changes in conditions that affect the patient’s plan of care. 

 

Certain requirements need to be met to become a hospice and palliative care nurse (17). Here are the general requirements: 

  • Licensure: Current, unrestricted license as a registered nurse (RN) or licensed practical/vocational nurse (LPN/LVN) in the state where they practice. The specific licensure requirements may vary by state.
  • Certification: Hospice nurses are often required to have specialized certifications related to hospice and palliative care. The most common certification for hospice nurses is the Certified Hospice and Palliative Nurse (CHPN) credential, offered by the Hospice and Palliative Credentialing Center (HPCC). This certification demonstrates expertise in providing care to patients with life-limiting illnesses. This certification requires two years of hospice experience for eligibility to take the certification test (16). 
  • Education and Experience: There are no specific education requirements for hospice nurses required by regulatory bodies. However, most hospice agencies prefer nurses with a bachelor’s degree in nursing (BSN) or higher. As written above, hospice and palliative care patients range in age and illness. Therefore, many agencies also prefer nurses with two years of experience in a medical-surgical healthcare setting (17).  
  • Training: Hospice nurses must receive comprehensive training in hospice care and be knowledgeable about the philosophy, principles, and practices of hospice and palliative care. The hospice agency typically provides this training and covers pain management, symptom control, psychosocial support, communication, and end-of-life care (17).
Quiz Questions

Self Quiz

Ask yourself…

  1. What is your experience with the importance of certification as perceived by patients and families?  
  2. What is your experience with the importance of certification as perceived by healthcare professionals?
Skills and Qualities 

Hospice and palliative care nurses must thrive on working independently since more than 80% of hospice and palliative care is provided in patient's homes. While hospice and palliative care are under the management of the physician, the hospice nurse is the primary assessor and at the patient's bedside.  

Hospice nurses must be organized, have firm boundaries, and be able to systematize their practice to see multiple patients in one day, with the requirements of driving, documenting, communicating with the interdisciplinary team, and providing care according to the individual patient care plan. In addition, they must provide support and education to the patients and their families.  

Nurses in hospice and palliative care settings require excellent communication, empathy, and the ability to navigate complex ethical dilemmas and difficult conversations.  

Quiz Questions

Self Quiz

Ask yourself...

  1. How do you stay current on the latest research and best practices regarding caring for patients with serious illnesses or at the end of life?  
  2. Can you describe a situation where you had to manage complex pain or symptoms? 
  3. What additional training or education have you pursued to better manage patients with serious illnesses or near the end of life?  

Conclusion

In conclusion, Hospice and Palliative Care represent two distinct but interconnected approaches to providing comprehensive medical care for individuals with serious illnesses. While hospice care focuses on terminal patients and aims to enhance their quality of life, Palliative Care addresses the needs of individuals at any stage of a serious illness.  

Nurses are crucial in advocating for patients, facilitating difficult conversations, and providing resources to support patients and their families. By understanding the philosophy, eligibility criteria, and duration of hospice and palliative care services, nurses can contribute to the holistic well-being of patients in these specialized fields. 

As society continues to recognize the importance of providing comprehensive end-of-life care and support for patients with serious illnesses, it is crucial to foster awareness, education, and support for hospice and palliative care services. By doing so, we can collectively work towards enhancing the experiences of those facing life-limiting illnesses, offering comfort, compassion, and dignity throughout their journey. 

Navigating Difficult End of Life Conversations

Introduction   

Talking about death is generally difficult for the average person. It is even considered taboo in some cultures or situations.  For some nurses, having end of life conversations is a routine part of the profession. A hospice nurse, for example, carries the responsibility of managing care for a dying patient, and ultimately informing the patient’s family that death is imminent.

A lack of training, experience, or confidence in this area could result in poor delivery, unrealistic expectations, and an overall negative dying experience. Most people do not have experience or even a baseline when it comes to death and dying. This makes end of life conversations much more important in the delivery of patient care.  

Perspectives About Dying and Death (Philosophical, Psychological, and Spiritual) 

Philosophical 

The human experience of death and dying is not one sided. On the contrary, there are many things to be considered to understand it fully. This goes beyond a scientific approach. An understanding of philosophical reasoning related to death is imperative to provide a thorough explication of the human dying experience. Historically, death has been an intrinsic part of life throughout various civilizations. 

Ancient Egyptians spent much time preparing for the next life. Life was perceived as a dream that passed quickly. Death was viewed as eternal. Egyptians believed that the dead would make their way over to The Kingdom of Orisis, where they would spend eternity. 

Ancient Greek civilization also viewed death in a particular light. According to San Filippo, “Greeks perceived death as a release of the soul from the body. The soul, which was considered to be part of the mind, was believed to be immortal. It was considered that the soul lived before the body and would live again in another life” (1). 

Lastly, it has been noted that when it comes to fearing death, people create philosophies and theologies due to an inability to visualize our own death and afterlife.  

Psychological 

The psychological aspect of death is just as important as the physical. The thought of death alone has the potential to evoke various memories and feelings. You will typically find that a person either accepts or fears death (positive outlook vs negative outlook). This can be a fear of suffering, pain, or of the unknown. These views are typically formed based on past experiences with death. 

 Often, a person may have no underlying baseline when it comes to dying or death. That first experience with death can potentially shape someone’s entire perspective. Fearing death could be attributed to a fear of the unknown, lack of relatable experience, a negative experience, or a lack of communication regarding death, due to a cultural taboo, for example.  

On the other hand, things like faith, positive experiences, and imminent death may cause someone to be more accepting of death. Often, someone facing imminent death may be forced to think about it and come to terms with it. In a study of terminally ill patients facing death, “The participants were afraid of death and earnestly desired to live but felt that death was imminent. To escape their distress, they attempted to accept the situation by thinking that all lives are finite, and death had to be accepted” (2). This is an example of coming to terms with an impending death and accepting it. 

Spiritual 

Spiritual perspectives on death should be considered when discussing views on dying. History shows that humans have long held beliefs that life does end when the body dies. Many tend to believe that once a person dies, their soul is then freed, and can go on to another life or be reincarnated into someone or something else. Religious ideologies contain a vast amount of knowledge and wisdom regarding death. “Religion and spirituality help individuals make sense of what awaits them near the end of life and help the dying cope with their terminal condition” (7).  

What happens after death may vary from one religion to the next. Many religions also have a heaven or heaven like final place where the deceased can rest and be with other who have also died. One of the oldest ideologies of human history is the belief that there can be life after death. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Historically, how has death been viewed in different civilizations? 
  2. Why might a patient fear death and dying? 
  3. What causes patients to be more accepting of death? 

Impact on Nurses 

Imagine working as a hospice nurse.  Your sole purpose is to provide end-of-life care for terminally ill patients. This includes providing information on what to expect at the end of life. At any given time, you have patients that could be imminently dying.  

You are a source of knowledge and comfort for a patient and their family during this time. In the end, you will likely be there when the patient takes their last breath. How can one prepare to handle this scenario time and time again? Should a nurse feel sadness for a patient that was expected to die, or should they emotionally separate themselves? 

The latter may prove hard to do. The reality is that nurses are frequently exposed to death and dying in a variety of settings. A patient’s dying process can be planned or not and this distinction may mean different things for different people. Typically, nurses are taught skills to help prevent death.  

This may be a hard thought process to overcome when the goal is not curative, but comfort focused. These patient interactions help to shape a nurse’s feelings on death and dying. “Nurses are frequently exposed to dying patients and death in the course of their work. This experience makes individuals conscious of their own mortality, often giving rise to anxiety and unease.  

Nurses who have a strong anxiety about death may be less comfortable providing nursing care for patients at the end of their life” (3).  This ‘death’ anxiety could lead to disastrous outcomes for both the nurse and the patient. Nurses should be aware of their own thoughts and attitudes towards death, and how these could affect their ability to provide patient care. 

Caring for the dying involves both skill and emotional support from nurses. Younger nurses and nurses with less experience with death may have greater difficulty caring for dying patients. End of life education and an introspective look at oneself are imperative when it comes to providing quality care. “Nurses’ professional experience is positively correlated with their position, professional level (rank), EOL care experience, competence in EOL, and another knowledge. 

 Nurses who have a positive attitude seem more likely to have more competence in dealing with patients’ symptoms at EOL and better knowledge of EOL care (3). The more palliative knowledge nurses had, the more competence they felt. Moreover, competence dealing with patients’ symptoms in EOL care was correlated with older nurses” (8). Positive conversations about death and dying usually lead to a positive dying experience. 

 To reach this point, nurses and other healthcare professionals need to know how to have these conversations. In a society that is so focused on the living, receiving education on death can be difficult. When death is perceived as a part of life, only then will people feel more comfortable talking about it.  

Quiz Questions

Self Quiz

Ask yourself...

  1. What role do nurses play in death and dying? 
  2. In what ways are nurses affected by death? 
  3. How do previous experiences shape our views about death? 
  4. What are some potential indicators of a nurse’s ability to provide quality care at EOL? 

Communication Strategies 

Many people are uncomfortable talking about death and dying and tend to shy away from such conversations. This may also be true for nurses. Talking about death should not be a formidable task. Nurses should be able to comfortably implement these conversations in their practice when needed. Effective communication is imperative throughout a patient’s trajectory.  

Conversations about death and dying can impact patient care. “Research has shown that talking about and planning the EOL is important for how the final days in a patient’s life may play out and is associated with reduced costs as well as a higher quality of care in the final weeks of life” (4). In a society so focused on life, it may be difficult for nurses and other health professionals to obtain the skills needed to confidently speak with patients about death. 

To effectively talk to patients about death, nurses should first be willing to initiate and discuss the topic. There are important strategies to remember when talking about the end of life. “Qualitative research on the end of life has revealed that medical personnel should consider the following strategies when conducting EOLD: open and honest conversation, setting treatment goals, and balancing hope with reality” (13).  

Patients should also be encouraged to express their thoughts, fears, and to ask questions. It is also important to be honest and forward with patients. No “beating around the bush”. This means using words like “dying” and “death” while having these conversations.  

One communication strategy, VALUE, “recommends to value and appreciate statements of family members, acknowledge their emotions, as well as to listen and ask questions to understand who the patient was as a person” (9). Nurses should keep the following in mind: a patient’s comfort level with death, goals of care, expectations, and cultural factors. Having this knowledge will help to guide the conversation.  

Lastly, when a nurse feels confident and exhibits calmness while talking about death, a patient will more than likely feel the same way. 

Quiz Questions

Self Quiz

Ask yourself...

  1. How do conversations about death impact patient care? 
  2. What can nurses do to effectively communicate with their patients about death? 
  3. What strategies should be utilized when talking about death? 

Stages of Grief 

Nurses are not immune from experiencing grief or loss. We mourn personally and we mourn alongside our patients and their families. “Grief and loss are something that all people will experience in their lifetime. The loss may be actual or perceived and is the absence of something that was valued. An actual loss is recognized and verified by others while others cannot verify a perceived loss.  

Both are real to the individual who has experienced the loss. Grief is the internal part of the loss; it is the emotions related to the loss” (4). Grief allows a person to begin to deal with the pain associated with loss and to heal. There are five stages of grief which were identified in Dr. Elisabeth Kübler-Ross in her book Death and Dying.  

  1. Denial: This stage Is not necessarily about denying that the loss happened. Instead, it is more about denying the feelings associated with the loss. Denial lets us face our feelings of grief. “As an individual is able to accept that this loss is their reality, they will be able to move into the healing process and denial will begin to diminish” (5). 
  2. Anger: A grieving person may feel anger towards a variety of people associated with the loss. This is a normal and a necessary part of the healing process. “Under the anger is the individual’s pain. Anger provides structure, and that is better than preceding numbness. It can be a challenge for some to feel the anger; sometimes it is easier to try and suppress the anger. Feeling anger and addressing anger is part of the grieving process” (5). 
  3. Bargaining: Grieving people may begin to say things to themselves like, “If this__, then this __”, or “I will do anything if you take the hurt away” (5). This stage may occur at any point in the grief process. Once this step is reached, the person can begin to move through the stages in different ways.  
  4. Depression: This stage involves a realization that the situation is real. “Empty feelings come forward, and one’s grief moves in on a deeper level than before. This type of depression is not a sign of mental illness; although reaching out for help may be the right step. It is an appropriate response to a great loss. An individual may withdraw from their daily life activities, and they may feel a fog of   intense sadness” (4). Depression after a major loss is normal and necessary in the healing process.  
  5. Acceptance: Entering this final stage does not mean one is completely okay with what has happened. In fact, one may never be as they once were prior to the loss. “Acceptance, as a stage, is about accepting that this is their new reality, and it is permanent. Life cannot go on as it once did, but through acceptance, life can and will go on” (5). Individuals in this stage must realize that change is necessary to adjust to the new normal. 

Not everyone experiences grief in the same way. Grief is a very personal experience that affects people in different ways. Nurses should be familiar with the stages of grief to be able to offer optimal patient care to grieving patients and their families. This includes recognizing signs of depression and possible suicidal ideation, providing empathy, compassion, education, and resources to those in need. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the stages of grief? 
  2. Why should nurses be familiar with the stages of grief? 
  3. What purpose does grief serve? 

End of Life Process 

Phases of Dying 

Although everyone experiences death differently and on their own terms, there are two main pathways that most people take before dying. The dying process can be broken up into two phases: the transitioning phase, and the actively dying phase. The amount spent in each phase varies from person to person. 

The transitioning phase usually begins 2-3 weeks prior to death. Major changes in function and the ability to do activities of daily life are observed during this time. Patients may even begin falling prior to entering this phase. Becoming bedbound is common as one will begin to spend most of their time sleeping. 

This means decreased responsiveness, less interest in normal activities and hobbies, decreased interaction with family and friends, and an overall decline in one’s interest in external factors. It is possible to be roused during this phase, but this may only be possible in short intervals. It is not uncommon for transitioning patients to speak to or about loved ones that have already passed away. They may even report seeing deceased family in the room with them (11). 

This should not be feared and is an important part of a person’s dying process. Incontinence may also begin during this time and briefs will be needed. Perhaps one of the most noticeable and difficult changes to witness, especially by friends and family, is changes in appetite. Patients will begin to show less interest in food and liquids. A greater difficulty swallowing will become apparent. “Refusal of food and fluid by a dying person is a common occurrence, particularly as the body slowly shuts down, and this may be the evidence signifying an actively dying process rather than starvation” (11). 

 Lastly, symptoms like restlessness, agitation, and pain may arise and detract from one’s comfort level. Although most patients will spend about two weeks transitioning, time can vary from days to weeks. The transitioning phase can also be skipped altogether, depending on the person. 

Once the transitioning phase has concluded, the actively dying phase will begin. Actively dying immediately precedes death. This phase is usually short, lasting about 48 hours. Once actively dying, death is imminent, and a patient is expected to pass away at any moment. This phase is markedly different from the previous phase, and symptoms tend to become more apparent. “The following five changes constitute objective evidence of the end of life: diminished daily living performance, decreased food intake, changes in consciousness and increased sleep quantity, worsening of respiratory distress, and end-stage delirium” (12). 

One key difference is one’s ability to response to tactile or verbal stimuli. The actively dying patient is obtunded and no longer responds to external forces.  There could be slight reactions, but nothing meaningful. This is a comatose state.  

There are many observable changes, including changes in vital signs. Blood pressure begins to drop, heart rate speeds up and eventually slow, respiratory rate picks up, and temperature may become elevated. Respiratory differences tend to be the most common observable changes. Cheyne-Stokes may occur, and the overall breathing pattern can be very irregular. Apnea is also common (11). 

Many patients experience what is known as the “death rattle”.  This very noticeable sound is due to an accumulation of secretions in the upper airway. This is a hallmark of the actively dying phase, but it is not experienced by everyone. “Death rattle is a strong predictor of imminent death, and nearly 80% of people die within 48 hours after its onset” (11).  

Skin changes also occur. The body may become cool to touch, cyanosis may develop in the nail beds of fingers and toes, and mottling can occur usually beginning in the lower extremities and later spreading to other parts of the body. Skin may also become very pale. Urine output will decrease and become concentrated as evidenced by an amber color. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What are the dying phases? 
  2. What changes are observed when someone is transitioning? 
  3. What are some expected physical changes in the active dying phase? 
  4. What education should a nurse provide to someone taking care of a patient that is actively dying? 

Nursing Assessment and Care 

Since there are so many drastic changes observed during the transitioning phase, proper education is crucial for caregivers. Nurses should reassure them that what the patient is experiencing is normal and to be expected. “At the end of life, most patients are in a state of lethargy, wherein their consciousness progressively declines, and sleep duration increases; therefore, it is necessary to provide appropriate explanations to patients and their families so that they can accept these symptoms as part of the natural end-of-life process” (12). 

Family members usually try to wake the sleeping transitioning patient and have them attempt activities that could be done in the past. This is dangerous for the pt and can lead to injuries and more agitation. Becoming bedbound is a major change and puts the patient at risk for pressure injuries and increased pain. Fragile skin combined with new episodes of incontinence are topics that should be discussed, and proper supplies should be used. 

Other potential barriers to a peaceful transitioning period are force feeding and aspiration. Nurses should provide education on what is acceptable and needed at this point. Patients will not die of hunger or lack of water. Allowing the patient to eat and drink small amounts is okay (12). 

This amount will decrease as the body starts shutting down. Ice chips can be used while the patient is still alert. Utilizing mouth swabs with water is enough to hydrate the oral cavity and keep the patient comfortable until the end. During this time, symptoms can seemingly come out of the blue.  

A once calm patient can become highly agitated in a short period of time. Medications should be added timely to ensure that the patient has a peaceful death.  Information on medication and interventions to control uncomfortable end of life symptoms like pain, agitation, and restlessness should be provided to caregivers. Hospice patients, for example, have a comfort kit with various medications to use during this time.  

Medications can be used as needed or scheduled to keep patients comfortable. (12). As the patient enters the actively dying phase and becomes less alert and aware, it is important that friends and family continue to talk to the patient and keep conversations positive around the patient. Hospice nurses, for example, are sure to tell caregivers that hearing is the last thing to go, so they should continue to speak to their loved one. Since vital signs start to become abnormal, reassurance is usually needed to keep family comfortable.  

Not all vital signs need to be taken in the final stages. Taking blood pressure, for example, could cause discomfort. Death education related to respiratory changes is imperative. “Abnormal breathing patterns such as shallow breathing sound become increasingly common starting 1 week before death” (12). 

Caregivers should be informed that breathing too fast or too slow at this point is not an emergency and there are things that can be done to promote comfort like applying oxygen, keeping the head of the bed upright, and keeping the room cool. Medications can also be given to decrease the death rattle. It should be noted that patients do not experience discomfort from the death rattle.  

Lastly, not having a bowel movement or passing urine during the last few days of life is normal and interventions are not needed. Education and support are especially important during the final phases of life. With their peaceful words and deep knowledge base, nurses can be instrumental in facilitating a peaceful death.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Is it reasonable to obtain vital signs every two hours? Why or why not? 
  2. If the family expresses concern about changes in bowel or urinary habits, what can you say to reassure them? 

Resources and Support 

Planning, coordinating, and executing quality end of life care can be challenging for health care workers. This period can also be one of the most challenging times for both patients and their loved ones. There are available resources for health care workers, patients, and their loved ones that provide information on end-of-life care. 

Hospice care is an invaluable resource and source of support. This is available to terminally ill patients with a life expectancy of 6 months or less.” Hospice care is the term given to the care provided when a patient is given a prognosis of death within 6 months, and they do not pursue curative treatments They focus on improving the quality of life which can mean many things” (10).   

Care can be provided in any setting that a patient calls home. The hospice team includes a medical director, registered nurse, chaplain, social worker, home health aide, and often a nurse practitioner. Symptoms and care can be managed at home with the help of covered medications, supplies, and medical equipment. Hospice allows patients to reach their goal of dying peacefully at home. A bereavement team also provides support during the process. (10?) 

Palliative care, another form of comfort care, can also be utilized to maintain comfort at the end of life. Unlike hospice, patients receiving palliative care do not need to have a life expectancy of 6 months or less. “Research found that timely EOL care discussions allowed family members to make use of hospice and palliative care services sooner and maximize their time with the patient” (6). 

Nurses should be educated in other end of life resource topics such as advanced directives, POLST (Physician Orders for Life Sustaining Treatment), and Durable Medical Power of Attorney. Looking ahead and having meaningful discussions regarding end-of-life planning can help prevent the stress of needing to address these things when death is imminent. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What care options are there for patients at the end of life? 
  2. What is the difference between palliative and hospice care? 
  3. What tools can the nurse use to help patients in end-of-life planning? 

Conclusion

End of life conversations have a profound impact on not only patient care, but also on the dying process itself. Research shows that when implemented appropriately, these conversations improve patient relationships with healthcare workers, lead to better outcomes, and allow for a more positive dying experience. Nurses play a critical role in end-of-life processes in many different settings. With education, practice, experience, and confidence, nurses can incorporate conversations about death and dying to provide quality care. 

References + Disclaimer

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  2. Alley, W.D., & Schick, M.A. (Updated 2023, July 24). Hypertensive Emergency. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470371/ 
  3. American Heart Association. (2023 June 7). Types of Blood Pressure Medications. Retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications 
  4. Arumugham, V.B., & Shahin, M.H. (Updated 2023, May 29). Therapeutic Uses of Diuretic Agents. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557838/ 
  5. Brater, D.C., & Ellison, D.H. (Updated 2022, November 30). Mechanism of action of diuretics. UpToDate. Retrieved from https://www.uptodate.com/contents/mechanism-of-action-of-diuretics#H5 
  6. Centers for Disease Control and Prevention. (2023, July 6). Facts about Hypertension. Retrieved from https://www.cdc.gov/bloodpressure/facts.htm 
  7. Centers for Disease Control and Prevention. (2021, May 18). High Blood Pressure Symptoms and Causes. Retrieved from https://www.cdc.gov/bloodpressure/about.htm 
  8. Farzam, K., & Jan, A. (Updated 2023, August 22). Beta Blockers. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK532906/ 
  9. Goyal, A., Cusick, A.S., & Thielemier, B. (Updated 2023, June 26). ACE Inhibitors. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430896/  
  10. Hariri, L., & Patel, J.B. (Updated 2023, August 14). Vasodilators. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK554423  
  11. Hill, R.D., & Vaidya, P. (Updated 2023, March 27). Angiotensin II Receptors Blockers (ARBs). In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537027/  
  12. Huxel, C., Raja, A., Ollivierre-Lawrence, M.D. (Updated 2023, May 22). Loop Diuretics. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK546656/ 
  13. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Loop Diuretics. [Updated 2021 Oct 13]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK548619/ 
  14. Mann, J.F.E, &Flack, J.M. (Updated 2023, June 22). Choice of Drug Therapy in Primary (Essential) Hypertension. UpToDate. Retrieved from https://www.uptodate.com/contents/choice-of-drug-therapy-in-primary-essential-hypertension 
  15. McKeever, R.G., & Hamilton, R.J. (Updated 2022, August 5). Calcium Channel Blockers. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482473/  
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