Event 1: Meet Donald Williams

Introduction to Donald Williams

Male
Age: 77
Height: 6 feet
Weight: 220 pounds

Background

Osteoarthritis/old football injury/veteran – highly stressful prior treatment (excessive weight during previous PT during the war), PT during the Vietnam War was a high anxiety event

Primary Problem

R TKA 2 weeks post-surgery.  Knee is painful and swollen, 
3 day hospital stay; 7 days in skilled care with discharge to home?  Home health 2 weeks for OT/PT, skilled nursing; home health aide helping with laundry?

Family

• Widower
• Daughter and son who live out of state

Location

Home Environment

• Living alone in an apartment; senior apartment with other seniors around him
• 2nd floor, laundry – shared laundry down the hall.
• Provides 2 meals a day but he prefers to do his own cooking
• Lives in a small town
• Lives 2.5 hours away from nearest VA
• Expects to drive in for rehab and doctor appointments; needs help for driving.

Hobbies

Shooting range; hunter (deer stand/duck blind)

Past Medical History

• Osteoarthritis
• Previous knee injury 1953 (Korean War)
• BPH (benign prostatic hypertrophy)
• Hypertension
• S/p MI at age 53 and rehab was successful, no subsequent problems/clinical sequela

Medications

• Metoprolol 50 mg daily
• Aspirin 81 mg daily
• Flomax 0.4 mg daily
• Tylenol 650 mg every 6 hours

Donald in His Own Words

Donald Williams is a 77-year-old Navy vet. He lives in Decorah, Iowa which is about 2.5 hours from the VA in Iowa City. He had a total knee replacement, which is why he was at the VA.

He damaged his knee in Vietnam and then damaged it further playing ball. Eventually it got arthritis and needed to be totally replaced or he wouldn't have been able to walk.

Mr. Williams is a little apprehensive about coming home because he lives alone in a senior apartment. His kids are 3 to 4 hours away and his passed away 6 years ago. He's a little concerned about doing the apartment things.

The VA said that they would send Mr. Williams help. He's going to be visiting with his nurse, the pharmacist, a social worker, occupational therapist and a physical therapist .

Mr. Williams says he's really eager to be back home and getting on his own again. He like to go hunting and says he's really ready to do that again.

Past Medical History

As you can see, Donald has osteoarthritis. His first right knee injury happened when he was in high school and then a second injury to this right knee in his 20’s during the Vietnam War. He had a highly stressful physical therapy treatment episode during the war. The physical therapy during the Vietnam was also a high anxiety event for him. Donald has benign prostatic hypertrophy and hypertension. He had a myocardial infarction at age 53 and cardiac rehab was successful, no subsequent problems/clinical sequela.

Nursing Physical Exam

Brief Systems Review

• HHENT Negative No co SOB or chest pain, no problems with bowels or urination Skin: No complaints of rash, lesions or itch
• Low back Pain: present with higher level of activity Co weakness right surgical knee; denies falls

Physical exam

• Alert and oriented
• Neck has no lymphadenopathies Thyroid gland palpable, no nodules Lungs clear bilaterally
• Heart sounds S1S2 present and no irregularities
• Abdomen: Soft, no tenderness, no masses palpable, no rebound, no hepatosplenomegaly; bowel sounds present
• Lower Extremities: 2+ peripheral pulses bilaterally,
• Left leg: no edema or ecchymosis of left leg, normal active ROM 5/5 strength
• Right leg: knee -swelling noted to right leg to mid-calf without tenderness, negative Homann’s, Range of Motion: 15-85 in seated position

Visual Inspection

• 22 centimeter well healed incision without drainage noted, (Steri-Strip in place) , mild ecchymosis noted around incision, skin without warmth or erythema, incision tender with motion and to palpation; swelling present from proximal knee to the ankle
• R Ankle: full ROM and 5/5 strength, no warmth or erythema,
• R Hip no pain to palpation, decrease ROM in flexion due to knee pain, 5/5 strength,
• Walking with a rolling walker with brakes, full weight bearing right lower extremity

Home Safety

A home fall prevention checklist for older adults that is published by CDC provides a guideline for home safety concerns which includes floors and pathways, lighting , handrails, kitchen, bathrooms, bedrooms, vision, and medication safety.

As part of the nursing assessment, a nurse reviewed Donald’s apartment and her checklist is listed here:

• Good lighting in bathroom and hallways for nighttime
• No throw rugs in the bathroom and kitchen
• Walkways big enough for rolling walker in all areas of the home
• Medication recommendation – lock up medications.

A Home Fall Prevention Checklist for Older Adults

Home Safety CDC Control and Prevention:

https://www.cdc.gov/homeandrecreationalsafety/pubs/english/booklet_eng_desktop-a.pdf

Tools in this Module

In this module, Donald’s care team utilizes a variety of tools for assessment for pain severity, pain impact, opioid risk, anxiety, cognition and knee function. We have rated the evidence in this module as weak evidence, moderate evidence or strong evidence.

• Pain Assessment
  • Iowa Pain Thermometer-Revised
• Multidimensional Pain Measure
  • PEG: Pain, Enjoyment, General Activity
• Opioid Risk Tool (ORT)
• General Anxiety Disorder (GAD7)
• Cognition Assessment
  • Mini-Cog™
• Functional Assessment
  • Knee Injury and Osteoarthritis Outcome Score (KOOS)General Anxiety Disorder (GAD7)

Donald's Results

For each tool, we have listed the abbreviation of the tool, the domain of assessment, his initial and final score with home health services, range of the tool score and a brief interpretation of the score.  Take a moment and review Donald’s results. See the Resources/References page for more information about the tool, the reference and strength of the evidence for the tool.

Telephone Medication Review

In this pharmacist’s telephone review, you will look at two different snippets between Donald and a pharmacist and a snippet between the pharmacist and the home health nurse. The topics covered include pain assessment, medication use, and the collaboration of a nurse and the pharmacist. You will also have a chance to look at a risk and benefit analysis for pain management following a total knee arthroplasty.

Collaborating Between the Pharmacist and the Nurse

Following is a conversation between the pharmacist, Jane, and the home health nurse, Dorothy.

Jane: Hi, Dorothy. This is Jane from Sullivan’s Pharmacy. How are you? Dorothy: Hi, Jane. Good and you?

Jane: Good, thanks. I am calling about Mr. Donald Williams. I did a telephone interview with Donald today about his medications. I had a couple of concerns that I wanted to share with you.

Donald seemed a little confused about his medications. I know he has had changes in his pain medications from his inpatient and skilled care stay since his knee operation and this was his first day home. He wasn’t sure of all the names of his medications but he was able to locate his medication list in his kitchen drawer. He appears to be taking his Tylenol too frequently – up to 6 times a day rather than every 6 hours up to 4 times a day.

Dorothy: Jane, thanks for following up about Mr. Williams. Your information helps me plan his visit for today. I will review his medications again with him and make sure he is able to take them correctly – I can follow-up on assessing his cognition as well. Any other concerns?

Jane: No, that covers it. Thanks again for following up. Have a good day. Dorothy: I really appreciate your calling. Have a good day.

Risk Benefit Analysis for Acute Pain Management Following a TKA

Let’s take a look at a risk benefit analysis for pain management following a total knee arthroplasty. The goal of a risk benefit analysis is to compare the risks and benefits for treatment choices and determine if the risks or benefits outweigh one another to assist in treatment choices and determine if the risks or benefits outweigh one another.

Rakel, et al, found that in people who underwent a total knee arthroplasty, people with severe movement pain preoperatively were 20 times more likely to have severe movement pain postoperatively. When the influence of preoperative movement pain was removed, depression became a predictor the greatest predictor (2012).

The goal of this risk benefit analysis is to compare the risks and benefits for pain management after a total knee arthroplasty.

Considerations to consider:

• What are the risks?
• How likely are the risks to happen?
• What are the benefits?
• How likely are the benefits to happen?

Pain Management Options after a total knee arthroplasty:

• Opioid medications
• Non-Opioid medications
• Non-pharmacological approaches

It is important to adequately treat acute pain. Each treatment decision should weigh the risks and benefits to help guide treatment decisions. In first line treatment, consideration should be given for non-pharmalogical strategies and non-opioid strategies as appropriate. Opioid medication may be needed as a second line treatment but consideration should be given to risks and benefits.

For more information regarding medication prescription for acute and chronic pain see the following references:

CDC: Factsheet: Guideline for Prescribing Opioids for Chronic Pain. Available at: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf Accessed June 17, 2018, 2018

CDC: Opioids for Acute Pain What You Need to Know. Available at: https://www.cdc.gov/drugoverdose/pdf/patients/Opioids-for-Acute-Pain-a.pdf Accessed June 17, 2018, 2018

Dowell Dp, Haegerich TMp, Chou Rp. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 65:1-49, 2016

Risks and Benefits for 3 Pain Management Options

Opioids

Risks

• Opioid Misuse/Abuse
• Side Effects: Constipation, Nausea, Drowsiness, Confusion, Slowed Breathing, Loss of Balance
• Falls
• Oversedation
• Addiction
• Substance Abuse
• Transition to Chronic Pain

Benefits

• Pain Relief
• Early Mobility
• Improved functions
• Improved quality of life

Non-Opioid Medications

Acetaminophen

Risks

• Potential overdose
• Liver failure
• Side effects are less than NSAIDs

Benefits

• Pain relief

NSAIDs

Risks

• Side effects
• Stomach Upset
• Stomach Bleeding
• Cardiovascular
• Kidney impairment
• Fluid Retention/Swelling

Benefits

• Pain relief
• Fewer Side Effects compared to Opioid Medication
• Decreased Swelling and Inflammation

Non-Pharmacological Treatments

Examples of non-pharmacological approaches

• Physical Therapy (PT)
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Cognitive Methods
• Exercise, (preoperative information giving, preoperative relaxation, guided imagery and breathing training, cognitive reframing, distraction, massage, acupuncture, TENS).

Risks

• PT: Increased Discomfort
• TENS: Skin Irritation
• Cognitive Modalities: Emotional upset, Negative feelings and fear

Benefits

• PT: Increased function
• TENS -Pain Relief
• Cognitive Modalities: Manage emotions, Improve Coping
• Fewer side-effects