Event 3: Mr. Monahan's Pain Treatment

Mr. Monahan’s Pain Treatment Goals

Indicates he would like to see back pain reduced to at least a 5 so that he can increase his activity and help out around the house.

“My back pain is so bad that I don’t always pay attention to my knees. I used to be able to do a lot more. I just want to be able to help Joan out more and be able to take care of Buster. I’d really like to wake up tomorrow and not have any pain. But, if you could cut it in half, I will be satisfied. I’ve always had back and knee pain. Kid, that’s what happens when you lay carpet. You ruin your back and knees.”

Mr. Monahan’s Problem List

  1. Hypertension
  2. Hypothyroidism
  3. GERD
  4. OSA
  5. Reduced visual fields, status post occipital lobe CVA
  6. Lower lumber back pain
  7. Knee pain, status post bilateral arthroplasty
  8. Constipation
  9. Impaired ability to perform activities of daily living
  10. Impaired ability to perform instrumental activities of daily living
  11. Reduced quality of life/enjoyment of life
  12. Altered sleep/wake pattern

Plan of Care

  • What are the priorities for today’s home visit?
  • What drug-disease interactions do you need to address in your plan?
  • What drug-drug interactions do you need to address in your plan?
  • How will you address Mr. Monahan’s pain and pain-related problems?
  • How will you address Mr. Monahan’s tramadol side effects?

Back Pain

Reduce back pain

  • Take tramadol daily as directed
  • Add acetaminophen 650 mg p.o. Q 8 hrs, prn
  • Ice pack to lower back, 20 minutes on, 40 minutes off. Wrap ice pack in a towel to protect skin
  • Limit activities that jar back (mowing lawn, carrying buckets of water)
  • Encourage activities that mobilize the patient
  • Provide instruction about strengthening core muscles and ergonomic movement
  • Phone physician or nurse practitioner if pain severity is not reduced in 3 days
  • Begin a weight reduction program 


Intervene on constipation

  • Assess dietary intake, hydration 
  • Initiate a bowel protocol

Potential Drug-Drug Interactions

Plavix – Ibuprofen – ASA

  • Speak with attending about the potential interactions related to these 3 drugs
  • Consider changing Mr. Monahan to acetaminophen if his liver enzymes are WNL

Potential Drug-Disease Interactions

Iburpofen, ASA and GERD

  • Talk with attending about adding a proton pump inhibitor

Poor Sleep Quality and Quantity

  • Use CPAP as prescribed
  • Limit stimulating activities (television) after 8:00 in the evening
  • Take a warm shower in the evening
  • Limit day time napping to one 30-minute nap a day, before 3:00 in the afternoon
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