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AGACNP at an urban, tertiary referral center working

You are a new AGACNP at an urban, tertiary referral center working in the emergency department (ED). You are presented with the following case:

Patient is a 45-year-old, Caucasian male, acute care nurse practitioner (ACNP) who comes in with the chief complaint of back pain, acute on chronic. He describes severely compromising, debilitating lumbar spine pain due to a fall from a 20-foot scaffolding several years ago. There is MRI evidence of multilevel degenerative spine disease and bulging discs, with a dx of “failed back surgery.”
In addition to the above, he is nauseated with emesis episodes that are too numerous to count this morning. He also has intractable diffuse abdominal pain, intermittent piloerection, and diaphoresis.
He tells you he is prescribed the following by a local pain clinic: OxyContin 20 mg BID, with oxycodone 5 mg q. 3 hours breakthrough pain, Lyrica 100 mg at HS, Lexapro 10 mg daily, and Xanax 0.5 mg BID prn anxiety. He reports that he received #60 OxyContin 20 mg and #60 oxycodone 5 mg 2 weeks ago but is saying that he has been out of medication x 2 days. When you inquired about how quickly he has used his pills, he admits to using more pills than prescribed due to increased pain following a recent fall at home. He wants help, admits to opioid addiction, and is accepting of inpatient admission.
He is also requesting methadone to assist with addiction/pain management.
He is receiving outpatient physical therapy as well as intermittent epidural blocks (last one was 2 weeks ago).
Answer all the following questions, in detail. Support your answer with two or three peer-reviewed resources.

What are your initial orders to help control his acute pain?
What is your diagnosis for his GI symptoms?
What is your response to his request for methadone? Can you prescribe methadone for acute/chronic pain or addiction as an AGACNP?
Ethically and professionally, what are your concerns for this patient and his own ACNP practice? What resources are available to you as a prescriber to track this patient’s opioid use/abuse? What referrals do you anticipate making for him while he is in the ED?
What populations of people are at risk for addition, pain medication diversion, and psychological conditions that may cause hyperalgesia or adverse reactions to pain regimens?
What resources are available to a provider of medical care who suffers from addiction?

Sample Solution

ose: Mrs. Grose believes in holding trust among the governess despite the governess’s constant suspicion. In addition, she also makes sure the children are being cared for properly just like the governess because she had taken care of the children prior to the arrival of the governess. Mrs. Grose’s purpose is to be the housekeeper in Bly and she plays the role of the only source that is available to obtain information about Miss Jessel and Peter Quint. The society of the book influenced Mrs. Grose through the concept of higher status. In the novel, Mrs. Grose’s employer is superior to her and the person of higher rank in society causes her to fear to anger her employer, which prevents her from involving the employer into the conflict early. Miles: Miles is one of the two children that the governess is taking care. Throughout the plot, he values working together with his sister such as switching spots in distracting the governess. In addition, he also values his relationship with Peter Quint. He has become corrupt from Quint influencing negatively by teaching him bad words when they spent so much time together. Miles’s purpose in the book is to play the role of the deception towards the governess with his attractiveness and charming personality. He distracts the governess from noticing his abnormality and cleverness in order to convince the governess that her time taking care of the children will be perfectly normal and run smoothly. Society has influenced Miles through the personalities of the other members of the society due to Miles’s young age and inability to distinguish what is right and wrong. Peter Quint is suspected of having taught the child immoral ideas. Flora: Flora values using the proper manner necessary for each situation as well as working with her brother, indicating she values the connection to her family members. Flora’s purpose is to mislead the governess into thinking that everything is going smoothly. She shows her affectionate and well-mannered side to make her first misconduct a shock to the readers and the governess. Society has influenced Flora because her sightings such as those of Miss Jessel which she knows are abnormal have caused her to feel reticent about herself in order to avoid talking about the ghost. Peter Quint: Peter seemed to care about sexual promiscuity and embraced actions preconceived to be immoral in society. Peter’s purpose is to be the ghost or the hallucination to instigate the governess’s behavior and actions in the book. Peter has been influenced by society because his personality clashed with moral ideas established in society. Society made him realize he doesn’t fit with moral standards causing him to be involved with terrible actions such as drinking and then having slipped on an icy path, which led to his death. Miss Jessel: Having been the previous governess, Miss Jessel also values the children and hoped that she took good care of the children when she was alive. Her purpose is to be the ghost or the hallucination
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