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APPENDIX VI: PAIN MANAGEMENT 883

Local anesthetics

Bupivacaine, ropivacaine (Naropin), or arricaine combined with

epinephrine

Nonsteroidal anti�inflammatOry drugs

Acetaminophen, kerorolac (Toradol), or ibuprofen

Sources: Data from JC Ballantyne, D Borsook. Postoperarive Pain. In D Borsook, AA

LeBel, 8 McPeek (cds), The Massachusetts General Hospital Handbook of Pain Man�

agement. 80ston: Little, Brown, 1996;252; C Pasero, M McCaffery. Providing epidural

analgesia. Nursing 1999;29(8):34; and WM Davis, MC Vinson. New drug approvals

of 2000, part 2. Omg Top;cs 2001; 145(5);89.

Table VI-S. Patienr�Controlied Analgesia

Indication:

Used for moderate to severe postoperative pain in patients who are capable

of properly using the pump

Mechanism of action:

A microprocessor pump thar comrols infusion of pain medicine,

usually through an intravenous line.

Dosage, dosage intervals, maximum dosage per ser time, and background

(basal) infusion rate can be programmed.

Patienr is provided with a button thar allows for self�dosing of pain

medicarion as needed.

Considerations:

Preoperarive education of the patienr on the use of patient�control1ed

analgesia

Ensuring that only the patienr doses him- or herself

General side effects:

Slmilar ro those of opioids (Table VI-3)

Medications: Generic (trade name)

Morphine is the drug of choice.

Dilaudid or meperidine (when morphine is conrraindicated or has failed to

relieve pain).

Sources: Dara from JC Ballantyne, D Borsook. Postoperative Pain. In D Borsook, AA

LeBel, 8 McPeek (cds), The Massachusetts General Hospital Handbook of Pain Man�

agemem. Boston: Little, Brown, 1996;254; CL White, RP Pokrupa, MH Chan. An

evaluation of rhe effectiveness of patient-conrrolled analgesia after spinal surgery. J

Neurosci Nurs 1998;30(4):225; and K Hoare, KH Sousa, L Person, et al. Comparing

three patient controlled analgesia methods. Medsurg Nurs 2000;9( I ):33.

884 AClJI'E CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table V I-6. Implanted Pump

Indicadon:

For patients with chronic pain, as a last resort before ablative surgery

Mechanism of action:

A pump, approximately the size of a hockey puck, is surgically implanted

into the subcutaneous tissue in the lower right or leh abdominal quadrant.

A catheter, which is placed in the epidural or intrathecal space, is tunneled

subcutaneously along the flank and connected to the pump.

Pumps are programmable or nonprogrammable and require refilling every 2-

12 wks.

Consideration:

Generally performed as all outpatient procedure, but patients may remain in

the hospital for several days for observation

General side effects:

Similar to systemic opioids (Table VI-3)

Medications: Generic (trade name)

Morphine or hydromorphone (Dilaudid)

Sources: Data from L Valentino, KY Pillay, J Walker, Managing chronic nonmalignant

pain with continuous intrathecal morphine. J Neurosci Nurs 1998;30(4):233; and M

York, JA Paice. Treatment of low back pain with intraspinal opioids delivered via

implanted pumps. Orrhop Nuts 1998; 17(3);61.

Physical Therapy Considerations for Pain Management

•

The physical therapist should be aware of the patient'S pain

medication schedule and the duration of the effectiveness of different pain medications when scheduling treatment sessions. (Pharmacist, nurse, physician, and medication teference books are good resources.)

• The physical therapist should also use a pillow, blanket, or his

or her hands to splint or suppOrt a painful area, such as an abdominal or thoracic incision or rib fractures when the patient coughs or performs functional mobility tasks, such as going from side-lying

to sitting at the edge of the bed.

• The physical therapist can also use a corset, binder, or brace to

support a painful area during intervention sessions that focus on

functional mobility.

•

The physical therapist should instruct the parient nOt to hold his

or her breath during mobility, because doing so increases pain.

AI'PENOIX VI: PAIN MANAGEMENT 885

References

J. Kittclberger KP, LeBel AA, Borsook D. Assessment of Pain. In D 80rsook, AA leBel, B McPeek (eds), The Massachusetts General Hospital Handbook of Pain Managemcnt. Boston: Litrle, Brown, 1996;26.

2. Cristo ph SD. Pain asscssment: the problem of pain in the critically ill

parient. Crir Care Nurs Clin N Am 1991;3(1):11-16.

3. Carey Sj, Turpin C, Smith j, ct al. Improving pain management in an

acute care setting; the Crawford Long Hospital of Emory University

experience. Orrhop Nurs 1997; 16(4):29.

4. Haggelil'. Pain management. J Neurosci Nurs 1999;31(4):251.

5. Turk DC, Okifuji A. Assessment of patients' reporting of pain: an integrared perspecrive. Lancer 1999;353(9166):'1784.

6. Acello B. Meeting jCAHO standards for pain control. Nursing

2000;30(3):52-54.

7. Nursing 2001 Drug Handbook (21st ed). Springhouse, PA: Springhouse

Corporarion, 200 I ;337-342.

8. Skidmore-Rorh L (ed). Mosby's Nursing Drug Reference. Sr. Louis:

Mosby, 200 I; 70, 135.

VII

Amputation

Jason D. Rand and Jaime C. Paz

Introduction

This appendix describes the most common types of lower- and uppetextremity amputations. The etiology of these amputations and the physical therapy management that is pertinent to the acute care setting

are described. Although the incidence of upper-extremity (VE) amputation is quite low compared to lower-extremity (LE) amputation, it is important that the acute care physical therapist have an understanding

of all types of ampurarions ro properly plan for the evaluation and

treatment of the patient.

Lower-Extremity Amputation

Peripheral vascular disease accounts for approximately 85-90% of LE

amputations in the developed world, with 25-50% of this percentage

resulting from diabetes mellitus.' Refer to Chapter 11 for more information on the complications of diabetes mellitus. Trauma is the second highesr cause of amputation in developed countries and is the primary

cause in developing parrs of the world.' Traumatic amputation often

results from environmental injury or land mines in various parts of the

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