Jenna Year Woman Question & Answer Guide (With Explanation)

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Original Question

Jenna is a 27-year-old woman with a history of recent intravenous (IV) drug use is admitted to the observation unit for IV antibiotics after the incision and drainage of an antecubital abscess. She has a history of heroin dependence, she indicates that she followed a boyfriend to Florida for treatment and that they left the treatment center together and have been “treatment hopping.” She says her boyfriend was arrested two weeks ago and she has been exchanging sex acts for money and or heroin during this time. She receives IV morphine followed by IV hydromorphone for acute pain, as she had a significant debridement performed. After the procedure, she is demanding increasingly higher doses of IV opioids, and the observation unit team is becoming uneasy regarding the dose and frequency of opioid medications that she is receiving. The nursing staff raises concerns that she has tampered with her IV tubing and may be using her IV to “inject something.” 1. How do you Approach This Patient with Respect to her Pain and her Behavior? 2. What lab work should be evaluated in Jenna’s case? 3. Knowing Jenna’s recent history what other assessments/screening should be implemented? Case Progression: Jenna requests to go to a treatment center and the case manager finds her a bed at a local detox facility. However, they will not accept Jenna until the course of IV antibiotics has completed and she can be safely transitioned to oral antibiotics. A psychiatrist consults on Jenna’s case, the IV morphine and hydromorphone are discontinued and the IV is removed. The psychiatrist also institutes a COWS protocol with orders to start 4mg of Subutex SL once her COWS score reaches 13, then to administer the medication QID if B/P is above 90/60 and P is greater than 60 and the medication is not causing Sedation. After 8 hours without the IV opioids Jenn starts to complain of abdominal cramping, nausea with intermittent “dry heaves” you note that she is mildly diaphoretic with visible perspiration on her brow/forehead, while speaking with you Jenna is rubbing her elbows and knees and telling you “they ache” she appears somewhat restless and is wringing her hands while speaking with you. She also reports experiencing anxiety, she also asks that you turn the lights down in the room and reports the light is “hurting my eyes.” Jenna also has slight rhinorrhea and lacrimation. You assess her vitals they are P 82, B/P 132/78, T 98.1, R 18, O2 98% on RA. 4. Jenna tells you she has never taken Subutex or Suboxone and asks for some information on the medication she says, “Isn’t that the stuff that makes you go into withdrawal right away?” How should the nurse respond? 5. Jenna is asking if she can start taking the Subutex, based on your assessment and Jenna’s presentation is ready to start the mediation? 6. What could happen if Subutex is started too closely to the previously administered opioid medications? 7. If Jenna was not a candidate for Subutex or Suboxone what other medication could be used to manager her withdrawal symptoms? 8. If Jenna were pregnant how would management of her care change or be altered? 9. If Jenna declined referral to a treatment center, what types of services should she be referred to? 10. What are some of the common medical comorbid diagnoses seen with IV drug use?

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