Pain Case Study

Wrenda Fisher, a 35-year-old mother of two, visits the pain clinic of the regional medical center in her community. Wrenda is interviewed by a certified pain management nurse. Her chief complaint is recent onset back pain, which has limited her ability to care for her children.
During the nurse’s initial interview, Wrenda shares information about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management.

Which information, obtained by the nurse, is most likely to influence Wrenda’s perception of her pain?

Wrenda’s younger child is an infant, who feeds every three hours.

Feeding an infant every three hours interrupts sleep and results in fatigue. Fatigue often heightens the perception of pain and impairs coping skills.

To assess the quality of Wrenda’s pain, the nurse asks which question?
“What word best describes the pain you are experiencing?”

The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching or stabbing.

Which behavior that Wrenda exhibits supports her subjective report of acute pain?
Frequent guarding.

Guarding, or protecting the painful area, is a common behavioral response to pain.

After completing the pain assessment, the nurse develops a plan of care. The nurse identifies pain and anxiety as the priority problems.
To determine the etiology of Wrenda’s anxiety, what is the priority nursing intervention?
Continue the interview with the client.

Further assessment by the nurse is needed to determine the cause of the client’s anxiety.

What is the best goal for the nurse to include in the plan of care related to the problem statement of, “Acute pain related to strain on muscles with movement?”
Client reports pain of 1.0 on a 0-10 scale.

The goal is a broad statement that reflects a positive direction for the client’s problem, in this case, acute pain.

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The nurse considers interventions to include in the plan of care.
Before implementing any interventions, what action is most important for the nurse to take?
Discuss the plan of care with the client.

After considering interventions to implement, the nurse should review the plan of care with the client and seek client input.

The nurse consults with the clinic director, a pain management physician, who recommends the use of NSAIDs and alternating heat and cold applications, as well as back exercises. The nurse provides client teaching about these treatments. Wrenda tells the nurse that she will take the acetaminophen (Tylenol) that she already has at home.
What instruction should the nurse provide?
Tylenol does not have an antiinflammatory effect.

Acetominophen (Tylenol) is an effective analgesic and antipyretic, but does not have an antiinflammatory effect.

Wrenda decides to purchase buffered aspirin, and asks if this medication is also safe to give her four-year-old son, since he occasionally experiences viral infections and becomes feverish.

What information should the nurse include in responding to Wrenda?

All aspirin products should be avoided in children unless specifically prescribed.

Aspirin products seem to be associated with Reye Syndrome in children under the age of eighteen, and should be avoided unless specifically prescribed.

Wrenda tells the nurse that she has an electric heating pad at home that she used when she sprained her ankle.

How should the nurse respond?

“The dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation.”

Heat, whether dry or moist, promotes muscle relaxation and relief of pain caused by stiffness or spasm.

Wrenda states that she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible.

Which instruction is most important for the nurse to provide?

Excessive exposure to cold can damage the skin.

In response to the client’s statement, the nurse should educate the client on safe application of the cold pack. The other information can then be included in the instructions.

The nurse further explains that the cold should only be applied as prescribed, for twenty to thirty minutes at a time. The nurse tells Wrenda to remove the cold pack if her skin appears reddened before the prescribed time period has elapsed.

How should the nurse explain the mechanism which causes the skin to become reddened from prolonged exposure to cold?
Reflex vasodilation occurs following the initial vasoconstricting effects of cold.

Cold causes vasoconstriction. After prolonged exposure, reflex vasodilation occurs to restore adequate blood supply to the tissues.

Wrenda returns to the pain clinic in a week, and reports that her pain has worsened. The pain management physician recommends the use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit and prescribes a schedule IV opioid analgesic. Wrenda states to the nurse that she is familiar with the TENS Unit, calling it a biofeedback treatment.

What is the best response by the nurse?

“Pain relief is actually provided by delivering small electrical currents to the skin.”

TENS (transcutaneous electrical nerve stimulation) is considered a type of cutaneous stimulation, in which electrodes attached to a battery-operated unit stimulate the skin and underlying tissues near the area of localized pain.

The nurse explains the use of the TENS unit, and demonstrates how to apply it.

Which instruction should the nurse include?

Be sure to use conducting gel or conductor pads when applying the electrodes to the skin.

Conducting gel or conductor pads are applied before attaching the electrodes to the skin to promote safe, effective conduction of the electrical current and reduce the possibility of injury to the client.

In addition to the TENS Unit, Wrenda has a prescription for a Schedule IV analgesic. The nurse recognizes that specific protocols are followed when a client is receiving scheduled (controlled) medications.

What characteristic of scheduled drugs results in the need for these specific protocols?

There is a high potential for abuse.

Scheduled (controlled) medications are those mediations determined to have a high abuse potential, so specific controls are designated to reduce access to these medications.

The clinic stocks a small number of scheduled medications, so the nurse obtains a dose of the prescribed medication for Wrenda. At the end of the shift, the nurse counts the remaining medications with the oncoming nurse, and notes that the count is not accurate.

What action should the nurse implement?

Review prescriptions for any scheduled drugs with all nurses with access to the medications to determine why the count is inaccurate.

The nurse should first consult with all nurses with access to the medications to determine if a medication was given to a client without proper documentation. This action will frequently resolve the discrepancy. If it does not, the nurse-manager should be consulted for further action to be taken based on the policy of the agency.

Five days later Wrenda returns to the pain clinic reporting that the medication, TENS unit, and other care measures have not been successful in reducing her pain, and that, in fact, the pain seems to be worsening. Wrenda is admitted to the medical center via the Emergency Department for diagnostic tests and pain management.

While Wrenda is in the emergency department, the healthcare provider prescribes an intramuscular (IM) injection of 60 mg of ketorolac (Toradol), a nonsteroidal antiinflammatory agent. The medication comes in a pre-loaded syringe labeled “30 mg/ml.”

Since Wrenda is fairly thin, which site is the best choice for the injection?

Ventrogluteal.

Two mls of medication (the amount needed for this prescription) can safely be injected into the ventrogluteal site of most people, even a thin person such as this client.

The nurse will first place the palm of the hand on what anatomical spot to locate the injection site?
The greater trochanter.

The nurse places the palm of the hand over the greater trochanter of the client’s hip. The index finger is pointed toward the anterosuperior iliac spine, and the middle finger toward the iliac crest.

Once the needle is inserted in the skin, what intervention should the nurse perform?
Pull back on the syringe plunger and observe for blood.

Aspiration for blood reduces the risk of injecting the medication into a capillary. If blood is observed in the syringe, the needle should be withdrawn and a new dose of medication prepared.

After completing Wrenda’s admission to the medical unit, the staff nurse offers to guide Wrenda through a series of relaxation exercises. The nurse first plans to assist Wrenda with a guided imagery exercise. Wrenda states she would like to sit in the armchair in the room, and identifies the image of watching a mountain sunset as being relaxing to her.

To ensure that the exercise is most effective, what action should the nurse implement?

Include as many sensory images as possible in the experience.

As the client creates an image in her mind, awareness of pain diminishes. Promoting the use of all the senses heightens the client’s awareness of the image, further diminishing the awareness of pain.

Wrenda states the guided imagery exercise was helpful, and is interested in learning additional exercises. The nurse guides Wrenda in a progressive relaxation activity. After first establishing a regular breathing pattern, the nurse tells Wrenda to locate an area where she can feel muscle tension.

What instruction should the nurse provide next?

Tense the muscle fully.

Once the muscle tension is identified, the client first tenses the muscle fully, then relaxes the muscle completely. In time, the client will be able to relax the tense muscles without first tensing them more fully.Other forms of non-pharmacologic pain-relief interventions include acupressure, distraction, music, biofeedback, and self-hypnosis. All of these measures can assist in pain management and provide the client with a sense of self-control.

Further assessment and testing indicates that Wrenda has a back problem that requires surgery, which is scheduled for the next day. The nurse knows that a patient-controlled analgesia (PCA) pump will be prescribed as part of Wrenda’s postoperative care.

When is the best time to teach Wrenda about use of the PCA?

The day before the surgery is scheduled.

Teaching is best provided before surgery, while the client is awake and alert, and not experiencing acute postoperative pain.

Following surgery, Wrenda returns to the nursing unit with an intravenous infusion and patient-controlled analgesia (PCA) pump. The prescription states, “Morphine sulfate 0.5 mg/hour infusion with additional demand dose of 1 mg every six minutes. Hourly limit of 10 mg.”

Prior to giving report to the oncoming nurse, the nurse reviews Wrenda’s usage of the PCA pump and determines that she has received four demand doses of morphine each hour for the last four hours.

What is the total dosage of morphine that Wrenda has received in the last four hours?

18 mg.

Wrenda receives a continuous infusion of .5 mg/hour, for a total of 2 mg in 4 hours. Each demand dose is 1 mg. She self-administered 4 doses per hour, for a total of 4 mg/hour for each of four hours, for a total of 16 mg. This is added to the amount in the continuous infusion, for a final total dose of 18 mg of morphine received in the last four hours.

On the second postoperative day, the nurse observes that Wrenda is no longer self-administering demand doses of the morphine.

What is the most likely reason for this change?

She is receiving adequate pain control without the additional doses.

The most likely explanation for no longer self-administering a demand dose is that the client’s pain has decreased, or is controlled effectively by other measures.

The nurse assesses Wrenda’s pain and determines that the evaluation of her use of the PCA pump is correct. Wrenda’s pain has lessened, and she no longer needs any demand doses of morphine. The nurse consults with the surgeon and the morphine is discontinued. Wrenda’s new prescription is for Vicodin, a medication that combines hydrocodone with acetaminophen.

What is the rationale for combining these two ingredients?

The synergistic effect of the two medications improves pain control.

A synergistic effect is one in which two medications work together to provide an increased effect. Non-opioids, such as acetaminophen, are often used in combination with opioids so that a lower dose of the opioid can be used, while still providing effective analgesia.

Wrenda has also been receiving docusate sodium (Colace), a stool softener. She asks the nurse if this needs to be continued.

How should the nurse respond?

“You may need to continue the Colace, because most opioid analgesics, including Vicodin, cause constipation.”

All opioid analgesics, including both morphine and Vicodin, can be constipating, so the nurse should instruct the client to continue the stool softener until determining the change in bowel patterns that results from the change in the analgesic.

The nurse overhears two other nurses discussing Wrenda’s pain management in the hallway. One nurse states that Wrenda is exhibiting drug-seeking behavior and is probably already addicted to her pain medications.

What is the priority nursing intervention?

Arrange to continue the conversation in a more private location.

The nurse must act as a client advocate, protecting the client’s privacy. Discussing the client’s behavior in the hallway violates her right to privacy.

Wrenda’s nurse believes that the other nurses are incorrect in their understanding of Wrenda’s pain management. The nurse explains this to the other nurses, providing the nurses with accurate information about pain management and addiction.
Veracity.

Veracity refers to practicing truthfulness.

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