NUR2447 Clinical Concepts of Pain Case Study for Freds Pain 

Fred complains of constant burning pain across his lower back with some tingling. Sometimes the pain also goes down his right leg and feels like an electric shock. On assessment the pain score is rated at 4/10, which Fred says never reduces below that level.  Occasionally the pain becomes more severe, up to a level of 10/10 and he is unable to move. Fred states that his activity level has been reduced to the point where he has difficulty walking further than about 500 metres.

When asked about his mood, Fred explains that he feels depressed about his situation. The constant pain causes mood fluctuations from day to day. These range from suicidal to anger, and he has a constant sense of frustration. The mood swings impact on his relationships with his family, and he is unable to concentrate on activities.

Section 1:  Part A:  

Discuss your assessment of Fred’s pain 

Include:

• The initial general questions you would ask and observations about his behaviours
• Four different relevantassessment tools you might utilise to assess the various elements and reflect the impact of the pain for Fred
• Include your rationales for the assessment processes and tools used 

Part B: Type of Pain

What type of pain is Fred experiencing? Provide rationale/s for your answer.

Describe the physiological changes related to the pain that you might expect Fred to exhibit, providing rationales.

Section 2: Part A: Management Plan

Outline a plan of care that addresses Fred’s pain management. Your plan must reflect a patient centred approach (physical and psychosocial) to promote optimal outcomes. Include any therapies that may be appropriate for the type of pain he is experiencing. Do not include medications in this section.

Answer     

Section 1: Part A 

The assessment of Fred’s pain requires the systematic evaluation of the pattern of muscle tension and sprain that the patient might have experienced following the occurrence of injury after felling from ladder. The evaluation of the intensity of patient’s low back pain would require the utilization of visual analogue scale (by the nurse professional). The pain intensity would then be calculated in terms of “worst pain” or “no pain” conditions (Lalloo & Henry, 2011). The patient would require indicating the location of pain and explaining the pattern of the tingling sensation that he might have experienced following the onset of localized-pain. The quality, severity, duration and timing of pain require assessment by the nurse professional by directly questioning the patient. In the presented case study, the quality of patient’s pain attributes to its radiating status; however, the associated signs and symptoms include tingling sensation, restriction of trunk movement and psychological distress and depression. The nurse also needs to capture the associated behavioural and psychosocial symptoms experienced by Fred in the presented case study. The nurse professional requires evaluating the impact of patient’s pain on his somatic as well as psychosocial functional status (Song, Eaton, Gordon, Hoyle, & Doorenbos, 2015). The nurse professional requires evaluating the mood-fluctuations, frustration and suicidal tendencies experienced by the patient under the influence of his pain related functional disabilities. The assessment of the extent of coping mechanisms practiced by the patient for pain management would provide a clue regarding the level and intensity of his unpleasantness experienced under the influence of burning pain (Stutts, Hirsh, George, & Robinson, 2010). The assessment of patient’s posture, mobility, restlessness level, activities of daily living and cultural factors is highly warranted in the presented clinical scenario for the subjective evaluation of patient’s pain and associated manifestations. The identification of patient’s ethnicity and assessment of his beliefs and sociocultural factors is highly essential in the context of evaluating the level of his pain perception (Campbell & Edwards, 2012).

The utilization of brief pain inventory (BPI) warranted in relation to the effective validation of patient’s chronic pain pattern (Ferreira, Teixeira, Mendonza, & Cleeland , 2011). The nurse professional would evaluate the past medical history of patient while attempting to determine the previously occurred injuries, pathological conditions and associated pain patterns. The patient would be required to "shade" the location of his pain in a diagram and share self-rating of his pain in accordance with its severity. The BPI assessment requires the tracking of patient’s ongoing pain management medications and the modifying factors that might aggravate or reduce the pain intensity at any point of time. These modifying factors might include sleep pattern, walking, sitting, standing or other general activities. The nurse professional requires the utilization of Katz Basic Activities of Daily Living Scale for tracking the influence of patient’s chronic pain on his activities of daily living and personal care (CSAT, 2012). This assessment tool needs to capture the level of dependence experienced by the patient while undertaking bathing activity. Similarly, evaluation of activities like dressing, toileting, transferring, continence and feeding warranted for assessing the level of self-dependence of the patient under the influence of chronic pain. This tool objectively determines patient’s instrumental activities of daily living in the context of their relationship with the chronic-pain pattern. In the present clinical scenario, the utilization of McGill Pain Questionnaire (MPQ) by the nurse professional will provide an insight regarding the quality of patient’s multidimensional pain and associated psychosocial manifestations (Gauthier, et al., 2014). The MPQ intervention will undoubtedly assist the nurse professional in evaluating the pain dimensions and nature attributing to “throbbing, shooting, stabbing, sharp, cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring, radiating, sickening, fearful and punishing. Resultantly, the nurse professional will determine whether the pain is mild, discomforting, distressing, horrible or excruciating. The nurse professional might also utilize Chronic Pain Acceptance Questionnaire (CPAQ) with the objective of determining the influence of patient’s chronic pain on this overall quality of life and behavioural outcomes (CSAT, 2012). The nurse professional will assign multiple questions related to the present clinical scenario for evaluating the intensity of pain related adversities experienced by the patient in his day-to-day life. The patient will be required to register a response to the subjective questions in terms of numbers of 1-6 that will indicate the truthfulness of the questions’ statements in patient’s daily life. This questionnaire will provide a clue to the nurse professional regarding the patient priority of keeping the pain intensity under control while undertaking daily tasks. The CPAQ questionnaire will also assist in the analysis of the requirement of pain control strategies for the treated patient. This questionnaire will also highlight the perceptions of the patient and their direct impact on his chronic pain experience. This will also provide an insight regarding the influence of fears, apprehensions and worries of the patient on his quality of life and associated outcomes.

Part B (Type of Pain)

In the present clinical scenario, Fred is experiencing sciatica nerve pain and associated clinical manifestations. Sciatica is also known as a slipped disk, and in the current scenario the patient experienced the same following his accidental fall from the ladder (IQWiG, 2014). Sciatica is associated with low back (radiating) pain that extends from the lower back to any of the lower extremities. Sciatica pain is usually experienced by the people above 30 years of age and leads to the restriction of movements (IQWiG, 2014). Sciatica might be associated with numbness (or tingling) and high-intensity pain as well as impaired bladder function. Most of these clinical manifestations are evidently stated in Fred’s scenario, thereby confirming the diagnosis of sciatica.

The patient might undergo degenerative cascade under the influence of his sciatica nerve pain (Wheeler, 2016). He could experience radial sprains in the annular fibres under the influence of previous trauma and torsional loading, thereby leading to endplate segregation (Wheeler, 2016). These events will eventually lead to the compression of patient’s nerve root. Abnormal bone growth and facets-hypertrophy will lead to the establishment of foraminal-canal stenosis (Wheeler, 2016). The absence of an adequate peripheral blood supply to the peripheral system will lead to the development of chronic nociception and associated adverse outcomes (Wheeler, 2016).

Section 2 Part A (Pain Management)

Nurse professional needs to encourage the patient for undertaking best rest and changing position for the systematic elevation in lumbar flexion. The nurse also needs to teach various relaxation techniques to the patient for the effective reduction in his lumbar tension and associated outcomes. The administration of acupuncture analgesia by a healthcare professional might also assist in the systematic reduction in patient’s chronic low back pain the present scenario (Ji, et al., 2015). The nurse professional in coordination with the physiotherapist requires educating the patient for undertaking stretching exercises with the objective of reducing the intensity of his lumbar sprain and associated chronic low back pain (Kamioka, et al., 2011). The administration of massage therapy will also assist in reducing the intensity of patient’s muscle spasms following the systematic improvement of his vascular circulation. The nurse professional also needs to encourage the patient in terms of improving his mobility pattern while minimizing tension on the traumatized location (i.e. lower back). The implementation of shared decision-making is highly warranted with the objective of improving the patient’s compliance to the recommended treatment intervention (Hofstede, et al., 2013). The nurse professional needs to effectively collaborate with other healthcare professionals with the objective of minimizing treatment errors and improving the environmental conditions in the clinical setting for reciprocal enhancement in patient’s psychosocial outcomes. The configuration of an effective therapeutic relationship between the nurse professional and treated patient is highly necessary with the objective of improving his trust and confidence on the recommended treatment approaches. This is the best approach for identifying the treatment challenges of the patient while concomitantly understanding his cultural conventions, beliefs, ideology and pain perception (Kourkouta & Papathanasiou, 2014). The nurse professional needs to administer cognitive behavioural therapy (CBT) for effectively influencing the emotion, cognition and behaviour of the treated patient with the objective of decreasing the intensity of his chronic pain (Roditi & Roinson, 2011). CBT approach assists in the elevation of problem solving and coping approaches in patient while restructuring his cognitive capacity for obtaining the behavioural outcomes. Similarly, the administration of acceptance-based interventions assist in the improvement in psychological flexibility for improving his self-perception and quality of life for the systematic mitigation of chronic pain pattern. The patient also needs to undertake relaxation training, diaphragmatic breathing, autogenic training and visualization imagery methods for reducing the intensity of somatic and psychosocial complications experienced under the influence of his sciatica pain. The deep breathing exercises as well as muscle relaxation interventions help in releasing the muscle tension and enhancement in oxygen intake. This leads to the systematic decrease in pain-related perceptions in the treated patient (Roditi & Roinson, 2011). The administration of holistic and person-centred individualized approaches also assist in the dietary management of the patient in accordance with his nutritional requirements to establish the pattern of weight management warranted for controlling the intensity of patient’s chronic back pain and associated with adverse outcome.

References

Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain Management, 2(3), 219-230. doi:10.2217/pmt.12.7

CSAT. (2012). Assessment Tools and Resources. In Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. USA: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK92056/

Ferreira , K. A., Teixeira , M. J., Mendonza , T. R., & Cleeland , C. S. (2011). Validation of brief pain inventory to Brazilian patients with pain. Support Care in Cancer, 505-511. doi:10.1007/s00520-010-0844-7

Gauthier , L. R., Young, A., Dworkin, R. H., Rodin, G., Zimmermann, C., Warr, D., . . . Gagliese , L. (2014). Validation of the short-form McGill pain questionnaire-2 in younger and older people with cancer pain. The Journal of Pain, 756-770. doi:10.1016/j.jpain.2014.04.004

Hofstede, S. N., Mheen, P. J., Wentink, M. M., Stiggelbout, A. M., Carmen , L. A., Lankamp, V., . . . Bodegom-Vos, L. (2013). Barriers and facilitators to implement shared decision making in multidisciplinary sciatica care: a qualitative study. Implementation Science. doi:10.1186/1748-5908-8-95

IQWiG. (2014, October 9). Slipped disk: Overview. Retrieved from NCBI: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072656/

Ji, M., Wang, X., Chen, M., Shen, Y., Zhang, X., & Yang, J. (2015). The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evidenced-Based Complementary and Alternative Medicine. doi:10.1155/2015/192808

Kamioka, H., Okuizumi, H., Okada, S., Takahashi, R., Handa, S., Kitayuguchi, J., & Mutoh, Y. (2011). Effectiveness of intervention for low back pain in female caregivers in nursing homes: a pilot trial based on multicenter randomization. Environmental Health and Preventive Medicine, 16(2), 97-105. doi:10.1007/s12199-010-0170-1

Kourkouta, L., & Papathanasiou, I. V. (2014). Communication in Nursing Practice. Materia Sociomedica, 26(1), 65-67. doi:10.5455/msm.2014.26.65-67

Lalloo, C., & Henry, J. L. (2011). Evaluation of the Iconic Pain Assessment Tool by a heterogeneous group of people in pain. Pain Research and Management, 16(1), 13-18. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052402/

Roditi, D., & Roinson, M. E. (2011). The role of psychological interventions in the management of patients with chronic pain. Psyshology Research and Behaviour Management, 41-49. doi:10.2147/PRBM.S15375

Song, W., Eaton, L. H., Gordon, D. B., Hoyle, C., & Doorenbos, A. Z. (2015). Evaluation of Evidence-Based Nursing Pain Management Practice. Pain Management Nursing, 16(4), 456-463. doi:10.1016/j.pmn.2014.09.001

Stutts, L. A., Hirsh, A. T., George, S. Z., & Robinson, M. E. (2010). Investigating patient characteristics on pain assessment using virtual human technology. European Journal of Pain, 14(10), 1040-1045. doi:10.1016/j.ejpain.2010.04.003

Wheeler, A. H. (2016, Feb 03). Low Back Pain and Sciatica. Retrieved from https://emedicine.medscape.com/article/1144130-overview#a2