Pain Management Case Study You have been assigned to the following patient (use
ID: 126799 • Letter: P
Question
Pain Management Case Study
You have been assigned to the following patient (use Tabers Medical Dictionary to look up unknown terminology):
Mr. Robert White, 73 years old, 2 days post-op for surgical decompression by laminectomy for cauda equine syndrome.
Mr. White rates his pain as a 10 and is very irritable, stating, “All this questioning is aggravating; you know I have pain – just give me what the doctor ordered as often as I can have it.”
1. Formulate an appropriate response to Mr. Whites’ statement
2. Discuss the factors that may be influencing his pain experience. You may be creative in identifying potential issues for a patient with surgery as extensive as this with an anticipated long recovery. Mr. White is not used to being incapacitated and dependent on others.
You review the medication orders for pain relief and see that Mr. White has been following:
Morphine sulfate 2 mg IV q4h prn for severe pain rated 7 or above.
Percocet 2 tabs orally q4h prn for moderate pain rated less than 7.
In the past 24 hours he has received Morphine q4h for pain consistently rated at a 10. He has refused an oral medication, stating, “They won’t work. Even the shot I get doesn’t last very long.
3. Using SBAR format, how would you address the problem with the surgeon?
Situation:
Background
Assessment
Recommendation:
The surgeon changes the pain medication orders for Mr. White, Stating, “Let’s get him pain free in the next few hours, he had a pretty extensive Laminectomy.”
The orders read as follows:
PCA:
Morphine 1 mg/ml
Loading dose: 4mg IV
Basal rate: none
Demand dose: 2 mg
Lockout interval: 15 minutes
Amitriptyline (Elavil) 50 mg orally bid, first dose now
Naloxone (Narcan) 2 mg IV prn, may repeat every 20 min
4. Describe the guidelines for general administration of analgesics in order to provide effective, individualized pain management.
5. What is PCA and what routes are used to administer it?
6. Explain each component of this PCA order.
7. What are the advantages of administering analgesia using PCA method?
8. Why is the Naloxene an important component of these medication orders?
9. Discuss the teaching that you will need to do with Mr. White to maximize effectiveness and safety of this method of pain control.
10. Mr. White complains of breakthrough pain (BTP). What does this mean and what can be done for the patient to provide pain relief?
11. Mr. White refuses the amitriptyline, stating, “I am not depressed – I am in pain!!” How should you respond to this statement?
12. Describe three interventions you can independently implement with Mr. White to enhance his pain relief.
Twenty – four hours later, Mr. White is much more comfortable and has used the PCA often to obtain pain relief. The shift report includes the following information: “Mr. White has taken maximum dosage of morphine for the shift. He does not seem to be having any side effects from the morphine; I just think hi pain can’t really be that bad – he just might like his drugs. I spoke to the surgical resident on call this morning and we may be trying a placebo in the PCA pump and encouraging more use of oral pain medication.”
13. You are uncomfortable with the intent to use a placebo drug in the PCA pump. List the pros and cons of the use of placebos in the treatment of pain. Decide if the order needs to be questioned and how you would present this to the surgical resident during morning rounds.
The surgeon discusses with Mr. White that the pain of this back injury and surgery may be an issue for at least a year, and he will need to schedule an appointment with the pain clinic upon discharge to facilitate full recovery. After this visit Mr. White tells you he is afraid he won’t be able to handle it for very long and worries about completing the needed physical rehabilitation when pain is such an issue for him.
12. What non-pharmacological pain relief measures can you discuss with Mr. White that may be ordered at the pain clinic?
13. Describe the difference between acute and chronic pain. Please give examples of each.
PCA:
Morphine 1 mg/ml
Loading dose: 4mg IV
Basal rate: none
Demand dose: 2 mg
Lockout interval: 15 minutes
Amitriptyline (Elavil) 50 mg orally bid, first dose now
Naloxone (Narcan) 2 mg IV prn, may repeat every 20 min
Explanation / Answer
1. when assessing the pain, the nurse must be sensitive to the client's level of discomfort. As he is in severe pain. assessment should be focused on affective, cognitive, and behavioral dimensions of the pain experience. Explain to him that the proper characteristic of the pain helps the nurse to the better understanding of his situation and to give proper interventions, therefore, relieve the pain is possible as soon as possible. And also use of pain scale chart helps the nurse to assess the pain quickly.
2. Factors influencing the pain:
Various factors that may affect the patterns of pain. The nurse has to assess the specific events or conditions that precipitate or aggravate pain. The nurse asks the client to describe activities that cause pain such as physical movements, turning to a certain way, coughing etc. Sometimes the pain radiates to the leg that causes painful response. Asking the patient if there is a particular time of the day the pain is worse, or if the pain is intermittent, constant, or a combination and plan intervention according to them. additionally, his age and fear also contribute to pain. Explain him about the number of vertebrate operated and invasiveness of the procedure and the pain will be severe for the initial 3-4 days postoperatively.
3. SBAR Format:
situation:
Hello surgeon, I am the Nurse taking care of Mr. Robert white. I am contacting you as because he is complaining of severe pain in the surgical site.
Background:
He admitted to the hospital and undergone surgical decompression by laminectomy, and he is on the 2nd postoperative day.
Assessment:
I found him lying on the bed with his hand on his back and telling that the pain is severe and unbearable even after the administration of the ordered pain medication. The surgical site looks good, the temperature is normal, but the blood pressure, heart rate, and the respirations are elevated.
Recommendation:
Can we give additional medication as the morphine is already administered and it doesn't work for him?.
4. Nursing Principles for Administering Analgesics:
Know the client previous response to analgesics:
Select the proper medication when more than one is ordered:
Know the accurate Dosage:
Assess the right time and interval for patients:
5. Patient-controlled Analgesia:
PCA is a safe method for postoperative pain management. It is a drug delivery system that allows the client to self-administer the opioids (morphine, hydromorphone, fentanyl) with minimal risk of overdose. The goal is to maintain the constant plasma level of analgesic so that the problem of prn dosing is avoided.
Systemic PCA usually involves Iv drug administration, but it can also be given subcutaneously. PCAs are portable infusion pump containing a chamber for a syringe that delivers a small preset dose of medication.Nurse must check the IV line and PCA dosage regularly to ensure proper functioning.
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