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Pain Managment

A 45-year-old Portuguese female, Mrs. M, with a 3-year history of squamous cell cancer of the cervix presents with severe pain in the perineum. The patient lives at home with 6 children ranging in age from 5 to 18. She speaks little English.

Question 1: Background: The patient describes her pain as an 8 on the 0-10 scale, occurring constantly in the perineum, but is worsened when she voids. She is currently taking hydrocodone/acetaminophen, 2 tablets every 4 hours (12 tablets - 60 mg hydrocodone ≈ 60 mg morphine). She frequently awakens and takes the medications during the night. She states (with help of the translator) that the medicines relieve the pain by approximately 25%.

What additional information do you need for a complete pain assessment?
Identify at least two problems with the current pain regimen

Question 2: Examination of the perineum reveals inflamed excoriated tissue from the labia to the rectum; the patient appears to have excoriation from urine and a possible rectovaginal fistula.

What interventions or strategies would you consider using to address this problem and to enhance the patient's comfort?

Question 3: Later, the excoriation is cleared, and the pain is under control with 10 mg of morphine q 4 hours (or 6 doses/day). She uses approximately 3 additional doses of 10 mg of morphine for breakthrough pain per day. Thus, she is using approximately 9 doses/24 hours. Unfortunately she awakens at night in pain.

What might be the best analgesic regimen for this patient? She describes no adverse effects to the medications.

Question 4: The patient is being prepared for discharge to home hospice when she expresses some concern regarding her children care and particularly her 18 year old son, who has a history of substance abuse. She is afraid he might use her medications.

Assuming you are the person she confided in, describe briefly both what you would do, and what you would look to other team members or services for.

Question 5. How are the pain management issues in this case similar or different from those you encounter in your area of practice (i.e. related to direct patient care and/or system level issues?) Briefly add some new information or 'lesson learned' about pain management in your posting.

Solution Preview

Question 1: Background: The patient describes her pain as an 8 on the 0-10 scale, occurring constantly in the perineum, but is worsened when she voids. She is currently taking hydrocodone/acetaminophen, 2 tablets every 4 hours (12 tablets - 60 mg hydrocodone ≈ 60 mg morphine). She frequently awakens and takes the medications during the night. She states (with help of the translator) that the medicines relieve the pain by approximately 25%.

What additional information do you need for a complete pain assessment?
Pain management requires obtaining a full "PQRST" assessment.
1. P = Provocative events (what provokes the pain)
- What causes pain?
- What makes it better?
- Worse?

2. Q = Quality
- What does it feel like?
- Is it sharp?
- Dull?
- Stabbing?
- Burning?
- Crushing?

3. R = Radiates
- Where does the pain radiate?
- Is it in one place?
- Does it go anywhere else?
- Did it start elsewhere and now localized to one spot?

4, S = Severity
- How severe is the pain on a scale of 1 - 10?
- Younger children can use an illustrated pain scale such as the "Baker-Wong Pain Scale" which is fairly accurate and reproducible.

5. T = Time
- Time pain started?
- How long did it last?

Identify at least two problems with the current pain regimen?
1. There is no long-acting pain medication. With cancer patients it is totally appropriate to use a long-acting narcotic pain medication such as oxycontin or fentanyl and short-acting pain medications such as morphine sulfate, vicodin, or oxycodone. Because of the many side-effects of narcotic medications, I would advocate using non-opiates for milder breakthrough pain and the short-acting ...

Solution Summary

The use of Fentanyl patches and other long-acting opiates is discussed in relation to chronic pain and frequent exacerbations of acute pain. Medical as well as nursing interventions are discussed in terms of patient comfort and relief of suffering. A nod to hospice care to co-ordinate therapies is given.

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