Module 2: Pain Management

Case Studies
Please Note: All case studies are intended to be generic so that substitutions can be made, according to your own clinical roles. For example, if a case study mentions a patient with a medical condition, you can substitute the disease cancer, so that it would be appropriate for oncology nurse, or visa-versa. You may also insert APRN for nurse practitioners, clinical nurse specialists, etc. In addition, hospice/palliative care nurses can review each case study, as though they were consulting on each of these case studies. Feel free to adjust the case studies so they are relevant to your participant’s clinical needs.

Module 2

Case Study #1 and Discussion

Mrs. M: Pain Management and Culture

A 45-year-old Hispanic 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.

  1. How might the nurse obtain a thorough pain assessment? What aspects of the pain assessment should be included?

The use of a skilled medical translator is imperative, not one who is a family member or a member of the patient's social circle. This is especially important when confronting pain and a potentially embarrassing disorder involving the genitalia. Also, if using family members, they may translate liberally, inserting their own hopes or beliefs, (e.g., mom doesn't have pain) rather than the patient's. A medical translator will understand the terminology and will not withhold information to protect the patient. Furthermore, asking the family to translate adds to their responsibilities, another source of stress. The pain assessment should include the location, intensity, quality, and pattern of the pain. Aggravating and alleviating factors should also be assessed.

  1. 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%.

The pain is severe, even with hydrocodone and acetaminophen. Furthermore, she awakens in pain. Another potential problem is her intake of acetaminophen (this combination contains 500 mg per tablet - the maximum dose is 2000 mg/day or 4 tablets). At 12 tablets she is at risk for overdose of acetaminophen potentially leading to liver toxicity. Physical assessment is indicated.

  1. Examination of the perineum reveals inflamed excoriated tissue from the labia to the rectum. Additionally, stool appears to extrude from the vagina.

The patient appears to have excoriation from urine and a possible rectovaginal fistula. Treatment includes frequent cleansing of and protection of the skin. A tampon or catheter with balloon may be inserted in the vagina to block the fistula. The nurse must also consider other interventions to provide odor control, if this is a problem. Strategies might include environmental techniques or, in some cases, antibiotics if infection is present. The current opioid regimen is insufficient. A short acting opioid, such as morphine, may be started every 4 hours around the clock with additional doses available for breakthrough pain on a prn basis (every hour as needed-since this is the peak time to effect for most oral opioids-longer intervals means that the patient will be in pain.) Starting with a short acting opioid will help determine the future long-acting opioid dose. In this case, liquid morphine will be used to assist with titration and ease of administration. A laxative/softener should be used to prevent constipation and strategies to treat nausea should it occur.

  1. 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.

Nine doses of 10 mg of morphine equals 90 mg/24 hours. Because the patient is awakening she would benefit from a conversion to 45 mg (one 30 mg tablet and one 15 mg tablet) po long-acting morphine every 12 hours with short acting morphine 10 mg for breakthrough pain every one hour prn (10-20% of the 24 hour dose).

  1. The patient is being prepared for discharge to hospice at home when she expresses some concern regarding her son, who has a history of substance abuse. She is afraid he might use her medications.

The nurse might initiate a meeting with the physician, social worker, the son and the patient. In a non-threatening manner, the son must be made aware of the consequences of his mother not having the medication she requires. Engage the home care or home hospice nurse in these conversations so that the opioid use can be monitored carefully and diversion immediately identified.

  1. Prior to her discharge to home hospice, the patient admits to the nurse that she is very afraid to die. When questioned further, she describes concerns regarding her children's care as well as her own guilt for having a child prior to marriage.

The nurse might explore more deeply the concerns regarding death. Does the patient fear the unknown, or is she primarily worried about her children's care after her death? Is there additional work that might help the patient prepare for her death, such as letting those close to her know that she loves them, saying goodbye, seeking apologies, and forgiving those who might have wronged her? The social worker may assist with plans regarding the children's long-term care. Letters to the children at milestones in their lives may be composed for future reading. Traditions may be passed on, such as recipes or activities around certain holidays. A psychologist or chaplain may help the patient address unresolved guilt related to having a child prior to marriage. The interdisciplinary team can work to assist family members and the children with strategies to address their concerns as well as those of the patient.

  1. The patient is well cared for by her family at home. Her condition deteriorates and she becomes weaker, unable to swallow. She does not have a venous access device and her home hospice team decides that subcutaneous morphine might be useful. Her current analgesic regimen is 100 mg long-acting morphine every 12 hours with 3 doses of 30 mg immediate-release morphine each day. What would be the appropriate subcutaneous dose?

The patient's 24 hour oral morphine dose is 290 mg. To obtain the parenteral equivalents, divide by 3. This equals 96.7 mg. Then divide by 24 to obtain the hourly rate. The patient's hourly rate would be 4.0 mg of morphine per hour continuous subcutaneous infusion. Remember to reassess after making changes in drug, dose, or route of administration, and with any new complaint of pain. The patient tolerated this dose well, achieving excellent relief. She died a few days later, comfortably in her home.

Module 2

Case Study #2

Mr. Jones: Calculating Equianalgesic Doses

Mr. Jones is taking two Percocet® (oxycodone 5mg/acetaminophine 325mg) tablets every four hours for bone pain related to metastatic cancer. His pain is a constant 6 on a 0 to 10 scale. Since his pain goal is 3, you decide to call his physician.

Discussion Questions:

  1. The doctor suggests increasing the Percocet® to two tablets q3h ATC. How would you respond to this order?
  1. A more appropriate approach would be to start the patient on a different opioid. Calculate the equianalgesic dose and schedule for the following options:
  1. oral MS - immediate release
  2. oral MS Contin® or Oramorph® SR
  3. oral hydromorphone (Dilaudid®)
  4. oxycodone (Roxicodone®)
  5. fentanyl patch (Duragesic®)
  1. Suggest new analgesic orders for this patient. Take into consideration that orders should include both scheduled and breakthrough pain medications and other drugs that might be especially effective for a patient with bone pain.

Faculty Guide:

The goal of this case is to insure that the participants understand:

  • dose ceiling of acetaminophen
  • the role of NSAIDs in bone pain
  • how to do analgesic conversions
  • concepts of titration

Specific points for each question:

  1. There are two major issues with the order:
  1. The dose limit of acetaminophen is 2000 mg. At his current dose of two Percocet® q4h, he is taking 650 mg per dose x 6 doses, or 3900 mg per day. Therefore, increasing the Percocet® is not a safe option. An option is use of oxycodone which is available without acetaminophen.
  2. The patient is likely to benefit from the addition of an NSAID to his regimen.
  1. To calculate the oral dose, begin by noting that 2 Percocet® q4h=12 tabs per 24 hours=60 mg oxycodone per 24 hours.
  1. MSIR: Look up the approximate equivalent dosages of oxycodone and morphine in an equianalgesic table. Use this dosage ratio to calculate the dose of morphine equivalent to 60 mg oxycodone. This is an easy one to start with since these drugs are equipotent.

30 mg PO oxycodone = 30 mg PO morphine

60 mg PO oxycodone X mg PO morphine

Solve for X (cross multiply)

60 x 30 = 30X

X = 1800/30

X = 60 mg morphine/24 hours

Since the duration of MSIR is 4 hours, you would divide the 24 hours dose into 6 doses, or:

10 MSIR q 4 hours

  1. MS Contin® or Oramorph® SR: Follow the same process as above, except the duration of action is 12 hours and you would divide the 24 hour dose into 2 doses, or:

30 mg MS Contin® or Oramorph® SR q 12 hours

  1. hydromorphone: 30 mg oral oxycodone is equivalent to 7.5 mg oral hydromorphone

30 mg PO oxycodone = 7.5 mg PO hydromorphone

60 mg PO oxycodone X mg PO hydromorphone

Cross multiply as above:

X = 15 mg PO hydromorphone/24 hours.

Since the duration of hydromorphone is 4 hours, you would divide the 24 hours dose into 6 doses, or:

2.5 mg hydromorphone q 4 hours

Since Dilaudid® does not come in 2.5 mg tablets, it is reasonable to give 3 mg per dose instead.

  1. The package insert suggests that 25 μg/h transdermal fentanyl is equivalent to 45-134 mg oral MS/24 hours. Therefore the calculated morphine dose of 60 mg/24 hours would suggest an equianalgesic dose of fentanyl would be 25 μg/h q 72 hours. However, most clinicians would double this dose and use a 50 μg/h patch.
  1. Any set of analgesic orders should include the following concepts:
  1. Since the pain is 6/10, it is reasonable to increase the baseline dose by 50%.
  1. Short acting breakthrough medications equivalent to 50 to 100% of the baseline dose should be available.
  1. Some possible combinations:
  • MS Contin® or Oramorph® SR 45 mg q 12 hours, with 7.5 to 15 mg MSIR (use liquid q2-4 hours PRN), (would be OK to use the Percocet® first)
  • MSIR 15 mg q 4 hours, with 7.5 to 15 mg MSIR q2-4 hours PRN
  • hydromorphone 4 mg q4 hours PRN, with 2-4 mg hydromorphone q2-4 hours PRN
  • change the Percocet® to plain oxycodone 15 mg q4 hours, with 5-15 mg q2-4 hours PRN or add oxycodone 5 mg to each dose Percocet®.

Note: An NSAID, such as ibuprofen 600 mg or naproxen 500 mg BID should be added to any of these regimens.

Source:

Gordon, D., Stevenson, K.K., & Dahl, J. (1996). Home care case studies and faculty guide. Madison,

WI: Wisconsin Cancer Pain Initiatives. The complete set of cases can be obtained from the City of Hope Pain and Palliative Care Resource Center: , Retrieved December 16, 2011.

Module 2

Case Study #3

Madeline: Pain and Suffering

Madeline S. is a 66-year-old German woman admitted to a home care agency for care related to end-stage cardiac disease and renal failure. She has complained of chronic generalized chest pain, frequent cramps in her legs, and worsening arthritis pain related to her immobility. The home care nurse has been in contact with Madeline's physician almost daily for the past week and her analgesics have been steadily increased with little pain relief but an increase in nausea, constipation and sedation. The nurse feels frustrated as she observes Madeline declining rapidly with worsening depression, withdrawal and weeping. Madeline's neighbor has noticed that her lights are left on 24 hours a day and the nurse has noticed that Madeline has several rosaries and prayer books now at her bedside. Madeline has refused referral to hospice but the home care nurse has requested a team conference with assistance from the local hospice affiliated with the home care agency.

Discussion Questions:

  1. What disciplines should be included in the case conference?
  1. What additional assessment might the nurse obtain?
  1. How can this patient's pain and suffering best be treated?

Module 2

Case Study #4

Diana: Assessment/Barriers

Diana is a 40-year-old woman with a history of breast cancer. Five years ago she underwent a lumpectomy with radiation, following by chemotherapy. One year ago she developed bone metastases in the lumbar spine and right clavicle, documented by bone scan. She is currently being treated with another regimen of chemotherapy that includes paclitaxol (Taxol®). She is returning to the oncology clinic for chemotherapy administration. The nurse is concerned about Diana's comfort and conducts a pain assessment.

History:

Diana at first reports no problems, but later admits that she developed very minor low back pain. She attributes this to increased activity as she has been remodeling her home. When the pain does not abate with over the counter medications (e.g., ibuprofen, acetaminophen) and non-pharmacological techniques (e.g., massage, heat), she will occasionally take a Vicoden® (5 mg hydrocodone/500 mg acetaminophen). When questioned why she does not take more, she states "I don't like taking narcotics" and "My husband doesn't like when I take the pills."

Diana describes her pain as 2 or 3/0-10, located in her low back. The pain is aching and throbbing. When pressed to report other pain sites, she admits she has some shoulder pain, but rates it as a 1 currently. She also describes tingling in the feet bilaterally, extending to the ankles. "It is not pain really, just burning".

Other history: Diana is married, lives with her husband and 2 teenage sons in a suburban home. She works as a receptionist in a dentist's office.

Physical Assessment:

During the history, Diana's posture indicated that she was not comfortable. When Diana gets up from her chair to get onto the exam table, the nurse notes that she does so with difficulty. Palpation of the lower lumbar spine (L3-4) produces pain. Diana denies pain when the clavicle is palpated. Straight leg raises of less than 30 degrees increase the low back pain significantly. Neurological examination reveals weakness in lower extremities, with R > L. Sensory loss is noted bilaterally in the toes and feet to the ankles. Reflexes are intact.

Discussion Questions:

  1. What are the barriers to pain relief in this case?
  1. What types of pain is Diana experiencing and what might be the underlying etiologies? What other questions should the nurse ask this patient?
  1. Devise a plan of care for this patient.

Module 2

Case Study #5 and Discussion

Joshua: Importance of Interdisciplinary Care

Case:

Joshua is an 18-year-old African American boy with an advanced sarcoma initially affecting the right leg but now with extensive metastases, including lung. He complains of severe pain in the leg. The patient lies in a fetal position with the lights off. Family members visit rarely and the patient is reluctant to return home. He is cachectic and clearly is approaching the end of life. He requests intravenous hydromorphone, as this has worked well in past hospitalizations. When the nurses attempt to administer the medication, the patient wants it injected quickly and in a port closest to the insertion site. The nurse expresses concern that the patient is addicted or manipulative, wanting to stay in the hospital to get intravenous medicines. As an advanced practice registered nurse (APRN), what assessment and interventions are warranted?

Discussion:

Extensive pain assessment is warranted, including the location, quality, intensity, medication history, and other factors. This type of pain might include nociceptive and neuropathic aspects, necessitating treatment with multiple medications. An assessment of the patient’s emotional state is also needed, including the family’s role and function. Especially important is to determine whether the patient is depressed, as well as his beliefs about his disease. A team approach is indicated given the complex bio-psychosocial-spiritual dimensions of this situation so the APRN calls a special team meeting to discuss. And the APRN may help the nurse to discuss her feelings and concerns regarding the patient’s request for more rapid injection of the drug.

Case continued:

Joshua’s response to the opioid indicates that the chosen dose reduces pain somewhat (he cannot articulate a percentage of relief but states that the pain is a 6-8 after the injection, down from an 8-10) without significant sedation. A higher dose produces some sedation, but improved relief. In questioning Joshua, he is not upset by the sedation. Corticosteroids are added to reduce inflammation. Besides physical assessment/interventions, what other psychosocial assessments and interventions would be appropriate? What other team members need to be involved?