CPSSIGNI2010

PAINSCENARIOSINTEACHING

GUIDELINEFORUSEofScenarios

AttachedarefourpatientscenariomodelsthatevolvedfromaSIGNursingIssuesworkshopattheCPS
2009meeting,withfurthervalidationfromtheSIGEducationCommitteemembersandexternalpain
experts.ACPSsurveyindicatedmemberswantedhelpwithpatientcases/scenariosforteaching.Thisis
abeginningandtheattachedpreliminaryversionsrelatetopatientswithdiabeticneuropathy,post
traumapain,sicklecelldiseaseandneonatalpain.Thepurposeisnottodevelopadefinitiveplanbutto
includekeyassessmentandmanagementconsiderationswithsomerelatedquestionstoguidethe
educator.Thelevelofcomplexitywillvaryaccordingtothestudent'slevel/need.Aninterprofessional
lensisimportantandhasbeenpartofthedevelopmentofthesescenarios.

1.PATIENTSCENARIO:SurgeryFollowingTrauma
Who:
Michaelisa38yearoldmalewhoisonasurgicalward48hoursaftersurgeryforafracturedrightfemur
anddebridementoffacialabrasionsfollowingamotorcycleaccident.
ChiefConcern:
severe,sharppainonmovementaroundincisioninrightlegNRS9/10,atrest2/10
constantburningpaininhisrightwristNRS7/10onmovement.
facialandrighttorsocontusions/abrasionspainfulwhenmovesNRS4/10.
somepostoperativefacialpainbutsaysitisnotasbothersomeNRS3/10.
HPI(HistoryofPresentIllness):
motorcycleaccident48hoursago;drivingundertheinfluenceofalcohol.
PACUpaincontrolinadequateNRS10/10;PCAmorphineinitiatedtoachievelevelsofNRS4
6/10
PHH(PastHealthHistory):
appendectomyage15,fracturedclavicleage19.
laminectomy(L45)1yearagoduetoaworkrelatedinjury.
PastMedications:
oxycodoneSR80mgq8hpox1yearforchronicbackpain(postbackinjury/surgery)
oxycodoneIR5mgwithacetaminophen325mg12poq4hPRN.
acetaminophen500mgq6Hpoforoccasionalheadache
ranitidineinlast2weeksforgastricdiscomfort
CurrentMedications(48hours):
oxycodoneSR100mgPOq8h
acetaminophen500mgPOq6hATC
gabapentin200POmgq8h
oxycodoneIR40mgPOq4hPRN(3dosesinpast24h)
Ibuprofen400mgPOq6hATC
lorazepam(Ativan)1mgslPRNq8h(anxiety)oroxazepam(Serax)30mgPOhsPRN(sleep)
PhysicalExam:
BP130/82P88regularR28T38.2
Height188cm,weight118kg
Smalllumpoveroldclaviclefracture,smallincisionscaratL5
Incisionoversurgicalsitehealingwellwithslightredness.
CPSSIGNI2010
Wristdoesnotappeardeformed,canrotateslowlywithpain
Handhasexquisitesensitivityoverdorsolateralaspectsandkeepsbedclothesoffit;alsohas
steadyburningandsomeshocklikepainNRS8/10
SocialHistory:
Canadianborn,graduatedgrade12highschool
worksonanassemblylineinmanufacturingcompany;isphysicallydemandingbutmanagingto
workmostdaysonlongactingopioid;hasgoodhealthcoverageandlongtermdisability
insurance
smokes1pk/dayx18years,occasionalmarijuanause;drinksbeer~24/week.
recentlylostalongtimehighschoolfriendtocancer.
marriedx12yearstowifeDenise(34years),worksfulltimeatthelocalBank.
twochildrenaged7and9(Todd&Alison)arehealthy;stayingwiththeirgrandmotherwholives
veryclosetotheirschool.
Michaelswifeconfidedthatsheisconcernedaboutherhusbandsrecentincreaseindrinking
alcoholsincehisfrienddied.
FamilyHistory
Michaelsmother(57years)isarecentlydiagnoseddiabetic,haschronicdepression.
Michaelsfather(59years)andhealthy
Twobrothersliveincity(aged40&36),oldestbrotherrecentlydiagnosedwithdiabetes
AssessmentConclusions
1.WhatareMichaelsmaincareissues/diagnoses?
2.Whatarethepatientpriorities?

Plan:Involveteam(possibilitiesincludebutarenotexclusive:medicine,nursing,occupationaltherapy,
pharmacy,physicaltherapy,psychology,socialwork)
1.assessmentregrievinganddruguse(medicineincludingpsychiatry,psychology,clergy,nursing,social
work)
2.painmanagement(medicine,nursing,physicaltherapy,psychology)
assessadequacyandpainmanagementincludingpreopbaselineandadditionalneeds
CouldIncreasegabapentintoeffectorAE(max3600mg/24h,AEdizziness,nausea,fatigue,
peripheraledema),ifAEcouldtrypregabalin(150mgBID)
InvolvePTformobilityprogram
Involvepsychology,nursingforselfmanagementprogram
3.dietmodification&assessfordiabetes(nutrition,nursing,socialwork)
4.home/workassessment(occupationaltherapy,socialwork,physicaltherapy)
5.familysupport(socialwork,nursing,psychology)

Somequestionstoconsiderinrelatedtomechanismsandrationalesindevelopingamanagementplan

1.Howdoyouapproachassessmentwithapatientexperiencingpaininmultiplesites?
2.WhattypesofpainisMichaellikelyexperiencing?mechanisms?Implications?
3.WouldyoubeconcernedaboutMichaelbeingprescribedasleepingpill?
3.Whatpostoperativepainmanagementplanwouldyouputinplacebeforesurgeryandwhy?
4.Whatredflagswouldyouconsiderfromthepatientshistory?Potentialscreeningtools?
5.Whatisthepurposeofmultimodalpainmanagementandrelatedrationales.
CPSSIGNI2010

2.PATIENTSCENARIO:DiabeticNeuropathy

Who:
Joseisa63yearoldmalediagnosedwithpainfuldiabeticneuropathyinhisfeet,obesity,CAD(coronary
arterydisease)andPVD(peripheralvasculardisease).

ChiefConcern:
describespaininbothfeetthatispresentdayandnightbutworseatnight
hassteady,burningconstantpaininhistoesandthebottomofhisfeetNRS8/10
haselectricshockpainaboutevery2hoursinfeetanduphislegsNRS10/10
feetaresensitivetolighttouchsuchasbedclothes
feetfeelnumbandfeelslikewalkingwithsolesonfeet,hasparesthesias

Medications:
Takes68acetaminophenwith30mgcodeine/dayswithlittlerelief
amitriptyline25mghs
gabapentin100mgTID

HistoryofIllness:
diagnosedwithTypeIIdiabetesmellitus20yearsagoandCADayearago.
hasbeenonoraldiabeticagentsfor10yearsanddietisnotalwayswellcontrolled
somekidneyimpairmentandretinopathyrelatedtohisdiabetes
is~40lbsoverweight,hasahistoryofhypertension,elevatedcholesterolandoccasionalbouts
ofatrialfibrillation.
hadCABGbypass5yearsago
Haspaininbothcalfmuscleswhenwalksabout100metres;relievedwhenhestopsandrests
describesasedentarylifestyleandfrequenttobaccoandalcoholuse.
sleepingandwalkingareaproblembecauseofpainandheisdepressed
duetoworkaccident20yearsagohedevelopedchronicbackpainthathemanageswith
heatingpadandacetaminophen.
statesheisallergictomorphinesulfate.

PhysicalExam:
BP170/100botharms,P85regular,T37C,chestclear
nopulsesinfeet,thickenednails,feetcool
lossofsensationinfeetuptomidcalftotouch,pinprick,cold
bothanklereflexesabsent,kneejerks1+
hasextremesensitivityinfeetwhichhesaysisaprobleminbedatnightbecauseofsheets
hasproblemswithconstipationandnausea
HbA
1C
10

SocialHistory:
borninPortugalandcametoCanadawhen15yearsold,speaksEnglishfairlywell.
hasbeenmarriedfor35yearstoMaria;theyhave2childrennotathome.
workedintrades/factorybutduetohisbackpainandlatterlyproblemswithlegshasnot
workedforthelastyear,hassmalldisabilitypension
CPSSIGNI2010
Mariais58yearsandworksatZellersfulltime,isthemainwageearner;wifeisawareofhis
needtowatchhisweightbutmealsaretheonlythingheenjoysrightnow,isworriedabouthim
livein2storysemidetachedhousewithnomortgage;bathroomisonthe2
nd
floorsohe
mostlyspendsdaysonmainfloorandusesaurinal
21yearolddaughterisinher3
rd
yearatTrentUniversity;callsorcomeshomeoftenandis
concernedaboutaddictiontopainmedications
sonlivesinNorthBay,worksinconstructionanddoesnotseethemoften.
Joses80yearoldmotherliveswiththem,isverydependentandrefusestoconsideran
assistedlivingfacilityorretirementhome,believesGodwillhelpherson.
smokesonepack/day,reducedfrom2packspreviously.drinks2glassesofwinewithdinner.
FamilyHistory
fatherdiedofaheartattackat61years
motheris80yearswithdiabetes(takespills)andarthritis
youngerbrotherinPortugalalsohasdiabetesandheartproblem

Assessmentconclusions
1.WhatareJosesmainhealthissues/diagnoses?
2.Whatarethepatientpriorities?

Plan:Involveteam(possibilitiesincludebutarenotexclusive:medicine,nursing,occupationaltherapy,
pharmacy,physicaltherapy,psychology,socialwork)
1.diabeticcontrolandmonitoring(endocrine,nursing)
2.painmanagement(medicine,nursing,physicaltherapy,psychology)
stopamitriptylinewhy?
CouldIncreasegabapentintoeffectorAE(max3600mg/24h,AEdizziness,nausea,fatigue,
peripheraledema),ifAEcouldtrypregabalin(150mgBID)
Confirmifmorphineallergyoradverseeffect,Ifyesusehydromorphone,tramadol
InvolvePTforexerciseprogram
Involvepsychology,nursingforselfmanagementprogram
3.dietmodification.nicotinehabit(nutrition,nursing,socialwork)
4.moodassessment(medicine,nursing,psychology,socialwork)
4.homeassessment(occupationaltherapy,socialwork,physicaltherapy)
5.familysupport(socialwork,nursing,psychology)

Somequestionstoconsiderinrelatedtomechanismsandrationalesindevelopingamanagementplan
1,Whatevidenceisthereforadiagnosisofpainfuldiabeticneuropathy?
2.Whataretheparametersofgooddiabeticcontrol?
3.Whyishispainmostlyinthefeet?Whatisextremesensitivityoftheskincalledandwhydoesitoccur
withneuropathicpain?
4.Howdoesthepainincalfmusclesdifferfrompaininhisfeetandwhatisthiscalled?
4.Whatrationalesneedtobeconsideredforpossibleapproaches?

CPSSIGNI2010

3.PATIENTSCENARIO:SickleCellDisease

Who:
Omarisa12yearoldboydiagnosedwithSickleCellDiseasebroughttotheemergencyroombyhis
motherwithvasoocclusivecrisis.

ChiefConcern:
Increasingpainoverthelastweekinback,chestandlowerlegsbilaterally
Ratespainas10/10usingnumericalratingscale
Paindescribedasconstant,burning,aching
Thismorningrefusingtoweightbear,c/odifficultybreathing

Medications:

ibuprofen200mgq6hrsprnathome
hydroxyurea(1000mgperday)
morphineinfusionforpainmanagementonprevioushospitaladmissionsstatesnoteffective,
++sideeffects(nausea,pruritis,drowsiness)

HistoryofIllness:

Preterminfant;experiencedmultiplepainfulproceduresasneonate
FirstVOCattheageof5yearsandfollowedbyhematology/oncologyteambutmanymissed
followupappointments
Increasedfrequencyofhospitalization(every2to3monthsinlastyear)

PhysicalExam:

Weight48kg
BP100/60,HR100,RR22,Temp37.1orally
Chestdecreasedairentrytobases;O2sat94%onroomair
Kneesinflamedbilaterally,refusingpalpationbecauseofpain

Social/FamilyHistory:

Omarliveswithhismother,fatherand4yearoldsisterinwestToronto
ImmigratedtoTorontofromSomaliaattheageof5
Fatheronlongtermdisabilityduetochronicbackpainsecondarytoworkplaceinjury;
motherisathome
Omarisingrade6;hasnotbeeninschoolforlastweek;missesanaverageof1weekof
schoolpermonthbecauseofpain
Likestoplaybasketballbutoftensitsoutbecauseofpain;minimalparticipationinphysical
educationclass
Identifiesoneclosefriend,likestoplayvideogamesfordistraction

CPSSIGNI2010

Assessment/Conclusions:

1. Whataretheimmediateandlongtermhealthconcernsforthispatient?
2. Whatarethepatientpriorities?

Plan:Involveteam(medicine,nursing,AcutePainService,PhysicalTherapy,ChildLife,pharmacy,
psychology,socialwork)

1. AcutePainManagement:involveacutepainserviceforconsiderationofPCAtoallowpatient
morecontroloverownpainmanagement;rotatetoanotheropioideghydromorphonefor
potentialsideeffectmanagement;optimizeIbuprofendose(400mgq6hscheduled);add
Acetaminophen825mgq6hscheduled
2. Involvephysicaltherapistforchestphysio
3. Involvechildlifefornonpharmpainmanagementstrategies
4. Involvesocialworkforassessmentoffamilycoping,financialsupportformedicationsathome
5. ChronicPainClinicreferralforlongtermpainmanagementplantopreventfrequent
admissions;psychologicaltherapyandphysicaltherapyforexerciseprogram

Otherquestionstoconsider:

1. Whatcouldchestpainsignify?
2. Whatotherfactorsmaybeinfluencingpainexperience?
3. Whatotherfactorsmaybecontributingtoschoolabsenteeism,limitedsocialrelationships?

CPSSIGNI2010

4.PATIENTSCENARIO:BabyZachary

Who:
BabyZacharyisa272/7weeksgestationagemaleinfant,birthweight1000g(appropriateforhis
gestationalage).TransferredtoNICUat15minutesofageforfurthermanagementofextreme
prematurity.
Maternalhistory/riskfactors
Zacharywasdeliveredbyemergentcesareansectionundergeneralanestheticduetofetalcompromise
followinginductionoflaborwithoxytocinsecondarytoworseningmaternalHELLPsyndrome.Momisa
36yearoldpreviouslyhealthyG1P0A3(3earlymiscarriages).BloodgroupA+.Protectiveserology.
Nomediationsexceptmultivitamins.Nonsmoker.Pregnancyconceivedfrominvitrofertilization
followingprolongedhistoryofinfertility.BabyZaccharyrequiresresuscitationwithintermittentpositive
pressureventilationandintubationinthebirthunit.Apgarscore1(1forHR<60minute)atoneminute;
6(2forHR>100;1tone;1grimace;1color;1irregularrespirations)at5minutes.

ChiefConcerninfirsthouroflife:
Severerespiratorydistressrequiringemergentintubation(withoutanalgesia)andventilationin
BirthUnitat2minutesofage.Receivesbovinelipidextractsurfactant(BLES)(5ml/kg)viaETT.
Transferredtooverheadwarmer,connectedtoventilator,cardiacrespiratoryleadsandsaturation
monitorattached.
Aninitialbloodglucosecollectedfromaheelstickat20minutesofageindicateshypoglycemia.A
PIVisinitiatedafter3attemptsintherightsaphenousvein.Glucoseisprovidedasacontinuous
infusion.Aheelstickisrepeatedforabloodglucoseandadditionallabs.
Anumbilicalarterialandvenouscatheterareplacedandsecuredwithtapeontheabdomen.
Anasogastrictubeisinsertedandconnectedtolowintermittentsuction.
AnXRayisdone.
Theumbilicalcathetersarebothinabittoofarandrequireadjustment.Theabdominaltapesare
removedandthelinesareadjusted.Theskinundertheoriginaltapehasbeenpartiallyremoved
withthetapeandisbleedingunderthenewdressing.
TheETTisslightlylow.Thetapeisremovedtoreadjustthetube.TheETTisinadvertentlydislodged.
ThebabyisabletobemaintainedwithintermittentpositivepressureventilationusingaNeopuff
butthedecisionismadetoreincubatewithoutanalgesia.Asecondyearpediatricresidentmakes2
unsuccessfulattemptsfollowedbysuccessfulintubationbyrespiratorytherapistwiththesecond
attempt.
ThebabynowrequiresanincreaseinventilationandO2requirements.Inadditionbecomesquite
labilewithanyfurtherhandlinghavingnumerousdesaturationsandepisodesofbradycardia.

Medications:
Standingorderfor0.1mlsucrose2minutespriortoskinbreakingprocedure.
StarterPriminewith0.5uheparin/ccat1.7ml/hviaUVC.
0.45%NACL+0.5unitsheparin/ccat1ml/hviaUAL.
Heplocksolutionasperunitroutineq6handpostmedsviaPIV.

PhysicalExam:
Fontanellesoftandflat,somespontaneouseyeopeningandmovementofallextremities,tone
slightlydecreased
CPSSIGNI2010
Airentryaudiblebilaterally,finecracklesthroughout,decreasedtobothbases.Mod.subcoastaland
intercostalretractionswithoccasionallyspontaneousrespirations.IMV60,PIP20,PEEP5,IT.3;FiO2
weanedfrom80%to30%postBLES
BP38/19meanof25inall4limbs,P175bpm(NSR),grade2/6SEMRUSB,T36.7C,peripheral
pulsespalpableX4,caprefill4secondscentrally,5peripherally
Abdomensoft,occ.BS,nourineorstoolpassedsincebirth,liver1cmBRCM,spleennotpalpated.
Normalmalegenitalia.Anuspatent.

Socialhistory
Motherisachiropractor.Sheremainsquiteillinthebirthunitandhasnotseenorheldherbaby.
FatherisanexplosiveforensicofficerinthemilitarycurrentlypostedinKandahar.Hasbeen
contactedandflighthomeisbeingarrangedbutmaytakeseveraldays.
Fewrelativeslocally,mostofthefamilyislivingoutsideofNovaScotiainCanadaandUnitedStates.
Bothsetsofgrandparentsarearrangingtocomeassoonaspossible.
Aclosefamilyfriendiswiththemotherandspeakingwithfatherandfamily

FamilyHistory
Nofamilyhistoryofearlyfetaldemise,chromosomalabnormalitiesoraberrations.
Noconsanguinity.

Assessmentconclusions
1.WhatareBabyZacharysmainhealthproblems/diagnoses?
2.Whatarethepatientpriorities?

Plan:Involveteam(medicine,advancedpracticenurses,nursing,respiratorytherapy,pharmacy,and
socialwork)
1.Ongoingmedialintensivecaremanagement(medicine,neonatalnursepractitioner,nursing,
respiratorytherapy,pharmacy)
2.Painmanagement(medicine,advancedpracticenurses,nursing,respiratorytherapy,pharmacy)
Continue24%sucroseforproceduralpain
InitiatenoninvasivemonitoringsuchastranscutaneouspO2/pCO2,endtidalpC02
Limitpainfulprocedures,continuearterialcatheterforbloodcollectionwhileacuityishigh.
Continueumbilicalvenousuntilskinmaturesandcentral,morepermanent,cathetercanbeplaced.
Institutenonpharmacologicstrategiesassoonaspossiblecontainment/nesting,facilitated
tucking,decreasednoiseandlight;maternalskintoskincare.
Limitroutinecareimmediatelyfollowingapainfulprocedure.

5.Familysupport(medicine,advancedpracticenurses,nursingsocialwork).

Somequestionstoconsiderinrelatedtomechanismsandrationalesindevelopingamanagementplan
1. Arethereanyconcernswithrepeateddoesofsucroseinverypretermneonates?
2. Whatistheevidenceabouttheuseofanalgesiaforintubationinneonates?Whatisan
appropriatechoiceofmedication?
3. Whatevidenceisthereforusingacontinuousinfusionofmorphineforongoingmechanical
ventilationinpreterminfants?
4. Whendoesaninfantexperiencechromingpain?
5. Aretheredifferencesbetweenchronicpainandongoingpaininpreterminfants?
6. Canweaccuratelypredictprocedural,chronicorongoingpaininpreterminfants?Aresome
typesofpainassessmenttoolsbetterthanothers?Why?
CPSSIGNI2010
7. Doestheassessmentofproceduralpainchangeifmultipleproceduresoccurinashortperiodof
time?
8. Whatotherfactorsconfoundourabilitytoassessandmangepaininthepreterm?