CONCEPT 27: Pain

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Case Presentation

Jenny Alvers is a 38-year-old otherwise healthy female who has been admitted directly to the intensive care unit (ICU) after an automobile accident and emergency abdominal surgery. In addition to surgery, she has deep face, neck, and chest lacerations and contusions. Jenny is on a ventilator and somewhat disoriented and restless with elevated blood pressure and heart rate. She is unable to provide a report of pain, but based on her pathologic condition, the nurse assumes that Jenny has pain and consults with the surgeon about orders for a continuous IV opioid infusion. Knowing that Jenny will be subjected to painful procedures such as endotracheal suctioning and wound care during her stay in the ICU, the nurse also requests supplemental IV opioid doses to administer prophylactically. Jennys sister reported that Jenny has no allergies but experienced severe nausea when she was given IV morphine following an appendectomy 3 years ago. The surgeon prescribes an IV infusion of hydromorphone at a dosage appropriate for an adult with moderate to severe pain and supplemental IV hydromorphone bolus doses every hour as needed. Scheduled doses of IV acetaminophen and IV ibuprofen are also ordered. The nurse suspects that Jennys restlessness could be related to unrelieved pain and, therefore, administers an IV hydromorphone loading dose before initiating the infusion. Infusions of IV ibuprofen followed by IV acetaminophen are also administered. An aqua pad circulating cool water is placed over Jennys chest to provide additional analgesia. The nurse reduces the external stimuli in the room as much as possible and provides Jenny with calm reassurance and orientation while caring for her. Within 45 minutes of these interventions, Jenny is no longer restless, her vital signs are within normal limits and stable, and she appears to be resting comfortably.

Case Analysis Questions

1. What factors place Jenny at high risk for inadequate pain relief?

2. What methods should be used now, and in the future, to assess Jennys pain?

3. What type of pain is Jenny most likely experiencing? How does this information affect treatment decisions?

Sample Solution

Case Analysis: Jenny Alvers

  1. Factors Placing Jenny at High Risk for Inadequate Pain Relief:

Several factors place Jenny at high risk for inadequate pain relief:

  • Critical illness and surgery: Major trauma and surgery are inherently painful experiences.
  • Impaired communication: Jenny’s inability to self-report pain due to ventilation and disorientation makes assessment challenging.
  • Past experience: Her previous nausea with morphine might make healthcare providers hesitant to prescribe opioids.
  • Multimodal pain: Jenny likely experiences a combination of nociceptive pain (from tissue damage) and neuropathic pain (from nerve injury) from her injuries.

**2. Methods to Assess Jenny’s Pain: **

Current methods:

  • Physiological assessment: Monitoring vital signs (elevated blood pressure and heart rate) can be indirect indicators of pain.
  • Behavioral assessment: Observing restlessness and facial expressions can provide clues about her pain level.

Future methods (once Jenny’s condition improves):

  • Self-report tools: Using pain scales like the Numeric Rating Scale or Faces Scale once Jenny is responsive will be the most accurate method.
  • Non-verbal communication: Observing nonverbal cues like wincing or guarding behavior can supplement self-report.
  1. Type of Pain and Treatment Decisions:

Jenny likely experiences a combination of:

  • Nociceptive pain: This arises from tissue injury (surgery, lacerations, and contusions) and responds well to opioids and other analgesics.
  • Neuropathic pain: This could be caused by nerve damage from the accident and might not respond well to traditional pain medications.

Treatment Implications:

  • Multimodal approach: A combination of therapies like opioids (for nociceptive pain), non-opioid analgesics (like ibuprofen and acetaminophen), and non-pharmacological interventions (cooling pad) is likely needed to address both pain types.
  • Titration and Monitoring: Pain medication dosages should be adjusted based on Jenny’s response and potential side effects like nausea.
  • Considering alternative medications: If opioids cause nausea, alternative medications like gabapentinoids may be considered for neuropathic pain.

By recognizing these factors and implementing a multimodal approach to pain management, healthcare professionals can ensure Jenny receives adequate pain relief and promote a faster recovery.

 

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