CPSSIGNI2010

PAINSCENARIOSINTEACHINGGUIDELINEFORUSEofScenariosAttachedarefourpatientscenariomodelsthatevolvedfromaSIGNursingIssuesworkshopattheCPS2009meeting,withfurthervalidationfromtheSIGEducationCommitteemembersandexternalpainexperts.ACPSsurveyindicatedmemberswantedhelpwithpatientcases/scenariosforteaching.Thisisabeginningandtheattachedpreliminaryversionsrelatetopatientswithdiabeticneuropathy,posttraumapain,sicklecelldiseaseandneonatalpain.Thepurposeisnottodevelopadefinitiveplanbuttoincludekeyassessmentandmanagementconsiderationswithsomerelatedquestionstoguidetheeducator.Thelevelofcomplexitywillvaryaccordingtothestudent'slevel/need.Aninterprofessionallensisimportantandhasbeenpartofthedevelopmentofthesescenarios. 1.PATIENTSCENARIO:SurgeryFollowingTraumaWho:Michaelisa38yearoldmalewhoisonasurgicalward48hoursaftersurgeryforafracturedrightfemuranddebridementoffacialabrasionsfollowingamotorcycleaccident.ChiefConcern:

severe,sharppainonmovementaroundincisioninrightlegNRS9/10,atrest2/10 constantburningpaininhisrightwristNRS7/10onmovement. facialandrighttorsocontusions/abrasionspainfulwhenmovesNRS4/10. somepostoperativefacialpainbutsaysitisnotasbothersomeNRS3/10.

HPI(HistoryofPresentIllness): motorcycleaccident48hoursago;drivingundertheinfluenceofalcohol. PACUpaincontrolinadequateNRS10/10;PCAmorphineinitiatedtoachievelevelsofNRS4

6/10PHH(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;hasgoodhealthcoverageandlongtermdisabilityinsurance

smokes1pk/dayx18years,occasionalmarijuanause;drinksbeer~24/week. recentlylostalongtimehighschoolfriendtocancer. marriedx12yearstowifeDenise(34years),worksfulltimeatthelocalBank. twochildrenaged7and9(Todd&Alison)arehealthy;stayingwiththeirgrandmotherwholives

veryclosetotheirschool.

Michaelswifeconfidedthatsheisconcernedaboutherhusbandsrecentincreaseindrinkingalcoholsincehisfrienddied.

FamilyHistory Michaelsmother(57years)isarecentlydiagnoseddiabetic,haschronicdepression. Michaelsfather(59years)andhealthy Twobrothersliveincity(aged40&36),oldestbrotherrecentlydiagnosedwithdiabetes

AssessmentConclusions1.WhatareMichaelsmaincareissues/diagnoses?2.Whatarethepatientpriorities?Plan:Involveteam(possibilitiesincludebutarenotexclusive:medicine,nursing,occupationaltherapy,pharmacy,physicaltherapy,psychology,socialwork)1.assessmentregrievinganddruguse(medicineincludingpsychiatry,psychology,clergy,nursing,socialwork)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)Somequestionstoconsiderinrelatedtomechanismsandrationalesindevelopingamanagementplan1.Howdoyouapproachassessmentwithapatientexperiencingpaininmultiplesites?2.WhattypesofpainisMichaellikelyexperiencing?mechanisms?Implications?3.WouldyoubeconcernedaboutMichaelbeingprescribedasleepingpill?3.Whatpostoperativepainmanagementplanwouldyouputinplacebeforesurgeryandwhy?4.Whatredflagswouldyouconsiderfromthepatientshistory?Potentialscreeningtools?5.Whatisthepurposeofmultimodalpainmanagementandrelatedrationales.

CPSSIGNI2010

2.PATIENTSCENARIO:DiabeticNeuropathyWho:Joseisa63yearoldmalediagnosedwithpainfuldiabeticneuropathyinhisfeet,obesity,CAD(coronaryarterydisease)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 HbA1C10

SocialHistory: borninPortugalandcametoCanadawhen15yearsold,speaksEnglishfairlywell. hasbeenmarriedfor35yearstoMaria;theyhave2childrennotathome. workedintrades/factorybutduetohisbackpainandlatterlyproblemswithlegshasnot

workedforthelastyear,hassmalldisabilitypension

CPSSIGNI2010

Mariais58yearsandworksatZellersfulltime,isthemainwageearner;wifeisawareofhisneedtowatchhisweightbutmealsaretheonlythingheenjoysrightnow,isworriedabouthim

livein2storysemidetachedhousewithnomortgage;bathroomisonthe2ndfloorsohemostlyspendsdaysonmainfloorandusesaurinal

21yearolddaughterisinher3rdyearatTrentUniversity;callsorcomeshomeoftenandisconcernedaboutaddictiontopainmedications

sonlivesinNorthBay,worksinconstructionanddoesnotseethemoften. Joses80yearoldmotherliveswiththem,isverydependentandrefusestoconsideran

assistedlivingfacilityorretirementhome,believesGodwillhelpherson. smokesonepack/day,reducedfrom2packspreviously.drinks2glassesofwinewithdinner.

FamilyHistory fatherdiedofaheartattackat61years motheris80yearswithdiabetes(takespills)andarthritis youngerbrotherinPortugalalsohasdiabetesandheartproblem

Assessmentconclusions1.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)

Somequestionstoconsiderinrelatedtomechanismsandrationalesindevelopingamanagementplan1,Whatevidenceisthereforadiagnosisofpainfuldiabeticneuropathy?2.Whataretheparametersofgooddiabeticcontrol?3.Whyishispainmostlyinthefeet?Whatisextremesensitivityoftheskincalledandwhydoesitoccurwithneuropathicpain?4.Howdoesthepainincalfmusclesdifferfrompaininhisfeetandwhatisthiscalled?4.Whatrationalesneedtobeconsideredforpossibleapproaches?

CPSSIGNI2010

3.PATIENTSCENARIO:SickleCellDiseaseWho:Omarisa12yearoldboydiagnosedwithSickleCellDiseasebroughttotheemergencyroombyhismotherwithvasoocclusivecrisis.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:involveacutepainserviceforconsiderationofPCAtoallowpatientmorecontroloverownpainmanagement;rotatetoanotheropioideghydromorphoneforpotentialsideeffectmanagement;optimizeIbuprofendose(400mgq6hscheduled);addAcetaminophen825mgq6hscheduled

2. Involvephysicaltherapistforchestphysio3. Involvechildlifefornonpharmpainmanagementstrategies4. Involvesocialworkforassessmentoffamilycoping,financialsupportformedicationsathome5. ChronicPainClinicreferralforlongtermpainmanagementplantopreventfrequent

admissions;psychologicaltherapyandphysicaltherapyforexerciseprogram

Otherquestionstoconsider:

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

CPSSIGNI2010

4.PATIENTSCENARIO:BabyZacharyWho:BabyZacharyisa272/7weeksgestationagemaleinfant,birthweight1000g(appropriateforhisgestationalage).TransferredtoNICUat15minutesofageforfurthermanagementofextremeprematurity.Maternalhistory/riskfactorsZacharywasdeliveredbyemergentcesareansectionundergeneralanestheticduetofetalcompromisefollowinginductionoflaborwithoxytocinsecondarytoworseningmaternalHELLPsyndrome.Momisa36yearoldpreviouslyhealthyG1P0A3(3earlymiscarriages).BloodgroupA+.Protectiveserology.Nomediationsexceptmultivitamins.Nonsmoker.Pregnancyconceivedfrominvitrofertilizationfollowingprolongedhistoryofinfertility.BabyZaccharyrequiresresuscitationwithintermittentpositivepressureventilationandintubationinthebirthunit.Apgarscore1(1forHR100;1tone;1grimace;1color;1irregularrespirations)at5minutes.ChiefConcerninfirsthouroflife: Severerespiratorydistressrequiringemergentintubation(withoutanalgesia)andventilationin

BirthUnitat2minutesofage.Receivesbovinelipidextractsurfactant(BLES)(5ml/kg)viaETT. Transferredtooverheadwarmer,connectedtoventilator,cardiacrespiratoryleadsandsaturation

monitorattached. Aninitialbloodglucosecollectedfromaheelstickat20minutesofageindicateshypoglycemia.A

PIVisinitiatedafter3attemptsintherightsaphenousvein.Glucoseisprovidedasacontinuousinfusion.Aheelstickisrepeatedforabloodglucoseandadditionallabs.

Anumbilicalarterialandvenouscatheterareplacedandsecuredwithtapeontheabdomen. Anasogastrictubeisinsertedandconnectedtolowintermittentsuction. AnXRayisdone. Theumbilicalcathetersarebothinabittoofarandrequireadjustment.Theabdominaltapesare

removedandthelinesareadjusted.Theskinundertheoriginaltapehasbeenpartiallyremovedwiththetapeandisbleedingunderthenewdressing.

TheETTisslightlylow.Thetapeisremovedtoreadjustthetube.TheETTisinadvertentlydislodged.ThebabyisabletobemaintainedwithintermittentpositivepressureventilationusingaNeopuffbutthedecisionismadetoreincubatewithoutanalgesia.Asecondyearpediatricresidentmakes2unsuccessfulattemptsfollowedbysuccessfulintubationbyrespiratorytherapistwiththesecondattempt.

ThebabynowrequiresanincreaseinventilationandO2requirements.Inadditionbecomesquitelabilewithanyfurtherhandlinghavingnumerousdesaturationsandepisodesofbradycardia.

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.subcoastalandintercostalretractionswithoccasionallyspontaneousrespirations.IMV60,PIP20,PEEP5,IT.3;FiO2weanedfrom80%to30%postBLES

BP38/19meanof25inall4limbs,P175bpm(NSR),grade2/6SEMRUSB,T36.7C,peripheralpulsespalpableX4,caprefill4secondscentrally,5peripherally

Abdomensoft,occ.BS,nourineorstoolpassedsincebirth,liver1cmBRCM,spleennotpalpated.Normalmalegenitalia.Anuspatent.

Socialhistory Motherisachiropractor.Sheremainsquiteillinthebirthunitandhasnotseenorheldherbaby. FatherisanexplosiveforensicofficerinthemilitarycurrentlypostedinKandahar.Hasbeen

contactedandflighthomeisbeingarrangedbutmaytakeseveraldays. Fewrelativeslocally,mostofthefamilyislivingoutsideofNovaScotiainCanadaandUnitedStates.

Bothsetsofgrandparentsarearrangingtocomeassoonaspossible. AclosefamilyfriendiswiththemotherandspeakingwithfatherandfamilyFamilyHistory Nofamilyhistoryofearlyfetaldemise,chromosomalabnormalitiesoraberrations. Noconsanguinity.Assessmentconclusions1.WhatareBabyZacharysmainhealthproblems/diagnoses?2.Whatarethepatientpriorities?Plan:Involveteam(medicine,advancedpracticenurses,nursing,respiratorytherapy,pharmacy,andsocialwork)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. Doestheassessmentofproceduralpainchangeifmultipleproceduresoccurinashortperiodoftime?

8. Whatotherfactorsconfoundourabilitytoassessandmangepaininthepreterm?