Clinical case example Ana is a 50-year-old female with chronic arthritis pain in her hands and knees. She states that the pain has worsened in the past two months, and she had previously tried therapies that do not alleviate the pain. She went for a morphine refill but was turned back to the pain specialist since the script was expired. So, Ana is asking the nurse practitioner for another prescription. Given the information provided, which tier aligns with Ana’s symptoms? Provide one short-term and one long-term intervention using the integrative approach examples: Suggest one immediate
Table 6: Tiered Integrative Approaches to Pain Management* Tiered Intervention Integrative Approaches Tier 1 Hot/cold therapy Relaxation response Guided imagery Tier 2 Aromatherapy Yoga Hydrotherapy Tier 3 Cognitive-behavioral (pain management therapy
Immediate interventions for Ana would include: • Therapeutic listening, presence, therapeutic use of self-touch. • Heat/cold therapy. Because of the recent change in pain and increase in the past two months, gather some diagnostics— check a rheumatoid factor, sed rate (ESR), and c- reactive protein (CRP). For long-term therapies, Ana could focus on some movement therapies, including: • Yoga. • Hydrotherapy. • Tai chi. These therapies might help with the circulation of joints. They might help with deep breathing exercises and a sense of appreciation for self.
intervention for your patient and provide a brief rationale.
Mindfulness-based stress reduction meditation Massage Acupressure Homeopathy Chiropractic NSAIDs Transcutaneous electrical nerve stimulation
Suggest one long-term
Tier 4
intervention for your patient and provide a brief rationale
Tier 5
Pharmacological therapies Surgical procedures Nerve blocks *Adapted from Integrative Nursing (Kreitzer & Koithan, 2019).
Instruments for evaluating pain Socrates
● Hyperalgesia (amplified pain response to stimulation that would normally evoke only mild pain). ● Pain insensitivity, which is also known as congenital analgesia and is one or more rare conditions in which a person cannot feel (and has never felt) physical pain. ● A sensory examination that could include response to light touch, light pressure, pinpricks, cold, or vibrations. (Clark & Galati, 2015) PQRST P What provokes symptoms? What improves or worsens the condition? What were you doing when it started? Do position changes or activities make it worse? Q Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing, or stabbing? R Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else? S Severity of symptoms or rating on a pain scale. Does it affect activities of daily living, such as walking, sitting, eating, or sleeping? T Time or how long have they had the symptoms? Is it worse after eating, changes in weather, or time of day? Other tools, such as the Brief Pain Inventory form, provide an assessment of pain and gauge treatment (AAFP, 2021).
It is critical to gain as much information as possible about the specific complaint of pain to properly determine a course of treatment. The SOCRATES acronym is a useful tool that can be used to remember key points to be collected when assessing a complaint of pain: ● S ite: Where exactly is the pain? ● O nset: When did it start? Was it constant/intermittent? Was it gradual/sudden? ● C haracter: What is the pain like? Sharp? Burning? Tight? ● R adiation: Does the pain radiate/move anywhere? ● A ssociations: Is there anything else associated with the pain, such as sweating or vomiting? ● T ime course: Does it follow any time pattern? How long does it last? ● E xacerbating/relieving factors: Does anything make it better or worse? ● S everity: How severe is the pain? Consider using a 1–10 scale. (Swift, 2019) The physical examination conducted as part of the initial patient screening contains all the elements common to contemporary practice. A few areas should be emphasized because of the unique nature of opioid prescriptions (Clark & Galati, 2015). Here are topics to consider: ● A rigorous evaluation of the patient’s nervous system. ● An assessment of allodynia (pain from the stimulation that would not normally evoke pain, such as light touch).
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Book Code: AUS3024
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