Assessing and Treating Clients With Pain
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Assessing and Treating Clients With Pain
Pain can greatly influence an individuals quality of life, as uncontrolled pain negatively impacts mood, concentration, and the overall physical and mental well-being of clients. Although pain can often be controlled with medications, the process of assessing and treating clients can be challenging because pain is such a subjective experience. Only the person experiencing the pain truly knows the intensity of the pain and whether there is a need for medication therapies. Sometimes, beliefs about pain and treatments for pain can have an adverse effect on the provider-client relationship. For this Assignment, as you examine the interactive case study consider how you might assess and treat clients presenting with pain.
The Assignment
Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the clients pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Complex Regional Pain Disorder
White Male With Hip Pain
BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was all in his head. He further reports that his physician believes he is just making stuff up to get narcotics to get high.
SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 oclock to 12 oclock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said there is no such thing as RSD, it comes from depression and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states I said no, there is no need for a wheelchair, I can beat this!
The client reports that he used to be a machinist where he made pretty good money. He was engaged to be married, but his fiancé got sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.
He reports that he does get down in the dumps from time to time when he sees how his life has turned out, but emphatically denies depression. He states you cant let yourself get depressed
you can drive yourself crazy if you do. Im not really sure whats wrong with me, but I know I can beat it.
During the client interview, the client states oh! Its happening, let me show you! this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. It will last about a minute or two, then it will let up he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states if there is anything you can do to help me with this pain, I would really appreciate it. He does report that his family doctor has been giving him hydrocodone, but he states that he uses is sparingly because he does not like the side effects of feeling sleepy and constipation. He also reports that the medication makes him loopy and doesnt really do anything for the pain.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One
BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was all in his head. He further reports that his physician believes he is just making stuff up to get narcotics to get high.
SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 oclock to 12 oclock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said there is no such thing as RSD, it comes from depression and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states I said no, there is no need for a wheelchair, I can beat this!
The client reports that he used to be a machinist where he made pretty good money. He was engaged to be married, but his fiancé got sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.
He reports that he does get down in the dumps from time to time when he sees how his life has turned out, but emphatically denies depression. He states you cant let yourself get depressed you can drive yourself crazy if you do. Im not really sure whats wrong with me, but I know I can beat it.
During the client interview, the client states oh! Its happening, let me show you! this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. It will last about a minute or two, then it will let up he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states if there is anything you can do to help me with this pain, I would really appreciate it. He does report that his family doctor has been giving him hydrocodone, but he states that he uses is sparingly because he does not like the side effects of feeling sleepy and constipation. He also reports that the medication makes him loopy and doesnt really do anything for the pain.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Select what the PMHNP should do:
Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed
Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed
