Pain Management – Mrs H Case Study
Mrs. H., a 55-year-old divorced Hispanic woman with stage IV breast cancer, is admitted to the ED suffering from confusion, pain, anxiety, agitation and constipation (states she has not had a bowel movement in 6 days). In obvious distress, she is crying, moaning, and attempting to get out of bed. Her sister reports that she first noticed that Mrs. H. was more anxious than usual approximately 12 hours earlier. Assessment reveals Mrs. H. to be mildly dehydrated, as demonstrated by poor skin turgor and a heart rate of 110. An IV is started, and she receives hydromorphone 1 mg IV push to control her pain and lorazepam 0.5 mg IV to reduce her agitation. Her laboratory values are normal, as is her oxygenation level (O2 sat is 93% on room air). She becomes less agitated and is transferred to the oncology unit. Mrs. H. has had several prior admissions for treatment of bone pain, primarily in several ribs on the lower left thorax and the right femur. During her last stay, Mrs. H. described right upper quadrant pain and was found to have liver metastases. She was placed on an analgesic regimen of long-acting morphine 60 mg every 12 hours, with immediate-release morphine 20 mg for breakthrough pain as needed. Until a few days ago, she required only two or three doses of breakthrough pain medication daily. But her pain recently intensified, and she has needed as many as six to eight doses of immediate-release morphine daily. She contacted her oncologist, and dexamethasone 16 mg PO daily was started two days ago. The nursing staff is surprised to see Mrs. H. so agitated. During past admissions, she appeared sad and somewhat withdrawn, although she consistently denied being depressed. Her sister and two teenage daughters have offered considerable support, visiting often during each of her previous hospitalizations. At the bedside now, they are tearful at witnessing their mother’s confusion about where she is and why she’s in bed.
Discussion Questions:
- How would you assess each of these symptoms (anxiety, depression, delirium, constipation, pain)?
- How would you develop a care plan to address each of these symptoms?
- What patient/family teaching is essential?
- What cultural considerations might be assessed and addressed?
- What long-term planning should be considered?