NUR 342 M2D2 Post & Notes

Using the case study below, describe how you would conduct your physical assessment.
J.P. is a 15-year-old African-American adolescent who was diagnosed with sickle cell disease 3 years
ago. J.P. lives with his grandmother and is struggling with his sexual identity. His father died when J.P.
was 5 years old, but he remembers his father hitting his mother. His mother died of a heroin overdose 7
years ago.
J.P. has come to the emergency department with pain related to the sickle cell crisis. His grandmother is
crying and shouting, "Why can't you help him? He's hurting!" Staff members are frustrated with his
frequent visits, and they express concern that he is addicted to the pain medication.
Subjective Data
Pain level is a 8/10 location = bilateral legs, described as deep muscle pain
Student in 10th grade, failing school
On the track team Lives with grandmother
Very spiritual
Uses complementary and alternative practices for pain
Objective Data
Vital signs: T 37 P 80 R 18 BP 140/68
Weight: 140
HT: 5 feet, 6 inches
Address all of the following:
• What other assessments should be done for this patient?
• The Initial Pain Assessment26 asks the patient to answer 8 questions concerning location,
duration, quality, intensity, and aggravating/relieving factors. Further, the clinician adds
questions about the manner of expressing pain and the effects of pain that impair one's
quality of life
• Pain-rating scales are unidimensional and intended to reflect pain intensity. They come
in various forms. They can indicate baseline intensity, track changes, and give some
degree of evaluation to a treatment modality
• Briefly identify the various types of pain he is suffering.
• Neuropathic pain is pain that does not adhere to the typical and rather predictable phases
in nociceptive pain. It is “pain caused by a lesion or disease of the somatosensory
nervous system.”19 Neuropathic pain implies an abnormal processing of the pain
message from an injury to the nerve fibers. This type of pain is the most difficult to
assess and treat. Pain is often perceived long after the site of injury heals, and it evolves
into a chronic condition. (Jarvis, 2016, p. 162)
• Nociceptive pain can change into a neuropathic pain pattern over time when pain has
been poorly controlled. This is because of the constant irritation and inflammation
caused by a pain stimulus, which alters nerve cells, making them more sensitive to any
future stimulus. The constant irritation from uncontrolled pain also decreases the number
of opioid receptors in the spinal cord.4 Neurons in the spinal cord dorsal horn may
experience excitotoxic and apoptotic cell death. There is significant depletion of
GABAergic interneurons; because GABA is an inhibitory neurotransmitter, this may
cause hyperalgesia and allodynia. (Jarvis, 2016, p. 162)
 • What type of pain does this patient describe?
• Deep somatic pain comes from sources such as the blood vessels, joints, tendons,
muscles, and bone. Pain may result from pressure, trauma, or ischemia. (Jarvis, 2016, p.
162)
• chronic (persistent) pain is diagnosed when the pain continues for 6 months or longer. It
can last 5, 15, or 20 years and beyond. Chronic pain can be divided into malignant
(cancer-related) and nonmalignant. Malignant pain often parallels the pathology created
by the tumor cells. The pain is induced by tissue necrosis or stretching of an organ by the
growing tumor. It fluctuates within the course of the disease. Chronic nonmalignant pain
is often associated with musculoskeletal conditions such as arthritis, low back pain, or
fibromyalgia. (Jarvis, 2016, p. 163)
• The vaso‐occlusion seen in SCD leads to a cycle of hypoxia, ischemia and tissue injury
which causes the activation of nociceptive pathways, stimulating peripheral afferent
pathways and resulting in a perception of pain. (Asnani, 2018)
• What standards of assessing pain should be applied to this patient's plan of care?
• Pain is defined as an “unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such damage. Pain is always
subjective.”2 The subjective report is the most reliable indicator of pain. Because pain
occurs on a neurochemical level, the diagnosis of pain cannot be made exclusively on
physical examination findings, although these findings can lend support. Self-report is
the “gold standard” of pain assessment. (Jarvis, 2016, p. 165)
•
• Describe interventions that should be included in the plan of care for this patient.
• Pain researchers are using functional MRI (fMRI) to visualize changes in brain activity
while patients experience pain. When these images are shown to patients in real time,
they can be used to help pain sufferers control their pain and improve their pain
experience. Patients viewing fMRI of their brains are taught strategies such as
meditation, guided imagery, and cognitive behavioral therapy to alter the response of
their brains to pain; they can see the impact of these therapies on their brains (Jarvis,
2016, p. 162)
• Along with pharmacological agents such as opioids, non‐steroidal anti‐inflammatory
agents, antidepressants and anti‐epileptics agents, non‐pharmacological interventions
such as cognitive behavioural therapy, herbal treatments, relaxation therapy, and
acupuncture have also shown benefit in managing SCD pain (Ballas, 2007, as cited in
Asnani, 2018).
•

References
th
Asnani, M., (February 5 , 2018), Interventions for treating neuropathic pain in people with sickle cell
disease, retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012943/full

Post

Assessments that should be done in this case study that are appropriate regarding J.P's complaints of

pain related to his diagnosed condition of sickle cell disease include conducting an “initial pain
assessment . . concerning location, duration, quality, intensity, and aggravating/relieving factors.”

(Jarvis, 2016, p. 162). The use of a pain-rating scale may also be appropriate in this case, in order to

determine “intensity, track changes, and give some degree of evaluation to a treatment modality”

(Jarvis, 2016, p. 162).

J.P. is suffering from acute nociceptive visceral and somatic pain due to the tissue ischemia that results

from his chronic sickle cell disease. J.P. seems to be suffering from an acute exacerbation, and may

benefit find relief in the form of a opiate such as morphine due to it's vasodilative effects (Asnani,

2018). J.P. describes his pain as being, “deep muscle pain”. Jarvis (2016) states that, “deep somatic

pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result

from pressure, trauma, or ischemia” (p. 162) which is similar to J.P's complaints of “deep muscle pain”.

While assessing J.P's pain it is important to understand that all pain is subjective based on the persons

experience. Jarvis (2016) states, “because pain occurs on a neurochemical level, the diagnosis of pain

cannot be made exclusively on physical examination findings, although these findings can lend

support. Self-report is the “gold standard” of pain assessment.” Patients may experience pain in

unexpected ways due to their level of pain tolerance as a result of living with chronic pain which the

body has adapted to in terms of hyper sensitivity to painful stimulus, and they may behave differently

then what many may expect someone to act in that given situation, such as using sleep as a way to

distract themselves from the pain (Jarvis, 2016, p. 172).

Interventions other then pharmacological approaches that the patient may benefit from include,

“strategies such as meditation, guided imagery, and cognitive behavioral therapy to alter the response

of their brains to pain” (Jarvis, 2016, p. 162). Asnani also gives some insight into possible

interventions related to the management of SCD, these include “opioids, non‐steroidal anti‐
inflammatory agents, antidepressants and anti‐epileptics agents, non‐pharmacological interventions

such as cognitive behavioural therapy, herbal treatments, relaxation therapy, and acupuncture have also

shown benefit in managing SCD pain” (Ballas, 2007, as cited in Asnani, 2018).

References

Asnani, M., (February 5th, 2018), Interventions for treating neuropathic pain in people with sickle cell

disease, retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012943/full

Jarvis, C. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier

Saunders.