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Module 2: Pain Management
Case Studies
Please Note:
All case studies are intended to be generic so that substitutions can be made, according
to your own clinical roles. For example, if a case study mentions a patient with a medical condition, you
can substitute the disease cancer, so that it would be appropriate for oncology nurse, or visa-versa. You
may also insert APRN for nurse practitioners, clinical nurse specialists, etc. In addition,
hospice/palliative care nurses can review each case study, as though they were consulting on each of
these case studies. Feel free to adjust the case studies so they are relevant to your participant’s clinical
needs.
Module 2
Case Study #1 and Discussion
Mrs. M: Pain Management and Culture
A 45-year-old Hispanic female, Mrs. M, with a 3-year history of squamous cell cancer of the
cervix presents with severe pain in the perineum. The patient lives at home with 6 children
ranging in age from 5 to 18. She speaks little English.
1. How might the nurse obtain a thorough pain assessment? What aspects of the pain
assessment should be included?
The use of a skilled medical translator is imperative, not one who is a family member or a
member of the patient's social circle. This is especially important when confronting pain and a
potentially embarrassing disorder involving the genitalia. Also, if using family members, they
may translate liberally, inserting their own hopes or beliefs, (e.g., mom doesn't have pain) rather
than the patient's. A medical translator will understand the terminology and will not withhold
information to protect the patient. Furthermore, asking the family to translate adds to their
responsibilities, another source of stress. The pain assessment should include the location,
intensity, quality, and pattern of the pain. Aggravating and alleviating factors should also be
assessed.
2. The patient describes her pain as an 8 on the 0-10 scale, occurring constantly in the
perineum, but is worsened when she voids. She is currently taking
hydrocodone/acetaminophen, 2 tablets every 4 hours (12 tablets - 60 mg hydrocodone ≈ 60
mg morphine). She frequently awakens and takes the medications during the night. She
states (with help of the translator) that the medicines relieve the pain by approximately 25%.
The pain is severe, even with hydrocodone and acetaminophen. Furthermore, she awakens in
pain. Another potential problem is her intake of acetaminophen (this combination contains 500
mg per tablet - the maximum dose is 2000 mg/day or 4 tablets). At 12 tablets she is at risk for
overdose of acetaminophen potentially leading to liver toxicity. Physical assessment is
indicated.
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Module 2: Pain Management
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© COH & AACN, 2007
Case Studies
Revised: March 2013
3. Examination of the perineum reveals inflamed excoriated tissue from the labia to the rectum.
Additionally, stool appears to extrude from the vagina.
The patient appears to have excoriation from urine and a possible rectovaginal fistula.
Treatment includes frequent cleansing of and protection of the skin. A tampon or catheter with
balloon may be inserted in the vagina to block the fistula. The nurse must also consider other
interventions to provide odor control, if this is a problem. Strategies might include
environmental techniques or, in some cases, antibiotics if infection is present. The current
opioid regimen is insufficient. A short acting opioid, such as morphine, may be started every 4
hours around the clock with additional doses available for breakthrough pain on a prn basis
(every hour as needed-since this is the peak time to effect for most oral opioids-longer intervals
means that the patient will be in pain.) Starting with a short acting opioid will help determine
the future long-acting opioid dose. In this case, liquid morphine will be used to assist with
titration and ease of administration. A laxative/softener should be used to prevent constipation
and strategies to treat nausea should it occur.
4. The excoriation is cleared, and the pain is under control with 10 mg of morphine q 4 hours
(or 6 doses/day). She uses approximately 3 additional doses of 10 mg of morphine for
breakthrough pain per day. Thus, she is using approximately 9 doses/24 hours.
Unfortunately she awakens at night in pain. What might be the best analgesic regimen for
this patient? She describes no adverse effects to the medications.
Nine doses of 10 mg of morphine equals 90 mg/24 hours. Because the patient is awakening she
would benefit from a conversion to 45 mg (one 30 mg tablet and one 15 mg tablet) po longacting morphine every 12 hours with short acting morphine 10 mg for breakthrough pain every
one hour prn (10-20% of the 24 hour dose).
5. The patient is being prepared for discharge to hospice at home when she expresses some
concern regarding her son, who has a history of substance abuse. She is afraid he might use
her medications.
The nurse might initiate a meeting with the physician, social worker, the son and the patient. In
a non-threatening manner, the son must be made aware of the consequences of his mother not
having the medication she requires. Engage the home care or home hospice nurse in these
conversations so that the opioid use can be monitored carefully and diversion immediately
identified.
6. Prior to her discharge to home hospice, the patient admits to the nurse that she is very afraid
to die. When questioned further, she describes concerns regarding her children's care as well
as her own guilt for having a child prior to marriage.
The nurse might explore more deeply the concerns regarding death. Does the patient fear the
unknown, or is she primarily worried about her children's care after her death? Is there
additional work that might help the patient prepare for her death, such as letting those close to
her know that she loves them, saying goodbye, seeking apologies, and forgiving those who might
have wronged her? The social worker may assist with plans regarding the children's long-term
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ELNEC-Core Curriculum
Module 2: Pain Management
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Case Studies
Revised: March 2013
care. Letters to the children at milestones in their lives may be composed for future reading.
Traditions may be passed on, such as recipes or activities around certain holidays. A
psychologist or chaplain may help the patient address unresolved guilt related to having a child
prior to marriage. The interdisciplinary team can work to assist family members and the
children with strategies to address their concerns as well as those of the patient.
7. The patient is well cared for by her family at home. Her condition deteriorates and she
becomes weaker, unable to swallow. She does not have a venous access device and her
home hospice team decides that subcutaneous morphine might be useful. Her current
analgesic regimen is 100 mg long-acting morphine every 12 hours with 3 doses of 30 mg
immediate-release morphine each day. What would be the appropriate subcutaneous dose?
The patient's 24 hour oral morphine dose is 290 mg. To obtain the parenteral equivalents,
divide by 3. This equals 96.7 mg. Then divide by 24 to obtain the hourly rate. The patient's
hourly rate would be 4.0 mg of morphine per hour continuous subcutaneous infusion. Remember
to reassess after making changes in drug, dose, or route of administration, and with any new
complaint of pain. The patient tolerated this dose well, achieving excellent relief. She died a few
days later, comfortably in her home.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-74
© COH & AACN, 2007
Case Studies
Revised: March 2013
Module 2
Case Study #2
Mr. Jones: Calculating Equianalgesic Doses
Mr. Jones is taking two Percocet® (oxycodone 5mg/acetaminophine 325mg) tablets every four
hours for bone pain related to metastatic cancer. His pain is a constant 6 on a 0 to 10 scale.
Since his pain goal is 3, you decide to call his physician.
Discussion Questions:
1. The doctor suggests increasing the Percocet® to two tablets q3h ATC. How would you
respond to this order?
2. A more appropriate approach would be to start the patient on a different opioid. Calculate
the equianalgesic dose and schedule for the following options:
a. oral MS - immediate release
b. oral MS Contin® or Oramorph® SR
c. oral hydromorphone (Dilaudid®)
d. oxycodone (Roxicodone®)
e. fentanyl patch (Duragesic®)
3. Suggest new analgesic orders for this patient. Take into consideration that orders should
include both scheduled and breakthrough pain medications and other drugs that might be
especially effective for a patient with bone pain.
Faculty Guide:
The goal of this case is to insure that the participants understand:

dose ceiling of acetaminophen

the role of NSAIDs in bone pain

how to do analgesic conversions

concepts of titration
Specific points for each question:
1. There are two major issues with the order:
a. The dose limit of acetaminophen is 2000 mg. At his current dose of two Percocet® q4h,
he is taking 650 mg per dose x 6 doses, or 3900 mg per day. Therefore, increasing the
Percocet® is not a safe option. An option is use of oxycodone which is available without
acetaminophen.
b. The patient is likely to benefit from the addition of an NSAID to his regimen.
2. To calculate the oral dose, begin by noting that 2 Percocet® q4h=12 tabs per 24 hours=60 mg
oxycodone per 24 hours.
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ELNEC-Core Curriculum
Module 2: Pain Management
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© COH & AACN, 2007
Case Studies
Revised: March 2013
a. MSIR: Look up the approximate equivalent dosages of oxycodone and morphine in an
equianalgesic table. Use this dosage ratio to calculate the dose of morphine equivalent to
60 mg oxycodone. This is an easy one to start with since these drugs are equipotent.
30 mg PO oxycodone = 30 mg PO morphine
60 mg PO oxycodone
X mg PO morphine
Solve for X (cross multiply)
60 x 30 = 30X
X = 1800/30
X = 60 mg morphine/24 hours
Since the duration of MSIR is 4 hours, you would divide the 24 hours dose into 6 doses,
or:
10 MSIR q 4 hours
b. MS Contin® or Oramorph® SR: Follow the same process as above, except the duration of
action is 12 hours and you would divide the 24 hour dose into 2 doses, or:
30 mg MS Contin® or Oramorph® SR q 12 hours
c. hydromorphone: 30 mg oral oxycodone is equivalent to 7.5 mg oral hydromorphone
30 mg PO oxycodone = 7.5 mg PO hydromorphone
60 mg PO oxycodone
X mg PO hydromorphone
Cross multiply as above:
X = 15 mg PO hydromorphone/24 hours.
Since the duration of hydromorphone is 4 hours, you would divide the 24 hours dose into
6 doses, or:
2.5 mg hydromorphone q 4 hours
Since Dilaudid® does not come in 2.5 mg tablets, it is reasonable to give 3 mg per dose
instead.
d. The package insert suggests that 25 μg/h transdermal fentanyl is equivalent to 45-134 mg
oral MS/24 hours. Therefore the calculated morphine dose of 60 mg/24 hours would
suggest an equianalgesic dose of fentanyl would be 25 μg/h q 72 hours. However, most
clinicians would double this dose and use a 50 μg/h patch.
3. Any set of analgesic orders should include the following concepts:
a. Since the pain is 6/10, it is reasonable to increase the baseline dose by 50%.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-76
© COH & AACN, 2007
Case Studies
Revised: March 2013
b. Short acting breakthrough medications equivalent to 50 to 100% of the baseline dose
should be available.
c. Some possible combinations:

MS Contin® or Oramorph® SR 45 mg q 12 hours, with 7.5 to 15 mg MSIR (use liquid
q2-4 hours PRN), (would be OK to use the Percocet® first)

MSIR 15 mg q 4 hours, with 7.5 to 15 mg MSIR q2-4 hours PRN

hydromorphone 4 mg q4 hours PRN, with 2-4 mg hydromorphone q2-4 hours PRN

change the Percocet® to plain oxycodone 15 mg q4 hours, with 5-15 mg q2-4 hours
PRN or add oxycodone 5 mg to each dose Percocet®.
Note: An NSAID, such as ibuprofen 600 mg or naproxen 500 mg BID should be added to any of
these regimens.
Source:
Gordon, D., Stevenson, K.K., & Dahl, J. (1996). Home care case studies and faculty guide. Madison,
WI: Wisconsin Cancer Pain Initiatives. The complete set of cases can be obtained from the City of Hope
Pain and Palliative Care Resource Center: http://prc.coh.org , Retrieved December 16, 2011.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-77
© COH & AACN, 2007
Case Studies
Revised: March 2013
Module 2
Case Study #3
Madeline: Pain and Suffering
Madeline S. is a 66-year-old German woman admitted to a home care agency for care related to
end-stage cardiac disease and renal failure. She has complained of chronic generalized chest
pain, frequent cramps in her legs, and worsening arthritis pain related to her immobility. The
home care nurse has been in contact with Madeline's physician almost daily for the past week
and her analgesics have been steadily increased with little pain relief but an increase in nausea,
constipation and sedation. The nurse feels frustrated as she observes Madeline declining rapidly
with worsening depression, withdrawal and weeping. Madeline's neighbor has noticed that her
lights are left on 24 hours a day and the nurse has noticed that Madeline has several rosaries and
prayer books now at her bedside. Madeline has refused referral to hospice but the home care
nurse has requested a team conference with assistance from the local hospice affiliated with the
home care agency.
Discussion Questions:
1. What disciplines should be included in the case conference?
2. What additional assessment might the nurse obtain?
3. How can this patient's pain and suffering best be treated?
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-78
© COH & AACN, 2007
Case Studies
Revised: March 2013
Module 2
Case Study #4
Diana: Assessment/Barriers
Diana is a 40-year-old woman with a history of breast cancer. Five years ago she underwent a
lumpectomy with radiation, following by chemotherapy. One year ago she developed bone
metastases in the lumbar spine and right clavicle, documented by bone scan. She is currently
being treated with another regimen of chemotherapy that includes paclitaxol (Taxol®). She is
returning to the oncology clinic for chemotherapy administration. The nurse is concerned about
Diana's comfort and conducts a pain assessment.
History:
Diana at first reports no problems, but later admits that she developed very minor low back pain.
She attributes this to increased activity as she has been remodeling her home. When the pain
does not abate with over the counter medications (e.g., ibuprofen, acetaminophen) and nonpharmacological techniques (e.g., massage, heat), she will occasionally take a Vicoden® (5 mg
hydrocodone/500 mg acetaminophen). When questioned why she does not take more, she states
"I don't like taking narcotics" and "My husband doesn't like when I take the pills."
Diana describes her pain as 2 or 3/0-10, located in her low back. The pain is aching and
throbbing. When pressed to report other pain sites, she admits she has some shoulder pain, but
rates it as a 1 currently. She also describes tingling in the feet bilaterally, extending to the
ankles. "It is not pain really, just burning".
Other history: Diana is married, lives with her husband and 2 teenage sons in a suburban home.
She works as a receptionist in a dentist's office.
Physical Assessment:
During the history, Diana's posture indicated that she was not comfortable. When Diana gets up
from her chair to get onto the exam table, the nurse notes that she does so with difficulty.
Palpation of the lower lumbar spine (L3-4) produces pain. Diana denies pain when the clavicle
is palpated. Straight leg raises of less than 30 degrees increase the low back pain significantly.
Neurological examination reveals weakness in lower extremities, with R > L. Sensory loss is
noted bilaterally in the toes and feet to the ankles. Reflexes are intact.
Discussion Questions:
1. What are the barriers to pain relief in this case?
2. What types of pain is Diana experiencing and what might be the underlying etiologies?
What other questions should the nurse ask this patient?
3. Devise a plan of care for this patient.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-79
© COH & AACN, 2007
Case Studies
Revised: March 2013
Module 2
Case Study #5 and Discussion
Joshua: Importance of Interdisciplinary Care
Case:
Joshua is an 18-year-old African American boy with an advanced sarcoma initially affecting the
right leg but now with extensive metastases, including lung. He complains of severe pain in the
leg. The patient lies in a fetal position with the lights off. Family members visit rarely and the
patient is reluctant to return home. He is cachectic and clearly is approaching the end of life. He
requests intravenous hydromorphone, as this has worked well in past hospitalizations. When the
nurses attempt to administer the medication, the patient wants it injected quickly and in a port
closest to the insertion site. The nurse expresses concern that the patient is addicted or
manipulative, wanting to stay in the hospital to get intravenous medicines. As an advanced
practice registered nurse (APRN), what assessment and interventions are warranted?
Discussion:
Extensive pain assessment is warranted, including the location, quality, intensity, medication
history, and other factors. This type of pain might include nociceptive and neuropathic aspects,
necessitating treatment with multiple medications. An assessment of the patient’s emotional state
is also needed, including the family’s role and function. Especially important is to determine
whether the patient is depressed, as well as his beliefs about his disease. A team approach is
indicated given the complex bio-psychosocial-spiritual dimensions of this situation so the APRN
calls a special team meeting to discuss. And the APRN may help the nurse to discuss her feelings
and concerns regarding the patient’s request for more rapid injection of the drug.
Case continued:
Joshua’s response to the opioid indicates that the chosen dose reduces pain somewhat (he cannot
articulate a percentage of relief but states that the pain is a 6-8 after the injection, down from an
8-10) without significant sedation. A higher dose produces some sedation, but improved relief. In
questioning Joshua, he is not upset by the sedation. Corticosteroids are added to reduce
inflammation. Besides physical assessment/interventions, what other psychosocial assessments
and interventions would be appropriate? What other team members need to be involved?
Discussion:
The APRN determines that the social worker and one of the palliative care nurses are able to
establish trust with Joshua and his mother. After extended discussions, the team learns that the
family does not visit often as they cannot afford to pay for parking. Financial burdens are high
and resources are very limited. Joshua expresses concern that he is a burden to his mother, who
awakens frequently during the night to care for him. His coming to the hospital is an attempt to
give her some peace and his reluctance to return home reflects this concern. Aggressive team
work is directed towards helping the family understand Joshua’s disease state, improving
communication between family members and Joshua, and assisting in obtaining financial and
other support. At the same time the team provides time for staff to express their concerns and
sadness at caring for a child at the end of life.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-80
© COH & AACN, 2007
Case Studies
Revised: March 2013
Case continued:
Joshua is discharged to his home with hospice care. He receives a subcutaneous infusion of
hydromorphone with boluses administered by his mother as needed. He dies at home with good
relief of pain. His mother, who in the past struggled with wanting aggressive therapy, had come
to some level of acceptance regarding her son’s death. She continues follow-up with the hospice
chaplain for bereavement care.
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-81
© COH & AACN, 2007
Case Studies
Revised: March 2013
Module 2
Case Study #6 and Discussion
Mrs. P: Honoring a Woman’s Wish
Mrs. P is a 78-year-old female with severe chronic obstructive pulmonary disease (COPD), cor
pulmonale, osteoporosis, and arthritis who lives alone in subsidized housing for the elderly. She
is dependent on home oxygen and oral steroids. Other medications include diuretics,
nonsteroidal anti-inflammatory drugs (NSAIDs), multiple bronchodilators, and respiratory
medications. She states that she wants to avoid further hospitalizations for her disease, does not
want to be intubated or resuscitated, and that she has a living will and durable power of attorney
for health care in place. Mrs. P is currently being followed by a registered nurse from the
transitional care department of a home hospice agency. Her two adult sons live out of state and
she has one married granddaughter in the area.
For seven days, Mrs. P has been on oral antibiotics for acute bronchitis, but her overall condition
has steadily declined. Today she is lethargic, unable to stand, and having difficulty swallowing
her medications. The homecare nurse discusses Mrs. P’s condition with her, her family, and her
physician. They develop a plan of care to keep Mrs. P at home until she dies.
Discussion Questions:
1. Given the information provided, what would you identify as a priority of care for Mrs. P?
2. What changes will need to be made to Mrs. P’s medication regime? (Consider the change in
health status and her age.)
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ELNEC-Core Curriculum
Module 2: Pain Management
Page M2-82
© COH & AACN, 2007
Case Studies
Revised: March 2013