Case Study
Pain management refers to the specialty medicine that has originated from the need of treating different types of pain namely, spinal, musculoskeletal and neuropathic pain (Macintyre and Schug 2014). Chronic or end stage kidney disease most commonly encompasses a range of pathophysiologic mechanisms that are associated with abnormal functions of the kidney and result in a progressive decline in the rate of glomerular filtration (Jha et al. 2013). The assignment will elaborate on a case study of an older adult, diagnosed with end stage renal disease and will provide an insight into the pain management techniques that can be adopted for treatment.
Case Study- A 78 year old female X (pseudo name) had been admitted to the nephrology department for her end-stage renal disease and reports signs of poorly controlled pain, vascular dementia and peripheral vascular disease. The patient had been diagnosed with ESRD in 2017, and needs dialysis every week for survival. Her family ruled out the option for a kidney transplant. Although haemodialysis is not a permanent cure for her condition, it has been considered as an effective strategy in increasing the life span of an affected patient. The patient has been diagnosed with musculoskeletal pain based on the symptoms reported such as, stiffness and aching in her legs, sleep disturbances, burning sensation in the lower limb muscles, and widespread pain that gets worsened with her movement. Furthermore, she also reported a swelling in the joints after minor movement and stiffness after resting for a considerable period of time. She was diagnosed with osteoarthritis by blood tests, analysis of the joint fluids and X-ray imaging. The patient has a body weight of 65 kilograms and was under the prescribed medication of angiotensin receptor blockers. Assessing her joints during a physical examination further confirmed the presence of swelling, redness and tenderness.
Pathophysiology- Pain is commonly defined as feelings of distress that are caused due to the action of some damaged stimuli. It is also referred to an unpleasant, emotional and sensory experience that is related with potential or actual damage to cells and/or tissues. Musculoskeletal pain are caused due to injury to the joints, bones, tendons, muscles, and ligaments (Mayer and Bushnell 2015). Although osteoarthritis had earlier been categorised as a non-inflammatory form of arthritis, there is mounting evidence to suggest that the inflammation occurs as a result of release of metalloproteinase and cytokines, into the joints. These compounds are primarily involved in excessive degradation of the matrix, which in turn characterises the degeneration of cartilage in osteoarthritis. A fine balance of the water content present in a healthy cartilage is maintained due to the compressive force that drives out water, and osmotic and hydrostatic pressure that draw in water (Arden et al. 2014). The collagen matrix is shows a disorganised state during the onset of the condition, along with a subsequent decrease in the content of proteoglycan in the cartilage. Increase in water content occurs due to breakdown of the collagen fibres (Hoff et al. 2013).
Pathophysiology
Failure of the proteoglycans to exert a protective effect increase susceptibility of the collagen to get degraded, thereby exacerbating degeneration. Further changes include thickening and fibrosis of the ligaments present in the joints and damage or wear of the menisci. Research evidences have also established strong correlation between enhanced quadriceps strength and reduction of pain (Herrero-Beaumont et al. 2017). Furthermore, a growing body of evidences have also emphasised on the fact that chronic pain is quite common in patients with ESRD and creates a virtual impact on different facets of health-related quality of life (Santoro et al. 2013). There occurs an exponential increase in in the challenges to treat chronic pain in an ESRD patient, who is on haemodialysis. All of these changes might have resulted in the onset of osteoarthritis in the patient X, undergoing haemodialysis for ESRD.
Bio-psychological and social impact- Time and again chronic pain has been recognised as a main public health issue that produces a significant social and economic burden on the sufferer and his/her family members. Severe chronic pain has been associated with increased risks of major mental disorders that commonly encompass anxiety, depression and post-traumatic stress disorder (Turk et al. 2016). With a subsidisation in the pain symptoms, the stressful response associated with mood alterations also show a marked reduction. However, in this case scenario, the patient X was found to be constantly stressed and tense about her health and inability to move. Over time, this stress aggravated her emotional problem and resulted in the onset of a depressed mood that was characterised by a reduced self-esteem, fatigue, confused thinking, social isolation and a fear of injury. Furthermore, another major biological impact created by osteoarthritis is an impairment in functional mobility (Bunzli et al. 2013). Research evidences have illustrated the fact that patients with osteoarthritis commonly experience major functional limitations in their hands and legs compared to individuals without the disease (Neogi 2013).
Additionally, depression also plays a crucial role in modifying the association between functional mobility and knee pain (Holmes, Christelis and Arnold 2013). In this case scenario, in addition to suffering from a persistent low mood, the patient X could not move on her own, without assistance, which in turn can be attributed to the stiffness in her joints and leg muscles. The subsequent disability also prevented her from participating in activities of daily living such as, doing household chore, dressing, feeding and fulfilling certain social roles in the context of the community or family. Behaviour and lifestyle modifications and several psychosocial attributes have been identified imperative for accommodating to daily activities and reducing the severity of impairment (Kjeken et al. 2013). However, osteoarthritis has often been found to create a negative impact on the health outcomes and daily functioning of affected people, thereby making them travel less distance or use more transportation.
The fact that depression in the patient X influenced the relationship between her functional mobility and knee pain is further illustrated by low mood and poor self-esteem due to inability to walk at a rapid speed or rise from a chair or bed, without assistance (Abdulmonem et al. 2014). All of these factors have been identified central in limiting the participation of the affected people in different social roles. Thus, the subsequent limitations that occurred as a result of being diagnosed with osteoarthritis prevented the patient X in taking part in social activities and also contributed to poor quality of life.
Bio-psychological and social impact
Pain assessment- Chronic pain is most commonly the major complaint reported by patients diagnosed with osteoarthritis and ESRD, thereby making evaluation of pain a fundamental requisite in assessing the health outcomes. In spite of the fact that pain is a subjective experience, management of the condition requires certain objective standards that are related to care. Pain is most commonly categorised into acute and chronic subtypes depending on the continuum of duration. An analysis of the patient suggested that she was suffering from chronic pain since it intensified and worsened over time and was found to persist for long time period. The initial pain assessment was conducted with the adoption of the WILDA approach that primarily focuses on words for describing pain, its location, intensity, alleviating or aggravating condition and the duration (Dansie and Turk 2013). The patient was asked certain questions like, “Tell me about the pain”, or “How would you describe your pain”.
Close attention was given to the patient narrative and few words were identified from her account as ‘burning’, ‘aching’, ‘miserable’, ‘unbearable’ and ‘sharp’. Following the universal scale of 0-10 for clinically assessing the pain made X give her pain a score of 9 that was associated with severe pain intensity, as perceived by her. The self-reporting Multidimensional Pain Inventory (MPI) was also used with the aim of assessing the pain interference and intensity, in addition to the psychological state of the patient (Choi et al. 2013). Responses provided by X for the 52 items present across three domains and 12 different subscales suggested that the patient was dysfunctional, and perceived severity of her pain as high. Furthermore, she also reported that the osteoarthritic pain directly interfered with her life, and resulted in severe psychological distress, by reducing her activities. In order to gain a sound understanding of the pain severity, she was also asked to mark the pain areas on a human figure outline (Barbero et al. 2015). X circled areas around her knees and legs, thereby confirming severe osteoarthritis.
Pain management- Owing to the complex nature of pain, there are a plethora of therapies, medications and mind-body techniques that effectively help in management of pain. The mainstay pharmacologic treatment for osteoarthritis include administration of acetaminophen (Moore and Hersh 2013). However, taking cues from trials that elaborated on the fact that acetaminophen exerts short-term effects on pain, the patient was prescribed diclofenac, a non-steroidal anti-inflammatory drug (van Walsem et al. 2015). The drug has been found effective in reducing presence of substances in the human body that lead to inflammation and pain. Furthermore, its efficacy in treatment of osteoarthritis supported its administration upon the patient. In addition, the patient was cautioned about the adverse impacts of diclofenac that include an elevation in blood pressure, and/or gastrointestinal bleeding (Malfait and Schnitzer 2013). 50 mg diclofenac was administered twice a day for managing the osteoarthritic pain symptoms.
In addition, intra-articular corticosteroid injection was also used for treating the osteoarthritic pain. This provided short-term relief from the unbearable pain, and has also proved its efficacy in trials that focused on treatment of knee pain. The patient was also warned of possible flare-up in symptoms within 24 hours of medication administration. Efforts were also taken to implement appropriate alternative and complementary medicine for treating osteoarthritis of the knees. Glucosamine and chondroitin are the most commonly used supplements that help in pain management. A combined administration of both have already been proved effective by different studies in the treatment of severe knee osteoarthritis (Fransen et al. 2014). Both of these are essential components of the cartilage and stimulate the body to produce more cartilage. In addition, efforts were also taken to implement certain non-pharmacological interventions such as exercise and moderate physical activity.
Moderate exercise has many a times proved its effectiveness with respect to management of pain and functionality in people suffering from osteoarthritis in the hips and the knees (Messier et al. 2013). Conducting these exercise at least thrice a week might help in managing the severe pain that X is currently suffering from. Providing clear advice to the patient and making the exercise activities enjoyable would prove beneficial in the long run. Furthermore, she also needs to be reassured about the significance of doing exercise. Other nonpharmacological interventions that can be applied in this scenario include gait, functional, and balance training for addressing the impairment of balance, position sense, and strength, with the aim of reducing falls (Liao et al. 2013).
Spirituality is crucial in pain management because the condition is associated with meaningless and endless suffering (Siddall, Lovell and MacLeod 2015). Spiritual issues in this case were related to feelings of guilt, anger and despair. The patient was allowed to seek support form a spiritual leader to manage her distress. The ethical principles of beneficence, autonomy, nonmaleficence and justice guided the entire pain management process (Gatchel et al. 2014). The patient’s valid consent were taken before administering any of the interventions. This demonstrated a respect towards her decision making skills and values. Furthermore, efforts were also taken not to inflict intentional or careless harm, in addition to taking positive steps to help her. With an increase in the trend in medical use of NSAIDs and opioid medications, there is a need to consult government officials for ensuring that efforts to curb abuse of drugs are not impeding the patient’s right to pain management. Gaining a sound knowledge of litigation that is relevant to pain management will also help in informed clinical decision making (Manjiani et al. 2014). Moreover, a rigid generalizations would lead to cultural stereotyping and serious inaccuracies. Thus, the fact that the patient’s experience of pain will manifest in behavioural and emotional responses, particular to her personal history, and culture, will also be taken into consideration.
Conclusion- Pain management is the branch of medicine that employs an interdisciplinary approach in order to reduce the suffering and improve the overall health and quality of life of patients living with chronic pain. Conducting a blood test of the ESRD patient X ruled out other potential reasons for joint pain like rheumatoid arthritis, and helped in diagnosing osteoarthritis. Osteoarthritis, the condition reported by the patient suffering from ESRD was primarily characterised due to breakdown of the bone and joint cartilage, thereby leading to stiffness and joint pain. Hence, the implementation of appropriate pharmacological, alternative and nonpharmacological interventions, in accordance to the cultural and legal aspects of the client was an essential step in pain management.
References
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