NURS 6912 Week 2 pain assessment writeup example

Two Pains in One Man: A Comprehensive Pain Assessment of Bone and Neuropathic Pain in Metastatic Prostate Cancer

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College of Nursing, Walden University

NURS 6912: Symptom Management for the Hospice and Palliative Care Clinician

Instructor Name

Month Day, Year

Two Pains in One Man: A Comprehensive Pain Assessment of Bone and Neuropathic Pain in Metastatic Prostate Cancer

Case Summary

Thirty years behind the wheel of a city bus ended in retirement for this composite 68-year-old, and two years later he has prostate cancer that has spread to his lumbar spine and pelvis. He is receiving hormone therapy and was referred to the palliative care clinic for pain that is limiting his walking and sleep. When asked to rate his pain, he answered, "Which one?" He describes a deep ache in his lower back and right hip that flares when he stands, and a separate burning pain that runs down the back of his left leg to the outer ankle, worse at night. This writeup assesses each pain on its own terms before any management is planned.

Cancer pain often involves more than one mechanism in the same person. An international survey of patients with cancer pain found that many had two or more distinct pain syndromes, and that bone pain and neuropathic pain were among the most common (Caraceni & Portenoy, 1999). Averaging them into one score would hide the differences that decide treatment.

Pain Profile 1: Bone Pain

The first profile follows a standard structure: location, quality, intensity, timing, what makes it worse, what relieves it and its effect on function.

Table 1

Bone Pain Profile

The pattern of a constant ache with sharp increases on movement is typical of incident pain from bone metastases. The spikes matter clinically because they are predictable, which means a plan can prepare for them rather than react after they begin.

Pain Profile 2: Neuropathic Leg Pain

The second pain differs in almost every feature.

Table 2

Leg Pain Profile

Pain following a band down the leg, with burning, electric qualities and pain from light touch of bedsheets (allodynia), suggests a neuropathic component, most likely from nerve root involvement at the level of the spinal metastases. The DN4 questionnaire, which combines seven interview items about pain qualities and associated sensations with three brief examination items, was developed to distinguish neuropathic from other pain (Bouhassira et al., 2005). His answers were positive for burning, electric shocks, tingling and numbness, and examination found reduced sensation to touch and brushing along the outer calf, a score of 6 of 10. A score of 4 or more supports a neuropathic component.

Severity and Interference

The Brief Pain Inventory asks patients to rate pain severity and the degree to which pain interferes with seven areas of life, and its two-factor structure of severity and interference has been supported in validation work (Tan et al., 2004). He completed it for his worst pain overall. His worst pain in the past 24 hours was 7 of 10, and his average pain 5 of 10. Interference was highest for walking (8 of 10), sleep (8 of 10) and general activity (7 of 10), and lowest for relationships with others (2 of 10). The pattern fits the two profiles: the bone pain takes his walking, and the leg pain takes his sleep.

Red Flag Screen: Spinal Cord Compression

Because he has spinal metastases and a new radiating leg pain, the assessment includes a screen for metastatic spinal cord compression, which requires urgent treatment to preserve function. An audit of delays in diagnosis found that patients often had back pain and radicular symptoms for weeks before diagnosis and that waiting for a sensory level or loss of bladder control led to late treatment (Levack et al., 2002). The screen asked about and examined for the following: back pain worse lying flat or with coughing, new weakness in either leg, a band of numbness around the trunk, difficulty walking beyond what pain explains and changes in bladder or bowel control.

He reports that his back pain is not worse lying flat, and he denies leg weakness, bladder or bowel change or numbness around the trunk. Strength in both legs is full on examination. The screen is negative today. Because the leg pain is new and radicular, the palliative clinician discussed the findings with his oncologist, who arranged imaging of the spine, and the patient and his wife were taught which symptoms mean going to the emergency department the same day.

Psychosocial Context

He is worried that the new pain means the cancer is growing, and he admits that he has been taking less of his as-needed medication than prescribed because he does not want to "get hooked." His wife reports that he has become short-tempered at night. These findings are part of the pain assessment: fear about meaning affects how pain is experienced, and his reluctance to use the analgesic explains part of the partial relief. His concern about addiction is common and deserves a direct conversation, not reassurance alone, because it is shaping how he takes his medication.

Summary

This man has two pains with different mechanisms, patterns and effects. The bone pain is incident pain on movement that takes his walking. The leg pain is neuropathic, worst at night, and takes his sleep. A single rating would have hidden that distinction. Management will need to address each mechanism separately, prepare for predictable movement-related spikes, respond to the result of the spine imaging and address his fears about the medication. Both pains will be reassessed with the same measures at his next visit.

References

Bouhassira, D., Attal, N., Alchaar, H., Boureau, F., Brochet, B., Bruxelle, J., Cunin, G., Fermanian, J., Ginies, P., Grun-Overdyking, A., Jafari-Schluep, H., Lantéri-Minet, M., Laurent, B., Mick, G., Serrie, A., Valade, D., & Vicaut, E. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain, 114(1-2), 29-36. https://doi.org/10.1016/j.pain.2004.12.010

Caraceni, A., & Portenoy, R. K. (1999). An international survey of cancer pain characteristics and syndromes. Pain, 82(3), 263-274. https://doi.org/10.1016/S0304-3959(99)00073-1

Levack, P., Graham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A., Hurman, D., McMillan, N., Rampling, R., Slider, L., Statham, P., & Summers, D. (2002). Don't wait for a sensory level: Listen to the symptoms. A prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology, 14(6), 472-480. https://doi.org/10.1053/clon.2002.0098

Tan, G., Jensen, M. P., Thornby, J. I., & Shanti, B. F. (2004). Validation of the Brief Pain Inventory for chronic nonmalignant pain. Journal of Pain, 5(2), 133-137. https://doi.org/10.1016/j.jpain.2003.12.005