| Course | NURS 6914 Advanced Palliative Concepts and Interdisciplinary Perspectives |
|---|---|
| Week | Week 3 |
| Paper type | Total pain case analysis |
| Length | About 1,050 words, 6 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Master of Science in Nursing (MSN) |
| Updated | September 2026 |
Free sample paper for NURS 6914 Week 3
Why the Pain Comes at Night: A Total Pain Analysis of a 71-Year-Old Combat Veteran With Metastatic Esophageal Cancer
Student Name
College of Nursing, Walden University
NURS 6914: Advanced Palliative Concepts and Interdisciplinary Perspectives
Instructor Name
Month Day, Year
Why the Pain Comes at Night: A Total Pain Analysis of a 71-Year-Old Combat Veteran With Metastatic Esophageal Cancer
The Puzzle
Nights are when the pain becomes unbearable for this composite 71-year-old, who served as an infantryman in Vietnam and now has esophageal cancer that has spread to his liver and bones. Over three weeks, his team has adjusted his opioid regimen twice. His daytime pain has improved from 7 to 3 of 10. His nighttime pain has not changed: he wakes after midnight rating it 8 or 9, calls out and sometimes asks for the nurse three times before dawn. His examination does not explain the difference; his tumor burden is the same by day and by night. His wife mentioned in passing that he has started having "the old dreams" again.
Cicely Saunders described total pain as suffering with physical, emotional, social and spiritual dimensions, each capable of intensifying the others (Saunders, 2001). Mehta and Chan (2008) argue that understanding the concept is a prerequisite for pain control, because treating only the physical dimension leaves the rest untouched. This analysis traces each dimension in his case and asks what connects them to the night.
Physical Dimension
His pain has two physical sources: a deep, constant ache in his upper abdomen and back from the liver metastases, and pain in his ribs from bone lesions, worse with movement. Both respond to his current opioid and a nonsteroidal class medication given with his oncologist's approval. Neither has a physical reason to worsen at night. Lying flat can increase discomfort from the liver, and the team has already raised the head of his bed. The physical assessment therefore explains his daytime pain well and his nighttime pain poorly.
Psychological Dimension
His wife's comment prompted a gentle conversation. He described nightmares of combat that had faded for decades and returned over the past month, along with waking with his heart pounding, scanning the dark room and being unable to settle. Serious illness, loss of control and the approach of death can bring back posttraumatic stress symptoms in veterans who had coped for years, and those symptoms can intensify pain and distress near the end of life (Feldman & Periyakoil, 2006). The We Honor Veterans program of the National Hospice and Palliative Care Organization encourages hospice teams to ask every patient about military service for exactly this reason. No one had asked him until now.
He also carries something the nightmares do not fully capture. He said, "I did things over there I have never told anyone." Moral injury describes the lasting psychological and spiritual harm that can follow acts that violate a person's deeply held moral beliefs, whether committed, witnessed or failed to prevent, and it differs from fear-based trauma in involving guilt and shame (Litz et al., 2009).
Social Dimension
He worries about his wife's finances after his death: their house has a second mortgage, and he is not sure she knows the passwords to their accounts. He has not spoken to his daughter in eleven years after an argument he now regrets. Both worries surface at night, he says, "when there is nothing else to think about."
His role has changed as well. For forty years he handled the bills, the repairs and the decisions, and he takes pride in having kept his family secure. Now he cannot drive or climb the stairs, and his wife handles everything he used to. He describes feeling like a burden, a social loss that feeds both his worry about money and his sense that there is little time left to put things right with his daughter. His wife, for her part, says she would rather hear his worries than have him lie awake with them, but he has not wanted to frighten her.
Spiritual Dimension
He was raised Catholic and stopped attending Mass after the war. He wonders whether he is forgiven for what he did, and whether there is anything after death for someone like him. He has not spoken with a chaplain.
When asked what gives him strength, he named his wife, the men he served with, several of whom he still calls on Veterans Day, and, after a pause, "maybe God, if He will still have me." That answer holds both a source of support and the heart of his distress. Spiritual pain of this kind is not a symptom to be treated away; it is a question he wants help carrying, and he has said he would welcome a visit from someone who understands both faith and what soldiers carry home.
What Connects Them to the Night
The dimensions converge after dark. The nightmares wake him, and he wakes into a quiet room where his worries about money and his daughter, and his question about forgiveness, have nothing to compete with. Fear and hypervigilance raise his arousal, which lowers his tolerance for the physical pain that is always present. The pain he rates at 8 or 9 is real, and it is more than physical. That is why adjusting the opioid again would likely fail: it addresses one strand of a four-strand problem.
An Integrated Plan
Physical. Keep the current opioid regimen, which works in the daytime; do not escalate for nighttime pain until the other dimensions are addressed. Review his evening medicines for anything that might worsen sleep or dreams.
Psychological. Refer to the Veterans Affairs palliative care team or a clinician experienced in trauma near the end of life. Offer a night light, an agreed routine for waking and a nurse who introduces herself on entering his room. Consider, with the prescriber, whether medication for nightmares is appropriate.
Social. The social worker will help him and his wife organize finances and passwords this week, and will ask whether he would like help contacting his daughter.
Spiritual. Offer a Catholic chaplain, ideally one familiar with veterans, to talk about forgiveness. If he chooses, the chaplain may offer the sacrament of reconciliation.
Coordination. One clinician, the palliative care nurse practitioner, will coordinate the plan and meet with him weekly, because four dimensions handled by four disciplines without coordination can become four separate conversations, each partial. The measure of success will be his nighttime pain rating, the number of calls before dawn and his own report of whether nights feel different.
References
Feldman, D. B., & Periyakoil, V. S. (2006). Posttraumatic stress disorder at the end of life. Journal of Palliative Medicine, 9(1), 213-218. https://doi.org/10.1089/jpm.2006.9.213
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
Mehta, A., & Chan, L. S. (2008). Understanding of the concept of "total pain": A prerequisite for pain control. Journal of Hospice and Palliative Nursing, 10(1), 26-32. https://doi.org/10.1097/01.NJH.0000306714.50539.1a
Saunders, C. (2001). The evolution of palliative care. Journal of the Royal Society of Medicine, 94(9), 430-432. https://doi.org/10.1177/014107680109400904
What the NURS 6914 Week 3 instructions ask for
Total pain assignments usually ask you to analyze a patient's suffering across its physical, psychological, social and spiritual dimensions and to propose an integrated plan. Four to five pages is a common length. Choose or describe a case in which the physical findings do not explain everything. Assess each dimension with specific findings, including service history for veterans and family relationships. Look for how the dimensions interact, for example at a particular time of day. Distinguish related concepts carefully, such as trauma-related symptoms and moral injury. Build a plan that addresses every dimension, explain which clinician coordinates it and define success in terms the patient would recognize, such as better nights.
How this NURS 6914 Week 3 example is built
The puzzle section describes the day and night difference and cites Saunders and Mehta and Chan on total pain. The physical section explains why his tumor accounts for daytime pain but not the nights. The psychological section cites Feldman and Periyakoil on posttraumatic stress at the end of life, mentions the We Honor Veterans program and cites Litz and colleagues on moral injury. Social and spiritual sections describe his money worries, his estrangement, his changed role and his question about forgiveness. A section explains why the strands converge after dark. The plan addresses each dimension and names the nurse practitioner as coordinator. Success is defined as better nights in his own report.
Reading the NURS 6914 Week 3 rubric
Total pain analyses are generally scored on completeness across dimensions, depth of assessment, integration and the plan. Completeness requires specific findings in all four dimensions, not a sentence each. Depth shows in recognizing patterns, such as why pain peaks at night. Integration is often the largest share and is earned by explaining how the dimensions amplify each other. The plan should address every dimension with a named discipline and a coordinator. Correct use of related concepts, such as moral injury, earns credit. Attention to veteran-specific care is valued in many sections. Evidence should come from primary palliative and trauma literature, and APA formatting completes the criteria. A night pattern explained across dimensions tends to earn more than four separate lists.
NURS 6914 Week 3 help: mistakes that cost marks
Total pain papers lose marks when the physical dimension gets two pages and the others a paragraph each. Another common loss is listing dimensions without showing how they interact. Some plans increase opioids for pain that the analysis has already shown is not only physical. Others assign each dimension to a different discipline with no one holding the whole. Find specific findings in all four dimensions, look for the pattern that connects them, keep the opioid plan steady unless the physical picture changes, treat every strand and name one coordinator. If your scenario gives a different patient, the desk can build the analysis around that person. Ask about military service in any older adult case you write.
Get a NURS 6914 Week 3 example written to your instructions
Upload your Week 3 case with its prompt and rubric; if your patient has a history that shapes suffering, such as military service, migration or incarceration, flag it. The total pain case returns organized dimension by dimension, with an interaction analysis and a coordinated plan, inside 24-48 hours, and the first one carries no charge.
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NURS 6914 Week 3 questions, answered
What is total pain?
Cicely Saunders' concept that suffering at the end of life has physical, psychological, social and spiritual parts that interact, so pain cannot be treated as a purely physical event. Here it explains why opioid adjustments helped his days but not his nights. Applying the concept to a specific puzzle, rather than defining it, is what your rubric is most likely to reward.
What is moral injury?
A term used in veteran and clinical literature for the lasting distress that follows acting, or failing to act, against one's own moral beliefs, often in combat. It differs from post-traumatic stress, though the two can coexist. It frames the guilt he eventually shares with the chaplain, giving the spiritual section analytic weight instead of a passing nod to faith.
Why does one clinician coordinate the plan?
Because total pain invites four parallel plans, and parallel plans fragment. The example keeps each dimension with the discipline best placed to respond but routes the plan through one coordinating clinician, with a single review point where all four strands are reassessed together. That structure mirrors the concept: a person whose suffering is connected needs a response that is connected too.
Where can I find a free NURS 6914 Week 3 sample paper?
The complete total pain analysis, four dimensions, the night pattern and the integrated plan, can be read on this page, free. An analysis of your own scenario's patient can be requested.
Why does the NURS 6914 Week 3 plan not raise his opioid for night pain?
Because the analysis shows the night pain is driven by nightmares, worries and a spiritual question as much as by the tumor, so more opioid would treat only one strand of it.