Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Three-person pain assessment role playing exercise

©2000 MCW Research Foundation
Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin. Published here with permission.

NURSE INTERVIEWER SCENARIO

You are a nurse seeing Mrs. K., a 75 y/o female with degenerative arthritis. You met her once, shortly after she was first seen by your agency. You have been away for the past 10 days, and return now to find that pain is reported to be an increasing problem and you are going to see her / care for her. All the information you have is that staff is increasingly concerned because she has been using/requesting more analgesics and appears to be a bit withdrawn. Her analgesic orders are for a hydrocodone/acetaminophen product, Tylenol #3, and Extra -Strength Tylenol. Mrs. K. is awaiting your visit.

PATIENT SCENARIO

History:

You are Mrs. K., a 75 year old woman with chronic arthritis. Two weeks ago you were admitted to Happy Valley Care Center/ Happy Valley Home Care following a fall and broken arm. Although the arm is healing well, you will likely need long term institutional care as you are unable to care for yourself due to the arthritis and have no home support.

Your pain has become worse over the past month, it is limiting your mobility. You note an aching pain in both hips, right worse than left, your low back, and right shoulder. The pain had been intermittent for years, but for the past month the pain has been almost continuous. The right hip pain is the biggest problem, becoming more intense with movement, especially at night. The pain wakes you up at night and you have trouble falling back to sleep. The pain is much worse whenever you get out of bed. Your current pain score using a 0-10 scale is 5/10 and will go to an 8/10 at night and with movement. The pain never goes below 3/10. Your goal for pain relief is to be able to sleep at night without pain.

Up until six months ago you were able to get by with prn NSAIDs. Six months ago your doctor told you to stop the NSAID because there was something wrong with your kidneys, you are not sure what the problem is. Since then, you have been taking Tylenol #3 and a hydrocodone/acetaminophen product. Current medications orders:

Tylenol Extra Strength, 1 tab po q 6 hours prn, general discomfort.

Tylenol #3, 1 tab po q 6 hours, prn pain.

Hydrocodone/acetaminophen, 1 tab po q 6 hours, prn for severe pain.

You have been asking for pain medication more frequently in the past week, although you really hate to take drugs. In fact, you think that some of the medication made you fall in the first place. Depending on the nurse that is working with you, you either receive 1 Tylenol #3 or 1 hydrocodone/acetaminophen every 6 hours. Tylenol #3 gives you no relief. The hydrocodone/acetaminophen starts working in about 30 minutes, reducing the pain from 8/10 to 3-4/10, but only lasts about 3 hours. A heating pad to your back has helped the back pain, but not the hip pain.

Social History:

Prior to admission to the nursing home, you had been living alone. You are a widow, with 2 children who live within 45 minutes of Happy Valley. You have noticed a decreased appetite over the past 2 weeks and have been less interested in social activities, preferring to stay in your bedroom. You are afraid that increasing pain will mean that you need surgery. Several years ago your best friend had hip surgery and died a few days after the operation. You last saw your physician about two weeks ago, but did not tell her/him that the pain was getting worse because you feared she/he would insist upon surgery.

Appearance, Affect and Responses to Interviewer

During the interview, you should be seated and appear to be uncomfortable, often shifting position in your chair. Your affect should be depressed, with little expression, short answers, and frequent 'sighs'. Your affect should indicate a "what does it matter" attitude. If asked, reply "of course I. m depressed, I. m in pain, I probably will need surgery. I might as well be dead." Only if prompted about your concerns, should you reveal that you are afraid of surgery because of what happened to your friend. Only if prompted, should you reveal that you are afraid to tell you physician about the worsening pain, because of your fear of surgery.

OBSERVER SCENARIO

Your job is to watch the interview process. Check off the following components of the assessment as they are completed. Once the pain assessment is completed, discuss the process and your observations with your team. Was the interviewer successful in obtaining a full assessment?

1. Griffie J, Weissman DE. Nursing staff education resource manual: A six session inservice education program in pain management for long-term care facilities. Medical College of Wisconsin, 2000. Published here with permission.

[Back to Featured Innovation]