Case+Study

We will judge who says this during presenating depending on how much time each person's sections take up.



Aetiology What are the possible aetiologies of David’s pain? Injured Calcanium on his left foot after falling from a height of 3 metres at work. Recurring weakness and discomfort in his ankle following a soft tissue injury whilst playing football 1 year ago.

Disorder / disease David's new injury is acute pain Recurring injury is chronic pain

Clinical Manifestations (signs & symptoms) Explain the physiological manifestations of the signs and symptoms David is experiencing.

Blood pressure is 120/70 Temperature is 36.6 Pulse is 120 Respirations is 22 Sao2 100% Pallor Sweating Nausea
 * Signs:**

Slight agitation Moaning Scored his pain 9/10 1 hour of throbbing in his left foot Tingling sensation in his metatarsal and tarsals Swelling and bruising over calcanium Unable to weight bare on his left foot
 * Symtoms**

Pathophysiology
 * Acute trauma to the Calcinium.
 * Pain is Transduced by the Spinal Nerves located near the L5 Dermatome.
 * The messaged is first Transmitted via the Adelta fibres then the C fibres.
 * A delta Fibres "Epricritic Pain"
 * Mechanical message
 * Sharp, Fast pain
 * Myelinated fibres increase speed of processing
 * Impulses conducted at around 20m/sec
 * C Fibres "Protopathic Pain"
 * Mechanical and Thermal Stimuli
 * Slow, dull, long lasting pain
 * unmyelinated fibres, slower response
 * Impulses conducted at around 2m/sec
 * The message is Perceived in the Frontal cortex and the primary sensory cortex of the post central gyrus of parietal lobe. The message is interpreted and an appropriate response is formulated - in Davids case, to release neurotransmitters
 * Modulation.
 * release of neurotransmitters such as serotonin, norepinephrine and endogenous opioids to counter the pain

Diagnosis The doctor has prescribed the R.I.C.E. treatment to help with David's pain.
 * Onset
 * Fell on Right Calcanium falling from a 3m height at work.
 * Previous Soft Tissue Injury from football on the same calcanium one year ago.
 * Provocation
 * Unable to bear weight on his foot
 * Quality
 * 1 hour of Throbbing pain in right foot
 * Tingling sensation in Metatarsals and Tarsals
 * Odema and Contusions over Calcanium
 * Region/Radiation
 * Right Calcanium
 * Not noted as radiating.
 * Severity
 * Patient Pain Score - 9/10
 * Time
 * This injury - Short amount of time
 * But precipitated by a previous injury on the same location
 * Associated Phenomena
 * Physiological Manifestations
 * Pallor
 * Sweating
 * Behavioural Manifestations
 * Agitated
 * Moaning
 * Nauseous
 * Non Pharmacological**

The idea behind RICE is to minimize the inflammation and swelling that occurs with a soft tissue injury. David will need to rest his ankle and not apply any pressure to it to assist in the recovery process. Applying ice to the sore area may relieve pain and reduce swelling by restricting blood flow to the area. Compression of David's ankle by bandaging the affected area will also help reduce swelling. Elevation of the ankle will decrease swelling and improve fluid drainage. David's ankle should be elevated higher than his knee and hip.

When selecting other non-pharmacological interventions for David, I would be considerate of the type of injury, and the amount of pain he is in. I would arrange for him to meet with a physiotherapist. A study conducted by Hultman //et al// (2010) found that early physiotherapy intervention has a positive effect on patient-focused foot and ankle function after an acute ankle sprain. Physiotherapy activities include bunching and sprawling toes, drawing the letters of the alphabet one at a time with your foot, walking on toes and heels, or more physical activities such ascycling, or running in a figure-8.

I would also advise David to undertake hot and/or cold therapy - this is good because it is something David can manage himself at home. As discussed before, hot and cold therapy is effective in relieving pain. I would discharge David with an ice pack as well as some spares, and educate him on how to use them.

Finally, I would encourage David to practice relaxation and distraction techniques. It has been suggested that relaxation decreases pain by relieving anxiety which is known to sharpen the perception of pain. Music is effective for pain distraction (Peric-Knowlton 1984) and so I would ensure David had access to an iPod, or failing that, a good magazine or a TV. I would encourage David to practice deep breathing and relaxation for when he is discharged. Relaxation techniques may also help David cope with his migraines, for which he says stress is a contributing factor.

I would keep in mind that the effectiveness of relaxation therapy depends on the open mindedness and attitude of the patient. Without making too many assumptions based on sterotypes, I would be mindful of the fact that David is a 30 year old tradesman, and may not be open to certain therapies, but I would check this with him first.

//Using your knowledge of physiology, explain how the following medication function in the management of pain - NSAIDs, Tramadol and Pethidine.//
 * Pharmacological:**

Ibuprofen, such as Neurophen, is used for the treatment of headache or migraine headache. It can also be used to treat muscular aches and pains. Adverse effects include abdominal pain and nausea. NSAIDs work by blocking the effects of Cox-1 and Cox-2 enzymes. These enzymes play a key role in making prostaglandins. Prostaglandins act as messenger molecules in the process of inflammation. By blocking the Cox enzymes, NSAIDs stop your body from making as many prostaglandins, which means less swelling and less pain.

Pethidine, as discussed earlier, is an opioid used for treatment of moderate to severe pain. Adverse effecfs include dependence, tolerance, respiratory depression and CNS disturbances such as dizziness, disorientation and hallucinations. Tramadol is a relatively new centrally acting synthetic analgesic. It's not related chemically related to the other opioids which inhibits reuptake of nor-adrenaline, and so it is sometimes referred to as an opioid-SSRI. It is more expensive than morphine, however itmay have a lesser potential for respiratory depression and dependency. Common side effects include nausea, dizziness, hypertension and seizures. At the spinal cord level, opioids stimulate opioid receptors and inhibit the release of substance P, involved in pain mediation, from the dorsal horn. Opioids also act to 'close the gate' in the dorsal horn, thus inhibiting afferent transmission. These drugs can also alter perception and emotional responses to pain, and in some cases, patientshave reported that they can still feel the pain, though they are no longer concerned about it.

Maxolon is an antiemetic/antinauseant which helps to control nausea and vomiting. Adverse effects to monitor include CNS disturbances including impaired alertness. It is likely that Mxolon has been prescribed to counter the effects of Tramadol and Pethidine.

Complications (acute & chronic):
 * Acute
 * Cardiovascular
 * Increased Blood Pressure and heart rate as a result of Injury
 * Immune
 * Increased immune response
 * Respiratory
 * Increased respirations as a result of pain.
 * Musculoskeletal
 * Tensing of muscles to counteract pain
 * Pressure Ulcers whilst in Hospital if unable to move from the bed
 * Cognitive/Psychological
 * Possible Fear or Anxiety surrounding injury and healing process
 * Short term implications for work and social life
 * Anger, Irritability


 * Chronic
 * Cardiovascular
 * Chronic Stress reaction can lead to an increase in Heart Rate and Blood pressure
 * Respiratory
 * Risk of Respiratory Depression due to Tramadol Use
 * Genitourinary/Gastrointestinal
 * Constipation or abdominal pains due to ongoing medication
 * Changes in appetite
 * Musculoskeletal
 * Tense muscles
 * Limited mobility
 * A lack of energy
 * Cognitive/Psychological
 * Depression, Anger and Anxiety
 * Affected emotional responses due to depression.
 * Fear of re-injury.
 * Long term implications for work and social life
 * Dependence on medication (Pethidine)

//Describe the Numeric rating scale and how you would you educate David about using this scale.//
 * Implications for nursing practice**

As discussed earlier, there are a number of different pain scales available for use, including hte colour scale, face scale, or more simple numerical scale. The choice of pain rating method should be appropriate for the patients age, lanuage, education and cognitive status. For David, being a 30 year old male who is coherrent, we would most likely use the numerical scale. The active involvement of David in his pain assessment and treatment will ensure that he shares a common goal for wellness, and will honestly communicate changes in the severity and nature of his pain. Pain should be assessed throughout David's treatment, after activities such as walking around, and at rest for instance in the morning. By using teh pain scale with David, we should be able to gauge quantifiable changes in his pain over time, rather than by simply asking him 'how are you feeling' once in a while. Given that David is a 30 year old male tradesman, it is likely that if simply being asked how he is feeling, will respond with 'yeah, ok'. And we moight not get a valid pain assessment. As well as talking to David, I would also include his family in the education process as they may need to assist in managing David's pain once he is discharged.