Case Study #4
Diana is a 40-year-old woman with a history of breast cancer. Five years ago she underwent a lumpectomy with radiation, following by chemotherapy. One year ago she developed bone metastases in the lumbar spine and right clavicle, documented by bone scan. She is currently being treated with another regimen of chemotherapy that includes paclitaxol (Taxol®). She is returning to the oncology clinic for chemotherapy administration. The nurse is concerned about Diana’s comfort and conducts a pain assessment.
Diana at first reports no problems, but later admits that she developed very minor low back pain. She attributes this to increased activity as she has been remodeling her home. When the pain does not abate with over-the-counter medications (e.g., ibuprofen, acetaminophen) and non-pharmacological techniques (e.g., massage, heat), she will occasionally take a Vicoden® (5 mg hydrocodone/500 mg acetaminophen). When questioned why she does not take more, she states “I don’t like taking narcotics” and “My husband doesn’t like when I take the pills.”
Diana describes her pain as 2 or 3/0-10, located in her low back. The pain is aching and throbbing. When pressed to report other pain sites, she admits she has some shoulder pain, but rates it as a 1 currently. She also describes tingling in the feet bilaterally, extending to the ankles. “It is not pain really, just burning.”
Other history: Diana is married, lives with her husband and 2 teenage sons in a suburban home. She works as a receptionist in a dentist’s office.
During the history, Diana’s posture indicated that she was not comfortable. When Diana gets up from her chair to get onto the exam table, the nurse notes that she does so with difficulty. Palpation of the lower lumbar spine (L3-4) produces pain. Diana denies pain when the clavicle is palpated. Straight leg raises of less than 30 degrees increase the low back pain significantly. Neurological examination reveals weakness in lower extremities, with R > L. Sensory loss is noted bilaterally in the toes and feet to the ankles. Reflexes are intact.
1) What are the barriers to pain relief in this case?
2) What types of pain is Diana experiencing and what might be the underlying etiologies? What other questions should the nurse ask this patient?
3) Devise a plan of care for this patient.