Angela Stevens,

28 years old

Overview

Is pain always what the patient says it is? Though the patient's rating of pain is

always relevant, the nurse must collect and cluster additional clinical data to make

correct clinical judgments regarding pain control. In this dilemma, a post-operative

patient with a history of narcotic tolerance and chemical dependency continues to

require increasing amounts of narcotics for pain control. How to guide

clinical decision making without being judgmental is the essence of this

patient dilemma.

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Clinical Dilemma Case Study Erin McLaughlin

Pain Control or Drug Seeking Behavior?

I. Scenario

History of Present Problem:

Angela Stevens is a 28-year-old woman who is post-operative day (POD) #2 after a small bowel resection

and lysis of adhesions. She has chronic abdominal pain due to severe Crohn's Disease and has developed

narcotic tolerance and dependence as a result. She has been clinically stable post-op, but has been c/o

increasing incisional pain despite the Fentanyl/Ropivicaine epidural drip being increased from 8 mL/hr·

to 12 mL/hr· earlier today. She has hydromorphone (Dilaudid) 1mg IV push prn every 3 hours for

abdominal pain that remains persistently greater than 6/10 on a 0-10 pain scale. Her pain goal is to be 4

or less.

Personal/Social History:

Angela is a single mother of two children ages three and one. She lives in her own apartment. She has

struggled with chemical dependency in the past and denies any current problems. A routine urine drug

screen before surgery was positive for benzodiazepines, even though she has no scheduled medications

in this pharmacologic classification. She is estranged from her mother and has little support at home.

What data from the histories is important and RELEVANT? Why is this significant to the RN? (Each

data point must include a corresponding significance.)

RELEVANT DATA from Present Problem Clinical significance to the RN

-Chronic abdominal pain from severe Crohn’s

Disease developing narcotic tolerance and

dependence

-She has been stable post-op but has been

complaining of increased incisional pain

-It is important to know that she has developed a

tolerance and dependence so that we, as the

nurse, can be aware to watch for the s/s of

addiction to hydromorphone

-Since she has been stable, need to watch her VS

to make sure that she stays stable and that when

she does state a higher level of pain, that her VS

match what she is saying

RELEVANT DATA from Social History Clinical Significance to the RN

-Single mother with little support at home

-She struggled with chemical dependency in the

past and denies current problems

-Has benzodiazepines in her urine even though

-She has no one that is watching her, watching for

signs of addiction

-A past history increases her chances of relapsing

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