Test Your Knowledge
Question 1
Betty moves her right arm in the primary care provider’s office, and she grimaces. When asked about her pain, she states she is not experiencing pain. Choose the most empathetic and compassionate response by the clinician that could improve assessment.
Discussion
During the assessment there is a difference between Betty’s behavior (a grimace) and her response (minimal pain. The answer to question demonstrates both empathy and compassion. Empathy is the ability to put aside your
own thoughts and beliefs and see the perspective of the other person. Compassion is the awareness of another in combination with a desire to help the other person. The other answers demonstrate a perception of Betty’s discomfort and pain but do not express a desire to help during the assessment.
Question 2
What tools would you use to best monitor Betty and her right shoulder pain and its impact?
Discussion
The answer to the question involves two tools that have been found to be a valid and reliable and helpful in older adults for measuring the multidimensional aspects of pain. The Iowa Pain Thermometer is tool that can be used
in older adults for self-report of pain intensity [3]. The thermometer has both a visual component and verbal descriptors. The thermometer helps with abstract thinking, sometimes a problem in older adults. The PEG is a multidimensional scale with components of addressing pain interference [4]. The PEG questions include pain
intensity, enjoyment of activity and general activity. The measures in the other answers may be used for assessment of pain and function but are not the best for a representation of pain and the impact of pain for Betty as an older adult.
Question 3
For Betty’s home health evaluation by Nursing, Social Services and Physical Therapy, what areas of assessment would be covered by all three but in different ways?
Discussion
The answer of pain in daily activities is covered by all three disciplines in home health services. The other answers may be covered by one or two of the disciplines but are not typically covered by all three disciplines. There is overlap of the assessment of pain in daily activities between the three disciplines. In this scenario, nursing focuses on pain assessment and pain education, social services on pain impact and physical therapy addresses pain assessment and pain with function. Coordination of the assessments between team members could reduce replication or provide reinforcement of patient reports of pain and its impact.
Question 4
A home health nurse is going to complete pain education with Betty regarding her right shoulder pain, which topic is most important to discuss with Betty to improve her pain?
Discussion
The answer of exercise is the most important topic to discuss with Betty to improve her pain. Exercise has been shown to reduce pain more than nutrition, bathing or coping alone [5].
Question 5
The top priority for a home health physical therapy evaluation regarding her right shoulder pain is:
Discussion
For physical therapy, home safety is the top priority for Betty regarding her shoulder pain. Since Betty lives alone, she needs to be safe to continue living on her own. Her psychosocial concerns, arm strength and range of motion may impact her pain and function but safety is the top priority.
Question 6
Betty is an older adult who lives in alone in a farmhouse in rural Iowa. Her closest neighbor is one mile away. What is the greatest barrier for access to medical care for Betty’s right shoulder pain?
Discussion
Betty’s greatest barrier for access to medical care is the lack of medical resources close to home which is necessary to engage independently in physical therapy or other treatment options. Her closest care provider is 45 minutes away by car. Her neighbors and daughter are able to assist but have time restrictions due to the length of the drive to medical care. Prior to her difficulty with her shoulder, she was independent at home and able to drive independently to her primary care provider or medical care. She also has limited alternatives for accessing care with family or social support. Finding a solution to address the lack of local medical care resources is the priority.
Question 7
In Betty’s pain assessment, she describes the location of her pain is in her right arm, that it is dull and achy and averages a 6-7 on a 0-10 scale. In addition, she notes some reduction in pain with over the counter medications. What other information would be most helpful to know about Betty’s shoulder pain?
Discussion
The answer for the question is pain interference with activity. In the question descriptor, pain quality (dull, achy), pain location (right arm) and pain reducing factors (over the counter medication) are listed. Pain interference with
activity will reveal more about function, functional impairments as well as aggravating and relieving factors for pain, more so than the pain 24 hour cycle.
Question 8
What of the following is a true statement regarding risk/benefit of NSAID use for an older adult?
Discussion
The answer is the risk for renal system concerns with the use of non-steroidal anti-inflammatory drugs (NSAIDs). Renal and hepatic system complications are legitimate concerns. NSAIDs have risk for cardiac complications and
do not have increased risk for delirium in older adults. Older adults are as likely to receive pain relief from NSAIDs as younger adults.
Question 9
. Betty is presenting to her primary care provider for a recheck after 4 weeks of home health services for Nursing, Physical Therapy and Social Services. She has now had pain for 8 weeks, and she reports her pain is the same. What medication changes should the primary care provider make to her medications?
Discussion
According to clinical practice guidelines and evidence based practice recommendations, a steroid injection for adhesive capsulitis is the most appropriate treatment option at this time [5-8]. Opioid medications are not indicated for Betty due to her diagnosis of adhesive capsulitis. Evidence shows a steroid injection
to address inflammation of the glenohumeral joint capsule directly through use of an injection would better address the inflammation and pain [9] and changing the NSAID or the dosage of the NSAID would not be recommended.
Question 10
As a primary care provider, what outcomes would you use to assess Betty’s progress and readiness for discharge from her home health services?
Discussion
Betty’s primary complaints upon seeking health care were focused on pain and function. Level of assistance is important in clinical decision making, however provides limited information about progress and not enough information about function in relation to homebound status. Medication usage, motion and strength are important considerations in Betty’s progress, but do not determine readiness for discharge or homebound status.
