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Chronic case – How much pain to endure

Francesca
Language: English
Country: Italy
Typology: health care professionals
Text:
This is the story of Francesca, a seventy-two year-old woman, suffering from obliterating arteriopathy to the lower limbs. She has extended ulcers in the lower limbs, covered by thick fibrin and necrotic tissue. They are hyper-exuding and the surrounding skin is eroded by the exudate. We first met Mrs. Francesca a year ago: she had been discharged about a month before from a hospital outside our Region, where she had been hospitalized due to the extensive lesions she had on her skin, and had undergone a by-pass operation due to her severe arteriopathy. During the last month, the patient has moved from her home to other hospitals for advice on infectious disease and analgesic, since the pain in her lower limbs, especially in those areas affected by the lesions, continues to be difficult to bear. At the moment of being treated, Mrs. Francesca was extremely confused and suffering. Throughout the day and most of the night, she walked back and forth; her analgesic position for rest was that of being sitting on a chair, with her bust bent forward. From that moment on, the work team has been formed by the home care service, the MMG, the Analgesic Therapy service of our ASL (Local Health Authority) together with Mrs Francesca. From that moment, until we managed to partially offset the pain, our goal was "to know and understand her pain". Francesca used to say: "It hurts, I do not sleep, they seem pins that prickle my skin, it is unbearable!". But how much pain does Francesca feel? Less than yesterday? And the day before yesterday, was it more or less painful? Since you started taking morphine, have you felt less pain? But more or less than yesterday? Francesca failed to answer our questions, she only knew that “today it hurts, it hurts very much”. So, what could we do? When we talked to other operators, we had different opinions about her pain. The evaluation was subjective and, consequently, we were unable to communicate with the operators of the Analgesic Therapy service in a direct way. We tried to change the therapeutic approach, depending on the intensity of the pain reported by the patient, with a succession of problems. Every time there were different difficulties. She was almost impossible to cure, it sometimes took more than an hour. The medication we used seemed to worsen her symptoms. For a long period, Francesca did not wish to move from home to undergo specialist examinations and diagnostic tests, because when she had done so, the pain had never ceased to torment her, not even for a moment. We asked Francesca to imagine a scale in which zero represented the absence of pain, and ten the maximum pain possible. The day after, Francesca told us her interpretation of the scale: a classic ladder directed upwards, starting from the smallest numbers towards the highest, and a beautiful six written at its side! Since that day, there has been a NUMBER for each day! "Hello Francesca, which number today?" "Last night, which number did we reach?" "Which are the numbers before and after the medication?" What is positive about this? This method has enabled all of us to adopt a common language, a clear interpretation of pain. It has allowed us to deal with emergencies in an organised manner, not to panic every time. It was important also for the patient, in that it has enabled her to appreciate the day in which she marked only four, aware of the difference from the day before, when she had reported a seven. This has allowed her to gain confidence, because she knows she can trust us when she complains about her pain. Thanks to close collaboration with the Analgesic Therapy Service and the MMG and to the attention paid when choosing products for medication, the pain has stabilized at a level of three/four, even if, unfortunately, Francesca has sometimes called us saying "Come here, it is nine!". In the meantime, her lesions have slightly improved, we manage to carry out the medication in an a-traumatic way. Francesca knows that perhaps they would never heal, but she thanks us every day… she is beginning to believe that it is not essential to feel bad to be medicated. In this system we have not considered Francesca’s husband, as he lives this situation, how he reacts in the face of so much suffering; certainly, he has been a great support both for her and for us, and, as it happens with the majority of the family members of our patients, sooner or later I must give him the certificate of "FAMILY ASSISTANT AND NURSE".


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