Determination Of Pain

In terms of pain development, elderly patients comprise of the largest population that is worst affected. This is primarily because the patients are affected by aging and prevalence of certain pain syndromes. It is important to understand the pain development is because of the aging (Manfredi, Breuer, Meier & Libow, 2003). As a nurse, the most important aspect to understand the process of diagnosing pain and its symptoms through a systematic process. From the case study, it is evident that the patient is undergoing pain. In pain detection, as a healthcare provider, it is important to comprehend that it is easy for one to overlook the symptoms thus careful assessment should be considered (Aubrun, 2005). According to information that is availed on diagnosing pain in geriatric patient, symptoms that are normally involved include insomnia, loss of appetite, which is characterized by change in behavioral patterns, lack of holding conversations, hypersensitivity to touch, depression, agitation and irritation. From the listed symptoms, it is evident that the patient suffers from signs and symptoms that are categorized under pain (“Pain Assessment and Management Strategies for Elderly Patients”, 2014). Judging from the case study, it is evident that this can be acute pain, as the patient has not been observed to react in this manner despite his past medical history, which indicates that he suffers from malaises such as dementia, osteoarthritis, peripheral vascular disease, and diabetes mellitus.

Pain Assessment in Cognitive Impaired Patient

In cognitively impaired patients, healthcare providers often understand the standards pain assessment procedures that are usually employed might be ineffective. However, there are methods that have been developed in assessing pain in elderly patient that are cognitively impaired. Firstly, it is important to ask simple and specific questions to the patient (Aubrun, 2005). Some of the terms that can be used to enable the patient to express themselves and the type of pain they are undergoing include “Do you feel any aches? Burning sensations? Heaviness? Soreness/”. In asking these questions, it is important to evaluate the tone, gestures and effect of the words employed when talking with the patient. Through this process, it is often to note that the elderly might fail to understand what they are being asked (Iyer, 2011). In such instances, ensure that as a care provide, eye contact is maintained, and that the tone of interaction is calm so that they do not feel as if they are being threatened.

Careful observation and monitoring is conducted in instance where verbal; communication fails to bear results (Manfredi, Breuer, Meier & Libow, 2003). This includes conducting an examination of the elderly patient by observing their behavioral patterns, symptoms that indicate discomfort, facial expression, guarding, and vocalizations (Steed & Study Group, 2010).. It is also essential important to observe the autonomic responses that occur because of manifestations of pain. This includes the alteration of the heartbeat, diaphoresis, change in respiratory rates and blood pressure. Lastly, it is imperative to involve the caregivers and family of the patient in assisting with the pain assessment. This is because of the close relationship they share with the patient thus they are able to appeal to them verbally and understand the type of pain they are feeling (Aubrun, 2005). Conversely, the healthcare provider should be aware that the assessment process is continuous thus ensure it is ongoing as they wait for the patient to communicate their concerns and needs in terms of healthcare treatment and medication.

Possible Causes of Pain

Venous Leg Ulcer

Venous leg ulceration is caused by venous hypertension, which is sustained when the veins become insufficient because the valves become incompetent (Li, 2014). In normal situations, the pressure of blood in the veins decreases when there is cessation of exercise (Steed & Study Group, 2010). This means that there is relaxation of the muscles that allows for the perforated veins, which act as the connecting element between the deep and join venous circulation to regulate pressure through decreasing it and preventing reflux of blood between the two branches. In the case of venous ulcer formation, it means that the pressure is not regulated hence remains high. The developed ulcer as observed in the elderly patient is likely to form in the gaiter part of the limbs or near the malleolus.

Arterial Ulceration

This type of ulceration normally occurs at the bony part of the foot or the toes and heels (Iyer, 2011). The wound that develops seems swollen with edges that are demarcated. On examining the wound, it is possible to detect that there is reduction of the arterial pulse in the posterior tibial arteries as well as those in the dorsalis pedis. This condition develops the patient lacks efficient capillary refill time. In normal cases, when the dorsum or the great toes are pressed for a few minutes, one observes that the skin color at the pinched part turns red and resumed color after a few seconds (Fukaya & Margolis, 2013). However, to understand that the patient has developed vascular complication, one is likely to observe that the skin takes time to resume normal color.


In elderly patients that are partaking in lifestyle behavior such as smoking, it is important to educate them on stopping the habit (Fukaya & Margolis, 2013). Measures should also be implemented in managing conditions such as hypertension and diabetes, which the patient in the case study suffers from. In terms of comfort, it is important to provide the patient with a comfortable sleeping arrangement that will allow them to sleep with their head raised to ensure there is adequate blood flow. There should also measures directed towards ensuring that the patient receives effective foot and leg care that will aid in the healing of the wound (Spentzouris & Labropoulos, 2009). Treatment with antibiotics is also advised. This step is important because it ensures that the arterial or venous ulcer does not deteriorate. In cases whereby the patient is feeling pain due to the ulcer, it is recommended that they be referred to a vascular surgeon who will administer opiod analgesia, as they are booked for surgery.

Risk Factor of Wound Development

Pain Sensation Impairment

This form of impairment is one of the risk factors that promote the chances of wound development. This is because patient that undergo this condition are likely to suffer from chronic and acute repetitive injuries (Spentzouris & Labropoulos, 2009). In some cases, the patient might suffer from sensory neuropathy, which causes them to overlook the wound hence causing neglect to the wound. The patient in the case study is at a high risk because they are diabetic.

PVD, PAD & CVI and their differences

PAD is an abbreviation for peripheral artery disease. It is characterized by painful muscle cramps that are experienced in the lower extremities during strenuous activities such as exercising, walking, jumping and climbing. It is observable that the pain diminishes after cessation of the said activities (Steed, 2006). Peripheral artery disease is often caused by the narrowing of peripheral arteries that are located within the leg region. Symptoms of this condition include bluish skin, skin ulcers, poor hair growth, and poor nail growth (“Pain Assessment and Management Strategies for Elderly Patients”, 2014). CVI is a condition that is manifested where the valves within the venous walls fail to function efficiently (Li, 2014). This makes it difficult for the blood in the lower extremities to be pumped to the blood because of the weakened valves that cause reflux. The main difference that can be observed between these conditions is the effect on the blood vessels that are affected (Steed, 2006). For instance in PVD, the vessels that are affected are the peripheral arteries, which become narrow. This is different from CVD because it involves the malfunctioning of the veins, which carry blood to the heart.

Educating Diabetic Type 2 Patient

It is important to understand that diabetic patients require education on the various ways through which they can make informed lifestyle changes that are pertinent in managing the condition (American Diabetes Association, 2015). The effective way of educating the patient is through developing a teaching plan that customizes the needs of the patient. The teaching plan should contain the methods on controlling their blood sugar levels and living a lifestyle that enables them to prevent developing severe complication (American Diabetes Association, 2015). It should also include food planning, recommended medication, managing hyperglycemic or hypoglycemic episodes, exercise routines, and information suitable to the patients in developing an understanding about the onset and management of the disease.



American Diabetes Association,. (2015). American Diabetes Association. Retrieved 14 December 2015, from

Aubrun, F. (2005). Management of Postoperative Analgesia in Elderly Patients. Regional Anesthesia And Pain Medicine, 30(4), 363-379.

Fukaya, E., & Margolis, D. (2013). Approach to diagnosing lower extremity ulcers. Dermatologic Therapy, 26(3), 181-186.

Iyer, R. (2011). Pain Documentation and Predictors of Analgesic Prescribing for Elderly Patients During Emergency Department Visits. Journal Of Pain And Symptom Management, 41(2), 367-373.

Li, J. (2014). Regional anesthesia for acute pain management in elderly patients. World Journal Of Anesthesiology, 3(1), 82.

Manfredi, P., Breuer, B., Meier, D., & Libow, L. (2003). Pain Assessment in Elderly Patients with Severe Dementia. Journal Of Pain And Symptom Management, 25(1), 48-52.

Pain Assessment and Management Strategies for Elderly Patients. (2014). Home Healthcare Nurse, 32(5), 281.

Spentzouris, G., & Labropoulos, N. (2009). The Evaluation of Lower-Extremity Ulcers. Semin Intervent Radiol, 26(04), 286-295.

Steed, D. (2006). Clinical Evaluation of Recombinant Human Platelet-Derived Growth Factor for the Treatment of Lower Extremity Ulcers. Plastic And Reconstructive Surgery, 117(SUPPLEMENT), 143S-149S.

Steed, D., & Study Group. (2010). Clinical evaluation of recombinant human platelet – derived growth factor for the treatment of lower extremity diabetic ulcers. Journal Of Vascular Surgery, 21(1), 71-81.

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