Chapter 35: Comfort and Pain Management

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused to time and place Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA.

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?

"Can you describe the type of pain you are having?" Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset.

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body." The client needs further instruction when they say they can use the TENS unit on other areas of the body. Such a statement would indicate that the client does not understand that the unit should be used as prescribed by the physician in the location defined by the physician. The TENS unit will decrease the amount of the pain medication used by the client as it increases the blood supply to the injured area and will not interfere with the activities of daily living.

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education?

"I will have my wife push the PCA button when I'm asleep." The client should be the only one to administer medication via the PCA pump. Using the pump prior to getting out of bed and/or ambulating will help decrease the pain. Distraction is an effective nonpharmacologic means of dealing with pain. Constipation is a common side effect from many pain medications. Increasing fluid intake is one way of attempting to prevent it.

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled.

The nurse is assessing a client who is experiencing pain. The nurse notes the client is experiencing acute rather than chronic pain when the client makes which statement?

"The pain is really sharp in this one spot." Acute pain can be differentiated from chronic pain because it is specific and localized whereas chronic pain tends to be nonspecific and generalized. Clients experiencing acute pain will indicate a recent onset whereas chronic pain has a remote onset. Acute pain is associated with sympathetic nervous system responses such as hypertension, tachycardia, restlessness, and anxiety; whereas chronic pain features the absence of autonomic nervous system responses and manifests with depression and irritability. Acute pain responds favorably when pain medication is administered. Chronic pain requires more frequent and higher doses of pain medication to elicit a positive response due to the threshold people build to the efficacy over time.

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed with safeguards to limit the possibility overmedication." The parameters programmed into the PCA pump prevent accidental overdose. Addiction is not a realistic risk for most clients. Care related to a PCA is not delegated to unlicensed care providers. The button should be pushed only by the client.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

- Consider cultural implications of the perception of pain. - Provide pain medication before activity that may increase pain. - Assess for pain control 30 minutes after administering an analgesic. Pain assessment should never be delegated to a UAP. Pain medication should be given in advance of an activity that may increase pain. The nurse should consider cultural implications associated with pain and assess for pain control after medication is given. Assumptions should not be made about pain.

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. What education should the nurse include?

- Do not drive while taking pain medication. - Avoid alcohol. - Do not smoke without someone else present. The teaching plan developed by the nurse should include instructions to take the medication with food to prevent stomach irritation. It should also include not smoking without someone else present to decrease the risk of the client falling asleep and starting a fire. The client should also be instructed to avoid alcohol and to avoid driving. The client does not need to avoid diary products.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

3 The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

Which medical client is most likely to be experiencing diffuse pain?

A client with shingles affecting her entire torso Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain?

Adding the use of hot or cold packs for pain control Chronic, inoperable back pain is difficult to manage. Treatment response is individual. Adding hot or cold packs with other measures, such as anti-inflammatory agents, may help to reduce pain. Narcotics should be avoided due to the tendency of developing tolerance over time, as well as addiction. Getting a surgical consultation may be helpful but will not help with the acute pain that the client is experiencing. Bed rest alone may worsen back symptoms.

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?

Administer a nonopioid medication The WHO three-step pain relief ladder begins with opioids for moderate to severe pain. Surgical clients most likely will require an opioid in the initial postoperative period. The addition of a nonopioid medication, such as a nonsteroidal anti-inflammatory drug, will potentiate the opioid. Documentation of pain level is an associated nursing action; however, it does not address the client's increase in pain. IV opioid medications are effective between 15 and 30 minutes after administration. Waiting 1 hour to reevaluate pain is too long. The client will most likely not be able to participate in nor benefit from complementary therapies, such as relaxation.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication. Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

Administering an oral dose of morphine to treat the client's breakthrough pain It is unsafe to administer narcotics or adjuvant drugs without the approval of the clinician responsible for the epidural injection. Suppositories, abdominal palpation, and feeding are not contraindicated when the client has an epidural in place.

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation?

Ask the boy to draw a cartoon about the color or shape of his pain. Asking the boy to draw a cartoon about the color or shape of his pain is an excellent intervention by the nurse. The child could be in pain and not complaining, so ignoring the boy's pain is not correct. Distracting the boy so he does not notice his pain would not be appropriate. Medicating the boy with analgesics to reduce the anxiety of experiencing the pain is not correct. Addressing the anxiety does not address the pain.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. The priority nursing intervention is to ask the client for the original bottle that the drug was dispensed into from the pharmacy. This will provide the most accurate identification of the medication. Other interventions can subsequently be implemented.

What type of pain will the client experience as a result of the intervention being preformed?

Cutaneous Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. This is the type of pain that results from introduction of an intravenous access line. Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Pain can originate in one part of the body but be perceived in an area distant from its point of origin. This is known as referred pain.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding. The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.

A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse?

Encourage client to confer with a spiritual advisor. The most appropriate action by the nurse would be to encourage the client to confer with a spiritual advisor to work through feelings of anger and resentment as it relates to God and the pain experience. Consulting a psychiatric nurse practitioner may help the client work through feelings of anger and resentment, but may not address the underlying feelings/beliefs related to God and the client's experience of pain. Encouraging the client to pray or to have visitors pray for the client may not help the client work through feelings of anger and resentment related to God and the experience of pain.

When asking an older adult client about abdominal pain, the client reports, "I don't want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action?

Gently mention that the client appears to be experiencing pain that can be treated. Pain is underdetected and poorly managed among older adults, because they often do not want to be perceived as a complainer, or they feel that pain is part of growing older. The nurse should gently mention that the client appears to be experiencing pain that can be treated, and then continue the conversation by reassuring that the client is not a bother. Documenting without addressing the client's report, confirming age as a reason for pain, and reminding that pain can be tolerated are inappropriate nursing actions.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress? When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects?

It activates the immune system. Therapeutic effects of laughter include activating the immune system. It also increases the pain threshold, reduces arterial wall stiffness, and improves endothelial function. It reduces the risk of myocardial infarction (MI) and reduces recurrence after MI in diabetes. It improves lung function in clients with chronic obstructive pulmonary disease (COPD), improves glycemic control, impacts on obesity, improves the success rate of in vitro fertilization, and is associated with satisfaction and an increased quality of life.

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics The nurse would expect to administer opioid analgesics to a client with severe pain following a mastectomy. Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. Corticosteroids would be used to address inflammation and swelling.

A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?

Placebos involve the use of deception and are considered unethical in most circumstances. Placebos have been shown to have some efficacy in the control of pain. However, because they involve deception they are usually considered unethical. In most circumstances, this fact overrides their possible efficacy. When a client is informed that a pill is a placebo, it loses the essential characteristic of a placebo.

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

Preventing constipation The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Urinary elimination and bowel incontinence are not affected by opioid use.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. The sedation score for this client is 3. This requires collaboration with the primary care provider to decrease the analgesic dose. Naloxone is not likely necessary, nor is it appropriate to completely discontinue the client's pain control.

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action?

Start with the lowest intensity and gradually increase it to the appropriate level. After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management. Patient-controlled analgesia (PCA) gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. PCA does not replace nursing care or reduce the amount of care that the client requires.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset. PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.

A nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique?

The nurse gives the client a massage before bed. Some forms of cutaneous stimulation include the following: massage, application of heat or cold (or both intermittently), acupressure, transcutaneous electrical nerve stimulation (TENS). All the options listed are examples of complementary and alternative relief measures, but only massage is an example of cutaneous stimulation.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain?

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. This drug delivery system may be used to manage acute and chronic pain in a health care facility or the home.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain. A PRN (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing.

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system.

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

phantom pain The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma.

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision?

verbal report Verbal reports of pain, although subjective, are the most dependable indicators of pain in people who are able to communicate verbally. Therefore, the nurse should use them as the primary source of data, even if they vary from other objective information. The nurse also collects objective data. Pain often increases respiratory and heart rates, as well as blood pressure. Pain often sets off a generalized increase in metabolism, such as an increase in oxygen consumption, blood glucose, free fatty acids, blood lactate, and ketones. Nonverbal cues, such as grimacing and increased muscle tension, may also be used.

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

visceral pain Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.