Gerontology - Chapter 27. Pain and Comfort

Each of the following is a nonpharmacological intervention for pain except which one? a. Acupuncture treatments c. Lidocaine patch b. Adjuvant therapy d. Capsaicin

ANS: A Acupuncture is a nonpharmacological treatment that helps reduce the perception of pain. An adjuvant is a medication that has been developed for a different purpose but serves to alter the perception of pain, possibly in combination with a pain medication. Lidocaine patches are a pharmacological treatment for pain relief. Capsaicin is a pharmacological means of providing comfort and alleviating pain and distress.

An older woman had hip replacement surgery 1 day ago, and the nurse thinks that the woman also has dementia. Which patient assessment does the nurse use to determine whether this woman is experiencing pain? a. Holds abdomen tightly. c. Is not verbalizing. b. Has stable vital signs. d. Moves during sleep.

ANS: A Because this older adult has a potential cognitive impairment and is likely to self-report pain unreliably, the nurse uses additional clinical indicators to detect pain. Muscle rigidity and guarding are clinical indicators of pain for a postoperative older adult, regardless of a cognitive impairment. An individual experiencing pain is unlikely to have stable vital signs. Not verbalizing can indicate a sensory impairment and warrants further investigation by the nurse. Nonetheless, this older adults verbalizations are potentially unreliable indicators of pain. Older adults move normally during sleep to adjust their position in bed; moving during sleep is not an indicator of pain unless the movements are agitated or restless in nature.

Which pain sensation is associated with nociceptive pain? a. Tissue inflammation c. Radiculopathies b. Postherpetic d. Nerve root irritation

ANS: A Nociceptive pain refers to pain that is related to the skin and tissue. Postherpetic and radiculopathies are both a type of neuropathic pain. Nerve root irritation is classified as a mixed or an unspecific pain.

Which of the following statement(s) is(are) true about pain in older adults? (Select all that apply.) a. Pain is not a normal aging process. b. Pain sensitivity decreases with age. c. If patients do not complain, they do not have pain. d. Opioid analgesics are often the best treatment for persistent pain.

ANS: A, D Pain is not a normal aging process. Something pathological is usually causing the pain. Pain sensitivity does not decrease with age. Some patients have a variety of reactions to pain; many are stoic and refuse to give in to their pain. Opioid analgesics are beneficial for moderate-to- severe persistent pain.

Which of the following statements is true about analgesic medications for older adults? a. Opioids are less effective in older patients than in younger patients. b. Stool softeners and laxatives should be used with opioids. c. Over-the-counter NSAIDs are generally harmless. d. The dose limit for acetaminophen is difficult to reach for older adults.

ANS: B Opioids often cause constipation and necessitate bowel stimulation to prevent constipation. A bowel regimen should be instituted at the same time as opioid treatment. Because of changes in metabolism with aging, opioids have a greater and longer-lasting analgesic effect in older patients. NSAIDs can cause gastrointestinal bleeding, kidney and liver damage, and drug interactions with potentially fatal results. The maximum daily dose of acetaminophen is 4000 mg, and the limit is lower for patients with kidney or liver failure and patients who use alcohol. A typical dose is two 500-mg (extra-strength) tablets.

The nurse uses comfort measures to enhance an older adults pharmacological pain management. Which of the following would be most helpful for the nurse to use to identify the relationships between the comfort measures, activity, and pharmacotherapy, and the older adults pain level? a. Older adults self-report c b. FPS-R c. Older adults pain diary d. Pain medication frequency

ANS: B The nurse instructs the older adult to maintain a pain diary to help the individual achieve some control over the pain experience. The diary is then used to identify trends or the timing of pain and the relationships between the patients pain level and the comfort measures, activity, and pain medications. Many older adults report feeling useful and having some control over the pain, or at least the pain management program, through maintaining a pain diary. Self-reporting is one parameter used to evaluate pain, but drawing a relationship between the pain level and other factors is still necessary. The FPS-R is a reliable pain assessment tool, but the task remains to link the pain rating to other factors. The frequency of medication administration provides a clue about the patients pain level.

An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the patient asks for pain medication 15 minutes before it is due. Which recommendation should the nurse implement? a. Validate the pain with other assessment data. b. Administer the pain medication as requested by the patient. c. Tell the patient that it is too soon for pain medication. d. Teach the patient alternative comfort measures.

ANS: B The nurse should administer the opioid pain medication as requested because the patient is asking for the pain medication within the prescriptions time limit. Most institutions allow the nurse to administer opioid medications 15 to 30 minutes before the designated time on the prescription; therefore the patient is not asking for the medication too early. In addition, the nurse has an obligation to the patient to administer the pain medication; not doing so violates the patients rights. The nurse can rely on the patients report to determine the need for pain medication. As long as the timing is suitable and the patient is stable, the nurse should administer the medication. The nurse should use assessment data to support withholding pain medication in the presence of oversedation or another assessment that would be potentially aggravated by administering the pain medication. The nurse violates the patients rights by stating that it is too soon for the medication and ignores the possibility that the patients pain is real. Although the nurse may believe the patient is not having pain and is exhibiting drug-seeking behavior, the nurse must administer the medication. The nurse must administer the pain medication as requested. When patients are experiencing pain, most often, it is not the optimal time to teach patients. However, when the patients pain is under control, the nurse should teach alternative comfort measures. Comfort measures can be used to enhance the therapeutic effect of the medication and breakthrough pain.

Which conditions are likely to cause an older adult chronic pain? (Select all that apply.) a. Hip replacement b. Bone metastasis c. Hypoproteinemia d. Migraine headache e. Compression fracture f. Postherpetic neuralgia

ANS: B, E, F Bone metastasis is likely to cause an older adult chronic pain because it is extremely difficult to eradicate cancer metastasis from bone. In addition, the invasion of cancer into bone can be very painful as a result of tumor growth pressing on nerves. Compression fractures are likely to cause chronic pain because the compressed vertebra is likely to press on spinal nerves, causing muscle spasms. Postherpetic neuralgia is a result of nerve damage from shingles and is likely to cause chronic pain; it is very difficult to treat effectively. A hip replacement is performed to relieve chronic pain or to repair a fracture and is more likely to cause acute pain. Hypoproteinemia is unlikely to cause chronic pain but is more likely to cause fatigue. A migraine headache is likely to cause acute, intense pain. Although headaches can be recurrent, they are usually time limited.

The safest opioid analgesic choice for an older patient who has severe acute pain is which of the following? a. Meperidine (Demerol) c. Morphine sulfate (Morphine) b. Pentazocine (Talwin) d. Safe opioids do not exist.

ANS: C Morphine sulfate (Morphine), oxycodone (Oxycontin), hydrocodone (Hycodan), hydromorphone (Dilaudid), and fentanyl (Sublimaze) are opioids that can be safely used with older patients. Meperidine and pentazocine are both contraindicated for older adults because their metabolites can produce confusion, psychotic behavior, and seizures. Used properly, opioids have a lower risk of certain side effects than nonsteroidal antiinflammatory agents (NSAIDs).

The older adult is at a higher risk for acute psychological pain than a younger adult because older adults: a. Have many illnesses. c. Experience more loss. b. Possess fewer assets. d. Live with impairments.

ANS: C Older adults are at higher risk for acute psychological pain than younger adults because they experience more loss such as the pain occurring in early bereavement or in a major depressive episode. Older adults tend to have more illnesses than younger adults, and illness can trigger depression. The lack of assets of younger and older adults is unlikely to be related to acute psychological distress unless a sudden loss of a large asset is experienced. Older adults do not necessarily live with impairments. Further, if impairment causes psychological distress, then the acute phase is likely to occur at the onset rather than in day-to-day activities.

An older man who had a gastric resection states that he wants to ambulate but the osteoarthritis (OA) in his knees causes too much pain. Which intervention should the nurse implement to increase the amount of walking this man can perform? a. Encourage the patient to keep his leg elevated.. b. Instruct him to rest until the pain disappears.. c. Suggest taking pain medication before walking.. d. Collaborate with the health care provider to make a walker available.

ANS: C The nurse suggests taking the pain medication before walking to provide relief during the time when the pain occurs. In addition, if the patient premedicates, then the analgesic effect is likely to last long enough to benefit the patient for any pain after walking. Elevating leg will provide comfort and decrease in edema after exercise; however inactivity may exacerbate the pain. Inactivity tends to exacerbate the pain of OA. Instead, the nurse recommends a balance of rest and exercise. A walker is not indicated and will not alleviate any pain in the knees; it is intended to provide stability for ambulation.

Which of the following pain sensation(s) is(are) associated with neuropathic pain? (Select all that apply.) a. Infection c. Inflammation b. Obstruction d. Postamputation

ANS: D Neuropathic involves a pathophysiological process of peripheral or central nervous system. Infection, obstruction, and inflammation are considered nociceptive pain sensations that are associated with injury to skin, mucosa, muscle, or bone.

An older Hispanic man states that he is not having pain, but he had knee replacement surgery 2 days ago. Which is the best pain assessment tool as recommended by the Hartford Institute for Geriatric Nursing (HIGN) from Try This for the nurse to apply for this man? a. Numeric Rating Scale b. Verbal Descriptor Scale c. Iowa Pain Thermometer d. Faces Pain Scalerevised (FPS-R)

ANS: D Hispanic men are less likely to report pain because their culture tells them to deny and withstand pain without complaining. The nurse uses the FPS-R to validate the patients report because the postoperative period in knee replacement surgery is very painful; this fact makes the nurse think that the patient is likely to have pain. The HIGN has data that support the claim that Hispanic and African-American older adults prefer using the FPS-R for evaluating pain. The Numeric Rating Scale, the Verbal Descriptor Scale, and the Iowa Pain Thermometer are valid and reliable assessment tools, but older Hispanic adults prefer using the FPS-R.

Compared with acute pain, which of the following statements is true of persistent pain? a. Leads to significantly altered vital signs. b. Is usually described as a burning pain. c. Is generally gone within 4 months. d. Can bring about long term changes in lifestyle.

ANS: D Persistent pain affects the patients experience on a continuing basis. Both acute pain and persistent pain can affect the vital signs. Persistent pain may be described in many possible ways. Persistent pain is unrelenting.

Which type of pain tends to occur persistently along a well-defined path in a region of the body? a. Unrelenting pain c. Postoperative pain b. Osteoarthritic pain d. Postherpetic pain

ANS: D Postherpetic neuralgia tends to persist in the dermatome of a spinal nerve. For example, postherpetic neuralgia of C8 (the 8th cervical spinal nerve) should cause burning, itching, or stinging pain along the back of one arm, through the elbow, and down to the smallest finger on the side of the same hand. Persistent pain does not occur along a well-defined path. Osteoarthritic pain is usually persistent but seldom occurs along a well-defined path; the pain is usually localized. Postoperative pain is acute pain that occurs in the area of the surgical procedure and incision.

The nurse administers an opioid analgesic to an older male postoperative patient in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the patients room? a. Place side rails up x 4. b. Position the patient comfortably. c. Offer toileting and a sip of water. d. Instruct him to ask for help before getting up.

ANS: D The most important intervention for fall and injury prevention is for the nurse to instruct the older adult to ask for help before getting up after receiving an opioid medication. This intervention is important because the medication can cause sedation and dizziness; therefore the nurse instructs him to ask for help to prevent a fall or injury. Side rails up x 4 is considered a restraint and may place the patient at risk for injury. Comfortable positioning is also a good supplemental intervention after administering pain medication. Offering toileting and hydration is a reasonable intervention to implement after administering pain medication, but it does not offer the same degree of safety as instructing the patient to call for help.

The nurse admits an older man who had abdominal surgery. Admission vital signs are heart rate (pulse) (P), 73 beats per minute (bpm); respiration rate (R), 20 breaths per minute; blood pressure (BP), 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not requested pain medication since surgery. Seven hours later, his vital signs are P, 98 bpm; R, 26 breaths per minute; and BP, 164/90 mm Hg; and he denies pain. Which intervention should the nurse implement? a. Administer an opioid medication by IV route. b. Check the surgical dressing for bleeding. c. Report the vital signs to the health care provider. d. Ask if he has about discomfort at the surgical site or any other location.

ANS: D The patients P, R, and BP increased significantly since his admitting vital signs and indicate the potential for pain or discomfort from the surgical incision. The older adult patient may also be experiencing pain unrelated to the surgery due to arthritic changes, neuropathies, etc. The patient can be misunderstanding the nurses question or be barred from saying, yes, by cultural patterns. Such miscommunication is common; therefore the nurse rewords the question using another term for pain such as discomfort, burning, or pressure. Administering an opioid medication by IV route is unethical without the patients request. When checking the surgical dressing for bleeding, the patient may show signs of pain rather than blood loss. Reporting the vital signs to the health care provider would be premature; the patients pain assessment is not complete.