Chapter 12: Pain Management

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?

"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." Explanation: The nurse needs to explore the reason a client denies pain when pain is expected during a treatment, as with a dressing change to burns, and when the client grimaces during the dressing change. The nurse needs to educate clients about effects of pain on recovery. The nurse also cannot ignore that pain relief will hasten recovery. The nurse should not allow the client to associate pain with his dressing changes.

A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client

"Only you are to push the button for medication." Explanation: With a PCA machine, clients control the administration of their pain medication within prescribed parameters. Family members or other visitors should not push the button on the PCA machine for the client; doing so overrides the safety features of the machine. Clients may become frustrated if pushing the button frequently does not result in pain relief. The nurse needs to instruct the client about time limits. Other instructions include not waiting until the pain is severe before pushing the button and that the PCA machine is used to control pain.

The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?

"When was your last bowel movement?" Explanation: Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies

Which of the following is a disadvantage of using the transdermal route of opioid administration?

A delay in effect until the dermal layer is saturated Explanation: A disadvantage of using the transdermal route of administration is that there is a delay in effect when the dermal layer is saturated. Advantages include a consistent opioid serum level, slightly less constipation than with oral opioids, and less cost as compared to the parenteral route

A client with appendicitis has had an appendectomy. After surgery, what type of pain does the nurse anticipate the client will have?

Acute pain Explanation: Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology. The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute pain. An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Referred pain is a term used to describe discomfort that is perceived in a general area of the body, but not in the exact site where an organ is anatomically located.

Acute pain can be distinguished from chronic pain by assessing which characteristic?

Acute pain is specific and localized. Explanation: Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect?

Addiction Explanation: Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?

Adjuvant drug therapy Explanation: Adjuvant drugs are medications that are ordinarily administered for reasons other than treating pain. Duloxetine is used to treat depression but is being used for neuropathic pain for this client.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics on a regular basis Explanation: Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

The nurse is assessing a client's level of pain. How is the pain best described?

An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. Explanation: Pain is a privately experienced, unpleasant sensation usually associated with disease, injury, or surgery. Although pain can have an emotional component, referred to as suffering, this is not the source of all pain. Although pain can be the result of disease, it can also be caused by injury, surgery, emotional or mental conditions, or other causes. Pain is a normal aspect of nervous system functioning. Neuropathic pain is pain that is processed abnormally by the nervous system.

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?

Bradypnea Explanation: Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?

Burning Explanation: When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

When taking a client history, the nurse notes that the client has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the client is experiencing which type of pain?

Chronic pain Explanation: Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by clients with a normally controlled pain management regimen.

Which of the following nursing interventions contributes to achieving a client's goal for pain relief?

Collaborate with the client about his or her goal for a level of pain relief. Explanation: The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?

Confusion Explanation: Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.

The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?

Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration. Explanation: The most appropriate action by the nurse would be to consult with the physician regarding the need for an increased dose of the drug and not to reduce its frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50%. Informing the client that he will not be able to receive more medication is not acting as a client advocate nor acting in the best interest of the client. Suggesting a psychiatrist consultation would not be an appropriate action because the client has a chronic illness that requires medication. Taking a non-narcotic analgesic would not provide the client with the pain relief that he has.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?

Diaphoresis Explanation: Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient ("pain signature"). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures.

Which of the following is the appropriate intervention to avoid physical withdrawal on drugs in a client?

Discontinue drugs gradually. Explanation: To avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. The most appropriate nursing action to avoid tolerance is to consult with the physician for an increased dosage of the drug. Subtherapeutic dosages and adjuvant drugs are not needed to avoid physical dependence of drugs in a client.

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain?

Do not administer if respirations are less than 12 breaths per minute Explanation: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 breaths per minute. The nurse should instruct a client who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose concentration when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

The client is scheduled for surgery. The nurse is reviewing with the client about postoperative pain management. The client states her goal after receiving treatment is "0." The first action of the nurse is to

Educate the client that this goal may not be achievable. Explanation: The client's goal of complete elimination of pain may be unrealistic. The nurse needs to first teach the client about setting an achievable goal. The nurse will plan to use a combination of pharmacologic and nonpharmacologic interventions for pain relief. The nurse may need to notify the surgeon of the client's goal of "0" for pain relief. The nurse does not ensure large doses of opioids are prescribed for the client. Many factors go into the prescription of medication for pain relief, including the client's response to the medication.

Which substance reduces the transmission of pain?

Endorphins Explanation: Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Ensure the client knows to taper down the dose if it is discontinued by the care provider. Explanation: Corticosteroids must be tapered slowly in order to prevent an adrenal crisis. These medications do not normally cause dependence and they do not pose a risk for GI bleeding. Grapefruit is not contraindicated.

The nurse is administering a narcotic analgesic for the control of a newly postoperative client's pain. What medication will the nurse administer to this client?

Fentanyl (Duragesic) Explanation: Opioid and opiate analgesics such as morphine and fentanyl (Duragesic) are controlled substances referred to as narcotics. The other medications are not opioid analgesics and should not be given for a newly postoperative client.

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?

Follow a bowel regimen. Explanation: The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. The client should not reduce fiber intake because this increases the risk for constipation. The client need not exercise regularly or avoid harsh sunlight because these have no effects on the drug therapy.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Gabapentin Explanation: The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

About which issue should the nurse inform clients who use pain medications on a regular basis?

Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Explanation: Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is

Instruct the son about lack of client consent. Explanation: One of the client's rights is to participate in management of his or her own care. The nurse follows the nursing process by assessing the client's perception of pain but does not awaken the client to do this. The nurse can administer the pain medication only after assessment. The nurse does not administer the pain medication but does take the opportunity to educate the son.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.

Intervertebral disk herniation Explanation: Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain. Migraines could be chronic pain but are not the best example here.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?

Neuropathic pain Explanation: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located.

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?

Older people experience reduced sensory perception. Explanation: Pain affects individuals of every age, sex, race, and socioeconomic class (American Geriatrics Society, 2009; Johannes, Le, Zhou, et al., 2010; Walco, Dworkin, Krane, et al., 2010).

Which of the following is a physiologic response to pain?

Pallor Explanation: Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

Which is a true statement regarding placebos?

Placebos should never be used to test a client's truthfulness about pain. Explanation: Many pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that placebos should not be used to assess or manage pain in any client, regardless of age or diagnosis. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective?

Position the client for comfort. Explanation: The nurse should provide a comfort level with positioning first. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and alternative measures should be tried first. Providing a fresh gown will not make the medication more effective. Ingesting food with an opioid medication does not make the medication more effective.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

Prolonged in duration. Explanation: A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

An elderly client has a fractured hip and is in Buck's traction. The client is disoriented and cannot express herself. At 0730 the client was calm. Now, at 0930, the client is restless and agitated. The nurse reviews the medication administration record. The last dose of opioid was at 0330. The nurse assesses the client's agitation may be from

Recurring pain Explanation: Elderly clients may experience cognitive dysfunction, such as confusion and agitation, as a result of unrelieved pain. Once the pain is relieved, the cognitive dysfunction clears. The nurse needs to become astute in assessing the reason for agitation. Opioid medications are often incorrectly attributed as causing cognitive dysfunction in elderly clients. No strong evidence states that being elderly contributes to diminished pain perception.

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system?

Respiratory Explanation: Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011).

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?

Risk for impaired gas exchange Explanation: Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting:

Severity of the pain as judged by the patient Explanation: The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

Which of the following is a disadvantage to using the IV route of administration for analgesics?

Short duration Explanation: Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client

That medication will be prescribed for pain relief Explanation: Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

Which of the following is a reliable source for quantifying pain?

The client's description of the pain Explanation: The client's description of the pain is the only reliable source for quantifying pain. Physiologic data such as vital signs or the extent or nature of the injury do not indicate the amount of pain.

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient?

The pain medication will be administered before the pain is experienced. Explanation: Two basic principles of providing effective pain management are preventing pain and maintaining a pain intensity that allows the patient to accomplish functional or quality-of-life goals with relative ease (Pasero, Quinn et al., 2011). Accomplishment of these goals may require the mainstay analgesic agent to be administered on a scheduled around-the-clock (ATC) basis, rather than PRN (as needed) to maintain stable analgesic blood levels.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?

The pump will deliver a preset amount of medication. Explanation: A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

A client comes to the clinic and informs the nurse that he needs more analgesics for chronic pain. The client states that the medication is not as strong, and he requires more than the prescribed dose. What does the nurse suspect is occurring with the client?

Tolerance Explanation: Tolerance is a condition in which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered. Addiction refers to a repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's mind-altering or mood-altering effects. Physical dependence means that a person experiences physical discomfort, known as withdrawal symptoms.

An adult with severe cognitive impairment has had a surgical procedure, and the nurse is having a difficult time assessing the level of pain the client is having postoperatively. What method can the nurse use to obtain data about the client's pain?

Use behavioral comparison of the client's current and previous behavior patterns. Explanation: Cognitively impaired older adults may be unable to report pain; comparison of current behavior with previous behavior patterns and reports from caregivers can help in assessing pain in these clients. Pain may manifest as agitation; aggression; withdrawal; or changes in behavior, positioning, or sleep patterns. The other methods would not be appropriate for a cognitively impaired client. Asking the client loudly will not increase his understanding.

The nurse is caring for a client with kidney stones who is complaining of severe pain. What type of pain does the nurse understand this client is experiencing?

Visceral Pain Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue. Neuropathic pain is pain that is processed abnormally by the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is almost totally opposite from those of acute pain.

Regarding tolerance and addiction, the nurse understands that

although clients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

A client reports having joint pain that has gotten worse over the last year despite gradually increasing doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?

chronic pain Explanation: This client is experiencing chronic pain, which is pain or discomfort that lasts for a period longer than 6 months. Pain or discomfort with a short duration is acute pain. It is associated with trauma, injury, or surgery. Referred pain is pain felt in the body in a location that is different from the actual source of the pain. Breakthrough pain is a period of acute pain experienced by those suffering from chronic pain.

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is

encourage the client to watch television Explanation: Distraction, such as watching television, helps relieve pain. Ice may be applied for 15 to 20 minutes at a time but may be uncomfortable when applied to the abdomen. Ambulating has other benefits for the client but may not relieve pain. The client should concentrate on breathing slowly in and out, not hold the breath.

A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen?

hepatotoxicity Explanation: The nurse will need to monitor the client receiving acetaminophen for hepatotoxicity. Intravenous acetaminophen should not cause renal toxicity, bleeding, and gastrointestinal effects.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about?

the limits on dose and frequency that are programmed into the PCA Explanation: Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?

visceral Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months.