Case Study 10 - Multiple Patients with Pain

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At the end of the shift, the opioid count shows that two tablets of OxyContin are unaccounted for. You have spoken to all the nurses and pharmacists who had access to the med cabinet during the shift, but no one will admit to removing these two tablets. What should you do? (select all) 1. inform the staff that no one can leave until the matter is resolved 2. fill out an incident report and include facts about what you found and what you did 3. interview all of the pts who have orders for OxyContin 4. discuss the matter with the unit manager and review potential problems of the current system 5. review available records of access and med retrieval for the past 24 hrs 6. ask the staff if they saw any other people (students, HCP, instructors) who may have accessed the cabinet during the shift

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During the shift, the following events occur at the same time. Prioritize the order for addressing these problems. 1. Mr. L is calling out loudly about right-sided flank pain caused by kidney stone 2. Mr. O, who was in motorcycle accident, is calling, "The pump tipped over and it's broken" 3. another nurse needs opioid wastage witnessed 4. Mr. A, with bacterial pneumonia, is urinating in the corner of his room

2

Mr. A has a single-lumen PICC and he has the following scheduled meds and IV solutions that need to be given now: vancomycin 1.5 g in 250 mL of D5W over 90 mins; levofloxacin 750 mg in 150 mL of NS over 90 mins; D5W and 0.45% NaCl 1000 mL with 20 mEq of potassium at 125 mL/hr; and an IV bolus dose of morphine 3 mg. What is your priority action? 1. call the HCP and ask if the med times can be staggered 2. call the pharmacy and inquire about the compatibility of meds and solutions 3. give the bolus dose of morphine, b/c it will tak the least amount of time 4. establish an additional peripheral IV site

4

Mr. A reports left-sided anterior chest pain. What is your priority action? 1. obtain order for ECG and continuous tele monitoring 2. auscultate the lung fields and compare to baseline assessments 3. give a PRN pain med and reevaluate after 30 mins 4. ask him to describe the pain and measure all VS

3

Mr. H (OR inguinal repair) is given a dose of pain med. One hour later he is anxious and appears uncomfortable and asks, "What's the matter, is something wrong, I'm still hurting." What action should you take first? 1. call HCP for change in med or dose 2. initiate NPO status in case surgery is needed 3. check for bladder distention and last voiding 4. reassure the pt that the hernia is not recurring

2

Mr. H is asking for pain med, and the HCP has ordered 10 mg of OxyContin PRN. The pharmacy has stocked 5-mg tabs of oxycodone immediate-release in the med cabinet. What is your first action? 1. call the HCP for clarification of the order 2. call the pharmacy and obtain the controlled-release form of the drug 3. ask the pt if immediate- or controlled-release action is preferred 4. give two of the 5-mg tabs to achieve correct dose

2

Mr. H returns from the OR following a hernia repair. He says that he is "afraid to walk b/c it will make the pain really bad." What will you explain as being the best option? 1. pain med q4h if he needs it 2. med 45 mins before ambulation or dressing changes 3. ATC pain med even if he has no report of pain 4. talking to the HCP for reassurance about the tx plan

3

Mr. L calls for pain meds. He describes the pain caused by kidney stone as excruciating. He is crying, diaphoretic, and pacing around the room. What is your priority action? 1. instruct him to do deep breathing 2. remind him to use PCA pump 3. give an "as needed" IV bolus dose 4. call the HCP immediately

3

Mr. L reports that the pain has decreased compared with earlier, but now he is having other s/s. Which symptom is of greatest concern? 1. painless hematuria with small clots 2. dull pain that radiates into genitalia 3. absence of pain but scant urine output 4. sensation of urinary urgency

1

Mr. O is at risk for compartment syndrome b/c of the cast. Which pain assessment finding would alert you to this? 1. pain on passive motion 2. sudden increase in pain 3. intense discomfort r/t itching sensation 4. absence of pain despite no recent med

3

Mr. O reports increasing pain in the right abdomen. On physical exam, you note hyperactive bowel sounds, a tense abdomen with guarding, and exquisite tenderness with gentle palpation. What is your priority action? 1. give a PRN pain med 2. notify HCP of your findings 3. take the complete set of VS 4. assist him to change positions

3

Ms. J is having severe pain and admits to it; however, she becomes very anxious when certain family members come and go and refuses to take the pain med. Which adjunct med would be most useful to Ms. J to help her manage these episodes? 1. naproxen (Naprosyn) 2. doxepin (Sinequan) 3. lorazepam (Ativan) 4. dicyclomine (Bentyl)

1

Ms. J is receiving opiates to control her pain caused by end-stage multiple myeloma. Which side effect is the major concern for this pt? 1. constipation 2. resp depression 3. N/V 4. sedation

4

Ms. J's son repeatedly insists that Ms. J is not getting enough pain med. He threatens to sue. You have used therapeutic communication skills with the son and advocated for the pt with the HCP. The HCP says to you, "I'll be in tomorrow, just tell the son to chill out." What is your best action? 1. call another HCP 2. continue to use current orders 3. have the son call the HCP 4. notify the unit manager

4

One of the staff members is talking about Mr. A, who has bacterial pneumonia, in the med room. "He complains all the time about pain everywhere. Well, he is going to have pain. He's a drug addict, so what does he expect?" What is your best response to this comment? 1. all pts have right to care regardless of race, creed, or other traits 2. i'll take Mr. A; i don't mind taking care of him 3. you should think about how he really feels 4. what can we do to help Mr. A cope with his pain?

2

The UAP reports that the new nurse is undermedicating the pts. What is the best way to handle this situation? 1. ignore her; the UAP is not qualified to judge an RN 2. ask the UAP to give specific examples 3. go to the new nurse and question her 4. do an assessment on all the nurse's pts

4

You are preparing to give Mr. L pain meds, but you not that the IV site is infiltrated, so you inform him that the IV catheter will have to be reinserted. He yells at you, "What's wrong with you people?! Can't you do anything right?!" What is the best response? 1. let me call the HCP and i can get an order for an oral med 2. this is not my fault, but if you will just give me a couple of mins i can fix it 3. let me call the nursing supervisor and you can talk to her about the situation 4. i know you are having pain. let me restart your IV line right now

4

You are talking to Ms. R (RA) about discharge plans and follow-up appointments. She begins to cry and says, "I was so active and athletic when I was younger." What is the most appropriate therapeutic response? 1. your shoulder will get progressively better with time and patience. don't cry. 2. i can see that you are really upset. is your shoulder hurting a lot right now? 3. i know what you mean. i used to be able to do a lot more when i was younger too. 4. it is difficult to deal with changes. what types of activities did you used to do?

3

For Mr. O, in addition to pain meds, which action will help the most to relieve pain associated with the tibia-fibula fracture caused by motorcycle accident? 1. instruct him to periodically move his toes 2. use diversional therapy 3. elevate injured leg above heart 4. place pt in high Fowler's

3

It is the end of the shift and the new nurse is trying to give pain meds to one pt, provide comfort measures for another pt, and redo pain assessments on all her pts. Her documentation is incomplete. What should you do? 1. offer to help her by performing the comfort measures 2. let her struggle through so she can find her own way 3. help her prioritize and delegate the tasks 4. ask someone from the oncoming shift to help her

2

The new nurse tells you she cannot find any documentation that shows the time of Mr. L's (kidney stone) last dose of pain med. What action should occur first? 1. help the new nurse look at the chart and MAR 2. tell the new nurse to ask the night nurse before she leaves 3. speak to the night shift nurse about documentation 4. have the new nurse ask Mr. L when he last had med

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Which end of shift tasks can be delegated to the UAP? (select all) 1. empty Ms. J's trash can and place personal items within reach 2. check Mr. A's linens for moisture and soiling and changing as needed 3. ask Mr. L if he needs a dose of pain meds prior to shift change 4. assist Ms. R to change position in bed to relive pressure on joints 5. ensure Mr. O's leg is elevated and evaluating comfort 6. empty Mr. A's urinal and record output

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Which morning tasks can be delegated to the UAP? (select all) 1. assist Ms. R, who has RA, with morning care 2. reinforce Mr. L, who has kidney stone, the need to save urine for straining 3. prepare Mr. H's room for his return from OR for hernia repair 4. report on condition of Mr. O's skin resulting from motorcycle accident 5. get coffee for Ms. J's (end-stage multiple myeloma) family 6. check on pulse ox reading for Mr. A, who has bacterial pneumonia

3

Which nonpharm pain measure to help Ms. R (RA) relieve early morning stiffness should be delegated to the UAP? 1. assist her to get in bathful of warm water 2. share some relaxation techniques 3. assist to take a warm shower 4. evaluate effectiveness of paraffin therapy

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Which tasks r/t pain mngmt can you delegate to the UAP? (select all) 1. report on grimacing seen in unresponsive pts 2. ask about location, quality, radiation of pain 3. remind pts to report pain as necessary 4. observe for relief after med is given 5. ask pts directly, "Are you having pain?" 6. determine if position change relieves pain

1. PT 2. RN 3. RN 4. RN 5. RN 6. UAP 7. UAP

Which team member (RN, UAP, PT) should perform the following tasks r/t Mr. A's pain mngmt? 1. instruct in an supervise use of a transcutaneous electrical nerve stimulation (TENS) unit 2. administer nonopioid pain med 3. answer questions about med side effects 4. identify contributing factors such as fatigue or anxiety 5. suggest relatives bring personal comfort items 6. assist pt to change position q2h 7. reinforce use of pillow to splint when coughing

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You are giving end of shift report about Ms. R (RA) to the oncoming nurse. Place the following info in correct order. 1. she had shoulder pain 4/10 and was reluctant to move around 2. do you have any questions for me 3. Ms. R is a 55 yo woman 4. she had shoulder arthroplasty 3 days ago 5. she received a PRN dose of tylenol with codeine, and pain is now 1/10 6. the PT must speak to Ms. R's daughter so page him when she arrives

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You are the leader of a team caring for pts on a med-surg unit. Your patients are as follows: Ms. R (55 yrs, rheumatoid arthritis, should arthroplasty 3 days ago, reports morning stiffness in joints, swelling in both wrists and proximal interphalangeal joints) Mr. L (35 yrs, hx of kidney stones, reports severe back and right-sided flank pain intermittently of 3-8/10, night shift nurse reports episodic N/V with hematuria and dysuria, he was admitted through the ED at 2200, currently using PCA) Mr. O (18 yrs, right tibia-fibula fracture in motorcycle accident 7 hrs ago, extensive skin abrasions underneath cast and on right anterolateral body, obvious chest and abdominal trauma ruled out in ED but being monitored for occult trauma, receiving analgesic via PCA pump) Mr. H (28 yrs, currently in OR for inguinal hernia repair, should return from OR later in shift) Ms. J (65 yrs with end-stage multiple myeloma, receiving palliative pain mngmt, family considering hospice care, been on unit for 2 wks, HCP signed DNR 3 days ago) Mr. A (55 yrs on unit for 3 wks, receiving IV antibiotics for bacterial pneumonia, hx of IVDA and chronic back pain, tested positive for HIV, SaO2 was decreasing during night shift) Which of these 6 pts can be assigned to the new RN? (select all) 1. Ms. R 2. Mr. L 3. Mr. O 4. Mr. H 5. Ms. J 6. Mr. A

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You are the leader of a team caring for pts on a med-surg unit. Your patients are as follows: Ms. R (55 yrs, rheumatoid arthritis, should arthroplasty 3 days ago, reports morning stiffness in joints, swelling in both wrists and proximal interphalangeal joints) Mr. L (35 yrs, hx of kidney stones, reports severe back and right-sided flank pain intermittently of 3-8/10, night shift nurse reports episodic N/V with hematuria and dysuria, he was admitted through the ED at 2200, currently using PCA) Mr. O (18 yrs, right tibia-fibula fracture in motorcycle accident 7 hrs ago, extensive skin abrasions underneath cast and on right anterolateral body, obvious chest and abdominal trauma ruled out in ED but being monitored for occult trauma, receiving analgesic via PCA pump) Mr. H (28 yrs, currently in OR for inguinal hernia repair, should return from OR later in shift) Ms. J (65 yrs with end-stage multiple myeloma, receiving palliative pain mngmt, family considering hospice care, been on unit for 2 wks, HCP signed DNR 3 days ago) Mr. A (55 yrs on unit for 3 wks, receiving IV antibiotics for bacterial pneumonia, hx of IVDA and chronic back pain, tested positive for HIV, SaO2 was decreasing during night shift) You decide to do a brief round of all the pts before shift report to ensure safety and help determine acuity and assignments. List the order in which you should briefly check in on these pts. 1. Ms. R 2. Mr. L 3. Mr. O 4. Mr. H 5. Ms. J 6. Mr. A