Chapter 43: Pain Management

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management?

"I need to reassess the patient's pain 1 hour after administering oral pain medication."

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works?

"Ibuprofen helps to decrease the production of prostaglandins."

The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication.

"It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?

"Pain assessment scales determine the quality of a patient's pain."

Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use?

"This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief."

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?

"What activities, if any, has your pain prevented you from doing?"

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?

"Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?

"You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?

"You need to drink plenty of fluids and eat a diet high in fiber."

Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? A. "Meditation controls pain by blocking pain impulses from coming through the gate." B. "Meditation will help me sleep through the pain because it opens the gate." C. "Meditation stops the occurrence of pain stimuli." D. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

A. "Meditation controls pain by blocking pain impulses from coming through the gate."

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) A. Apply ice using firm pressure over skin. B. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. C. Apply ice until numbness occurs and discontinue application. D. Apply ice for no longer than 10 minutes.

A. Apply ice using firm pressure over skin. Cold therapies are particularly effective for pain relief. Ice message involves applying a frozen cup of ice firmly over the skin. When numbness occurs, remove the ice for usually 5 to 10 minutes.

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: A. Calls the health care provider, and questions the order. B. Applies the patch the third postoperative day. C. Applies the patch as soon as the patient reports pain. D. Places the patch as close to the hop dressing as possible.

A. Calls the health care provider, and questions the order. Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? A. Only the patient should push the button. B. Do not use the PCA until the pain is severe. C. The PCA prevents overdoses from occuring. D. Notify the nurse when the button is pushed.

A. Only the patient should push the button. Patient preparation and teaching are critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to "push the button" for the patient.

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? A. Relaxation and guided imagery. B. Transcutaneous electrical nerve stimulation (TENS). C. Herbal supplements with analgesic effects. D. Pudendal block.

A. Relaxation and guided imagery.

A postoperative patient is currently asleep. Therefore the nurse knows that: A. The sedative administered may have helped him sleep, but assessment of pain is still needed. B. The intravenous (IV) pain medication is effectively relieving his pain. C. Pain assessment is not necessarily. D. The patient can be switched to the same amount of medication by the oral route.

A. The sedative administered may have helped him sleep, but assessment of pain is still needed. Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment.

While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends: A. Transitioning use of adjuvants with nonsteroidal antiinflammatory drugs (NSAIDs) to opioids. B. Using acetaminophen for refractory pain. C. Limiting the use of opioids because of the likelihood of side effects. D. Avoiding total sedation, regardless of how severe the pain is.

A. Transitioning use of adjuvants with nonsteroidal antiinflammatory drugs (NSAIDs) to opioids. The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation.

Peripherally inserted central catheter

Alternative intravenous access when the patient requires intermediate-length venous access greater than 7 days to 3 months. Intravenous access is achieved by inserting a catheter into a central vein by way of a peripheral vein.

The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain?

Anxiety and fear.

Side effect

Any reaction or consequences that results from medication or therapy.

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action?

Ask the health care provider to verify the dosage and frequency of the medication.

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?

Ask the patient to rate and describe the pain.

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? A. "Older patients often have difficulty determining what is causing their pain." B. "It is safe to administer opioids to older adults as long as your start with small doses and frequently assess the patient's response to the medication." C. As adults age, their ability to perceive pain decreases." D. "Patients who have dementia probably experience pain, and their pain is not always well controlled."

B. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95%. B. Difficulty arousing the patient. C. Respiratory rate of 10 breaths/min. D. Pain intensity rating of 5 on a scale of 1 to 10.

B. Difficulty arousing the patient. Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate? A. No action is required by the nurse because the order is appropriate. B. Request to have the ordered changed to ATC for the first 48 hours. C. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. D. Begin the Vicodin when the patient shows nonverbal symptoms of pain.

B. Request to have the ordered changed to ATC for the first 48 hours. The American Pain Society (2003) states that, if you anticipate pain for the most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Stool softener. B. Stimulant laxative. C. H2 receptor blocker. D. Proton pump inhibitor.

B. Stimulant laxative. Patients usually become tolerant of the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives; not simple stool softeners, to prevent and treat constipation.

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. The patient's wife is the best resource for determining the level of pain since she has been with hiim continually for the entire day. B. The patient's report of pain is the best method for assessing the pain. C. The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. D. The nurse is the most experienced at assessing pain.

B. The patient's report of pain is the best method for assessing the pain. A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain.

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? A. The drug. B. The time interval. C. The dose. D. The route.

B. The time interval. Controlled-or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? A. "This is the only pain medication I will need to be on." B. "I can administer the pain medication as frequently as I need to." C. "I feel less anxiety about the possibility of overdosing." D. "I will need the nurse to notify me when it is time for another dose."

C. "I feel less anxiety about the possibility of overdosing."

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? A. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." B. "You should take your medication after you walk to make sure you do not fall while you are walking." C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." D. "You need to take oral pain medications when you experience severe pain."

C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain."

The nurse anticipates administering an opioid fentanyl patch to which patient? A. A 15-year-old adolescent with a broken femur. B. A 30-year-old adult with cellulitis. C. A 50-year-old patient with prostate cancer. D. An 80-year-old patient with a broken hip.

C. A 50-year-old patient with prostate cancer.

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A. Assess the patient's body language. B. Observe cardiac monitor for increased heart rate. C. Ask the patient to rate the level of pain. D. Ask the patient to describe the effect of pain on the ability to cope.

C. Ask the patient to rate the level of pain.

What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? A. Keeping the reversal agent in a syringe in the patient's bedside table. B. Applying a gauze dressing to the epidural catheter insertion site. C. Labeling the tubing that leads to the epidural catheter. D. Asking the nursing assistive personnel to check on the patient at least once every 2 hours.

C. Labeling the tubing that leads to the epidural catheter.

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? A. Neurological factors. B. Competency of the surgeon. C. Meaning of pain. D. Postoperative support personnel.

C. Meaning of pain.

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain. B. The potential for addiction. C. The amount of daily acetaminophen. D. The risk for gastrointestinal bleeding.

C. The amount of daily acetaminophen. The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control.

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? A. The surgery successfully cured the patient's pain. B. The patient's culture is possibly influencing the patient's experience of pain. C. The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. D. The nurse is allowing personal beliefs about pain to influence pain management at this time.

C. The patient's culture is possibly influencing the patient's experience pain.

Neurotransmitter

Chemical that transfers the electrical impulse from the nerve fiber to the muscle fiber.

Hypnotics

Class of drug that causes insensibility to pain and induces sleep.

Holistic health

Comprehensive view of the person as a biopsychosocial and spiritual being.

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in distress. Which response by the nurse is most therapeutic? A. "Your vitals do not show that you are having pain; can you describe your pain?" B. "You do not look like you are in pain." C. "OK, I will go get you some narcotic pain relievers immediately." D. "What would you like to try to alleviate your pain?"

D. "What would you like to try to alleviate your pain?"

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient's respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: A. Discontinue all ordered opioids. B. Close the room door to allow the patient to recover. C. Administer the remaining naloxone over 4 minutes. D. Assess patient's vital signs every 15 minutes for 2 hours.

D. Assess patient's vital signs every 15 minutes for 2 hours. Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory depression may return.

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: A. Call the patient's health care provider. B. Administer pain medication as ordered. C. Check the patient's vital signs. D. Assess the characteristics of the pain.

D. Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependance.

D. Physical dependance. Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

When teaching the patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? A. TENS works by causing distraction. B. TENS therapy does not require a health care provider's order. C. TENS requires an electrical source for use. D. TENS electrodes are applied near or directly on the site of pain.

D. TENS electrodes are applied near or directly on the site of pain. TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain.

Therapeutic effect

Desired benefit of a medication, treatment, or procedure.

Infusion pump

Device that delivers a measured amount of fluid over a period of time.

Placebos

Dosage form that contains no pharmacologically active ingredients but may relieve pain through psychological effects.

Patient-controlled analgesia

Drug delivery system that allows patients to self-administer analgesic medications on demand.

Opioid

Drug substance derived from opium or produced synthetically that alters perception of pain and that, with repeated use, may result in physical and psychological dependence (narcotic).

Laxatives

Drugs that act to promote bowel evacuation.

Anxiolytics

Drugs used primarily to treat episodes of anxiety.

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis?

Give medications around-the-clock.

Adverse effect

Harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.

Endorphins

Hormones that act on the mind such as morphine and opiates and produce a sense of well-being and reducing pain.

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment?

Increasingly higher doses of opioid are needed to control pain.

The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient?

Infants respond behaviorally and physiologically to painful stimuli.

Infusions

Introduction of fluid into the vein, giving intravenous fluid over time.

Local anesthesia

Loss of sensation at the desired site of action.

Regional anesthesia

Loss of sensation in an area of the body supplied by sensory nerve pathways.

Guided imagery

Method if pain control in which the patient creates a mental image, concentrates on that image, and gradually becomes less aware of pain.

Holistic

Of or pertaining to the whole; considering all factors.

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about?

Patient drinks 1 to 2 glasses of wine every night.

Threshold

Point at which a person first perceives a painful stimulus as being painful.

Tolerance

Point at which a person is not willing to accept pain of greater severity or duration.

Prostaglandins

Potent hormonelike substances that act in exceedingly low doses on target organs. They can be used to treat asthma and gastric hyperacidity.

Synapse

Region surrounding the point of contact between two neurons or between a neuron and an effector organ.

Analgesic

Relieving pain; drug that relieves pain.

A patient arrives at the emergency department experiencing a headache and rates the pain as a 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?

Softly plays music that the patient finds relaxing.

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What type of pain does the nurse document that the patient has?

Somatic pain.

Cutaneous stimulation

Stimulation of a person's skin to prevent or reduce pain perception. A massage, warm bath, hot and cold therapies, and transcutaneous electrical nerve stimulation are some ways to reduce pain perception.

Hospice

System of family-centered care designed to help terminally ill people be comfortable and maintain a satisfactory lifestyle through the terminal phase of their illness.

Transcutaneous electrical nerve stimulation (TENS)

Technique in which a battery powered device blocks pain impulses from reaching the spinal cord by delivering weak electrical impulses directly to the surface of the skin.

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?

The patient rates pain at an acceptable level of 3 on a 1 to 10 scale.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

The patient who is experiencing 8/10 pain and has a STAT order for pain medication.

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes?

The patient's need for analgesic medication decreases during the dressing changes.

The nurse knows that which technique is best for assessing pain in a child who is 4 years of age?

Use the FACES scale.

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time?

Visceral pain.