EAQ - Chapter 11 - Pain

Which statement made by the student nurse indicates effective learning when differentiating between A and C peripheral nerve fibers?

"A fibers are myelinated, and C fibers are unmyelinated. Rationale: A fibers are myelinated, whereas C fibers are unmyelinated. A fibers are larger in diameter, whereas C fibers are smaller in diameter. Because A fibers are larger in diameter, they transmit signals more rapidly to the central nervous system (CNS) compared with the smaller C fibers. The sensations caused by the stimulation of A fibers are localized, whereas the sensations caused by the stimulation of C fibers are diffuse.

Which conditions are associated with visceral pain? Select all that apply.

Appendicitis Cholecystitis Rationale: Visceral pain results from the activation of nociceptors of the visceral organs. Pain associated with appendicitis and cholecystitis is visceral pain. Chronic nonmalignant pain is often associated with musculoskeletal conditions such as arthritis and fibromyalgia. Pain caused by kidney stones is an example of acute pain.

Patients with which conditions are at risk for chronic nonmalignant pain? Select all that apply.

Arthritis Fibromyalgia Low back pain Rationale: Arthritis, fibromyalgia, and low back pain are all musculoskeletal disorders associated with severe nerve and tissue damage, which may result in chronic nonmalignant pain. Skin infection and thyroid disorder are not associated with nerve damage and may not cause chronic nonmalignant pain. Skin infection may result in acute pain because of inflammation and tissue damage. Thyroid disorder is associated with low serum thyroxine levels, resulting in impaired metabolism.

Which neurotransmitters are released at the site of injury? Select all that apply.

Histamine Bradykinin Prostaglandin Rationale: Histamine, bradykinin, and prostaglandin are the neurotransmitters that are released at the site of injury. These neurotransmitters send the signal of pain to the spinal cord. Glutamate and gamma-aminobutyric acid are released from the brain and block the transmission of pain impulses.

Opioids inhibit which part of nociception?

Movement of the pain impulses from the spinal cord to the thalamus via the ascending fibers

During a pain assessment, the nurse asks the patient, "What does your pain feel like?" The patient responds, "I have numbness and tingling and occasionally shooting pain." The nurse reports which type of pain to the provider?

Neuropathic

A patient with carpal tunnel syndrome reports having a tingling and burning sensation in the thumb, middle, and index fingers. Which type of pain would the nurse report to the provider?

Neuropathic Rationale: The presence of a tingling, burning sensation in the thumb, middle, and index fingers indicates that the patient has neuropathic pain. It is caused by impaired processing of the pain impulses from the site of injury to the nerve fibers. The patient with referred pain has an injury at a particular site, but experiences pain at other sites of the body. Referred pain is caused by damage to a spinal nerve, which sends signals to two different parts of the body. If the patient has pain resulting from skin surface damage, it indicates that the patient has cutaneous pain. Nociceptive pain is associated with aching, throbbing, and a cramping sensation. Because the patient does not report having any aching or throbbing sensation, the nurse would not interpret that the patient has nociceptive pain. p. 172

The aging patient with dementia appears agitated and is pacing and yelling. Which would the nurse infer as the cause of the agitation?

Pain

Which is characteristic of C fibers?

Presence of diffused sensations Rationale: C fibers are unmyelinated sensory fibers that cause pain signals to be more diffuse. The C primary sensory fibers produce a diffused and aching sensation. Because of the absence of Schwann cells, these fibers are not covered with a myelin sheath. Because the C primary sensory fiber is unmyelinated, it has a smaller diameter and transmits signals slowly.

Which type of pain would the nurse document in the medical record for a patient complaining of right upper quadrant abdominal pain that moves to the shoulder?

Referred

Which condition is associated with deep somatic pain?

Tendinitis Rationale: Tendinitis is the inflammation of tendons, which causes deep somatic pain. Intestinal pain and severe stomach cramps indicate that the patient has visceral pain. Pain felt by the patient while changing position is an indicator of incident pain. If the patient with coronary disease experiences pain in the neck, then it indicates that the patient has referred pain.

The nurse asks the patient to make a mark along a 10-cm horizontal line from "no pain" to "worst pain imaginable." Which pain assessment tool is the nurse using during the assessment?

Visual Analogue Scale

Which statement, if made by a nursing student about the transduction phase of nociception, indicates effective teaching?

"The peripheral tissue secretes histamine and prostaglandins during this phase." Rationale: In the transduction phase of nociception, the peripheral tissues secrete neurotransmitters such as prostaglandins and histamines at the site of the injury. These neurotransmitters transmit the pain impulses from the sensory nerve fibers to the spinal cord. During the perception phase, the pain stimuli are received and interpreted by the higher cortical structures of the brain and cause the sensory perception of pain. During the transmission phase, endogenous opioids are secreted in the brain and block the pain signals by activating opioid receptors. If the opioid receptor does not block the pain impulse during transmission, then the impulse moves from the spinal cord to the thalamus.

Which question would the nurse ask the patient with rheumatoid arthritis to evaluate the effectiveness of corticosteroid therapy?

"What makes your pain better or worse?"

Which pathologic disorders are associated with nociceptive pain? Select all that apply.

Arthritis Mechanical back pain

Which is an expected finding in a patient with diabetic peripheral neuropathy?

Burning pain in feet bilaterally Rationale: The diabetic patient with peripheral neuropathy shows symptoms of burning pain in the feet bilaterally, which worsens during the night. The patient with reflexive sympathetic dystrophy has brittle nails, and the skin appears pale, dry, and shiny. Patients with trigeminal neuralgia have severe stabbing or piercing pain in the facial area. Cancer patients who undergo chemotherapy may develop chemotherapy-induced peripheral neuropathy. This symptom manifests as burning, shooting pain in glove- and-stocking manner.

The patient with trigeminal neuralgia has been experiencing intense facial pain for 1 year that is refractory to analgesics. The nurse assesses the patient for which other symptoms? Select all that apply.

Confusion Depression Rationale: If the patient's pain lasts for more than 6 months and is unresponsive to analgesics, it indicates that the patient has poorly controlled chronic pain; this condition can increase serotonin levels in the brain, resulting in confusion and depression. Anxiety, hypoventilation (not hyperventilation), and urinary incontinence may occur with chronic pain but are more often associated with acute pain.

Which criteria are assessed using the PAINAD pain assessment scale? Select all that apply.

Consolability Facial expression Body language Rationale: While using the PAINAD assessment tool, the nurse would monitor five parameters: breathing, vocalization, consolability, facial expression, and body language. Because of the pain, the patient may suffer from hypoxia and hyperventilation. The nurse would check the patient's breathing rate. The patient may make a whimpering sound in response to pain, so the nurse would monitor vocalization. The patient may be confused because of the dementia and may not be open to suggestions. Therefore the nurse would check if the patient is consolable. The patient may exhibit a facial grimace in response to pain and may change the body posture to promote comfort, so the nurse would monitor patient's facial expressions and body language. Pain does not impair visual acuity and does not cause hearing impairment. Therefore the nurse need not monitor the patient's vision and hearing.

The nurse asks the patient with lower back pain, "How does the pain limit your daily activities?" to determine which aspect of the patient's pain experience?

Degree of impairment

Which pain assessment tool is appropriate for a 2-year-old patient?

FLACC scale Rationale: The FLACC scale is a nonverbal pain assessment tool that is used to assess the intensity of pain in infants and children under 3 years of age by observing the facial expression, leg movement, activity level, cry, and consolability in the child; the scale gives a score from 0 to 10. The CRIES scale is a 3-point scale that helps assess postoperative pain in preterm infants and neonates. The PAINAD scale is a pain assessment tool that helps measure pain in patients with dementia. It uses breathing, vocalization, and facial expression as assessment tools. Faces Pain Scale-Revised (FPS- R) is a pain assessment tool that helps assess the intensity of pain through drawings of different facial expressions. p. 168

Which pain scale would the nurse use to assess the pain level in a 6- year-old child?

Faces pain scale Rationale: Children over the age of 5 years old can use the faces pain rating scale. The visual analog scale lets the patient make a mark on a 10-cm horizontal line. The numeric rating scale has the patient rate the pain from a "0" having no pain to a "10" the worst pain imaginable. The verbal descriptor scale uses words to describe the patient's meaning of the pain. A 6-year-old child would not be able to use the visual analog scale, the numeric rating scale, and the verbal descriptor scale.

Which examination visualizes neurochemical changes in the brain caused by nociception?

Functional magnetic resonance imaging (fMRI)

Which associated disorders may be found in a patient with neuropathic pain? Select all that apply.

Herpes zoster Trigeminal neuralgia Distal polyneuropathy Rationale: Herpes zoster, trigeminal neuralgia, and distal polyneuropathy are the disorders that cause neuropathic pain because they cause a primary lesion, called a neuroma, and damage the nervous system. Liver metastasis is visceral damage that results in nociceptive pain. Postoperative pain is somatic damage that causes nociceptive pain. p. 172

The patient reports severe lower back pain while standing for the past 2 days. The nurse documents which type of pain?

Incident Rationale: Incident pain is a type of acute pain caused by certain body movements. Lower back pain while standing indicates that the patient is having incident pain. If a patient experiences lower back pain for more than 6 months, which is not the case here, then it indicates chronic pain. Breakthrough pain occurs in patients who undergo opioid therapy; the patient experiences sudden pain because of the reduced half-life of the medication. Malignant pain is a type of chronic pain; it is induced by tissue necrosis or by the stretching of an organ by a growing tumor.

Which type of pain does the nurse document in the medical record for a patient with herpes zoster (shingles) who reports a pain level 10/10?

Neuropathic Rationale: The pain from herpes zoster (shingles) runs along a nerve in the somatosensory nervous system and occurs from injury to the nerve fibers. Somatic pain originates from musculoskeletal tissues. Visceral pain originates from larger internal organs. Nociceptive pain develops when functioning and intact nerve fibers in the periphery and central nervous system are stimulated. p. 164

The patient with severe electric shock-like pain complains of significant pain not adequately relieved by the prescribed nonsteroidal antiinflammatory drug (NSAID). The nurse attributes this failed therapy to the patient having which type of pain?

Neuropathic pain Rationale: The presence of severe electric shock-like pain in the thighs indicates that the patient has neuropathic pain, which is not effectively treated by NSAIDs. Neuropathic pain is the result of abnormal processing of pain messages from the site of injury to the nerve fibers. NSAIDs decrease prostaglandin levels, but do not increase neurotransmitters or halt nerve damage. Therefore neuropathic pain is not effectively treated by NSAIDs. Visceral pain, cutaneous pain, and breakthrough pain are effectively treated with NSAIDs, because they are examples of nociceptive pain. However, the patient who has visceral pain will experience a deep squeezing pressure with local tenderness. The patient who has cutaneous pain will experience a localized dull, aching pain. The patient who has breakthrough pain will have episodic pains with the symptoms of acute pain.

Which patient has referred pain?

Patient 3 - Acute appendicitis and complains of severe pain in the umbilical area. Rationale: Referred pain is pain that is experienced at a site different from the origin of the injury. The patient with appendicitis has an inflamed appendix in the lower right quadrant of the abdomen but has the sensation of pain in the umbilical area. Therefore it indicates that the patient has referred pain. Patient 1 has a deep, throbbing pain because of skin burns. Therefore this finding indicates that the patient has cutaneous pain. Patient 2 has menstrual pain along with severe vomiting, which indicates that the patient has somatic pain. Patient 4 has pain because of a shoulder fracture, which indicates that the patient has somatic pain.

Which statement is correct regarding the care of these patients?

Patient 4 requires non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. - Px has arthritis and complains of a localized dull ache in the knees. Rationale: Patient 4 has arthritis, which is associated with nociceptive somatic pain. Nonsteroidal antiinflammatory drugs (NSAIDs) reduce prostaglandin levels and alleviate the inflammation and pain associated with arthritis. Therefore the nurse anticipates that patient 4 should be prescribed NSAIDs. Patient 1 has mechanical back pain, which is associated with nociceptive pain. Muscle relaxants relieve muscle spasm and alleviate pain. Antidepressant drugs do not provide muscle relaxation and alleviate back pain. Therefore the nurse does not anticipate antidepressants to be prescribed to Patient 1. Patient 2 has neuropathic pain, which can be alleviated with local anesthetics but not with muscle relaxants. Patient 3 has cancer pain. Opioid drugs, not corticosteroids, help alleviate cancer pain.

Which phase of nociceptive pain signifies the conscious awareness of a painful sensation?

Perception Rationale: Perception is the third phase of nociceptive pain, and it signifies the conscious awareness of a painful sensation in the patient. During this phase, the limbic system interprets the noxious stimuli and elicits emotional responses to pain in the patient. During the modulation phase, the body slowly reduces the pain by stopping the processing of a painful stimulus. During the transduction phase, the pain signals are transmitted from the site of injury to the spinal cord. During the transmission phase, the pain signals move from the spinal cord to the brain; they do not elicit emotional responses to pain.

A patient with joint pain has edema and skin discoloration at the knees. The patient feels severe knee pain when the nurse touches the affected area with a cotton swab. The nurse also observes the patient has pale, dry, shiny skin and brittle nails. Which would the nurse anticipate administering to the patient? Select all that apply.

Pregabalin Prednisone Amitriptyline Rationale: The presence of pale, dry skin, brittle nails, joint pain, edema, and discoloration of the affected extremity indicates that the patient has complex regional pain syndrome (CRPN). Damaged nerves result in impaired functioning of the sensory, motor, and autonomic nerves. Because of nerve damage, the patient feels severe pain even with the contact of a cotton swab. Pregabalin, prednisone, and amitriptyline block the pain impulses from the damaged nerves and help alleviate pain and inflammation. Therefore the primary health care provider would prescribe these medications to the patient. Aspirin and acetaminophen reduce prostaglandin levels and alleviate nociceptive pain. These drugs do not repair damaged nerve fibers and do not alleviate neuropathic pain.

A pregnant patient reports to the nurse, "I feel like my abdominal muscles are being stretched." Which criterion of the PQRST method of pain assessment would the patient's statement address?

Quality/Quantity Rationale: Stretching refers to the quality/quantity of pain on the PQRST pain assessment scale. The letters PQRST stand for Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity Scale, and Timing. The patient informs the nurse that the abdominal muscles feel stretched, but she does not indicate the severity of the pain. This indicates the patient is addressing Quality/Quantity on the scale. If the patient reports about severity of pain on a scale of 0 to 10, then the patient is addressing the Severity Scale. If the patient reports directly about the site of pain, then the patient is addressing Region/Radiation. Information about the therapies that helped in relieving pain represents the element Provocation/Palliation.

Which phase of nociceptive pain involves the release of bradykinin and prostaglandins?

Transduction Rationale: During the transduction phase, bradykinin and prostaglandins are released from the injured tissues. These chemicals transmit pain signals from the injury site to the spinal cord. Perception is the third phase of nociception and is associated with conscious awareness of a painful sensation. The modulation phase is associated with alleviation of the pain stimulus, because there is no release of bradykinin and prostaglandins from injured tissues. During the transmission phase, endogenous opioids are released, which activate opioid receptors and block the transmission of pain impulses. p. 161

In which phase of nociception does the drug oxycodone block the signal of pain?

Transmission Rationale: Oxycodone, an opioid, activates opioid receptors in the spinal cord during the transmission phase to block the signal of pain and inhibit the perception of pain. The opioid receptors are not present in the perception, modulation, and transduction phases. In the perception phase, the patient shows an emotional response to the pain stimulus. In the modulation phase, the release of a third set of neurotransmitters from the brain will show analgesic effects. In the transduction phase, the release of neurotransmitters from the injury site to the spinal cord takes place.