Pain Assessment (HESI)

The nurse preceptor is educating the novice nurse about the use of McCaffery and Pasero's Hierarchy of Pain Measures. Which statement by the nurse preceptor accurately describes this tool?

"The Hierarchy of Pain Measures includes behavioral pain assessment." (McCaffery and Pasero's Hierarchy of Pain Measures provides several strategies for promoting self-reporting of pain by patients. Included in this tool are measures for use in behavioral pain assessment. Rather than replacing self-reporting of pain, this tool prioritizes self-reporting. The Hierarchy does not assume that patients are unable to self-report pain. Instead, this tool incorporates behavioral pain assessment tools for use in patients who are unable to self-report.)

The nurse is assessing a patient reporting pain in the back. What questions does the nurse ask to inquire about the precipitating factors of the pain? Select all that apply.

"Was the onset of the pain sudden or slow?" "What do you think causes the present pain?" "Have you done anything to relieve the pain?" "What were the results of any steps you took?" (Precipitating factors are factors that trigger or cause the onset of pain. To know about the precipitating factors of the pain, the nurse asks the patient about the nature of the onset of pain, the likely cause, steps taken to relieve the pain, and the results of such steps. Effects of the pain on lifestyle factors, such as diet and sleep, provide information about the aggravating factors. A description of where the pain travels from its site of onset provides information about the localization of the pain.)

The emergency department nurse is caring for a patient who sustained a 1-inch laceration on her thumb. Treatment by the primary health care provider includes application of antibiotic ointment and a small dressing; no sutures were needed. As the nurse prepares to review the patient's discharge instructions, the patient states, "My thumb really hurts! I need something for pain now!" Which response by the nurse is most appropriate?

"I will tell your primary health care provider that you are having a lot of pain."

Which patient conditions place the patient at highest risk for undertreatment of pain? Select all that apply.

Alzheimer's disease Senile dementia (Patients with problems of cognition, such as Alzheimer's disease and senile dementia, are among those at highest risk for undertreated pain because they are unable or have difficulty reporting their pain. Rheumatoid arthritis, diabetic neuropathy, and postherpetic neuralgia are not directly associated with cognitive impairment.)

The nurse is using McCaffery and Pasero's Hierarchy of Pain Measures to assess a cognitively impaired patient. Which action does the nurse implement first?

Assessing the patient's ability to use a standard pain assessment tool (The first component of McCaffery and Pasero's Hierarchy of Pain Measures includes attempting to obtain the patient's self-report. The nurse should not assume a patient cannot provide a report of pain; many cognitively impaired patients are able to use a self-report tool if simple actions are taken. If use of a standard pain assessment tool is ineffective, secondary strategies include increasing the size of the font and other features of the scale; presenting the tool in vertical format (rather than the frequently used horizontal); and repeating instructions and questions more than once. Behavioral signs are assessed after assessing the patient's ability to use a standard pain assessment tool.)

Which objectives are accomplished by conducting an analgesic trial for a cognitively impaired patient? Select all that apply

Confirming the presence of pain Establishing a basis for a pain treatment plan (An analgesic trial may be conducted to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is thought to be present. An analgesic trial is not used to determine the cause of the patient's pain, nor is it used to estimate pain tolerance. Assessment of severity of pain, which requires self-reporting, cannot be accomplished by way of an analgesic trial.)

Which term is used to describe pain quality?

Cramping (Cramping is a descriptor that is used to describe pain quality. Descriptors such as "steady," "intermittent," and "periodic" are used to describe pain duration.)

A patient reports sharp, shock-like, burning, shooting pain in the feet and legs that is associated with numbness. The nurse suspects that the patient is experiencing what condition?

Diabetic neuropathy

Which components are included in McCaffery and Pasero's Hierarchy of Pain Measures? Select all that apply.

Evaluating physiologic indicators of pain Attempting to obtain self-report Observing patient behaviors Conducting an analgesic trial (Key components of McCaffery and Pasero's Hierarchy of Pain Measures include requiring the nurse to (1) attempt to obtain a self-report; (2) consider underlying pathology or conditions and procedures that might be painful (e.g., surgery); (3) observe behaviors; (4) evaluate physiologic indicators; and (5) conduct an analgesic trial. Using nonpharmacologic measures is not a component of McCaffery and Pasero's Hierarchy of Pain Measures.)

Which intervention facilitates nursing assessment of the severity of the patient's pain?

Obtaining a self-report Of these interventions, only self-report allows for assessment of pain severity. Behavioral signs, analgesic trials, and vital signs are not reliable sources of data related to pain severity.

Provoked: what caused the pain and what makes it better or worse

P in PQRST Pain assessment pneumonic

Which term describes pain produced by inflammation of the trigeminal nerve (trigeminal neuralgia) that is diffuse in nature, extending across the various nerves that innervate the face?

Projected (Pain that is caused by inflammation of the trigeminal nerve (trigeminal neuralgia) and that is diffuse in nature (as opposed to being well-localized), extending across the entire face is an example of projected pain. Radiating pain is a sensation that is felt along a specific nerve or nerves. Referred pain is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin.)

Quality: what does it feel like? sharp or dull, localized or diffuse

Q in PQRST Pain assessment pneumonic

Which component of pain assessment is addressed by the patient describing his pain as "searing"?

Quality (Descriptors such as "searing" are used to describe pain quality, which refers to the patient's sensory perception of the pain. Intensity refers to severity of pain. Onset refers to when the pain started. Duration addresses whether the pain is constant or intermittent.)

Region: where it hurts

R in PQRST Pain assessment pneumonic

During change-of-shift report, the day shift staff learns that a patient who had back surgery has been reporting increasing lower back pain during the night. It is most appropriate for which day staff member to assess the patient's pain?

RN team leader who is responsible for updating the care plan for the patient (The RN team leader should assess this patient's level of pain and the need for a change in the plan of care. The LPN/LVN will assist with management of the patient's pain, but assessment should be done by the RN. The RN nurse manager has the education and scope of practice to assess the patient's pain, but providing direct patient care is not the designated role for this nurse. The RN from the emergency department will not be familiar with assessments and interventions for postoperative back pain.)

Which term describes right shoulder pain caused by gallstones?

Referred Right shoulder pain related to gallstones is an example of referred pain, which is felt in an area distant from the site of painful stimuli. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Radiating pain is felt along a specific nerve or nerves.

Severity: use the pain scale (faces, etc)

S in PQRST Pain assessment pneumonic

Which data is most reliable for use in assessment of a patient's pain?

Subjective patient reports (Subjective descriptions of the experience and measurement of pain intensity are more reliable and accurate than observable qualities of pain. All accepted guidelines identify the patient's self-report as the gold standard for assessing the existence and intensity of pain (Pasero & McCaffery, 2011). Because the amount of pain and responses to it vary from person to person, interpreting pain solely on actions or behaviors, including emotional responses, can be misleading and is not recommended. Physiologic changes are not reliable indicators of pain, as patients may report pain in the absence of any observable or documented physiologic changes. )

Timing: does it come and go, constant, hurt more or less at certain times?

T in PQRST Pain assessment pneumonic

A nurse is caring for a patient with a history of dementia and associated long-standing pain. In which order should the nurse follow the recommendations for the Hierarchy of Pain Measures as given by the primary health care provider? Obtain a self-report.'' "Conduct an analgesic trial.'' Incorrect "Consider underlying painful pathology, conditions, and procedures.'' "Evaluate physiologic indicators." "Observe the behaviors.'

The first step in the Hierarchy of Pain Measures involves obtaining a self-report from the patient. The next priority is to take into consideration underlying painful pathology, conditions, and procedures such as surgery in order to find if the pain is related to the surgery. After this, observation of the behavior is important as a patient with dementia may exhibit certain physiologic and emotional distress. This is followed by evaluation of physiologic indicators which includes family members, parents, and caregivers. Lastly, an analgesic trial is conducted on the patient wherein a dosage appropriate to the estimated intensity of pain is provided.

Effective pain assessment requires the nurse to understand which principles related to pain perception among older adults? Select all that apply.

The incidence of pain is higher in older adults. Older adults may be reluctant to report pain (The incidence of pain is higher in older adults. However, many older adults are reluctant to report pain for a variety of reasons including the belief that it is normal and that they are bothering the nurse. Self-reports of pain by older adults are not considered to be inaccurate; rather, they provide crucial assessment data. Many older adults, even those with mild to moderate dementia, are able to use a self-report assessment tool if nurses and other caregivers take the time to administer it. Sensitivity to pain does not diminish with age. Pain is not an inevitable consequence of aging.)

The primary health care provider instructs the nurse to obtain the patient's pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

Use a standard pain assessment tool Increase features of the scale, such as the font size Repeat the instructions and questions more than once (Using a standard pain assessment tool will help in the correct assessment of the levels of pain. Increased font size and other features of the scale helps provide clarity as the patient responds to the nurse's questions. It is important for the nurse to repeat the instructions and questions more than once. The nurse should allow ample time for the patient to respond. Asking the patient about their present level of pain rather than pain history will help in establishing a line of treatment. )

The pain resource nurse (PRN) is creating a brochure for nurses about pain assessment. Which information will the PRN include in the brochure?

Vital signs may be below normal in the presence of severe pain. (Patients may have normal or below normal vital signs in the presence of severe pain. Intubated, mechanically ventilated patients may be alert enough to indicate their pain rating through nonverbal means, such as pointing to a number on a pain rating scale. Physiologic indicators are the least sensitive indicators of pain and may signal the existence of conditions other than pain or a lack of it (e.g., hypovolemia, blood loss). Behavioral tools are used to help confirm the presence of pain and the efficacy of an intervention; however, pain intensity requires patient reporting.)

Which individuals may serve as the newly admitted patient's surrogate for the purpose of behavioral pain assessment? Select all that apply.

personal caregiver, spouse, parent (A surrogate who knows the patient well (for example, a parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain. The primary health care provider is not a suitable surrogate, nor is the patient's physical therapist.)