CH. 44 Pain Management

What are some categories for grouping related to type of pain?

(nociceptive, neuropathic, or psychogenic), category of pain (acute or chronic), cause (medical condition, disease process, or injury), or meaning (indication of improvement, sign of worsening condition, unrelated).

If the plan of care is designed according to the guidelines and regulations, nurses will be able to avoid problems related to pain management, such as?

-undertreatment of pain -the underestimation of chronic pain prevalence -inadequate pain management -potential inappropriate overutilization of pharmacologic therapies.

A patient presents to the emergency department immediately following an arm injury that occurred during a football game. The patient rates the pain in the left arm and shoulder an 8 on a 0-10 pain scale. The patient grimaces, guards the arm and shoulder, and clenches the teeth during the assessment. Which hypothesis would the nurse identify? A. Acute Pain B. Chronic Pain C. Difficulty Coping D. Inadequate Pain Control

A. Acute Pain The patient cues indicate that the patient is experiencing Acute Pain (sudden onset, identifiable cause, behaviors).

The nurse is caring for a patient who was involved in a mountain bike accident and is experiencing severe pain. The nurse determines that Acute Pain is the priority hypothesis. Which statement reflects a short-term outcome for the patient experiencing pain? A. Patient will report a pain level of less than 3 on a 0-10 scale within 5 postoperative days. B. Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. C. Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 day of beginning new pain medication. D. Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 week of beginning new pain medication.

B

A patient is restless and moaning, and rates pain a 10 on a 0-10 pain scale 1 hour following administration of prescribed pain medication. Which hypothesis would the nurse identify? A. Anxiety B. Acute Pain C. Inadequate Pain Control D. Pain Management Satisfaction

C

Following a back injury that occurred while gardening, a patient states that the pain level increases when walking or bending but is relieved when lying down. Which hypothesis would the nurse identify? A. Anxiety B. Chronic Pain C. Difficulty Coping D. Risk for Activity Intolerance

D. Risk for Activity Intolerance Patient cues indicate that the patient's activity level can be affected by the pain because the pain level increases when walking or bending and is relieved when lying down.

What would be the ICNP diagnoses/Hypotheses based on these cues? Patient grimacing Visible restlessness

Difficulty Coping

Using your clinical judgement how do you Prioritize Hypotheses?

If left unmanaged, which cues have the potential to cause the most harm?

What would be the ICNP diagnoses/Hypotheses based on these cues? Skin on right leg pale and cool to touch Decreased sensation in right foot Weak pulses distal to fracture Capillary refill of 4 seconds in right foot Elevated pulse and blood pressure

Impaired Circulatory System Function

What would be the ICNP diagnoses/Hypotheses based on these cues? Clenched teeth Restlessness Moaning Patient rates pain an 8 on a 0-10 pain scale 1 hour after administration of prescribed pain medication, reflecting no change from the original pain scale rating assessed premedication.

Inadequate Pain Control

Patient goals should be developed as SMART goals:

Specific Measurable or Meaningful Attainable or Action-Oriented Realistic or Results-Oriented Timely or Time-Oriented

Why does a nurse connect related cues?

To form a hypothesis appropriate for the patients unique pain experience.

Using your clinical judgement how do you Generate Solutions?

What is the ideal patient state given what the nurse knows and has assessed?

Questions to assist the nurse in prioritizing the hypotheses for patients experiencing pain Urgency

Which hypotheses are most likely to be life-threatening or affect airway, breathing, and circulation? If any of these issues exist, they must be addressed first. Example: A patient who has experienced a motor vehicle accident may be in severe pain. Injury, such as a broken bone, may also cause inadequate circulation. Impaired circulation would be a priority to reduce pain, swelling, and damage to tissues.

After assessing a patient with a fractured wrist, the nurse selects a hypothesis of Difficulty Coping. Which cues would lead the nurse to select this hypothesis? Select all that apply. 1. The patient is grimacing. 2. The patient appears restless. 3. The patient has an elevated blood pressure and pulse. 4. The patient reports pain of 5 on a 0-10 pain scale. 5. The patient has decreased sensation in the fingers of the affected wrist.

1,2,

Which pain management activities can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Performing oral hygiene 2. Providing back rubs 3. Repositioning the patient 4. Administering pain medication 5. Calling the health care provider to request pain medication

1,2,3

The provider prescribed pain and anxiety medications for a postoperative patient. The lowest pain rating the patient reports during the shift is 7 on a 0-10 pain scale. Which interprofessional team members would the nurse collaborate with to determine nonpharmacologic solutions for the patient? Select all that apply. 1. Music therapist 2. Physical therapist 3. Massage therapist 4. Health care provider 5. Pain management specialist

1,2,3,5,

Which questions would the nurse ask to assist in prioritizing hypotheses for patients experiencing pain? Select all that apply. 1. Which hypotheses are most likely to occur? 2. Which hypotheses might affect the patient's airway? 3. Which hypotheses influence activities of daily living? 4. Which hypotheses can increase the risk for complications? 5. Which hypotheses are most likely to be life-threatening?

1,2,4,5

Why is interprofessional collaboration important?

It helps to determine patient outcomes and generate solutions for developing a comprehensive plan of care which ensures that the patients pain needs are met. The ultimate goal of collaboration is progression of the patient toward the desired outcome of pain relief.

Patient goals can be short-term or long-term. What is the short term goal and long term goal for a patient ICNP Diagnosis/Hypothesis for Acute Pain

Short-term Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. Long-term Patient will report a pain level of less than 3 on a 0-10 scale within 5 postoperative days.

What are relationship assessments gathered from information during pain assessement?

Subjective, gathered through health history, including pain experience and medical, mental health, and substance use components Objective, information gathered through physical assessment and observation of clinical, behavioral, and psychological manifestations of pain

What would be the ICNP diagnoses/Hypotheses based on these cues? Long bone fracture (right femur) Reported pain of 10 on a 0-10 pain scale Request for pain medication Elevated pulse and blood pressure

Acute Pain

What would be the ICNP diagnoses/Hypotheses based on these cues? Injured arm playing basketball the previous day Guarding arm and shoulder Grimacing Patient rates pain a 9 on a 0-10 pain scale

Acute pain

Which collaborative team members may be involved in providing care to a patient with pain? Select all that apply. 1. Art therapist 2. Physical therapist 3. Massage therapist 4. Pain management specialist 5. Muscle manipulation specialist

2,3,4,5

Which factors influence legal and ethical aspects of generating solutions for pain management? Select all that apply. 1. Patient perception of pain 2. Professional standards of practice 3. Organizational policies and procedures 4. Regulatory pain management standards 5. Pain management position statements

2,3,4,5

Place the steps in the order that the nurse implements them when caring for a patient experiencing pain. 1. Organize and link patient cues related to pain. 2. Determine patient goals/outcomes related to pain management. 3. Complete a pain assessment. 4. Prioritize hypotheses related to pain and pain management. 5. Identify hypotheses related to pain and pain management.

3,1,5,4,2

Which phrases describe potential hypotheses related to pain management? Select all that apply. 1. Nursing interventions 2. Expected patient outcomes 3. Factors that alleviate pain 4. Issues the patient is at risk for developing 5. Actual problems the patient faces

3,4,5

Which statement describes the process nurses use to organize and link cues for a patient experiencing pain? A. Group collected cues according to type/category of pain, cause, or meaning. B. Collect objective cues through the health history, including pain experience. C. Apply critical thinking skills to cluster patient cues, linking them to the disease process. D. Gather subjective cues through physical assessment and observation of manifestations of pain.

A

Which strategy can the nurse use to care for an athlete who experiences occasional stress and muscle pain before or after sports? A. Collaborate with a massage therapist B. Request a prescription for pain medication C. Gather objective data through the health history D. Provide education regarding breakthrough pain

A. Collaborate with a massage therapist Collaboration with interprofessional team members is an important component of pain management. Massage therapists use hands-on manipulation of soft tissue to benefit patients with occasional stress and muscle pain.

What are some Common International Classification of Nursing Practice (ICNP) nursing diagnoses that are associated with pain?

Anxiety Acute Pain Chronic Pain Difficulty Coping Inadequate Pain Control Risk for Activity Intolerance Pain Management Satisfaction Risk for Negative Response to Nurse-Controlled Analgesia Risk for Negative Response to Patient-Controlled Analgesia

The nurse collaborates with unlicensed assistive personnel (UAP) to implement care for patients experiencing pain. Which action can the nurse delegate to UAP? A. Administering morphine sulfate for pain B. Darkening the room to create a peaceful environment C. Performing massage and range-of-motion exercises D. Asking the health care provider to prescribe lorazepam for anxiety

B. Darkening the room to create a peaceful environment The nurse maintains ultimate responsibility for overseeing the implementation and documentation of all pain-related care, and some nonpharmacologic pain management activities may be delegated to UAP, such as darkening the room.

The nurse is caring for a patient who was involved in a mountain bike accident and is experiencing severe pain. Which question would allow the nurse to prioritize hypotheses according to risk? A. Which hypotheses are most likely to occur? B. Which hypotheses are most likely to affect breathing? C. Which hypotheses have the potential for complications? D. Which hypotheses are most likely to be life-threatening as a result of injury?

C, Which hypotheses have the potential for complications? This question will allow the nurse to identify the most serious hypotheses or those with the potential to increase the risk for complications.

The nurse is caring for a patient who reports pain of 9 on a 0-10 scale. The nurse administers the prescribed pain medication. Which statement reflects a patient goal developed in accordance with the SMART acronym? A. Patient will state better pain management within 1 hour of starting prescribed pain medication. B. Patient will verbalize an improvement in pain after taking prescribed dose of analgesia medication. C. Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. D. Patient will describe satisfactory pain control at a level less than 4 on a rating scale of 0-10.

C. Patient will report a pain level of less than 3 on a 0-10 scale within 1 hour of starting prescribed dose of analgesia. Patient goal is a SMART goal: specific, measurable, attainable, realistic, and time-oriented.

What are some nonpharmacologic pain management activities may be delegated to unlicensed assistive personnel?

Changing bed linens Darkening the room Talking to the patient Performing oral hygiene Administering back rubs Repositioning the patient

Which solution involves the collaboration of a primary health care provider, nurse, and pharmacist when caring for a patient with pain from an injury to an extremity? A. Ordering a music therapist consult B. Providing assistance with ambulation C. Elevating the extremity and applying an ice pack D. Administering acetaminophen/oxycodone

D. Administering acetaminophen/oxycodone Administration of acetaminophen/oxycodone requires collaboration of a health care provider, nurse, and pharmacist.

A 40-year-old patient presents to the emergency department with a fracture of the right femur following a four-wheeler accident. The nurse organizes relevant cues and links them to form hypotheses, as depicted in the table. Organizing/Linking Cues -Long bone fracture (right femur) -Reported pain of 10 on 0-10 pain scale -Request for pain medication -Elevated pulse and blood pressure ICNP Diagnoses /Hypotheses Acute Pain Organizing/Linking Cues -Patient grimacing -Visible restlessness ICNP Diagnoses /Hypotheses Difficulty Coping Organizing/Linking Cues -Long bone fracture (right femur) ICNP Diagnoses /Hypotheses Risk for Impaired Patient Mobility Organizing/Linking Cues -Skin on right leg pale and cool to touch -Decreased sensation in right foot -Weak pulses distal to fracture -Capillary refill of 4 seconds in right foot -Elevated pulse and blood pressure ICNP Diagnoses /Hypotheses Impaired Circulatory System Function Which patient goal relates to the priority hypothesis? A. Increased patient mobility B. Improved mood and coping C.Decreased pain level in right leg D. Neurovascular checks of right leg within normal limits

D. Neurovascular checks of right leg within normal limits The patient cues reflect that Impaired Circulatory System Function is the most urgent, most serious, and most likely hypothesis.

What would be the ICNP diagnoses/Hypotheses based on these cues? Patient states that back was injured while working in the yard. Patient grimaces and presents a bent posture when walking. Patient states that pain level increases when walking or bending, and pain is relieved when lying down. Health care provider imposed an activity restriction as a component of the treatment plan for back injury.

Risk for Activity Intolerance

Patient goals can be short-term or long-term. What is the short term goal and long term goal for a patient ICNP Diagnosis/Hypothesis for Activity Intolerance

Short-term Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 day of beginning new pain medication. Long-term Patient will perform activities of daily living, reporting a pain level of 3 or less within 1 week of beginning new pain medication.

The nurse should also consider legal and ethical aspects of managing pain and ensure alignment with the following:

The American Nurses Association (ANA) Standards of Practice ANA Code of Ethics for Nurses ANA position statement, "The Ethical Responsibility to Manage Pain and the Suffering It Causes" (ANA, 2018) Pain assessment and management standards published by The Joint Commission

What does a nurse do once hypotheses have been developed?

The nurse needs to prioritize them

What are examples of relevance of the cues to the patients unique situation?

The pain experience is subjective, so individual responses can vary for the same types of injuries or experiences. More than one problem can exist. Some assessment findings may be related to a medical condition or injury, but not necessarily related to pain.

Questions to assist the nurse in prioritizing the hypotheses for patients experiencing pain Likelihood

Which hypotheses are most likely? Which are least likely? Example: A patient with no support system may be more likely to experience Difficulty Coping with Pain.

Questions to assist the nurse in prioritizing the hypotheses for patients experiencing pain Risk

Which hypotheses are the most serious or have the potential to increase the risk for complications? Example: A patient who is immobilized as a result of an injury may be at Risk for Impaired Skin Integrity.

Using your clinical judgement how do you Analyze cues?

Which potential conditions have cues similar to those the nurse identified when assessing the patient? (What are potential patient problems based on analysis of patient cues?)

Prioritization of hypotheses includes?

evaluating and ranking the hypotheses according to importance, including criteria such as urgency, likelihood, or risk

What do Hypotheses idenitfy?

issues that the nurse should address to alleviate or control the patient's pain. The hypotheses can be actual problems the patient is currently facing (such as acute pain) or problems the patient is at risk for developing (such as risk for activity intolerance).

What are members of the interprofessional team?

nurses, advanced practice nurses, health care providers, music therapists, massage therapists, occupational therapists, physical therapists, pain management specialists, muscle manipulation specialists, social workers, psychologists, clergy, and other specialists who provide complementary therapies to manage pain in addition to medication.

Once hypotheses are prioritized, what are they used for?

plan patient goals and outcomes, which will be the foundation of generating the plan of care. The nurse should ensure a course of direction for personalized care tailored to the individual's unique needs, factoring in patient variables such as comorbidities.

What should a nurse consider the impact of unique patient characteristics

such as culture, life experience, or prior pain experiences, when prioritizing hypotheses. Another consideration is which hypotheses may eliminate other problems if resolved.