Chapter 35

Neuromodulators

chemicals released in the nervous system that influence the sensitivity of the receiving neuron to neurotransmitters

transmission

conduction of pain sensations from the site of an injury or inflammation along clear and unclear pathways to the spinal cord and then on to higher centers

acute pain

short-term, self-limiting, often predictable trajectory; stops after injury heals

Pain assessment tools

-Wong-Baker FACES -Beyer Oucher pain scale -CRIES pain scale -FLACC scale -COMFORT scale

categories of pain

-duration -location or source -mode of transmission -etiology

Sources of Pain

-nociceptive -cutaneous -somatic -visceral -neuropathic

The dose that is delivered when the client activates the machine is preset.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

WHO 3 step analgesic ladder

* 1- nonopioid * 2 - opioid for mild to moderate pain * 3 - opioid for moderate to severe pain+adjuvant

basic method of assessing pain

*self report *report of family memeber *non behavioral *pysiologic

Nonpharmacologic Pain Relief Measures

- Distraction - Humor - Music - Imagery - Relaxation - Cutaneous stimulation - Acupuncture - Hypnosis - Biofeedback - Therapeutic touch - Animal-facilitated therapy

Diagnosing pain

-Type of pain. -Etiologic factors, to the extent that they are known and understood. -Patient's behavioral, physiologic, and affective responses. -Other factors affecting pain stimulus, transmission, perception, and response

Guarding of the chest area

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

referred pain

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

"The pump is programmed so that it's not possible for you to overdose on your pain medication."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

1

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?

stool softeners and increased fluid intake

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

Encourage client to confer with a spiritual advisor.

A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Administer the pain medication.

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Capnography

A client is receiving opioid analgesia for pain control. The nurse is assessing the client for possible respiratory depression. Which method would be most reliable for the nurse to use to identify impending respiratory depression?

Assess for medication prescription for breakthrough pain.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

Endorphins

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

teaching client to remove items from home that remind them of work

A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Neuromatrix Theory?

administering backrub when client's head hurts

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

neuropathic pain

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?

visceral pain

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

CRIES Pain Scale

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

Substance P

A neurotransmitter that is involved in the transmission of pain messages to the brain. Increase firing of of nerves

in the postoperative stage with occasional pain.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client:

Avoid massaging this area and report the finding to the health care provider.

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action?

increased blood pressure

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

Stop the PCA pump.

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?

Administer the medication if respiratory rate is > 9.

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Observe the client's skin over bony prominences. Warm the lubricant in the palm of the hand. Keep hands in contact with the client's skin at all times.

A nurse is giving a client a back massage. Which actions should the nurse perform? Select all that apply.

Respiratory depression

A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?

Affective

A nurse observes a client that had a hysterectomy crying hysterically. What type of pain response is this client experiencing?

Administer a nonopioid medication

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?

"Acute pain tends to increase during the day and is called a routine pain response"

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

3

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

Pharmacologic Pain Relief Measures

Analgesic administration Nonopioid analgesics Opioids or narcotic analgesics Adjuvant drugs

endogenous opioids

Chemicals produced by the body that reduce pain, enhance positive mood, and suppress appetite.

idiopathic pain

Chronic pain without identifiable physical or psychological cause

CRIES pain scale

Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless

Factors affecting pain experience

Culture Ethnic variables Family, gender, and age variables Religious beliefs Environment and support people Anxiety and other stressors Past pain experience

nursing interventions for pain

Establishing trusting nurse-patient relationship Manipulating factors affecting pain experience Initiating nonpharmacologic pain relief measures Managing pharmacologic interventions Reviewing additional pain control measures, including complementary and alternative relief measures Considering ethical and legal responsibility to relieve pain Teaching patient about pain

chronic pain

Enduring pain that does not decrease over time; may occur in muscles, joints, and the lower back, and may be caused by enlarged blood vessels or degenerating or cancerous tissue. Other significant factors are social and psychological.

Beyer Oucher pain scale

For use in young patients, combines a 0-to-100 scale with six photographic images of children in pain. This scale is helpful for use with older children. Adaptations of the Oucher pain scale are also available for various ethnic groups.

Elevated 30 degrees

How should the nurse position the head of the bed for a client receiving epidural opioids?

Assessment Parameters for Pain

Psychological Emotional Sociologic Physiologic

perception of pain

Pain threshold Adaptation Modulation of pain Neuromodulators Endorphins, dynorphins, enkephalins

General Assessments of Pain

Patient's verbalization and description of pain Duration of pain Location of pain Quantity and intensity of pain Quality of pain Chronology of pain Aggravating and alleviating factors Physiologic indicators of pain Behavioral responses Effect of pain on activities and lifestyle

origin of pain

Physical Psychogenic Referred

Numeric Sedation Scale

S: sleep, easy to arouse: no action necessary 1: awake and alert; no action necessary 2: occasionally drowsy, but easy to arouse; no action necessary 3: frequently drowsy, drifts off to sleep during conversation; reduce dosage 4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

Respiratory status, oxygen saturation, pain, and sedation level

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

Administration of 0.4 mg of naloxone

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opiod anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?

29-year-old who has a speech impediment 34-year-old with schizophrenia 41-year-old who is from a different country 60-year-old with early onset dementia

The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply.

Use massage and heat application to the lower back

The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client

Client who is anxious about discharge

The nurse is evaluating pain of several clients who had hip replacement surgery. Which client is most likely to have the greatest perceived pain?

They bind to opioid receptor sites throughout the CNS.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?

"Can you describe the type of pain you are having?"

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?

"I should only take medication when my pain is intense."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

reviewing and revising the pain management treatment plan

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

It may cause depression in clients.

The nurse recognizes which statement is true of chronic pain?

Wong-Baker FACES® scale

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?

You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken. Do not drive a vehicle while taking this medication.

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply.

"Tell me more about your pain."

Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client?

Cutaneous

What type of pain will the client experience as a result of the intervention being preformed?

Behavioral

When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response?

A client with shingles affecting her entire torso

Which medical client is most likely to be experiencing diffuse pain?

Respiratory

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Document the finding.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Wong-Baker FACES scale

a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain

Bradykinin

a powerful vasodilator that increases capillary permeability and constricts smooth muscle

Biofeedback

a system for electronically recording, amplifying, and feeding back information regarding a subtle physiological state, such as blood pressure or muscle tension

neuropathic pain

abnormal processing of pain message; burning, shooting in nature

transduction

activation of pain receptors

duration of pain

acute and chronic

nociceptive pain

acute pain; a pain sensation that results abruptly sharp, aching, or throbbing

adjuvant drugs

assist primary drugs in relieving pain

perception of pain

awareness of the characteristics of pain

Stimulator of Nociceptors or Pain Receptors

bradykinin, prostaglandins, substance P

physical pain

cause of pain can be identified

FLACC scale

face, legs, activity, cry, consolability

Prostaglandins

hormone like substance that send additional pain stimulates to the CNS

COMFORT scale

infants, children, adults who are unable to use NRS or Wong Baker FACES pain rating scale

endorphins

natural, opiate-like neurotransmitters linked to pain control and to pleasure

Enkephalins

opioids that are widespread throughout the brain and dorsal horn of the spinal cord and are believed to reduce pain sensation by inhibiting the release of substance P

somatic pain

originating from muscle, bone, joints, tendons, or blood vessels

visceral pain

pain originating in the internal organs in the thorax, cranium, or abdomen

referred pain

pain that is felt in a location other than where the pain originates

psychogenic pain

physical cause for pain cannot be identified

common responses to pain

physiologic, behavioral, affective

modulation of pain

process by which the sensation of pain is inhibited or modified

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

dynorphin

the endorphin having the most potent analgesic effect

the pain process

transduction, transmission, perception, modulation