Chapter 44

identify some principles to evaluate related to pain management:

Evaluate the patient for the effectiveness of the pain management after an appropriate period of time; entertain new approaches if no relief; evaluate the patient's perception of pain.

The international association for the study of pain (IASP) defines pain as:

An unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Explain how a person's cultural background factors affect coping with pain:

Individuals learn what is expected and accepted by their cultural; different meanings and attitudes are associated with pain across various cultural groups.

chronic episodic pain

Occurs sporadically over an extended duration of time.

Reducing pain perception and reception:

One simple way to promote comfort is by removing or preventing painful stimuli; also distraction, prayer, relaxation, guided imagery , music, and biofeedback.

What is patient-controlled analgesia (PCA)? and What is the goal of PCA?

PCA allows patients to self-administer opioids with minimal risk of overdose; the goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing.

Briefly explain gate control theory of pain:

Pain has emotional and cognitive components in addition to physical sensations. Gating mechanisms located along the CNS regulate or block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed.

Incident pain

Pain that is predictable and elicited by a specific behaviors such as physical therapy or wound dressing changes

Spontaneous pain

Pain that is unpredictable and not associated with any activity or event

End-of-dose failure pain

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic

cutaneous stimulation

Stimulation (including massage, warm bath, ice bag, and transcutaneous electrical stimulation (TENS) reduces pain perception by the release of endorphins, which block the transmission of painful stimuli.

The main benefit of multimodal analgesia is:

The use of different agents allows for lower than usual doses of each medication, therefore lowering the risk of side effects, while providing pain relief that is good or even better than could be obtained from each of the medications alone.

pallative care

care provided where the goal is to live life fully with an incurable condition.

idiopathic pain

chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

distraction

directs a patient's attention to something other than pain and thus reduces the awareness of pain.

Music

diverts the person's attention away from the pain and creates a relaxation response.

pain tolerance

emotional and cognitive components in addition to physical sensations. Gating mechanisms located along the CNS regulate or block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed.

regional anesthesia

injection of a local anesthetic to block a group of sensory nerve fibers; perineural local anesthetic infusion.

local anesthesia

intended for local infiltration of an anesthetic medication to induce loss of sensation to a body part.

acute pain

is protective, has a cause, is of short duration, and has limited tissue damage and emotional response

Chronic pain

lasts longer than anticipated, does not always have a cause, and leads to great personal suffering.

Relaxation

mental and physical freedom from tension or stress that provides individuals a sense of self-control

epidural analgesia

permits control or reduction of severe pain and reduces the patients overall opioid requirement; can be short or long term.

Hospice

provided at the end of life; it emphasizes quality of life over quantity.

Identify the physiological factors that influences pain

1. Age-children and aging 2. Fatigue- heightens the perception of pain and deceased coping abilities. 3. Genes- can possibly increase or decrease a person's sensitivity to pain and determines pain threshold or tolerance. 4. Neurologic function- any factor that interrupts or influences normal pain reception or perception affects a patient's awareness of and responses to pain.

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 5. Use a slow, circular steady massage.

A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

1. Calls the health care provider and questions the order

The goals of effective pain management are:

1. Improves quality of life 2.Reduces physical discomfort 3.Promotes earlier mobilization and return to previous baseline functions 4.Results in fewer hospital and clinic visits 5.Decreases length of stay, resulting in lower health care costs.

List some common biases and misconceptions about pain:

1. Patients who abuse substances (drugs and alcohol) overreact to discomforts. 2. Patients with minor illnesses have less pain than those with severe physical alterations. 3.Administering analgesics regularly leads to drug addiction. 4. The amount of tissue damage in an injury accurately indicates pain intensity. 5.Health care personnel are the best authorities on the nature of a patient's pain. 6. Psychogenic pain is not real. 7. Chronic pain is psychological 8. Patients who are hospitalized will experience pain. 9. Patients who cannot speak do not feel pain.

Identify the social factors that can influence pain:

1. Previous experience-prior experience does not mean that a person accepts pain more easily in the future. 2. Family and social support-can make the experience less stressful; the presence of parents is especially important for children experiencing pain. 3. Spiritual factors-benefits for individuals physical and emotional health.

Identify the psychological factors that can influence pain:

1.Attention- the degree to which the patient focuses on pain. 2.Anxiety and fear- perceive pain differently if it suggest a threat, loss, punishment, or challenge. 3. Coping styles- pain can be a lonely experience that often causes patients to feel a loss of control.

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 12 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

2. Difficulty arousing the patient

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for the past year to manage her arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3h, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

2. Request to have the order changed to around the clock (ATC) for the first 48 hours.

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the nonpharmacological therapy? (Select all that apply.) 1. Turn TENS on before patient feels discomfort. 2. TENS works peripherally and centrally on nerve receptors. 3. TENS does not require a health care provider order. 4. Remove any skin preparations before attaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.

2. TENS works peripherally and centrally on nerve receptors. 4. Remove any skin preparations before attaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.

A new medical resident writes an order for oxycodone CR 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

2. The time interval

Place the following steps in the correct order for administration of patient-controlled analgesia: 1. Insert drug cartridge into infusion device and prime tubing. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 3. Demonstrate to patient how to push medication demand button. 4. Secure connection and anchor PCA tubing with tape. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 6. Insert needleless adapter into injection port nearest patient. 7. Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking. 8. Program computerized PCA pump as ordered to deliver pre-scribed medication dose and lockout interval. 9. Attach needleless adapter to tubing adapter of patient-con-trolled module.

3. Demonstrate to patient how to push medication demand button. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 7. Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking. 1. Insert drug cartridge into infusion device and prime tubing. 9. Attach needleless adapter to tubing adapter of patient-con-trolled module. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 6. Insert needleless adapter into injection port nearest patient. 4. Secure connection and anchor PCA tubing with tape. 8. Program computerized PCA pump as ordered to deliver pre-scribed medication dose and lockout interval.

(ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants

3. Stool softeners

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

3. The amount of daily acetaminophen

Placebo:

A medication or procedure that produces positive or negative effects in patients that are not related to the placebo's specific physical or chemical properties.

Addiction:

A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

Drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time

physical dependence (addiction)

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

Define Adjuvants or co-analgesics:

A variety of medications that enhance analgesics or have analgesic properties that were originally unknown.

Identify the ABCDE clinical approach to pain assessment and management.

A. Ask about pain regularly. Assess pain systematically. B. Believe the patient and family in their report of pain and what relieves it. C. Choose pain-control options appropriate for the patient, family, and setting D. Deliver interventions in a timely. logical, and coordinated fashion. E. Empower patients and their families. Enable them to control their course to the greatest extent possible.

Nonpharmacologic interventions include the following, briefly explain each: Cognitive behavioral approaches: Physical approaches:

A. Change patient's perception of pain, and provide patient with a greater sense of control ( distractions, prayer, relaxation, guided imagery, music, and biofeedback) B. Aim to provide pain relief, correct physical dysfunction, alter physiological responses, and reduce fears associated with pain-related immobility.

List potential or actual nursing diagnoses related to a patient in pain:

A. Difficulty coping B. Fatigue C. Impaired Mobility D. Impaired Sleep E. Social Interaction

Give some examples of barriers to effective pain management. A. Patient: B. Health care provider: C. Health care system:

A. Fear of addiction, worry about side effects, fear of tolerance ("won't be there when I need it"), take too many pills already, fear of injections, concerns about not being a "good" patient, don't want to worry family and friends, may need more tests, need to suffer to be cured, pain is for past indiscretions, inadequate education, reluctance to discuss pain, pain is inevitable, pain is part aging, fear of disease progression, primary health care providers from treating illness, primary health care providers have more important or ill patients to see, suffering in silence is noble and expected. B. Inadequate pain assessment. concern with addiction, opiophobia, fear of legal repercussions, no visible cause of pain, patients must learn to live with pain, reluctance to deal with side effects of analgesics, fear of giving a dose that will kill the patient, mot believing the patient's report of pain, primary health care provider time constraints, inadequate reimbursement, belief that opioids "mask" symptoms, belief that pain is part of aging, overestimation of rates of respiratory depression. C. Concern with creating "addicts" ability to fill prescriptions, absolute dollar restriction on amount reimbursed for prescriptions, mail order pharmacy restrictions, nurse practitioners and physician assistants not used efficiently, extensive documentation requirements, poor pain policies and procedures regarding pain management, lack of money, inadequate access to pain clinics, poor understanding of economic impact of unrelieved pain.

List the nursing principles for administering analgesics (4)

A. Know patient's previous response to analgesics. B. Select proper medications when more than one is ordered. C. Know accurate dosage. D. Assess right time and interval for administration

Identify the three types of analgesics used for pain relief:

A. Nonopioids (acetaminophen and NSAIDs) B. Opioids (narcotics) C. Adjuvants or co-analgesics

List the patient outcomes appropriate for the patient experiencing pain. (3)

A. Patient reports that pain is a 3 or less on a scale of 0-10 B. Avoids factors that intensify pain C. Use pain-relief measures safely D. Level of discomfort does not interfere with dressing self.

list the factors impacted by pain:

A. Quality of life B. Self-care C. Work D. Social support

List the guidelines recommended for nonpharmacologic therapies in the older adult:

A. Tailor the nonpharmacological techniques to the individual. B. Cognitive behavioral strategies may not be appropriate for the cognitively impaired. C. Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain and are generally safe and effective.

Identify the common characteristics of pain that the nurse would asses:

A. Timing (Onset, duration, and pattern) B. Location C. Severity D. Quality E. Aggravating and precipitating factors F. Relief measures G. Contributing symptoms

Identify the four physiological processes of normal pain:

A. Transduction: Converts energy produced by stimuli (thermal, chemical, or mechanical) into electrical energy. B. Transmission: Excitatory neurotransmitters send electrical impulses across the synaptic cleft between the nerve fibers, enhancing the pain impulses. C. Perception: The point the person is aware of pain; gives awareness and meaning to pain, resulting in a reaction. D. Modulation: The inhibition of pain impulse is the last phase of the normal pain process, which occurs due to release of inhibitory neurotransmitters.

Match the characteristics on the left with the appropriate pain category on the right. Acute Pain Chronic Pain A. Has a protective effect B. Lasts more than 3 to 6 months C. Usually has identifiable cause D. Dramatically affects quality of life E. Viewed as a disease F. Eventually resolves with or without treatment

Acute Pain: A. Has a protective effect C. Usually has identifiable cause F. Eventually resolves with or without treatment Chronic Pain: B. Lasts more than 3 to 6 months D. Dramatically affects quality of life E. Viewed as a disease

To adequately assess the quality of a patient's pain, which question would be appropriate? A. "Is it a sharp pain or a dull pain?" B. "Tell me what your pain feels like." C. "Is your pain a crushing sensation?" D. "How long have you had this pain?"

Answer: "Tell me what your pain feels like." Rationale: A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain.

A substance that can cause analgesia when it attaches to opiate receptors in the brain is: 1. Endorphins 2. Bradykinin 3. Substance P 4. Prostaglandin

Answer: Endorphins Rationale: When the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids that hinder the transmission of pain and help produce an analgesic effect.

Pain is a protective mechanism warning of tissue injury and is largely a(n): A. Objective experience B. Subjective experience C. Acute symptom of short duration D. Symptom of a severe illness or disease

Answer: Subjective experience Rationale: only the patient knows whether pain is present and what the experience is like.

The use of patient distraction in pain control is based on the principle that: 1. Small C fibers transmit impulses via the spinothalamic tract. 2. The reticular formation can send inhibitory signals to gating mechanisms. 3. Large A fibers compete with pain impulses to close gates to painful stimuli 4. Transmission of pain impulses from the spinal cord to the cerebral cortex can be inhibited.

Answer: The reticular formation can send inhibitory signals to gating mechanisms. Rationale: The reticular activating system inhibits painful stimuli if a person receives sufficient sensory stimulation, a person is able to ignore or become unaware of pain.

Herbals

Are not sufficiently studied; however, many use herbals such as echinacea, ginseng, gingko biloba, and garlic supplements.

Pain clinics:

treat persons on an inpatient or outpatient basis; multidisciplinary approach to find the most effective pain-relief measures