Pain Management (Hesi)
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be either selective or nonselective depending on the enzymes they block. Which drug is a selective NSAID?
Celecoxib (Celecoxib is a selective NSAID that selectively blocks the cyclooxygenase-2 (COX-2) enzyme responsible for inflammation and the production of prostaglandins. NSAIDs like aspirin, ibuprofen, and naproxen block both the COX-1 and COX-2 enzymes; they do not selectively inhibit either the COX-1 or COX-2 enzymes and are therefore nonselective NSAIDs.)
What are the common nonpharmacologic interventions that are used to manage pain? Select all that apply.
Guided imagery, Therapeutic Touch, magnet therapy, and acupuncture are nonpharmacologic therapies used for pain management. No pharmacologic product or drug is used with these interventions. Cryotherapy gels are pharmacologic interventions consisting of local short acting gels which are pharmacologic formulations.
Which drug is the gold standard opioid for both acute and chronic pain?
Morphine (In medicine, "gold standard" means the "best available" drug, test, or procedure with which others are compared. Morphine is the gold standard opioid for both acute and chronic pain. It is available in many dosage strengths (both short- and long-acting) and can be given through almost any route. Codeine is a slow-acting, weak drug mainly used for cough relief rather than pain relief. Hydrocodone is similar to codeine and is available in combination with acetaminophen and ibuprofen, but it is rarely used for controlling pain because of added toxicities from these non-opioids. Methadone is very effective as a pain reliever but its action is very complex and is potentially unsafe because of cardiac toxicity.)
Which group of medications includes fentanyl?
Opioid analgesics (Fentanyl is an opioid analgesic. Nonopioid analgesics include acetaminophen and the NSAIDs. Adjuvant analgesics include a variety of agents with unique and widely differing mechanisms of action, such as local anesthetics and some anticonvulsants and antidepressants.)
Which drug should be administered to reverse opioid-induced respiratory depression?
Nalaxone (Nalaxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Nalaxone is administered slowly until the patient awakens and breathes properly thereby reducing respiratory depression. Ketamine is N-methyl-D-aspartate (NMDA) antagonist used as an anesthetic to reduce pain perception. However, it is not effective to reduce respiratory depression. Oxycodone is a mu opioid agonist given to relieve pain caused by cancer. Gabapentin is an anticonvulsant used for treating surgical pain as a part of postoperative treatment.)
The nurse recognizes which medications as being included among the adjuvant analgesics? Select all that apply.
lidocaine and nortriptyline (Adjuvant analgesics include local anesthetics, such as lidocaine, and some antidepressants, such as nortriptyline. Opioid analgesics include hydromorphone and oxycodone. Aspirin is a nonopioid analgesic. )
Which is a hydrophilic drug?
morphine (A hydrophilic drug readily dissolves in water. Morphine is a classic example of a hydrophilic drug. Fentanyl and methadone are lipophilic or capable of dissolving in lipids. Hydromorphine is less hydrophilic than morphine and also less lipophilic than fentanyl. )
The nurse is caring for an older adult patient who is experiencing severe pain after an injury. Which instruction of the primary health care provider does the nurse adhere to ensure patient's safety?
"Do not give meperidine." (When Meperidine is administered to older adults, it causes decreased renal functions. These patients are unable to efficiently eliminate normeperidine which is a CNS-toxic metabolite of Meperidine. Using a multimodal approach will result in a combined use of analgesics to achieve the desired outcome. Starting with a low dose of the analgesic and going slow with the drug dosing will help in achieving adequate analgesia based on the patient's response. Educating the patient and/or his/her family about the management of pain would help to spread awareness about when to approach the primary health care provider in case of a possible drug side effect or unrelieved pain. )
A nursing student asks the nurse preceptor to explain the benefits of patient controlled analgesia (PCA). Which information will the nurse preceptor include in the explanation?
"Patients who use PCA may receive a continuous dose of opioid analgesic." (PCA allows for continuous dose (via setting a basal infusion rate) of opioid medication. A PCA infusion device ("pump") is used when PCA is delivered by invasive routes of administration. Patients do not set their own maximum dose of pain medication; instead, the PCA is programmed so that the patient can press a button ("pendant") to self-administer a set dose of analgesic ("PCA dose") at a set time interval ("demand" or "lockout") as needed. Only patients who are cognitively and physically able to use any equipment that is needed to administer the therapy are candidates for PCA.)
A patient who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping patient. What does the nurse say to the visitor?
"Please allow the patient to push the button when needed." (The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. Telling the family member not to touch any equipment in the patient's room is not only nonspecific, it is also disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the patient is asleep does not mean that the patient is pain-free.)
A patient who has mild abdominal pain is prescribed ibuprofen. What instruction does the nurse give to the patient?
"Stop taking the medication if you have bleeding." (Ibuprofen is a nonsteroidal anti-inflammatory drug that may increase gastrointestinal bleeding. Therefore, the nurse instructs the patient to stop medication if bleeding occurs. Grape juice increases absorption of the drug. Therefore, ibuprofen should not be taken with grape juice. Ibuprofen may cause gastric irritation if taken on empty stomach. Ibuprofen does not cause or aggravate itching. )
A postoperative patient reports, "I have pain from a mild headache." Which PRN medication does the nurse administer?
Acetaminophen (Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain. Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Although oxycodone hydrochloride contains acetaminophen, it is also a narcotic; this level of pain control is not needed for a mild headache. )
A patient with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this patient?
Adding duloxetine as adjuvant therapy (Both tricyclic and other antidepressants such as duloxetine help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin. Adding acetaminophen would not address the patient's depression. Increasing the opioid dose can cause respiratory depression. Discontinuing the opioid can cause relapse pain.)
Epidural analgesia is used for acute pain management that includes postoperative pain and chronic cancer pain. What precautions are needed when administering epidural analgesia? Select all that apply.
An antiemetic relieves the associated nausea and vomiting. The patient's respiration and sedation levels are monitored at frequent intervals (An antiemetic may relieve the associated nausea and vomiting of epidural analgesia, which are common side effects of epidural opioids. The patient's respiration and sedation levels are monitored at frequent intervals. Patients who receive epidural opioids are also at risk for respiratory depression resulting from high plasma or cerebrospinal fluid concentrations of the instilled drug. A high concentration of bupivacaine is not used for significant pain relief; rather, low concentrations of local anesthetics are used to prevent significant sensory and motor deficits. Lower motor weakness is less with ropivacaine as compared to bupivacaine. Diphenhydramine, which is an antihistaminic drug, does not relieve the itching side effect of epidural analgesia because epidural-induced pruritus does not appear to be caused by histamine release.)
The nurse is attending to an older patient with chronic liver disease. What interventions does the nurse perform for this patient? Select all that apply.
Ask the patient to assess only the existing pain Relay the adverse effects of acetaminophen to the caregiver. Suggest using a pillbox to organize daily medications
The nurse is preparing a plan of care for a patient who has received a prescription for fentanyl through a patient-controlled analgesia pump. The nurse should question the prescription if the patient has a history of what?
COPD (Fentanyl is a potent opioid agonist and may cause respiratory depression. It should be used with caution in patients with decreased respiratory reserve or potentially compromised respiration. No extra precautions are needed for patients with a history of Bell's palsy, cataracts, or West Nile Virus; they are not at an increased risk of an adverse effect.)
A patient is suffering from inflammatory pain caused by rheumatoid arthritis. The nurse offers some immediate non-pharmacologic advice for pain management. Which is the most effective advice for the patient?
Cold applications (Cold applications are helpful to reduce inflammation in patients with rheumatoid arthritis. The effect of cryotherapy generally lasts for only 2 hours and is not a preferred choice. Body massage, rest, and relaxation are only advised so that the pain is not exacerbated further. )
Which side effect of opioid medications does the nurse recognize as being the number one reason for medication noncompliance?
Constipation
A patient with chronic osteoarthritis is prescribed celecoxib as an analgesic. What makes this drug beneficial for long term use?
Decreased risk for gastrointestinal bleeding
A patient with chronic osteoarthritis is prescribed celecoxib as an analgesic. What makes this drug beneficial for long term use?
Decreased risk for gastrointestinal bleeding (Colecoxib is a cyclooxygenase-2 (COX-2) inhibitor that causes effective pain relief without associated gastrointestinal bleeding, generally seen with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). Renal side effects are similar to those with the non-selective NSAIDs. All COX-2 inhibitors, including celecoxib, are associated with an increase in cardiovascular disease. Fluid retention in the body occurs due to the renal effects of analgesic drugs; thus, celecoxib shows no difference in fluid retention when compared to other analgesics.
A patient reports increasing pain during dressing changes. Which interventions are recommended for the patient? Select all that apply.
Distraction Music therapy Premedication
The nurse is establishing a plan of care for a hospitalized patient with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant?
Engagement in conversation about the patient's family to distract the patient.
The nurse is attending to a patient post tonsillectomy. The patient reports pain at 8 on a 0-to-10 scale and requests medication. What action does the nurse take?
Give a full dose of prescribed medication.
The nurse is attending to a patient on a medical-surgical unit who is receiving morphine for bone cancer pain. What action does the nurse take to prevent constipation in the patient?
Give foods high in bulk and roughage (The nurse encourages the patient to have foods that are high in bulk and roughage to prevent constipation. The nurse assesses the patient's previous bowel habits and keeps a record of the bowel movements to observe changes in the elimination pattern. The nurse may administer a saline enema if stool softeners and stimulant laxatives are ineffective.)
Gabapentin is an adjuvant analgesic effective in treating fibromyalgia. What statements are correct about gabapentin? Select all that apply.
It is an anticonvulsant drug given for persistent neuropathic pain. Primary side effects are sedation and dizziness (Gabapentin is used in treating persistent neuropathic pain. Primary side effects are sedation and dizziness, which are usually transient and most notable during the titration phase of treatment. Gabapentin is an anticonvulsant drug, not a tricyclic antidepressant. It is not contraindicated in diabetes; in fact, it is useful in diabetic neuropathy. Gabapentin can be administered at doses of up to 3600 mg daily with few side effects as compared to other anticonvulsants.)
What are the advantages of acetaminophen? Select all that apply.
It is available in liquid form. It can be taken on an empty stomach. It is preferred in postoperative patients It has no effect on platelet aggregation
Fentanyl is an opioid administered through the transdermal route to relieve pain. What are the disadvantages of the transdermal route of opioid administration? Select all that apply.
It is less useful for patients with generalized edema. It needs to be supplemented with other analgesics initially.
Which are aspects of a multimodal analgesic approach? Select all that apply.
Makes use of two or more classes of analgesics Prevents analgesic gaps that may lead to worsening of pain Involves lower doses of drug administration in the treatment plan (Multimodal analgesic treatment involves the use of two or more classes of analgesics. It prevents analgesic gaps that may lead to worsening of pain or unnecessary episodes of uncontrolled pain. Lower doses of a drug are generally administered as a part a multimodal approach. Multimodal analgesic treatment is effective for prolonged or persistent postsurgical pain. Multimodal analgesic treatment uses a combination therapy of different analgesics to maximize pain relief. Multimodal analgesia uses lower doses of medication so the risk of side effects is reduced. )
A patient with a history of opioid abuse experiences abdominal cramps, muscle twitching, nausea, and vomiting. The nurse recognizes that the administration of what medication, an opioid reversal agent, is the likely cause of the patient's symptoms?
Naloxone (Abdominal cramps, muscle twitching, nausea, and vomiting occur when a patient abusing opioids receives naloxone, a reversal agent. Clonidine alleviates the symptoms of withdrawal when given to a patient abusing opioids. Placebos have no effect when given to a patient abusing opioids. Corticosteroids are used to reduce pain and inflammation caused by arthritis and other chronic pain.)
A patient with a history of opioid abuse experiences abdominal cramps, muscle twitching, nausea, and vomiting. The nurse recognizes that the administration of what medication, an opioid reversal agent, is the likely cause of the patient's symptoms?
Naloxone (Abdominal cramps, muscle twitching, nausea, and vomiting occur when a patient abusing opioids receives naloxone, a reversal agent. Clonidine alleviates the symptoms of withdrawal when given to a patient abusing opioids. Placebos have no effect when given to a patient abusing opioids. Corticosteroids are used to reduce pain and inflammation caused by arthritis and other chronic pain.)
Morphine is an opioid that blocks pain transmission. What are the common side effects of morphine? Select all that apply.
Nausea and vomiting Pruritus Sedation Respiratory depression
The nurse is preparing a patient for home care pain management following discharge. Which intervention does the nurse implement?
Offer flexibility in home management of the patient's current regimen.
Which class of medications includes naloxone?
Opioid antagonists (Naloxone, which is an opioid antagonist, is indicated for reversal of opioid-induced respiratory depression and excess sedation. Opioid analgesics include fentanyl and morphine. Nonopioid analgesics include acetaminophen and the NSAIDs. Adjuvant analgesics include a variety of agents with unique and widely differing mechanisms of action, such as local anesthetics and some anticonvulsants and antidepressants.)
What is the preferred route of administration of analgesics?
Oral (The oral route is generally the preferred route of administration of analgesics. This is because oral administration is least expensive, best tolerated, and the easiest to administer. Topical, intramuscular, and subcutaneous routes are not commonly used to administer analgesics. These routes are preferable during an emergency and when the oral route is not feasible. )
The pharmacist is teaching for a group of staff nurses about multimodal analgesia. When explaining the risks and benefits of multimodal analgesia, which information will the pharmacist include in the teaching? Select all that apply.
Prevention of analgesic gaps Reduction in medication doses (Goals of multimodal analgesia include carefully combining analgesics to maximize relief and prevent analgesic gaps that may lead to worsening pain. This approach may allow for a reduction in doses of each of the drugs in the treatment plan. Prevention of analgesic gaps has the potential to decrease, not increase, episodes of uncontrolled pain. A reduction in medication doses has the potential to decrease, not increase, the risk for medication side effects. This approach also offers the promise of reducing, not increasing, the incidence of prolonged or persistent postsurgical pain)
A postoperative patient is receiving epidural analgesia and reports itching. What does the nurse do next?
Reduces the analgesic dose (Pruritus (itching) is a common side effect of epidural opioids and is first treated by reducing the analgesic dose. Because epidural-induced pruritus does not appear to be caused by histamine release, diphenhydramine may not be effective in relieving itching and may work only via its sedating effects. Antiemetics are given to relieve nausea and vomiting. If a health care provider needs to be called, it would be the anesthesiologist, not the surgeon.)
When caring for a patient who is receiving morphine, the nurse prioritizes assessing for which medication side effect?
Respiratory depression (Respiratory depression is a potentially life-threatening side effect of opioid analgesics, such as morphine. Additional side effects associated with opioid medications such as morphine include tolerance, nausea and vomiting, and constipation; however, these effects are not life threatening.)
The nurse is reviewing the medication history of patients who have been prescribed meperidine. The nurse should question which patient's prescription?
The nurse should question meperidine prescription for patient B with acute kidney disease because of the risk of accumulation and renal excretion of the toxic metabolite normeperidine, which may lead to central nervous system toxicity. Meperidine helps control moderate to severe pain by acting on neuropathic brain centers. It is effective in controlling pain from a migraine headache, after joint replacement surgery, and in peripheral artery disease.
Which term best describes the condition where continuous exposure to a drug leads to a decrease in the drug's effects over time?
Tolerance (Tolerance is a normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid. Addiction is a primary, chronic neurological disease that is characterized by behaviors that can include impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction is an iatrogenic syndrome created by the undertreatment of pain. It is characterized by patient behaviors such as anger and escalating demands for more or different medications, and results in suspicion and avoidance by staff. Physical dependence is an adaptation manifested by a drug-class - it is a specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.)
The nurse is reviewing the medication history of patients who have been prescribed meperidine. The nurse should question which patient's prescription?
acute kidney disease (The nurse should question meperidine prescription for patient B with acute kidney disease because of the risk of accumulation and renal excretion of the toxic metabolite normeperidine, which may lead to central nervous system toxicity. Meperidine helps control moderate to severe pain by acting on neuropathic brain centers. It is effective in controlling pain from a migraine headache, after joint replacement surgery, and in peripheral artery disease.)
The nurse is caring for patients in the emergency department. Which patient should limit opioid analgesic use?
respiratory depression (Opioid analgesics bind to opioid receptors found in the central and peripheral nervous systems and in the gastrointestinal tract. Opioids can cause respiratory depression and should not be used with such patients. Opioids are effective in the treatment of cancer pain, after joint replacement surgery, and for chronic pain.)