CH. 11 Pain Management

What are the 2 types of pain management?

Drug and nondrug interventions

Is Cancer Nociceptive or Neuropathic pain?

It can be nociceptive or neuropathic

TRUE or FALSE - Fewer than 1% of clients who need drugs for pain relief, even for more than 6 months become addicted

TRUE

The nurse is caring for a client with metastatic bone cancer. The client asks the nurse, "Why am I getting larger doses of this pain medication? It does not seem to be affecting me." What is the nurse's best response?

- "Over time you become more tolerant of the drug." Explanation: Over time, the client is likely to become more tolerant of the dosage. Little evidence indicates that clients with cancer become addicted to the opioid medications. Clients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer.

An unlicensed assistive personnel (UAP) reports to the nurse that a postsurgical client has pain rated as 8 on a 0-to-10-point scale. The UAP tells the nurse that the client is exaggerating and does not need pain medication. What is the nurse's best response?

- "Unless there is strong evidence to the contrary, we should take the client's report at face value.'" Explanation: Self-report is considered the most reliable measure of the existence and intensity of the client's pain and is recommended by the Joint Commission. A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. Rechecking without offering an intervention would be insufficient, and the law is not the sole reason for providing care. It would be wrong for the nurse to teach the UAP that clients report pain to get the nurse's attention.

The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?

- "When was your last bowel movement?" Explanation: Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.

A 10-year-old client twisted an ankle playing soccer. The ankle can't support weight and has already begun to swell despite application of an ice pack. As part of the pain assessment, the nurse must determine the intensity of the client's pain. Which question will the nurse ask to obtain this information?

- "Which one of the faces on this card shows how much your ankle hurts?" Explanation: Adult patients are asked to report the intensity of their pain using a word scale, linear scale, or a numeric scale of 1 to 10. The Wong-Baker FACES Pain Rating Scale is an assessment tool used with children, the mentally challenged, and patients who would have difficulty understanding other assessment tools. Patients are asked to describe their pain by choosing a face that depicts how much they hurt. Intensity is not related to the timing of the injury, the general location of the pain, or the specific location of pain in the ankle.

The nurse is to administer meperidine 75 mg intramuscularly to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client? Enter the correct number ONLY.

- 1.5 Explanation: The dose ordered is 75 mg. The dose available is 50 mg. The quantity is 1 mL. 75 mg/50 mg x 1 mL = 1.5 mL.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission?

- A child quickly removing a hand when touching a hot object Explanation: 1. Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. 2. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. 3. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.

The emergency department nurse is caring for an adult client who was in a motor vehicle accident. Radiography reveals an ulnar fracture. Which type of pain is the nurse addressing with this client?

- Acute Explanation: Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. "Osteopenic" pain is not a recognized category of pain.

The majority of clients in a pain management practice have chronic pain. The physician group utilizes several different methodologies to treat pain. During the holiday season, they sent CDs featuring a popular comedian to all their clients—not only as a gift but also as a treatment modality. This is an example of which treatment modality?

- All responses are correct. Explanation: Various techniques are used alone or in addition to more traditional pain management techniques, including: - imagery - biofeedback - humor - breathing exercises - progressive relaxation - distraction - hypnosis. In this case, the CD provides humor, relaxation, and distraction from the pain. Humor is one alternative treatment modality, but the CD also incorporates other aspects. Distraction is one alternative treatment modality, but the CD also incorporates other aspects. Relaxation is one alternative treatment modality, but the CD also incorporates other aspects.

The nurse understands that which statement is true about tolerance and addiction?

- Although clients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

How much should an ineffective dose be increased by?

- An ineffective dose should be increased by 25% to 50% *ALWAYS Consult with physician

Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture?

- Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. Explanation: The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.

A patient who is postoperative day 1 following a discectomy has lit his call light and requested a dose of hydromorphone, which he receives on a p.r.n. basis for breakthrough pain. What should the nurse first do in response to the patient's request?

- Assess the characteristics of the patient's pain. Explanation: The most appropriate immediate response to a patient's complaint of pain is an assessment of characteristics such as: - intensity - quality - onset - location - timing - associated or aggravating factors - radiation. This assessment should normally precede the nurse's chosen interventions.

Two clients have recently returned to the postsurgical unit after knee arthroplasty. One client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the clients' different perceptions of pain?

- Awareness and emotions affect the perception of pain. Explanation: Different people feel different degrees of pain from similar stimuli due to the effects of awareness and emotions, which vary from person to person. The nurse should not assume the client is exaggerating the pain, because clients are the best authority on their pain, and definitions for pain state that pain is "whatever the person says it is, existing whenever the experiencing person says it does." Variances in vasoconstriction do not affect pain perception. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these clients.

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain?

- Believe a patient when he or she states that pain is present. Explanation: The highly subjective nature of pain causes challenges in assessment and management; however, the patient's self-report is the undisputed standard for assessing the existence and intensity of pain (APS, 2008; McCaffery et al., 2011). Accepting and acting on the patient's report of pain are sometimes difficult. Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain. Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care.

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?

- Bradypnea Explanation: Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?

- Burning Explanation: When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

A client is receiving care on the oncology unit for breast cancer that has metastasized to the lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should consider which characteristic of cancer pain?

- Cancer pain can be acute or chronic and typically requires comparatively high doses of pain medications. Explanation: Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer clients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer clients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention

Define Tolerance

- Condition in which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered - aka consequence of poor pain control

Describe Transduction

- Conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord * Initiated by cellular disruption

The decision to order an opioid dosage for an elderly patient that is slightly smaller than the dose of medication prescribed for younger patients is based on the following physiologic reason:

- Decreased renal excretion of drugs increases toxic levels. Explanation: In the elderly, metabolism tends to decrease, respiratory system depression is increased, and metabolism is decreased. The kidneys tend to decrease renal excretion.

Define Referred pain in regards to Nociceptive Visceral Pain

- Discomfort in a general area of the body but not in the exact site where an organ is located

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

- Ensure the client knows to taper down the dose if it is discontinued by the care provider. Explanation: Corticosteroids must be tapered slowly in order to prevent an adrenal crisis. These medications do not normally cause dependence and they do not pose a risk for GI bleeding. Grapefruit is not contraindicated.

A 20-year-old man has presented to the emergency department with a 24-hour history of abdominal pain. The nurse who is admitting the patient notes that he is diaphoretic, wincing, and guarding the lower right quadrant of his abdomen. The nurse asks the patient to rate his pain on a scale of 1 to 10, to which the patient responds, "One or two." How should the nurse best respond to this patient's statement?

- Explain the 0-to-10 pain scale in greater detail. Explanation: While it is important to accept a patient's self-report of pain, this does not mean that further education about pain scales is not sometimes necessary. This is especially the case when there is a clear inconsistency between patient's subjective pain report and the nurse's assessment findings. Thus, further teaching should take place prior to choosing an intervention or documenting the patient's pain as "slight."

Why do some patients fear taking prescribed drugs?

- Fear of addiction

The nurse is admitting a client with an abdominal tumor who is experiencing increasing unrelieved pain over the last three days despite taking opioids, as prescribed. Which sign—a manifestation of unrelieved pain—should the nurse expect to assess in this client?

- Hyperglycemia Explanation: Unrelieved pain produces harmful effects on many body systems. - Reduced insulin secretion can cause elevated blood glucose levels. - Tachycardia (not bradycardia) may occur with the increased release of catecholamines. - Decreased gastric and bowel motility would occur, resulting in hypoactive (not hyperactive) bowel sounds. - With increased secretion of antidiuretic hormone, fluid volume overload can occur. - Poor skin turgor is a sign of fluid volume deficit, or dehydration.

A patient is being seen in the health clinic for chronic headaches. He has been using pain medications on a regular basis. Which of the following would be part of the teaching plan for a patient?

- Inform the primary health care provider about the use of salicylates before any procedure. Explanation: Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents; these drugs do not cause photosensitivity.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.

- Intervertebral disk herniation Explanation: Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain. Migraines could be chronic pain but are not the best example here.

The nurse is assuming the care of an adult client who has been experiencing severe and intractable pain. When reviewing the client's medication administration record, the nurse notes the presence of gabapentin. The nurse is justified in suspecting which phenomenon in the etiology of the client's pain?

- Neuropathy Explanation: The anticonvulsants gabapentin and pregabalin are first-line analgesic agents for neuropathic pain. Neuroplasticity is the ability of the peripheral and central nervous systems to change both structure and function as a result of noxious stimuli; this does not likely contribute to the client's pain. Similarly, psychosomatic factors and misperception of pain are highly unlikely.

A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level?

- Numeric Rating Scale (NRS) Explanation: The NRS is most appropriate for this client. The VDS (Verbal Discriptor Scale) requires the patient to use words or phrases; in this situation, intense pain may affect the client's ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing?

- Older clients should receive a reduced dose. Explanation: A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully?

- Older people are more sensitive to drugs. Explanation: Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

Define Neuropathic Pain & how it results

- Pain processed abnormally by the nervous system - Results from damage to either the pain pathways in peripheral nerves or pain-processing centers in the brain

- Describe Perception - Define Pain Threshold - Define Pain Tolerance & its 3 variables

- Perception: Brain experiences pain at a conscious level; locates pain, its intensity, and what it means; and gives emotional response. - Pain threshold: point at which the pain-transmitting neurochemicals reach the brain, causing conscious awareness - Hyperalgesia (increased sensitivity to pain) - Pain tolerance: amount of pain a person endures once the threshold has been reached Variables: 1. age 2. gender 3. fatigue

Describe Transmission

- Peripheral nerve fibers form synapses with neurons in the spinal cord. - Impulses move from the spinal cord to the brain.

Define Physical Dependence

- Person experiences physical discomfort, known as withdrawal symptoms, when a drug taken routinely for some time is abruptly discontinued

Which is a true statement regarding placebos?

- Placebos should never be used to test a client's truthfulness about pain. Explanation: Many pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that placebos should not be used to assess or manage pain in any client, regardless of age or diagnosis. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

A client who is watching television with a visitor reports severe pain and wants pain medication. Which action will the nurse take?

- Prepare a dose of pain medication as prescribed. Explanation: The client's report of pain is the undisputed standard of pain assessment. Since the client reported severe pain, a dose of pain medication should be prepared. Watching the client's actions to determine pain level is inappropriate, as personal and cultural differences yield different demonstrations of pain levels and behaviors are not as reliable of indicators as the client's report of pain. Encouraging the client to use distraction techniques to manage their pain would not be indicated in this scenario, as the client is already using these techniques and still reporting severe pain, indicating the need for medication. There is no reason to wait for the visitor to leave before providing the client with the pain medication.

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be described?

- Prolonged in duration Explanation: Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

Define Addiction

- Repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's mind-altering or mood-altering effects

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting:

- Severity of the pain as judged by the patient Explanation: The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

A 75-year-old client has been admitted to the rehabilitation facility after falling and fracturing the left hip. The client has not regained functional ability and may have to be readmitted to an acute-care facility. When planning this client's care, what should the nurse know about the negative effects of the stress associated with pain?

- Stress is particularly harmful in older adults who have been injured or who are ill. Explanation: The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in clients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm.

What is the emotional component of pain?

- Suffering

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses

- That the client's past experiences with pain may influence her perception of current pain Explanation: Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries.

The nurse is caring for a client with a fractured pelvis and a ruptured bladder resulting from a motor vehicle accident. The nurse's aide (NA) reports concern to the nurse because the client's resting heart rate is 110 beats per minute, respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status?

- The client's rating of pain Explanation: The nurse's assessment of the client's pain is a priority. There is no suggestion of diabetes, and leukocytosis would not occur at this early stage of recovery. The client does not need to fully understand pain physiology to communicate the presence, absence, or severity of pain.

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient?

- The pain medication will be administered before the pain is experienced. Explanation: Two basic principles of providing effective pain management are preventing pain and maintaining a pain intensity that allows the patient to accomplish functional or quality-of-life goals with relative ease (Pasero, Quinn et al., 2011). Accomplishment of these goals may require the mainstay analgesic agent to be administered on a scheduled around-the-clock (ATC) basis, rather than PRN (as needed) to maintain stable analgesic blood levels.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?

- The pump will deliver a preset amount of medication. Explanation: A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

A client receiving an intravenous (IV) opioid following surgery is being switched to an oral form of the drug. To provide safe care for the client, which concept of equianalgesia should the nurse follow? Select all that apply. - There is a difference in potency between oral and IV doses of morphine. - Equianalgesic conversion prevents giving the client an opioid overdose. - Equianalgesic conversion is only for opioid-tolerant clients. - Oral analgesics do not control pain as well as IV analgesic administration. - The dose and frequency of the opioid conversion is guided by the client's individual response to the drug.

- There is a difference in potency between oral and IV doses of morphine. - Equianalgesic conversion prevents giving the client an opioid overdose - The dose and frequency of the opioid conversion is guided by the client's individual response to the drug. Explanation: Equianalgesic conversion from an IV to an oral opioid is guided by the ratio representing the difference in potency between the two drugs. This conversion assures that the client is not over- or under-dosed when switching routes of opioid administration. Using the equianalgesic conversion as a guide, doses and frequency of administration are guided by the client's individual response. Equianalgesic conversion is used for selecting doses for opioid-naive clients. It is not to be used for opioid-tolerant clients. When the drug and dose are properly selected, oral opioids can be as effective as IV opioids.

What are pain assessment tools useful for?

- They quantify pain intensity

How can you as a nurse avoid withdrawal symptoms?

- To avoid withdrawal symptoms, drugs should be discontinued gradually - Lowered over 1 week or longer

Define Allodynia

- an exaggerated pain response * example: stroking a clients hair and it hurts terribly

A client is admitted to the trauma unit after being injured in an industrial accident. The nurse needs to carefully monitor traumatic injuries. How often should the nurse assess and document the client's pain?

- every time the client's vital signs are assessed Explanation: The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain assessment should be done on a different schedule that is not related to drug administration or food consumption. An hour after administration may be too long to wait for assessment of the effects of the intervention.

A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen?

- hepatotoxicity Explanation: The nurse will need to monitor the client receiving acetaminophen for hepatotoxicity. Intravenous acetaminophen should not cause renal toxicity, bleeding, and gastrointestinal effects.

Chronic pain - How long does it last? - What does it affect? - What are the 6 symptoms?

- lasts longer than 6 months - Affects quality of life & others begin to show negative reactions to sufferer - Symptoms 1. Breakthrough pain ( a sudden increase in pain) 2. depression 3. Hopelessness 4. Weight loss 5. Fatigue 6. Physical immobility

Acute Pain - How long does it last? - When does the pain ease? - What are the 5 symptoms?

- less than 6 months - Associated with tissue trauma: eases with healing - Symptoms: 1. Elevated B.P 2. Elevated HR 3. Elevated RR 4. Diaphoresis 5. Dilated pupils

A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?

- neuropathic and chronic Explanation: When classified according to its source, pain can be categorized as nociceptive or neuropathic. When classified according to its onset, intensity, and duration, pain can be categorized as either acute or chronic. Because the client is without breakthrough pain at this time, he has no acute pain. Nociceptive pain is transmitted from a point of cellular injury to the brain. This is not the type of pain related to long-term diabetes mellitus. Neuropathic pain sustained by injury or dysfunction of the peripheral or central nervous systems. This type of pain is related to long-term diabetes mellitus

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing?

- neuropathic pain Explanation: Neuropathic pain can affect cancer patients due to nerve damage from chemotherapy or radiation therapy. Somatic pain is caused by damage or disorders that affect bones, joints, muscles, skin, or other structures. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is pain felt in the body in a location that is different from the actual source of the pain.

A client who is recovering from knee replacement surgery asks for the lowest possible dose of pain medication, and reports having been able to handle pain ever since childhood. Which of the following aspects of pain is the client describing to the nurse?

- tolerance Explanation: Pain tolerance is the amount of pain a person can endure once the pain threshold has been reached. The pain threshold is the point at which pain-transmitting chemicals reach the brain, resulting in conscious awareness of the pain. Pain perception is the phase of impulse transmission during which the brain experiences pain at a conscious level. Pain transmission is the phase of impulse transmission during which peripheral nerve fibers form synapses with neurons in the spinal cord. The pain impulses move from the spinal cord to sequentially higher levels in the brain.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

-Gabapentin Explanation: The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

Which of the following is a physiologic response to pain?

-Pallor Explanation: Physiologic responses to pain include: - pallor - tachycardia - diaphoresis - hypertension.

What are the 4 Routes of Pain Medication Administration

1. Analgesic drugs: oral, rectal, transdermal, or parenteral - Equianalgesic dose 2. Patient-controlled analgesia (PCA) 3. Intraspinal analgesia 4. Palliative sedation: relieving intractable pain experienced by dying client

What are the 5 causes of Nociceptive VISCERAL Pain?

1. Arises from internal organs such as the heart, kidneys, & intestine that are diseased or injured 2. Ischemia 3. Compression of an organ 4. intestinal distention 5. contraction

List the 5 Techniques for Pain management

1. Blocking brain perception 2. Interrupting pain-transmitting chemicals 3. Combining analgesics 4. Substituting sensory stimuli 5. Altering pain transmission

Name 5 Nonverbal behaviors of a client in pain

1. Clenched jaw 2. Frowning 3. Crying 4. Rocking 5. Fidgeting

What are the 5 causes of Nociceptive SOMATIC pains?

1. Mechanical 2. Chemical 3. Thermal 4. Electrical injuries 5. Disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue

List the 4 types of Pain scales

1. Numeric scale 2. Word scale 3. Linear scale 4. FACES scale

Nursing Care Plan: Acute Pain 1. Nursing Diagnosis? 2. Expected outcome? 3. List 3 Interventions

1. Nursing diagnosis: Acute Pain 2. Expected outcome: Client will rate pain intensity at tolerable level of "5" within 30 minutes of pain management technique. 3. Interventions - Assess client's pain and its characteristics at least every 2 hours while awake. - Modify or eliminate factors that contribute to pain. - Administer prescribed analgesics or alternative pain management techniques promptly

What are the 2 kinds of Drug Therapy? Define them & Give examples of each.

1. Opioids—narcotic - interfere with pain perception centrally (at the brain) - Used for mild to moderate pain - Ex: Oxycodone, morphine sulfate 2. Nonopioids—non-narcotic - alter neurotransmission at the peripheral level (sight of injury) - Used for mild pain - Ketorolac tromethamine (Toradol), Tylenol

What are the 4 Nursing Management in regards to pain?

1. Performs a comprehensive assessment of each client's pain on admission - Determines the onset, quality, intensity, location, and duration of pain 2. Administration of analgesics every 3 hours rather than PRN often provides a uniform level of pain relief. 3. Collaborates with client: informs of pain relief options 4. Assess complications related to pain or prolonged pain medication; risk for falls, knowledge deficit, constipation

What are 5 examples of Neuropathic pain?

1. Phantom limb pain 2. Spinal cord injuries 3. Strokes 4. Diabetes 5. Herpes zoster (shingles)

What 5 guidelines do Accredited healthcare facilities follow?

1. Right to assessment and pain management 2. Assessment is appropriate for age, developmental level, condition, and culture. 3. Pain is reassessed regularly. 4. Healthcare workers are educated on pain management. 5. Client's choices of pain management are respected

What are the 2 types of Nociceptive pains?

1. Somatic pain 2. Visceral pain

What are the 3 types of Nociceptive Somatic Pain?

1. Superficial somatic pain/cutaneous pain: from insect bite or paper cut; perceived as sharp or burning discomfort 2. Deeper somatic pain: caused by trauma; produces sensations that are sharp, throbbing, and intense 3. Dull, aching, diffuse discomfort with long-term disorders Ex: arthritis

List the 7 Alternative NON-drug methods

1. Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) 2. Acupuncture and acupressure 3. Heat or cold application 4. Spinal surgery: rhizotomy, cordotomy 5. Distraction 6. Relaxation 7. Imagery

What are the 4 phases of pain transmission?

1. Transduction 2. Transmission 3. Perception 4. Modulation

What are the 7 symptoms of Nociceptive Visceral Pain?

1. Usually diffuse 2. Poorly localized 3. Accompanied by ANS (Autonomic Nervous System) symptoms such as nausea 4. vomiting 5. pallor 6. Hypotension 7. sweating

Define Pain

A privately experienced, unpleasant sensation usually associated with disease or injury

What 6 questions can you as a nurse asses for pain in a client?

Ask for Client's description of: 1. onset 2. quality 3. intensity 4. location 5. duration 6. What makes the pain better or worse?

Chronic pain is described as an unpleasant sensory and emotional experience associated with: A. Actual tissue damage B. Actual or potential tissue damage C. Only observable pain behaviors D. Physiologic signs and symptoms that the pain exists

B. Actual or potential tissue damage Rationale: Chronic pain is associated with actual or potential tissue damage. Chronic pain is associated with many pain behaviors that people do not normally associate with pain. There is no change in vital signs with chronic pain.

Describe Modulation

Brain transmits a response down the spinal nerves to the point where the pain transmission originated to alter the pain experience. - Endogenous opioids —neurochemical; Painful sensation is reduced.

How is nerve damage treated?

By radiation or drugs

A client taking opioids for cancer pain begins to require more medication to provide the same amount of analgesia. This is known as: A. Physical dependence B. Drug tolerance C. Drug addiction D. Obsessive-compulsive

C. Drug tolerance Rationale: Drug tolerance is the need for an increased opioid dose to maintain the same effect.

To evaluate adequately the effectiveness of pain control regimens, the nurse should: A. Be casual and informal B. Not bother if the client is quiet C. Use a pain assessment tool D. Rely on the feedback from the client's family member

C. Use a pain assessment tool Rationale: An effective pain treatment requires a thorough pain assessment.

As a Nurse when assessing for pain what 5 things should you ask about in regards to a clients pain?

Determines the: 1. Onset 2. Quality 3. Intensity 4. Location 5. Duration of pain

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

Explanation: A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. - Helplessness is an emotional response to pain. - Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. - Inability to perform normal exercise because of pain is a physical restriction related to pain. - Pain is highly personal and subjective. The client's report is the most reliable indicator of pain. The client works with the nurse and doctor to establish a pain management regimen.

A nurse can administer analgesics through various routes. Which medication routes provide absorption into the systemic circulation? Select all that apply.

Explanation: The rectal, epidural space, oral mucosa, and subcutaneous sites are systemic routes of analgesic administration. The topical route of administration is locally absorbed.

The nurse plans nonpharmacologic interventions for a client who is approaching discharge after a left knee arthroplasty to address the client's pain. For each intervention, click to specify if the therapy indicates a physical modality, cognitive and behavioral method, or movement therapy for the treatment of pain.

Nonpharmacologic pain management strategies should be included in the plan of care for clients who experience acute pain during hospitalization. The application of heat or cold is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Treating pain with hot and cold can be extremely effective for a number of different conditions and injuries, with cold therapy being effective for acute injuries and hot therapy being effective for chronic pain. Relaxation is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. This nonpharmacologic pain management strategy releases endorphins, the body's natural pain killer. Yoga is a movement therapy that the nurse includes in the client's plan of care to address postoperative pain. By building strength, releasing muscle tension, improving flexibility, and bolstering joints and bones, yoga can bring the body into balance, thereby alleviating pain. Aquatic therapy is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Aquatic therapy uses the physical properties of water to assist in client healing and exercise performance as is supported by evidence-based practice (EBP) guidelines for the treatment of pain associated with knee arthroplasty. Distraction is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. Mental distractions block pain signals from the body before they ever reach the brain, thus distraction is an appropriate nonpharmacologic pain management strategy to include in this client's plan of care. Thai Chi is a movement therapy that the nurse includes in the client's plan of care to address postoperative pain. Thai Chi is a low-impact, slow-motion, mind-body exercise that combines breath control, meditation, and movements to stretch and strengthen muscles and can be an effective nonpharmacologic pain management strategy for a client who is postoperative for knee arthroplasty. Proper body alignment is a physical therapy the nurse includes in the client's plan of care to address postoperative pain. Making sure the client's hips, back, and head are in proper alignment can be a great way to prevent muscle strains, joint pain, or back pain after knee arthroplasty. Imagery is an example of a cognitive and behavioral method that the nurse includes in the client's plan of care to address postoperative pain. Guided imagery places the client's mind into a state of deep relaxation, reducing the presence of stress hormones, decreasing muscle tension, and ultimately shifting attention away from pain.

Define Nociceptive Pain

Noxious stimuli that are transmitted from the point of cellular injury over peripheral sensory nerves to pathways between the spinal cord and thalamus and from the thalamus to the cerebral cortex of the brain

How do you classify pain?

SOURCE - Nociceptive: nerve fibers are triggered by inflammation, chemicals, or physical events, such as stubbing a toe on a piece of furniture - Neuropathic: nervous system is damaged or not working correctly, usually chronic ONSET, INTENSITY & DURATION - acute or chronic?

Define Nociceptors (part of transduction) & what 2 fibers they consist of

Specialized pain receptors located in the free nerve endings of peripheral sensory nerves 1. A-delta fibers: can carry pain impulses fast or slow; get sharp, acute initial pain 2. C-fibers: throbbing, aching, or burning after initial pain

What is Assessment biases?

When a client's pain is misunderstood