Chapter 18: Clinical Judgment to Promote Relief from Pain

Which of the following is not considered a pharmacological intervention for pain? a. Acupuncture treatments b. Cannabinoids c. Lidocaine patch d. Capsaicin

ANS: A Acupuncture is a nonpharmacological treatment that helps reduce the perception of pain. Cannabinoids is considered an adjuvant medication. Lidocaine patches are a pharmacological treatment for pain relief. Capsaicin is a pharmacological means of providing comfort and alleviating pain and distress.

An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain? a. Holds abdomen tightly. b. Has stable vital signs. c. Is not verbalizing. d. Moves during sleep.

ANS: A Because this older adult has a potential cognitive impairment and is likely to self-report pain unreliably, the nurse uses additional clinical indicators to detect pain. Muscle rigidity and guarding are clinical indicators of pain for a postoperative older adult, regardless of a cognitive impairment. An individual experiencing pain is unlikely to have stable vital signs. Not verbalizing can indicate a sensory impairment and warrants further investigation by the nurse. Nonetheless, this older adult's verbalizations are potentially unreliable indicators of pain. Older adults move normally during sleep to adjust their position in bed; moving during sleep is not an indicator of pain unless the movements are agitated or restless in nature.

Which of the following pain sensation(s) is(are) associated with neuropathic pain? (Select all that apply.) a. Stabbing b. Aching c. Tingling d. Burning e. Shooting

ANS: A, C, D, E Neuropathic involves a pathophysiological process of peripheral or central nervous system. Associated sensations include stabbing, tingling, burning, and/or shooting. Aching is not associated with nerve pain.

An older aphasic client has severe osteoarthritis, bilateral contractures of the lower extremities, and a stage IV pressure ulcer. The nurse practitioner prescribes analgesic medications to be administered around-the-clock, with as-needed doses to be administered as appropriate. What observation by the nurse would indicate that the pain regimen is effective? (Select all that apply.) a. "Client slept throughout the night." b. "Client winces only when turned and repositioned." c. "Client slept during dressing change." d. "Client cooperative during AM care." e. "Client ate 80% of breakfast, 70% of lunch and 100% of dinner."

ANS: A, C, D, E Pain cues presented by this client is the wincing when being turned, indicating that this intervention is pain producing. The remaining observations are concurrent with effective pain management.

Which of the following statement(s) is(are) true about pain in older adults? (Select all that apply.) a. Some pain medications are more appropriate than others for use with older adults. b. Pain sensitivity decreases with age. c. If clients do not complain, they do not have pain. d. Culture influences one's tolerance and expression of pain. e. The experience of pain is not limited to that which is of physical origin.

ANS: A, D, E Some pain medications are more appropriate for management of pain experienced by the older adult. Culture, ethnicity, and individual characteristics all influence one's tolerance and expression of pain. Pain sensitivity does not decrease with age. Some clients have a variety of reactions to pain; many are stoic and refuse to give in to their pain. Pain can be both physiological and psychological in origin.

Which of the following statements is true about analgesic medications for older adults? a. Opioids are less effective in older clients than in younger clients. b. Stool softeners and laxatives should be used with opioids. c. Over-the-counter NSAIDs are generally harmless. d. The dose limit for acetaminophen is difficult to reach for older adults.

ANS: B Opioids often cause constipation and necessitate bowel stimulation to prevent constipation. A bowel regimen should be instituted at the same time as opioid treatment. Because of changes in metabolism with aging, opioids have a greater and longer lasting analgesic effect in older clients. NSAIDs can cause gastrointestinal bleeding, kidney and liver damage, and drug interactions with potentially fatal results. The maximum daily dose of acetaminophen is 4000 mg, and the limit is lower for clients with kidney or liver failure and clients who use alcohol. A typical dose is two 500-mg ("extra-strength") tablets.

The nurse uses comfort measures to enhance an older adult's pharmacological pain management. Which of the following would be most helpful for the nurse to use to identify the relationships between the comfort measures, activity, and pharmacotherapy, and the older adult's pain level? a. Older adult's self-report b. Older adult's pain diary c. FPS-R d. Pain medication frequency

ANS: B The nurse instructs the older adult to maintain a pain diary to help the individual achieve some control over the pain experience. The diary is then used to identify trends or the timing of pain and the relationships between the client's pain level and the comfort measures, activity, and pain medications. Many older adults report feeling useful and having some control over the pain, or at least the pain management program, through maintaining a pain diary. Self-reporting is one parameter used to evaluate pain but drawing a relationship between the pain level and other factors is still necessary. The FPS-R is a reliable pain assessment tool, but the task remains to link the pain rating to other factors. The frequency of medication administration provides a clue about the client's pain level.

An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the client asks for pain medication 30 minutes before it is due. Which recommendation should the nurse implement? a. Validate the pain with other assessment data. b. Administer the pain medication as requested by the client. c. Tell the client that it is too soon for pain medication. d. Teach the client alternative comfort measures.

ANS: B The nurse should administer the opioid pain medication as requested because the client is asking for the pain medication within the prescription's time limit. Most institutions allow the nurse to administer opioid medications 30 to 60 minutes before the designated time on the prescription; therefore, the client is not asking for the medication too early. In addition, the nurse has an obligation to the client to administer the pain medication; not doing so violates the client's rights. The nurse can rely on the client's report to determine the need for pain medication. As long as the timing is suitable and the client is stable, the nurse should administer the medication. The nurse should use assessment data to support withholding pain medication in the presence of over sedation or another assessment that would be potentially aggravated by administering the pain medication. The nurse violates the client's rights by stating that it is too soon for the medication and ignores the possibility that the client's pain is real. Although the nurse may believe the client is not having pain and is exhibiting drug-seeking behavior, the nurse must administer the medication. The nurse must administer the pain medication as requested. When clients are experiencing pain, most often, it is not the optimal time to teach clients. However, when the client's pain is under control, the nurse should teach alternative comfort measures. Comfort measures can be used to enhance the therapeutic effect of the medication and breakthrough pain.

Which conditions are likely to cause an older adult chronic pain? (Select all that apply.) a. Hip replacement b. Osteoarthritis c. Hypoproteinemia d. Headaches e. Low back pain

ANS: B, E Common sources of chronic pain include osteoarthritis and low back pain. A hip replacement is performed to relieve chronic pain or to repair a fracture and is more likely to cause acute pain. Hypoproteinemia is unlikely to cause chronic pain but is more likely to cause fatigue. A migraine headache is likely to cause acute, intense pain. Although headaches can be recurrent, they are usually time limited.

An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement? a. Share with the client that it is important to get out of bed and that there is pain medication available if it does hurt. b. Use the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain. c. Offer pain medication, administer the medication, and wait 30 minutes before getting her out of bed. d. Allow the client to remain in bed but share that getting up will be required at least twice a day starting the next morning.

ANS: C The administration of an as-needed analgesic 30 to 60 minutes before an activity may eliminate discomfort and fear of discomfort. It may also enhance the individual's capacity for the activity. It is not true that performing an activity quickly will lessen the pain or that the client will get used to the pain. A Hoyer lift is only indicated when an individual is completely immobile. Activity is an important part of rehabilitation.

When educating a client on the use of an adjuvant medication, which statement best demonstrates the nurse's understanding of this therapy? a. "These medications are used instead of opioids to decrease the likelihood of addiction." b. "Adjuvant medications are prescribed because they seldom cause any significant side effects." c. "These types of medications are used to eliminate the side effects of opioid medications." d. "These drugs are used in combination with analgesics to increase the effect of the analgesics."

ANS: D Adjuvant medications are not analgesics but are thought to alter the perception of pain and are used with analgesics to potentiate the effect of the analgesics. Adjuvant medications are used with opioids and may have long half-lives in older adults. The nurse must monitor the client for adverse effects. Adjuvant medications do not eliminate the side effects of opioids.

An older Hispanic man who speaks little English states that he is not having pain, but he had knee replacement surgery 2 days ago. Which is the best pain assessment tool for the nurse to apply for this man? a. Numeric Rating Scale b. Verbal Descriptor Scale c. Iowa Pain Thermometer d. Faces Pain Scale-revised (FPS-R)

ANS: D Hispanic men are less likely to report pain because their culture tells them to deny and withstand pain without complaining. The nurse uses the FPS-R to validate the client's report because the postoperative period in knee replacement surgery is very painful; this fact makes the nurse think that the client is likely to have pain. The Numeric Rating Scale, the Verbal Descriptor Scale, and the Iowa Pain Thermometer are valid and reliable assessment tools, but older Hispanic adults prefer using the FPS-R.

Compared with acute pain, which of the following statements is true of persistent pain? a. Leads to significantly altered vital signs. b. Is usually described as a burning pain. c. Is generally gone within 4 months. d. Can bring about long-term changes in lifestyle.

ANS: D Persistent pain affects the client's experience on a continuing basis. Both acute pain and persistent pain can affect the vital signs. Persistent pain may be described in many possible ways. Persistent pain is unrelenting.

The nurse admits an older adult who had abdominal surgery. Admission vital signs are heart rate (pulse) (P), 73 beats per minute (bpm); respiration rate (R), 20 breaths per minute; blood pressure (BP), 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not requested pain medication since surgery. Seven hours later, his vital signs are P, 98 bpm; R, 26 breaths per minute; and BP, 164/90 mm Hg; and he denies pain. Which intervention should the nurse implement? a. Administer an opioid medication by IV route. b. Check the surgical dressing for bleeding. c. Report the vital signs to the health care provider. d. Ask if he has about discomfort at the surgical site or any other location.

ANS: D The client's P, R, and BP increased significantly since his admitting vital signs and indicate the potential for pain or discomfort from the surgical incision. The older adult client may also be experiencing pain unrelated to the surgery due to arthritic changes, neuropathies, etc. The client can be misunderstanding the nurse's question or be barred from saying, "yes," by cultural patterns. Such miscommunication is common; therefore, the nurse rewords the question using another term for pain such as discomfort, burning, or pressure. Administering an opioid medication by IV route is unethical without the client's request. When checking the surgical dressing for bleeding, the client may show signs of pain rather than blood loss. Reporting the vital signs to the health care provider would be premature; the client's pain assessment is not complete.

The nurse administers an opioid analgesic to an older adult postoperative client in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the client's room? a. Place side rails up x 4. b. Position the client to achieve their comfort. c. Offer toileting and a sip of water. d. Instruct the client to ask for help before getting up.

ANS: D The most important intervention for fall and injury prevention is for the nurse to instruct the older adult to ask for help before getting up after receiving an opioid medication. This intervention is important because the medication can cause sedation and dizziness; therefore, the nurse instructs him to ask for help to prevent a fall or injury. Side rails up 4 are considered a restraint and may place the client at risk for injury. Comfortable positioning is also a good supplemental intervention after administering pain medication. Offering toileting and hydration is a reasonable intervention to implement after administering pain medication, but it does not offer the same degree of safety as instructing the client to call for help.