H&S Chapter 11- CARE OF THE CLIENT WITH PAIN

the best combination of treatment is recommended

using a combination of pharmacologic and nonpharmacologic techniques

Gender Determinants of Pain

women have lower thresholds for pain, rate noxious stimuli are more painful and have lower tolerance for intense pain do men May discourage men for reporting pain or seeking medical care Women are more likely to have ongoing relationship with a medical professional

Physiological response: Acute Pain

R/t Sympathetic response Increase HR - tachycardia Increase BP - hypertension Increase RR dilate pupil anxiety Sweating - diaphoresis muscle tension Pallor

Ice packs, cold water baths, and cold-emitting chemical packs can help alleviate

low back pain with spasticity ( muscles are continuously contracted) activity induced muscle pain pain associated with obstetric and gynecologic procedures

Either wet or dry heat can be used to

manage lower back pain present without spasm manage N/V and diarrhea caused by peristalsis and acid production reduce reflex muscle spasms associated with menstrual cramps

Bupivacaine (Marcaine)

more potent Used for nerve blocks and epidural anesthetic Greater risk for CNS and cardiac toxicity

Pharmacologic methods of pain control include

narcotic analgesics such as oxycodone and morphine non-narcotic analgesics such as aspirin and acetaminophen corticosteroids such as prednisone local anesthetics atypical analgesics, such as antidepressants, which can be effective for neuropathic pain

Physiological responses: Chronic Pain

no change in vital signs depression fatigue decreased level of function disability

A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by

offering the client a pain scale to measure his pain.

Application of heat or cold is help to

reduce pain associated with underlying muscle, skeletal, or neurological pathology

Use of Aspirin and NSAIDS (Anti-inflammatory)

reduce pain by inhibiting local prostaglandin synthesis. Released at site of injury and stimulates inflammation

Definition of Splinting

reduces tidal volume (air exchanged with each breath) Increase inspiratory and expiratory pressures Result = pneumonia and atelectasis and respiratory acidosis

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statement indicates that the client knows how to use the device?

"I should tell the nurse if the pain doesn't stop after I use this device

Nurse's role in pain assessment

Accept patient's self-report Serve as advocate Act promptly to relieve pain Respect values and preferences of patient, family members, and significant others

Other applications to reduce pain

Active and passive range-of-motion exercises can help alleviate pain. The nurse can use passive exercises with patients who are immobile. Relaxation, massage, acupressure, and controlled breathing techniques

The client reports chest pain. The nurse uses which of the following questions to assess the pain further.

1. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." 2. "What aggravates your chest pain?" 3. "How long have you experienced this pain?" 4. "Please point to where you are experiencing pain."

When evaluating a patient's response to acute pain, the nurse assesses for the presence of physiologic responses associated with the pain experience.

1. Decreased urinary output 2. Hyperglycemia 3. Increased cardiac output 4. Increased metabolic rate

The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does all of the following:

1. consults with the healthcare provider about the client's report 2. evaluates the pain level using the established pain scale 3. assesses respirations, pulse, and blood pressure

Duration of pain

Acute pain Chronic pain

Quality of Life Impact by pain

ADLs, anxiety, depression, hopelessness fear, anger, insomnia and relationships

When a patient is suffering from acute pain, the nurse should anticipate which patient complaints Select all that apply. A. Insidious onset of pain in the lumbar region B. Phantom limb pain following amputation C. Pain present for several months' duration D. Guarding of a midline abdominal incision E. Sharp, stabbing pain in a specific area

ANS:

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain? 1) Acute 2) Chronic 3) Intractable 4) Neuropathic

ANS: 1 Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than 6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.

The hydromorphone administered at the beginning of the shift worked well to address Mr. Jones' pain. Thirty minutes post administration, he rated his current level of pain at a 3 on a 1 to 10 scale. It is now early afternoon and Mr. Jones is preparing for physical therapy. Which nursing action is most appropriate at this time? A. Assessing the patient's current level of pain B. Monitoring the patient for respiratory depression C. Asking the therapist to initiate therapy on the next shift D. Administering a prn dose of prescribed oral pain medication

ANS: A Rationale: Physical therapy often causes an exacerbation in the level of pain experienced by the patient. It is important for you to assess Mr. Jones' current level of pain and implement an intervention to manage his pain in preparation for physical therapy. There is no indication that you have administered an opioid pain medication necessitating an assessment for respiratory depression. While administering a pain medication prior to physical therapy may be appropriate, you cannot make this determination prior to conducting a pain assessment.

Which questions should you ask Mr. Jones in order to conduct a focused pain assessment? Select all that apply. A. "When did your pain begin?" B. "Can you describe your pain for me?" C. "Are there any activities that make your pain worse?" D. "When was the last time you received pain medication?" E. "Can you trace your pain for me?"

ANS: A, B, C, and E Rationale: OPQRST-AAA is a useful mnemonic the nurse can use to evaluate pain symptoms, with each letter representing an important line of questioning: • O - Onset of pain • P - Provocation • Q - Quality of pain • R - Region or radiation • S - Severity • T - Time and duration • AAA - Aggravating/alleviating factors and associated symptoms. It is not necessary to ask the patient when he last received pain medication. This information is provided during shift report and can be verified with the medication administration record (MAR). A brief interview using the OPQRST-AAA mnemonic can be conducted in less than 5 minutes and can occur simultaneously with other assessment activities. The information gained through this structured questioning approach clarifies the nature of pain experienced by the patient and informs the clinician's review and selection of effective therapeutic interventions.

Mr. Jones is now three days postoperative. His pain is being managed with scheduled doses of ibuprofen (800 mg every 8 hours by mouth) and prn doses of acetaminophen with hydrocodone. Mr. Jones has not had a bowel movement since surgery. Which nursing action is appropriate based on the current data? A. Notify the healthcare provider immediately. B. Administer the prn dose of docusate sodium. C. Assist the patient in a guided imagery exercise. D. Place the patient on a bedpan and provide privacy.

ANS: B Rationale: Constipation is a known side effect for patients who are receiving opioid analgesics in the treatment of acute pain. The most appropriate nursing action based on the current data is to administer the prn dose of docusate sodium, a stool softener. There is no reason to notify the healthcare provider immediately regarding the patient's constipation. Guided imagery is a nonpharmacological intervention to treat pain and is not effective in treating constipation. Placing the patient on a bedpan and providing privacy is not indicated at this time.

A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client's health history would lead the nurse to consult with the provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin (Coumadin)

ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

Mr. Jones received a dose of acetaminophen with codeine prior to the physical therapy session. After the session Mr. Jones states, "I am very uncomfortable now that therapy is over. I don't want a strong pain medication because it made me really drowsy. What else can I have to treat my pain?" You review Mr. Jones' medication prescriptions and find that he cannot receive anything for two more hours. Which nursing actions are appropriate based on the current situation? Select all that apply. A. Using acupressure on the affected knee B. Initiating guided imagery with Mr. Jones C. Applying cold therapy to Mr. Jones' left knee D. Repositioning Mr. Jones and elevating his left knee with a pillow E. Implementing passive range of motion to the lower left extremity

ANS: B, C, and D Rationale: Mr. Jones is not due to receive another dose of pain medication for two more hours. You should implement nonpharmacological pain management strategies to address his pain at this time, including guided imagery, cold therapy, and repositioning the patient and elevating his left knee. These interventions have been proven to address the type of pain that Mr. Jones is experiencing after a physical therapy session. Acupressure and implementing passive range of motion may further aggravate Mr. Jones' current level of pain.

Which tool should you use to assess Mr. Jones' current level of pain? A. FACES pain scale B. FLACC pain scale C. Numerical pain scale D. Neonatal infant pain scale

ANS: C Rationale: A numerical pain scale allows the patient to rate current level of pain on a scale of 1 to 10. This unidimensional measurement is designed to assess treatment response to both pharmacologic and non-pharmacologic interventions for many forms of acute pain, including burns, postoperative pain, and chronic non-cancer pain. Evidence suggests that this unidimensional scale may be less effective as a measure of chronic pain or of mixed acute and chronic pain. The FACES scale is more appropriate for a pediatric patient. The FLACC pain scale is more appropriate when assessing pain for an infant patient. The neonatal infant pain scale, referred to as NIPS, is designed for a neonate.

You are responsible for providing care to Mr. Jones, a 58-year-old salesman who was admitted to the surgical unit for a left total knee replacement surgery. Mr. Jones is 12 hours post-op. During shift report, the assigned nurse shares the following information with you: • Pain rating of an 8 of 10 during initial assessment • Prescribed pain medication (morphine) administered per order • Post-medication administration assessment revealed pain rated at 5 of 10. Patient was restless most of the overnight. You enter Mr. Jones' room to complete a shift assessment. Which is your priority action? A. Palpating a radial pulse B. Monitoring blood pressure C. Conducting a pain assessment D. Inspecting the surgical incision

ANS: C Rationale: Pain assessment and management is your priority based on the information shared during the shift assessment, which portrays the concern that the patient's pain has not been controlled with morphine alone. The American Pain Society champions this relatively straightforward way to improve pain management, since inclusion of a pain assessment when assessing vital signs (blood pressure, pulse, and respirations) gives the pain assessment clinical priority.

You administer the prescribed IV hydromorphone to Mr. Jones. Which is your priority assessment based on the current data? A. Pain B. Heart rate C. Respiration D. Blood pressure

ANS: C Rationale: While it is important to reassess Mr. Jones' level of pain, the priority assessment after administering an IV opioid drug such as hydromorphone is to monitor the patient for the adverse reaction of respiratory depression. Heart rate and blood pressure are not priority assessments for this patient based on the current data.

The nurse assesses Mr. Jones' current level of pain and finds that it is back to an 8 on a 1 to 10 scale. He describes the pain in his left knee as "stabbing and angry." Which prescribed pain medication should you administer to Mr. Jones? A. aspirin B. morphine C. ibuprofen D. hydromorphone

ANS: D Rationale: Mr. Jones' is experiencing acute, severe pain; therefore, it is appropriate to administer an intravenous opioid to address his pain. While morphine and hydromorphone are both intravenous analgesics, the patient's pain has not been addressed by morphine thus far; therefore, hydromorphone is the most appropriate pain medication to administer at this time. Hydromorphone is eight times more potent than morphine. Aspirin is often contraindicated after a surgical procedure due to the risk for bleeding. Ibuprofen, a non-steroid anti-inflammatory drug (NSAID), is appropriate to treat chronic pain due to inflammation.

The patient is receiving the first dose of an opioid analgesic for pain. The nurse expects the patient will also be ordered a(n): A. Antacid agent B. Anti-anxiety agent C. Laxative or stool softener D. Breakthrough pain reliever

Answer: C Rationale: Opioids inhibit peristalsis in the GI tract. Patients who take regular doses of opioids frequently become constipated. Interventions such as diet modifications and laxative agents may be needed to prevent or minimize the problem of constipation. Other common side effects of opioid administration include nausea and vomiting, sedation, and respiratory depression.

Which patient would benefit most from the use of a patient-controlled analgesia pump? A. 75-year-old woman with confusion who is in the last stages of the dying process B. 15-year-old girl who is recovering from a head injury from an automobile accident C. 42-year-old man who is mentally alert and is recovering from a fractured femur D. 60-year-old man who is mentally alert and is experiencing left-sided weakness after a stroke

Answer: C Rationale: The mentally alert, physically able patient is the best candidate to receive PCA. When a patient is cognitively impaired or unable to push the PCA button, another method of administration should be considered.

Health teaching of non-opioid

Ask about use of non-opioids Clarify brand names vs. over-the-counter names Inform patients about combination products containing non-opioids (Tylenol and Percocet) Advise not to exceed safe maximum daily dose due to adverse side effects

Use of Opioids

Autonomic effects include pupil constriction, dry mouth, reduced sensitivity to cold Mutes activity of sympathetic nervous system causing relaxation, sedation, slowed breathing, and reduction in anxiety Opioid receptors Delta, Kappa, Mu

The family practice physician group, where you practice nursing, treats a high number of older adult clients. Many of these older adults use nonopiod pain medications on a regular basis. Which of the following client education principles should you teach to these clients? Choose all correct options.

Avoid OTC analgesics consistently without consulting a physician Inform the primary healthcare provider about the use of salicylates before any procedure

A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (ALL THAT APPLY)

Bradypnea Orthostatic hypotenstion Nausea

Origin of pain

Cutaneous or superficial pain - cause short term pain Visceral pain - Abdominal cavity, cranium, or thorax Deep somatic pain - in ligaments, tendons, nerves, blood vessels, and bones Radiating pain - start at the origin and extend to other locations (e.g., severe sore throat may extend to ears and head) Referred pain - occur in an area that is distant from the original site (e.g., pain from heart attack may be experienced down the left arm, through back, or into jaw) Phantom pain - pain is perceived to originate from an area that has been surgically removed Psychogenic pain - pain arises from mind

Local anesthetics

Eliminate sensation and pain without LOC Relax vascular muscle walls bringing increased blood flow into region Lidocaine (Xylocaine) most common

Very powerful influences on the pain experience are

Ethnicity Culture

Behavioral Response: Acute Pain

Grimacing - an ugly, twisted expression on a person's face, typically expressing disgust, pain, or wry amusement. Moaning Flinching - make a quick, nervous movement of the face or body as an instinctive reaction to surprise, fear or pain Guarding - abdominal

Processing Pain Messages

In early stages of injury damaged cells release chemicals including histamine, bradykinin, and prostaglandins. Cause activation of nociceptors (neurons that respond to stimuli) that transmit pain messages to brain and spinal cord. Other chemicals stimulate the inflammatory response

Unrelieved pain trigger GI system by

Intestinal secretions and smooth muscle tone increase Gastric emptying and mobility decrease

Gender responses to analgesia

Men required more opioid dosing to achieve pain relief Men report more analgesic relief with ibuprofen

Definition: Nociceptive Pain

Most common type of pain Arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems Usually throbbing, aching, localize pain typically response to opioids and non-opioids medication.

Cause of pain

Nociceptive pain Neuropathic pain

Tolerance of opioid

Normal response Effects of analgesia decrease; client may require higher dose Not the same as addiction

Physical dependence of opioid

Normal response Withdrawal symptoms occur when opioid is suddenly stopped Not the same as addiction

Populations at highest risk for inadequate pain control

Older adults Substance abusers Those whose primary language differs from that of the health care professional

Older Adults and Pain

Older patients in pain may be reluctant to report pain because of cognitive impairment Older adults use analgesia agents longer than younger adults and pain is likely to slow recovery from surgery

How does the body react to pain?

Onset of acute pain activates SNS to minimize blood loss, maintain perfusion to vital organs, prevent infections, and promote healing If pain continues, the body adapts, and PNS take over

Physical assessment techniques to help understand patient's pain

Palpation and ROM Verbal and non-verbal response

"gold standard" for pain existence and intensity assessment

Patient's self-report

Definition: Chronic Pain

Persists or recurs for indefinite period (months to years) not always linked to identified tissue injury or damage Unpredictable - intensity can change over time Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness

A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing for?

Presence of associated symptoms

Factors the Shape the Pain Experience

Prior experience with pain Expectations of pain Anxiety Situational meaning of pain for a particular patient (laboring mom)

Unrelieved pain trigger Endocrine system by

Release excessive ACTH = Adrenocorticotropic hormone ADH = antidiuretic hormone GH = growth hormones catecholamines glucagon Insulin and testosterone decrease Results = activate carbohydrate, protein, and fat catabolism (breakdown); hyperglycemia; and poor glucose use

Unrelieved pain trigger genitourinary system by

Release of excessive amount of Catecholamines Aldosterone ADH Cortisol Angiotensin II Prostaglandin Results = decrease urinary output urinary retention fluid overload hypokalemia hypertension increase cardiac output

Side effects of Opioids

Respiratory depression Nausea and vomiting Constipation

Non-Opioid Analgesics

Salicylates (Aspirin) Acetaminophen (Tylenol) NSAIDS (Motrin Advil, Toradol, Dolobid, Aleve)

Two types of nociceptive pain

Somatic pain Visceral pain

Addiction of opioid

compulsive behavioral pattern to take medication for its psychic effects without regard for negative consequences

Physiological Impact by pain

Stress response Increases heart rate, blood pressure and O2 demand Decreases GI motility Causes immobility Decreases immune response Delays healing Increased risk of development of chronic pain

Definition: Acute Pain

Sudden onset Short duration - hours to weeks Linked with tissue injury or damage Acts as warning sign - alerts and prompts withdrawal, avoidance, and protective responses Results from sudden, accidental trauma; surgery; ischemia; inflammation

patient's pain level is subjective mean ?

This means that only the patient can determine the amount of pain he or she is experiencing. It is not an objective sign that the nurse can definitively measure or observe.

Definitions of Pain

Unpleasant sensory/emotional experience associated with actual or potential tissue damage Self-report always most reliable indication of pain

Corticosteroids

Used to treat Acute inflammation and pain following nerve and spinal cord injuries Used as adjuvant (aid) therapy for pain control in cancer patients Increases effectiveness of other medication

Purpose of Positioning

a tried-and- true non-pharmacologic pain management method. The nurse helps the patient find a position that promotes comfort and alleviates pain Side lying positions or head elevations can minimize stress on muscle groups or incisions Upright sitting positions that encourage forward leaning improve pain caused by shortness of breath

Definition: Neuropathic Pain

arises from abnormal or damaged pain nerves (Phantom limb pain, pain below the level of a spinal cord injury, diabetic neropathy) usually intense, shooting, burning, numbness, itching, or "pins and needles" Difficult to localize

Unrelieved pain trigger respiratory system by

breath shallowly - limit thoracic and abdominal movement - in an effort to reduce pain. This is called Splinting

Use of Tylenol

has few anti-inflammatory effects Activates one of body's own natural pain-inhibiting neurochemical systems

Unrelieved pain trigger cardiovascular system by

hypercoagulation increase HR, BP, cardiac workload, an oxygen demand Combination of hypercoagulation and increase cardiac workload = * unstable angina (chest pain) * intracoronary thrombosis (clot formation in vessels that supply heart) * Myocardial ischemia and infarction (heart attack)

Side effects of Corticosteroids

hyperglycemia weight gain myopathies (Muscle disease) Cushing's syndrome mental status changes

Unrelieved pain trigger musculoskeletal system by

impaired muscle function fatigue immobility Prevent ADLs and physical therapy

Somatic: Nociceptive Pain

in bones, joints, muscles, skin, or connective tissues

Cutaneous: Nociceptive Pain

in skin or subcutaneous tissue

Visceral: Nociceptive Pain

internal organs such as the stomach or intestines can be sharp or dull and difficult to localize