Karch Focus on Pharmacology Chapter 26- Narcotics, Narcotic Antagonists, and Antimigraine Agents (Opioids & Analgesic Agents)

gate-control theory

theory that states that the transmission of a nerve impulse can be modulated at various points along its path by descending fibers from the brain that close the "gate" and block transmission of pain information and by A fibers that are able to block transmission in the dorsal horn by closing the gate for transmission for the A-delta and C fibers

Pain occurs when

tissues are being damaged

C fibers

unmyelinated, slow-conducting fibers that carry peripheral impulses associated with pain to the spinal cord

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? chronic neuropathic deeper somatic visceral

visceral Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months.

Which of the following is a reliable source for quantifying pain? The extent of the client's injury The client's description of the pain The nature of the client's injury or condition The client's vital signs

The client's description of the pain The client's description of the pain is the only reliable source for quantifying pain. Physiologic data such as vital signs or the extent or nature of the injury do not indicate the amount of pain.

Opioid Antagonists

drugs that block the opioid receptor sites; used to counteract the effects of opioids or to treat an overdose of opioids

Opioid Agonists

drugs that react at opioid receptor sites to stimulate the effects of the receptors

Opioids

drugs, originally derived from opium, that react with specific opioid receptors throughout the body

spinothalamic tract

nerve pathway from the spine to the thalamus along which pain impulses are carried to the brain

opioid receptors

receptor sites on nerves that react with endorphins and enkephalins, which are receptive to narcotic drugs

acute pain vs chronic pain

Acute pain: short term, self-limiting, dissipates after injury heals, follows a predictable trajectory Chronic Pain: continues 6 months or longer, types are malignant and nonmalignant, does not stop when injury heals -Interferes with sleep & activities of daily living

Which agents are often considered first-line treatment for pain?

Anti-inflammatory agents

A client informs the nurse of having taken ibuprofen every 6 hours for 3 weeks to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is taking a proton pump inhibitor for the treatment of this disorder. What should the nurse instruct the client about the use of the ibuprofen? "Don't you know that you can cause bleeding when you take that medication so often?" "It would be best to contact the health care provider before taking any over-the-counter medications." "Ibuprofen is contraindicated when taking a proton pump inhibitor." "You should never take ibuprofen; it can cause considerable problems."

"It would be best to contact the health care provider before taking any over-the-counter medications." Clients should not use an over-the-counter analgesic agent, such as aspirin, ibuprofen, or acetaminophen, consistently to treat chronic pain without first consulting a physician. -Ibuprofen is not contraindicated when taking a proton pump inhibitor. -Asking "Don't you know that you can cause bleeding when you take that medication so often?" implies accusation and is not a therapeutic response

A client who is receiving morphine reports nausea after every dose of medication. What is the nurse's best response to this client? "I will ask the health care provider if I can give you acetaminophen for the pain instead of the morphine." "This is a common side effect of the medication. I will try to make sure you have something to eat when you take the morphine." "I will mark your chart that you are allergic to morphine." "I'm sorry. That means you won't be able to have any more pain medication."

"This is a common side effect of the medication. I will try to make sure you have something to eat when you take the morphine." Nausea is a common side effect of morphine. Giving it with food helps to reduce the occurrence of the problem.

A client who has been prescribed sumatriptan as abortive therapy for migraines reports, "I took that pill about an hour-and-a-half ago, but I feel like a headache is returning. Can I take another pill?" How should the nurse respond? "Yes, it's likely safe to take one more dose of your sumatriptan." "You can take another pill now and one more in 1 hour, but then no more." "You should probably go to the emergency department." "Wait at least half-an-hour before you take another pill."

"Wait at least half-an-hour before you take another pill." Clients can take a second dose of oral sumatriptan when symptoms return but no sooner than 2 hours after the first tablet. There's no evidence that the client needs to go to the emergency department.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies "I will notify your physician." "A lot of people have a similar problem with this medication." "What do you mean by the word sick?" "A nausea medication has been prescribed that I will give you."

"What do you mean by the word sick?" Nausea may occur with opioid use; however, before taking any other action, the nurse needs to clarify that this is what the client means by the word "sick."

A nurse has entered a client's room at the beginning of a shift to quickly assess the client's airway, breathing, circulation, and consciousness. The nurse observes that the client is wincing, stating, " Oh, I am in so much pain right now." What initial question should the nurse ask this client? "In the past, what has helped your pain?" "When did this pain begin?" "Would you like me to get you something?" "Where exactly are you hurting?"

"Where exactly are you hurting?" To begin the pain assessment, first determine the location of the pain. Location gives possible clues to the source of the pain and can help identify whether the pain is acute or of a more chronic nature. -Questions about preferred treatments and the timing of the pain are appropriate and important, but it is normally necessary to first ascertain the location of the client's pain.

A nurse is caring for a client diagnosed with depression in the mental health unit. The nurse understands that therapeutic effects of tricyclic antidepressants occur at which time point? 3 weeks 4 weeks 1 week 2 weeks

3 weeks Patients need to know that a therapeutic effect may not take effect until they have taken the medication for 3 weeks.

The nurse is caring for a client who has been prescribed a nonopioid analgesic in addition to a narcotic analgesic. What effect will the nurse expect? Increased exertion Antagonism Interference Additive effect

Additive effect Acetaminophen is added to narcotic analgesics for additive effects of pain relief without the addition of narcotic adverse effects. -Acetaminophen will neither provide an antagonistic effect nor cause an interference of action. -Acetaminophen will increase excretion.

The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving? Adjuvant drug therapy Replacement drug therapy Withdrawal therapy Alternate drug therapy

Adjuvant drug therapy Adjuvant drugs are medications that are ordinarily administered for reasons other than treating pain. Duloxetine is used to treat depression but is being used for neuropathic pain for this client.

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to Administer the prescribed dose of morphine. Assess the reason for the client's anxiety. Administer the prescribed alprazolam (Xanax). Assist the client out of bed and into a chair.

Assess the reason for the client's anxiety Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. -Pain medication should not be administered for anxiety. -The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction.

The nurse observes that a new client's medication regimen includes sumatriptan. What assessment should the nurse prioritize? Assessing the client for narcotic withdrawal syndrome Assessing the client for respiratory depression Assessing the client for migraine pain Assessing the client's lying, sitting and standing blood pressure

Assessing the client for migraine pain Sumatriptan is indicated for the treatment of acute migraine and cluster headaches. As such, the nurse should assess the client for indications of this health problem, more so than respiratory status or blood pressure. -Narcotic withdrawal syndrome is unrelated.

What is a priority nursing assessment of a client prescribed oral sumatriptan? Head to toe assessment Urinary output Glasgow coma scale Blood pressure

Blood pressure After administration of sumatriptan, the nurse should assess for adverse effects. These include increased blood pressure as well as chest pain, shock, dizziness and vertigo. -Urine output and head to toe assessment are not warranted. -The Glasgow comas scale is used to determine best neurological function and not migraine pain.

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? Intermittent Burning Severe Chronic

Burning 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.

The nurse notes a client prescribed an extended-release opioid requests that all medications be crushed to facilitate the administration. What information about this form of opioid presents a problem respecting the client's request? Crushing the medication interferes with its absorption. The medication can be very irritating to mucous membranes. The crushed medication can permanently stain teeth. Crushing the medication may precipitate an overdose.

Crushing the medication may precipitate an overdose Health care providers and clients must be cautioned to avoid crushing or chewing the tablets or opening capsules because immediate release of the drug constitutes an overdose.

Which of the following is a required nursing intervention for a client receiving morphine sulfate?

Do not administer if respiratory rate is less than 12. When administering morphine sulfate, do not give if the respiratory rate is less than 12 per minute. -Bleeding gums must be reported with administration of aspirin. -Weight must be monitored with corticosteroids. -Caffeine should be avoided with administration of Ritalin.

The nurse receives a phone call from a male client who has become constipated while taking the opioid analgesic prescribed for his pain. The nurse instructs the client to do what to help relieve this problem? (Select all that apply.) Eat a diet low in fiber Take a daily stool softener Drink 2 to 3 quarts of water per day Take a laxative twice a day Try to establish a regular bowel routine

Drink 2 to 3 quarts of water per day Take a daily stool softener Try to establish a regular bowel routine

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client? Exercise regularly. Reduce fiber intake. Follow a bowel regimen. Avoid harsh sunlight.

Follow a bowel regimen The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. -The client should not reduce fiber intake because this increases the risk for constipation. -The client need not exercise regularly or avoid harsh sunlight because these have no effects on the drug therapy.

When taking a client history, the nurse notes that the client is taking herbal remedies in addition to acetaminophen. Which herb, when taken in conjunction with acetaminophen, enhances the risk of bleeding? Ginkgo Echinacea Kava Willow

Ginkgo Ginkgo, when taken with acetaminophen, enhances the risk of bleeding. Echinacea, willow, and kava, when taken with acetaminophen, increase the potential for hepatotoxicity and nephrotoxicity.

What action should the nurse take when administering meperidine 75 mg IM every 4 hours to a young adult? Call the health care provider for a smaller dose. Give the dose by mouth. Give the medication as prescribed. Administer half the dose.

Give the medication as prescribed The client should be administered the full dose of medication, which is within dosing recommendations. A client with adequate hepatic and renal function should not receive a lower dose of meperidine without specific instruction from the prescribing care provider. -There is no apparent reason to change the route of administration, and such action cannot be implemented without the instruction of the prescribing care provider.

Prostaglandins are chemical substances with what property? Reduce the perception of pain Inhibit the transmission of noxious stimuli Inhibit the transmission of pain Increase the sensitivity of pain receptors

Increase the sensitivity of pain receptors Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. -Endorphins and enkephalins reduce or inhibit transmission or perception of pain. -Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

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. A migraine headache Appendicitis Intervertebral disk herniation Angina

Intervertebral disk herniation 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.

Which route of administration of medication is preferred in the most acute care situations? Subcutaneous Intramuscular Intravenous Epidural

Intravenous Intravenous is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum concentrations and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. -Subcutaneous administration results in slow absorption of medication. -Medication administered intramuscularly is absorbed more slowly than intravenously administered medication.

The client tells the nurse that the health care provider described a drug as having "no ceiling effect." How should the nurse respond when the client asks what that means? It is a drug that reduces the likelihood of drug abuse and dependence. It is a drug that has a special caution because use of this drug is more likely to have adverse effects. It is a drug that no longer has a patent and can be sold by its generic name. It is a valuable drug to use because dosage can be increased to relieve pain when pain increases or tolerance develops.

It is a valuable drug to use because dosage can be increased to relieve pain when pain increases or tolerance develops. A drug with no ceiling effect is one in which there is no upper limit to the dosage that can be given to clients who have developed tolerance to previous dosages. This characteristic is especially valuable in clients with severe cancer-related pain because drug dosage can be increased and titrated to relieve pain when pain increases or tolerance develops. None of the other statements explain the terminology.

A client has been administered an opioid. For what effect should the nurse regularly assess? Tachycardia Edema Level of consciousness (LOC) Oliguria

Level of Consciousness (LOC) Opioids will produce decreased LOC. -Oliguria is not a result of the administration of an opioid. -Edema is not a result of the administration of an opioid. -Tachycardia is not a result of the administration of an opioid.

The nurse is caring for a client who is receiving morphine via patient-controlled analgesia (PCA). In addition to pain assessment, what assessments should the nurse prioritize? urine output and inspection of the IV site respiratory rate and fluid balance level of consciousness and respiratory rate apical heart rate and temperature

Level of consciousness & respiratory rate The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics.

A client is undergoing inpatient addiction rehabilitation following many years or addiction to heroin. What medication would be the most useful adjunct to treatment? Tramadol Oxycodone Oxymorphone Methadone

Methadone Methadone is used for detoxification and temporary maintenance treatment of narcotic addiction. -Oxycodone is used for the relief of moderate to severe pain in adults. -Oxymorphone is used for the relief of moderate to severe pain in adults, preoperative medication, and obstetrical analgesia. -Tramadol is used for the relief of moderate to moderately severe pain, and its use should be limited in clients with a history of addiction.

Prior to administering morphine, the nurse checks the client's medication history. The nurse will contact the health care provider and hold the morphine if the nurse notes the client is currently taking which medication? Monoamine oxidase (MAO) inhibitor NSAID Antibiotic Antihypertensive

Monoamine oxidase inhibitor (MAO) inhibitor The client should not receive morphine within 14 days of receiving an MOA inhibitor.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be: Attributed to a specific cause Prolonged in duration. Rapidly occurring and subsiding with treatment. Separate from any central or peripheral pathology.

Prolonged in duration A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

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: Medical interventions for pain management Anticipated harmful effects of the pain experience Severity of the pain as judged by the patient Anticipated duration of the pain

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

Why is pain a subjective experience?

The physiological processes that cause pain are perceived and reacted to in different ways because of learned experiences, cultural differences, and environmental stimuli.

Morphine, an opioid agonist, is administered for both acute and chronic pain. Along with the administered dosage, what determines the patient's response to morphine? The patient's disease process The patient's insistence on receiving the drug The route of administration The patient's gender

The route of administration Patient response to morphine depends on the route of administration and the dosage.

The nurse administers hydromorphone IV to the postoperative client as prescribed. What is the best method for the nurse to evaluate the client's response to the medication? Use a pain assessment tool before and 30 minutes after administration. Ask the client if the medication has been effective. Observe the client's behavior without the client's awareness, 30 minutes after administration. Assess the client's vital signs before and after drug administration.

Use a pain assessment tool before and 30 minutes after administration. A standard pain assessment tool should be used both pre- and postanalgesia. This type of data is more accurate than asking the client a yes/no question about the effectiveness of the medication. -The nurse should observe the client's response, but this does not provide the most accurate assessment data. -Similarly, vital signs should be monitored, but trends do not necessarily demonstrate effectiveness.

A group of students is reviewing various methods for assessing pain. The students demonstrate understanding of the material when they identify what as the most reliable method?

Using a pain rating scale A pain rating scale is the most reliable method because it provides measurable evidence of pain severity. A client's description of pain is useful, but does not provide objective or quantifiable data over time. Although percussing or palpating provides information, it would increase the client's pain and be inappropriate. Vital sign changes occur for numerous reasons and are not the best indicator of pain in clients who can speak.

A clinic nurse assesses a client with diabetes who reports taking naproxen (Aleve) and the herb bilberry for osteoarthritis. To assess for an adverse reaction between naproxen and bilberry, the nurse asks the client "Have you been constipated?" "Have you noticed an increase in your pain levels?" "Has your blood sugar been elevated more than usual?" "Do you bleed easily?"

"Do you bleed easily?" Naproxen, a nonsteroidal anti-inflammatory drug, with the herb bilberry may enhance a client's risk for bleeding. Diarrhea, constipation, or both are frequent adverse reactions to naproxen but not bilberry. Bilberry may cause hypoglycemia. Naproxen does not. There should not be an increased level of pain as a result of the interaction of naproxen and bilberry.

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." "Please point to where you are experiencing pain." "What aggravates your chest pain?" "How long have you experienced this pain?" "You've never had this pain before, have you?"

"How long have you experienced this pain?" "Please point to where you are experiencing pain." "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." "What aggravates your chest pain?" The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

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? "What do you usually take for constipation?" "When was your last bowel movement?" "Are you able to increase fluids and fiber in your diet?" "Can you take bisacodyl?"

"When was your last bowel movement?" 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.

What is neuropathic pain?

- pain that arises from abnormal or damaged pain nerves [e.g., phantom limb pain, pain below the level of a spinal cord injury, diabetic neuropathy]; - usually intense, shooting, burning, or "pins and needles" Neuropathic pain is caused by nerve injury.

What is nociceptive pain?

- pain that arises from damage to or inflammation of tissue other than that of the PNS and CNS; - usually throbbing, aching, localized; - typically responds to opioids and nonopioid medications Nociceptive pain is caused by a direct stimulus to a pain receptor.

What is psychogenic pain?

-real to the patient but originates from psychological factors -physical cause of pain cannot be identified Psychogenic pain is pain that is associated with emotional, psychological, or behavioral stimuli.

When describing the onset of action of naloxone, the nurse would explain that the drug achieves its effect in which amount of time? 30 to 60 minutes 1 to 2 minutes 15 to 30 minutes 10 to 15 minutes

1 to 2 minutes Naloxone is capable of restoring respiratory function within 1 to 2 minutes of administration. The shorter the time to restoring respiration, the less time the client has to depend on manual or mechanical ventilation, and the better the outcome for the client.

The nurse administers morphine 15 mg oral solution to a client with cancer pain at 09:30. What time should the nurse reassess the client for peak analgesic effect? 10:00 11:00 9:45 10:30

10:30 With oral administration, peak activity occurs in about 60 minutes. The duration of action is 5 to 7 hours.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every 24-36 hours. 12-24 hours. 36-60 hours. 48-72 hours.

48-72 hours Fentanyl patches should be replaced every 48-72 hours, depending on patient response. The other time frames are incorrect.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? Administering the analgesics on an as-needed per client request Administering the analgesics intravenously Administering analgesics with increased dosage Administering the analgesics on a regular basis

Administering the analgesics on a regular basis Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

When caring for a patient who is deaf, which of the following should be used to elicit information regarding the patient's level of pain? An outside interpreter should be used. Verbally asking the rate of pain Use of Braille Computer-generated speech

An outside interpreter should be used For people who are deaf of hard of hearing, outside interpreters (i.e., not family members) should be used. -For people with disabilities that result in communication impairment, computer-generated speech may be useful. -For people who are blind and who know how to read Braille, pain assessment instruments can be obtained in Braille. -The patient is deaf, so verbally asking to rate the pain on a scale would be inappropriate.

The nurse has administered a dose of naloxone and the client's respiratory depression improved within five minutes. When the nurse reassessed the client two hours later, the client demonstrates symptoms of respiratory depression. Which action should the nurse perform next? Continue to monitor the client's vital signs and oxygen saturation levels. Call the provider as another dose of opioid antagonist may be necessary. Administer a second dose and then notify the provider to obtain an order. No further action is required because the naloxone has already been administered.

Call the provider as another dose of opioid antagonist may be necessary. The effects of some opioids may last longer than the effects of naloxone. A repeat dose of naloxone may be ordered if results obtained from the initial dose are unsatisfactory. Therefore, calling for an order would be an appropriate response. -Taking no action in light of respiratory depression, or merely continuing to monitor the client, could lead to deterioration in the client's condition. -No medication should be administered without a provider order.

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? Reassess the patient's pain in 30 to 45 minutes. Document the fact that the patient has slight pain. Administer ibuprofen or acetaminophen rather than an opioid. Explain the 0-to-10 pain scale in greater detail.

Explain the 0-to-10 pain scale in greater detail 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."

What action should the nurse take when administering meperidine 75 mg IM every 4 hours to a young adult? Give the dose by mouth. Administer half the dose. Call the health care provider for a smaller dose. Give the medication as prescribed.

Give the medication as prescribed The client should be administered the full dose of medication, which is within dosing recommendations. A client with adequate hepatic and renal function should not receive a lower dose of meperidine without specific instruction from the prescribing care provider. There is no apparent reason to change the route of administration, and such action cannot be implemented without the instruction of the prescribing care provider.

The nurse notes a respiratory rate of 6 breaths/min in a client in the postanesthesia recovery unit. Which drug would the nurse anticipate being given immediately? Naloxone Butorphanol Acetaminophen and diphenhydramine Epinephrine

Naloxone Naloxone has long been the drug of choice to treat respiratory depression caused by an opioid. Therapeutic effects occur within minutes after IV, IM, or sub-Q injection and last 1 to 2 hours. -Butorphanol would worsen respiratory depression. -Acetaminophen and diphenhydramine are used to treat headache. -Epinephrine may be prescribed for an allergic reaction but not for respiratory depression.

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? nociceptive and chronic neuropathic and acute neuropathic and chronic nociceptive and acute

Neuropathic & chronic 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. -Acute pain is pain or discomfort of short duration: from a few seconds to less than 6 months. This is not the type of pain related to long-term diabetes mellitus.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? Breakthrough pain Visceral pain Referred pain Neuropathic pain

Neuropathic pain An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? Referred pain Breakthrough pain Visceral pain Neuropathic pain

Neuropathic pain An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. -Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. -Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. -Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located.

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 have increased hepatic, renal, and gastrointestinal function. Older people metabolize drugs more rapidly. Older people have lower ratios of body fat and muscle mass. Older people are more sensitive to drugs.

Older people are more sensitive to drugs 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.

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient? Older people experience reduced sensory perception. Older people are expected to experience chronic pain. Older people have increased sensory perception. Older people have a decreased pain threshold.

Older people experience reduced sensory perception Pain affects individuals of every age, sex, race, and socioeconomic class, and everyone should be assessed for pain. Additionally, older adults tend to experience reduced sensory perception.

A nurse is caring for a client diagnosed with a migraine. The client received acetaminophen-aspirin-caffeine by mouth. Which method should be used to assess for the therapeutic effects of the medication? Glasgow coma scale Subjective assessment Vital signs Pain scale

Pain scale The method the nurse should prioritize in this situation is using the pain scale. Following the administration of the acetaminophen-aspirin-caffeine combination, the client should exhibit diminished pain. The nurse assesses for pain using the pain scale. -A subjective assessment would involve more than just the pain scale. -Assesing vital signs would be an objective assessment and not necessarily confirm therapeutic effects -The Glasgow coma scale would not be indicated for migraine headache.

Which of the following is a physiologic response to pain? Hypotension Dry skin Bradycardia Pallor

Pallor Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

Which phase of pain transmission occurs when the one is made aware of pain? Modulation Transmission Perception Transduction

Perception Perception is the pain process where one becomes aware of the pain as a result of neural activity. -Modulation involves the response to noxious stimuli. -Transduction refers to the processes by which noxious stimuli activate primary afferent neurons called nociceptors. -Transmission describes the action potential that is created by transduction being transmitted along fibers.

A male client is given regular doses of morphine for a period of 6 months. His dosage now needs to be reduced gradually. The health care provider advises the nurse to pay attention to the clinical management of the client's pain to allow proper agonist coverage during the change in drug dosage. Why is the client likely to suffer unnecessary pain and discomfort if proper management is not ensured? Adverse effects of the drug Tolerance to the drug Physical dependence on the drug Addiction to the drug

Physical dependence of the drug If morphine use lasts longer than 3 months, then physical dependence will occur. Dependence is characterized by a withdrawal or abstinence syndrome when morphine is discontinued; it represents an exaggerated rebound from its acute effects. Physical dependence is not the same as tolerance or addiction.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective? Encourage the client to eat crackers. Provide the client with a fresh gown. Consult with the health care prescriber to include hydroxyzine with the opioid. Position the client for comfort.

Position the client for comfort The nurse should provide a comfort level with positioning first. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and alternative measures should be tried first. -Providing a fresh gown will not make the medication more effective. -Ingesting food with an opioid medication does not make the medication more effective.

Both categories of migraine abortive drugs (ergot alkaloids and serotonin agonists) exert powerful vasoconstrictive effects and also have what potential? Manage hypotension Lower blood pressure Raise blood pressure Manage hypertension

Raise blood pressure Both categories of migraine abortive drugs (e.g., ergot alkaloids and serotonin agonists) exert powerful vasoconstrictive effects and have the potential to raise blood pressure.

An elderly client has a fractured hip and is in Buck's traction. The client is disoriented and cannot express herself. At 0730 the client was calm. Now, at 0930, the client is restless and agitated. The nurse reviews the medication administration record. The last dose of opioid was at 0330. The nurse assesses the client's agitation may be from Effects of the opioid medication Increased uptake of opioids Recurring pain Diminished pain perception

Recurring pain Elderly clients may experience cognitive dysfunction, such as confusion and agitation, as a result of unrelieved pain. Once the pain is relieved, the cognitive dysfunction clears. The nurse needs to become astute in assessing the reason for agitation. -Opioid medications are often incorrectly attributed as causing cognitive dysfunction in elderly clients. -No strong evidence states that being elderly contributes to diminished pain perception.

A family member of a client in the emergency department reports that the client has been illegally using fentanyl. The nurse should prioritize assessment of what vital sign to assess for overdose? temperature blood pressure respiratory rate heart rate

Respiratory rate All the client's vital signs are important areas of assessment. However, opioids have a profound effect on respiratory rate, and this is a priority assessment.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client How anxiety could increase his pain perception About activities that would distract him from pain That the nurse will notify the surgeon of his fear That medication will be prescribed for pain relief

That medication will be prescribed for pain relief Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. -Diversional activities may be used in addition to analgesics. -Anxiety about pain could increase the client's perception of pain. -Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

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 is experiencing pain relating to the burn injuries from several years ago That based on her past experiences the client's perception of pain should be less That the client's past experiences with pain may influence her perception of current pain That the client has become dependent on drugs from her previous experience of burns

That the client's past experiences with pain may influence her perception of current pain 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.

The nurse is caring for a postoperative client with a history of opioid abuse who has been ordered to receive a dose of an opioid antagonist medication. Which issues should the nurse be prepared to address? During pain assessment, the client may report less pain. Multiple doses may be needed to be therapeutic. The client may begin to demonstrate symptoms of withdrawal. Double the standard dosage of the medication may be needed.

The client may begin to demonstrate symptoms of withdrawal. The client may begin to demonstrate symptoms of withdrawal when he or she has a history of opioid abuse and is administered an opioid antagonist. -The other answers are incorrect. -In fact, clients will likely have increased pain due to antagonistic effects of the drug. The standard dosage and a single dose will be administered even with a history of opioid abuse.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress? Teach the client to avoid pushing the button multiple times because additional doses will be given. The pump will deliver a preset amount of medication. Chance of sedation is rare when using a PCA pump. The client should wait until the pain is severe to push the button to prevent overdose.

The pump will deliver a preset amount of medication. 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.

Which of the following is a true statement with regards to the nursing process of pain control? The use of physiologic signs to indicate pain is unreliable. Usually all patients exhibit the same pain behaviors. Nonverbal expressions of pain are reliable indicators of the quality of pain. Formulate treatment plans based on behaviors.

The use of physiologic signs to indicate pain is unreliable Use of physiologic signs to indicate pain is unreliable. Although it is important to observe for any and all pain behaviors, the absence of these behaviors does not indicate an absence of pain. It is unwise to make judgments and formulate treatment plans based on behaviors that may or may not indicate pain. Not all patients exhibit the same behaviors, and there may be different meanings associated with the same behavior. -Nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence or severity of pain experienced.

When evaluating the plan of care for a client receiving opioid analgesics for pain management, the nurse considers the plan successful when what occurs? (Select all that apply.) An adequate breathing pattern is maintained. Therapeutic response is achieved and discomfort is reduced. Client reports decreased bowel movements. Client reports decreased urinary output. Client maintains adequate nutritional status.

Therapeutic response is achieved and discomfort is reduced. An adequate breathing pattern is maintained. Client maintains adequate nutritional status

When evaluating the plan of care for a client receiving opioid analgesics for pain management, the nurse considers the plan successful when what occurs? (Select all that apply.) Client maintains adequate nutritional status. Therapeutic response is achieved and discomfort is reduced. Client reports decreased urinary output. An adequate breathing pattern is maintained. Client reports decreased bowel movements.

Therapeutic response is achieved and discomfort is reduced. An adequate breathing pattern is maintained. Client maintains adequate nutritional status. The plan of care is considered effective when therapeutic response is achieved and discomfort is reduced; an adequate breathing pattern is maintained; the number of bowel movements is maintained; and adequate nutritional status is maintained. Urinary output should mirror increased fluid intake (increased fluid in, increased fluid out).

Where do opioids & analgesic agents act?

These agents all work in the central nervous system (CNS)—the brain and the spinal cord—to alter the way that pain impulses arriving from peripheral nerves are processed.

A client diagnosed with migraines associated with the menstrual cycle has been prescribed estradiol. When providing client teaching, what preferred route of administration will the nurse describe? Transcutaneous Sublingual Intravenous Intramuscular

Transcutaneous It is thought that that the natural decline in estrogen in the late luteal phase of the menstrual cycle, prior to menstruation, is associated with the increased risk of migraine. Transcutaneous administration of estradiol prevents migraines by minimizing this decline. Estradiol is not administered by the other routes for migraine prevention. Transcutaneous is also known as transdermal, which is topical

How are pain impulses transmitted?

Two small-diameter sensory nerves, called the A-delta and C fibers, respectively, respond to stimulation by generating nerve impulses that produce pain sensations. -The A-delta fibers are small, myelinated fibers that respond quickly to acute pain. -The C fibers are unmyelinated and are slow conducting

The nurse has just administered an opioid antagonist to a client who had been experiencing respiratory depression. How soon can the nurse expect to see improvement in the client's respiratory function? Improvement will occur within 30 minutes from the time of administration. Slow improvement can be noted throughout the shift. Within one to five minutes, an effect may be seen. Response is highly individualized based upon client weight.

Within 1 to 5 minutes, an effect may be seen Onset of action is generally rapid and may be seen within one to five minutes. Additional doses may be required to achieve optimal effects.

The nurse receives a prescription for morphine sulfate 8 mg IV every hour as needed for pain. For what client should the nurse question this order? a 78-year-old client with osteoarthritis a 28-year-old client with a fractured tibia a 17-year-old client, 1-day postoperative appendectomy a 45-year-old client, 1-day postoperative mastectomy

a 78-year-old client with osteoarthritis Older clients are more likely to experience the adverse effects associated with narcotics, including central nervous system, gastrointestinal, and cardiovascular effects. Furthermore, a strong narcotic analgesic would not be indicated for chronic osteoarthritis pain. For both of these reasons, the nurse would question the large dosage of a narcotic. The other clients could appropriately receive morphine 8 mg unless they were smaller than average adults.

When diagnostic testing reveals a bone fracture, what type of pain is the client experiencing? chronic visceral pain acute somatic pain visceral pain neuropathic pain

acute somatic pain Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in the skin, bone, muscle, and soft tissue. -Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues either from acute or chronic injuries. -Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system.

pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage

Ergot Derivatives

drugs that cause a vascular constriction in the brain and the periphery; relieve or prevent migraine headaches, but are associated with many adverse effects

Opioid agonists-antagonists

drugs that react at some opioid receptor sites to stimulate their activity and at other opioid receptor sites to block activity

An older adult client experiencing recurrent tension headaches reports taking an over-the-counter (OTC) combination of acetaminophen, aspirin, and caffeine several times a week. The nurse should recognize that this combination medication may be contraindicated if the client has a history of what medical condition? peripheral vascular disease contact dermatitis gastrointestinal (GI) bleeding coronary artery disease

gastrointestinal (GI) bleeding Aspirin is normally contraindicated in clients who have had a history of GI bleeding. The other listed health problems do not contraindicate the use of combination acetaminophen, aspirin, and caffeine.

migraine headache

headache characterized by severe, unilateral, pulsating head pain associated with systemic effects, including gastrointestinal (GI) upset and sensitization to light and sound; related to a hyperperfusion of the brain from arterial dilation

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends increasing the amount of bran and fresh fruits and vegetables inserting a bisacodyl (Dulcolax) rectal suppository every morning ingesting up to 6 glasses of fluids per day using milk of magnesia 30 mL every day

increasing the amount of bran and fresh fruits and vegetables Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. -The client should ingest 8 to 10 glasses of fluids per day. -Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. -A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

A 60-year-old client tearfully explains to the nurse how her husband downplays her frequent migraines and tells her that she needs to "just push through a headache." She describes how her migraines have limited her ability to provide childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning this client's care? spiritual distress related to migraine headaches situational low self-esteem related to migraine headaches ineffective role performance related to migraine headaches ineffective health maintenance related to migraine headaches

ineffective role performance related to migraine headaches Many nursing diagnoses likely apply to this client's situation, but there is evidence that she grieves her inability to perform a caregiving role for her grandchildren. -There is no evidence that the client's health maintenance is inadequate or that she has low self-esteem. -Spiritual distress is also not in evidence.

A fibers

large-diameter nerve fibers that carry peripheral impulses associated with touch and temperature to the spinal cord

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment? intensity, variations, range of motion, and the client's goal for pain control location, onset, alleviating factors, and aggravating factors nutritional deficiencies, onset, duration, and effects of pain quality, location, intensity, and family history

location, onset, alleviating factors, and aggravating factors Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards.

Which client would the nurse identify as being opioid naive? person who routinely takes opioids one who is psychologically dependent on opioids individual who is physically dependent on opioids one who does not routinely take opioids

one who does not routinely take opioids Opioid-naive clients are defined as those who do not use opioids or infrequently use them. Those who routinely take and are physically or psychologically dependent on opioids are not considered opioid naive.

What is referred pain?

pain felt in a part of the body other than its actual source Example: A person experiencing pain from damage to the heart muscle may actually feel the pain in the neck or jaw.

triptan

selective serotonin receptor blocker that causes a vascular constriction of cranial vessels; used to treat acute migraine attacks

A-delta fibers

small-diameter nerve fibers that carry peripheral impulses associated with pain to the spinal cord

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about? the importance of limiting the use of the PCA to no more than twice per hour the use of non-pharmacologic pain interventions to minimize use of the PCA the limits on dose and frequency that are programmed into the PCA the fact that naloxone will be kept readily available at all times

the limits on dose and frequency that are programmed into the PCA Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. -Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. -The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.