Chronic Pain and Headaches Review (Prep U)
A client is returning to the medical unit after surgery and has a history of migraines. Which intervention would the nurse prioritize for the overall treatment of this client?
Administer hydromorphone and/or sumatriptan medications for relief. Migraine is a complex of symptoms characterized by periodic and recurrent attacks of severe headache lasting from hours to days in adults.When migraines or other types of headaches have been diagnosed, the goal of nursing management is pain relief. Administration of hydromorphone (opiate) medication provides pain relief. This medication has a dual benefit by also providing relief from any surgical pain. Triptans (sumatriptan) are considered the first-line treatment of the management of moderate to severe migraine pain. It is reasonable to try nonpharmaceutical interventions first, but the use of medications should not be delayed. Non-pharmaceutical interventions include providing comfort measures such as a quiet dark environment, elevation of the head to 30 degrees, and symptomatic treatment such as administration of antiemetic medication. Antiemetic (ondansetron or trimethobenzamide) medications are not typically scheduled nor given as a prevention or anticipated measure except with ergotamine preparations. Hydration has been linked to migraines by some research but is not the first priority when treating migraines.
A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol?
Alcohol causes vasodilation of the blood vessels. Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.
A client reports having joint pain that has gotten worse over the last year despite gradually increasing doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?
Chronic pain This client is experiencing chronic pain, which is pain or discomfort that lasts for a period longer than 6 months. Pain or discomfort with a short duration is acute pain. It is associated with trauma, injury, or surgery. Referred pain is pain felt in the body in a location that is different from the actual source of the pain. Breakthrough pain is a period of acute pain experienced by those suffering from chronic pain.
How can the nurse determine that a client's pain is characteristic of acute pain?
It is associated with a specific injury. Pain often is described as being acute or chronic (persistent) (Pasero & Portenoy, 2011). Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.
The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Keep a food diary. Maintain a headache diary. Sleep no more than 5 hours at a time. Exercise in a dark room. Use St. John's Wort.
Keep a food diary. Maintain a headache diary. The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.
A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?
Temporomandibular disorder The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
"A secondary headache is associated with an organic cause, such as a brain tumor." A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.
The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?
"When was your last bowel movement?" 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.
The nurse has assessed a client's pain subsequent to a broken ankle. How would the nurse categorize and document the client's pain?
Acute Acute pain is of early onset and associated with an injury. Pain decreases as healing occurs. Chronic pain is constant or intermittent and persists beyond the healing time.
The nurse is assessing a client's level of pain. How is the pain best described?
An unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery. Pain is a privately experienced, unpleasant sensation usually associated with disease, injury, or surgery. Although pain can have an emotional component, referred to as suffering, this is not the source of all pain. Although pain can be the result of disease, it can also be caused by injury, surgery, emotional or mental conditions, or other causes. Pain is a normal aspect of nervous system functioning. Neuropathic pain is pain that is processed abnormally by the nervous system.
A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?
As soon as the client senses the onset of symptoms A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.
When taking a client history, the nurse notes that the client has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the client is experiencing which type of pain?
Chronic pain Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by clients with a normally controlled pain management regimen.
While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
Cluster A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.
When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.
Intervertebral disk herniation 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.
A patient is being seen in the ER following a motor vehicle accident (MVA). He is having severe back pain. The preferred route of administration of medication in the most acute care situations is which of the following routes?
Intravenous The IV route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels 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. Intramuscular administration of medication is absorbed more slowly than intravenously administered medication.
A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient?
Low back pain Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life. Examples of noncancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.
A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?
Lung sounds are diminished in the apical area. Lung sounds may be reduced, especially in the apical area. The nurse would not hear rhonchi, crackles, or a pericardial friction rub unless the client had underlying cardiac or respiratory disorders.
Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing?
Older clients should receive a reduced dose. A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.
The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
Perform stretching exercises and frequent position changes. Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.
The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. Red wine Nausea Menstruation Exposure to flashing light Change in environmental temperature Prolonged positioning
Red wine Menstruation Exposure to flashing light Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation), exposure to flashing light, and particular food/beverages and alcohol can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to changes in environmental temperature does not trigger a migraine headache. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?
Take medication as soon as symptoms of the migraine begin. The nurse reinforces the drug therapy regimen and instructs the client on self-administration of medications. To stop the migraine headache, the nurse stresses the importance of taking medication as soon as symptoms of the migraine begin and not when the migraine intensifies.
A nurse is caring for a client with recent history of migraines. What aspect of this client's current status may rule out the safe use of triptans?
The client has angina. Triptans can cause chest pain and are contraindicated in clients with ischemic heart disease. Hypertension, older age, and the presence of stress do not rule out the use of triptans.
A client comes to the clinic expressing the need for more analgesics for chronic pain. Stating that the medication is not as strong, the client reports requiring more than the prescribed dose. What does the nurse suspect is occurring with the client?
Tolerance Tolerance is a condition in which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered. Addiction refers to a chronic, relapsing, treatable disease characterized by craving, dysfunctional behaviors, inability to control impulses regarding consumption of a substance, and compulsive use despite harmful consequences (Oliver et al., 2012). Physical dependence means that a person experiences physical discomfort, known as withdrawal symptoms.
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?
Verapamil (Calan) Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.
What is a major concern for the nurse when caring for a patient with chronic pancreatitis?
Weight loss Weight loss is a major problem in chronic pancreatitis. More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack (Bope & Kellerman, 2011).
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?
seasonal changes Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
"I use this to prevent migraines." Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?
"There is a strong familial tendency." Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.
The nurse is planning to teach a client who was recently diagnosed with migraine headaches. It is best to teach the client
In a quiet room Learning may be optimized by minimizing factors that interfere with the process. These factors include pain and fatigue, which are common during the headache recovery phase (which is immediately following a migraine). Also, the presence of visitors could interfere with learning. If family members are to participate in providing care, then learning sessions should be scheduled with family members present. A quiet room is appropriate to the learning situation.
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
Relaxes muscles Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.
A client sustained second- and third-degree burns to the chest and neck 4 days ago and is now refusing analgesics stating, "I don't want to become addicted to pain medication." What is the best response by the nurse?
"Although misusing the medication may cause addiction, there is little evidence that those who require narcotics for legitimate pain become addicted." The American Society for Pain Management Nursing describes addiction as a chronic, relapsing, treatable disease—characterized by craving, dysfunctional behaviors, inability to control impulses regarding consumption of a substance, and compulsive use despite harmful consequences (Oliver et al., 2012). Although opioid drugs can result in addiction, there is very little evidence that those who require narcotics for legitimate pain actually become addicted. The other options are nontherapeutic responses to the client's concern about addiction.
The advance practice nurse is treating a client experiencing a neuropathic pain syndrome. Which statements by the client demonstrates an understanding of concepts related to neuropathic pain?
"My phantom limb pain serves no purpose, and I may need to take antidepressants to help." Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the tricyclic antidepressants desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for treatment of neuropathic pain.
An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility?
Administer an analgesic as prescribed to facilitate the client's mobility. At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the client's level of comfort during ambulation and allow the client to ambulate. Motivating the client or having another person with the same diagnosis visit is not an intervention that will help with mobility. The client should not be encouraged to "push through the pain."
Acute pain can be distinguished from chronic pain by assessing which characteristic?
Acute pain is specific and localized. Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.
A client with osteoarthritis of the hip for a number of years reports a dull, aching pain with ambulation and pain shooting down the leg at night while sleeping. The nurse recognizes that the client is experiencing which type of pain?
Chronic pain The pain from osteoarthritis is a chronic pain that persists over a period of time due to the degeneration of the hip joint. Acute pain has a shorter duration and resolves with healing. Breakthrough pain is a temporary increase in controlled persistent pain. Neuropathic or pathophysiologic pain is caused by injury to a nerve with impaired processing of sensory input.
Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect?
Compartment syndrome Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.
The nurse is caring for a client with kidney stones who reports severe pain. What type of pain does the nurse understand this client is experiencing?
Visceral pain Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Somatic pain is caused by mechanical, chemical, thermal, or electrical injuries or disorders affecting bones, joints, muscles, skin, or other structures composed of connective tissue. Neuropathic pain is pain that is processed abnormally by the nervous system. Chronic pain is discomfort that lasts longer than 6 months and is almost totally opposite from those of acute pain.
A client comes to the outpatient clinic to receive cortisone injections in the neck for pain that has been occurring consistently for 8 months. What type of pain is this client experiencing?
Chronic pain The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute pain. 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. 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. Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology.
The nurse on a rehabilitation unit receives a report about a new client who has fibromyalgia and has difficulty with ADLs. The off-going nurse also reports that the client is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What aspect of chronic pain syndromes could account for this client's behavior?
Chronic pain can cause intense emotional responses. Regardless of how clients cope with chronic pain, pain that lasts for an extended period can result in depression, anger, or emotional withdrawal. Nowhere in the scenario does it indicate the client is upset about the hospitalization or has a psychiatric disorder. Fibromyalgia is closely associated with chronic pain.
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the appropriate action by the nurse?
Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration. The most appropriate action by the nurse would be to consult with the physician regarding the need for an increased dose of the drug and not to reduce its frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50%. Informing the client that they will not be able to receive more medication is not acting as a client advocate nor acting in the best interest of the client. Suggesting a psychiatrist consultation would not be an appropriate action because the client has a chronic illness that requires medication. Taking a non-narcotic analgesic would not provide the client with the pain relief needed.
A client agreed to be a part of a research study involving migraine headache management. The client asks the nurse if a placebo was given for pain management or if the new drug that is undergoing clinical trials was given. After discussing the client's distress, it becomes evident to the nurse that the client did not fully understand the informed consent document that was signed at the start of the research study. What is the best response by the nurse?
"The research study is in place and there is no way to know now." Telling the truth (veracity) is one of the basic principles of nursing culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a client, and revealing a diagnosis to persons other than the client with the diagnosis. The nurse is following the guidelines of the research study, so re-educating the client about the study is the best the nurse can do. Saying "What difference does it make?" or "You signed informed consent documents" is not helpful because these statements are not supportive. While it is true that the nurse does not know what treatment the client received, this statement is also not supportive.
A client with appendicitis has had an appendectomy. After surgery, what type of pain does the nurse anticipate the client will have?
Acute pain Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology. The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute 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. 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.
A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks the client is having. What instructions should the nurse give this client?
Identify and avoid factors that precipitate or intensify an attack. The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs, if that is possible.
The home health nurse is developing a plan of care for a client who will be managing chronic pain at home with NSAID analgesics. Which pain management interventions should the nurse teach the client? Select all that apply. Use a pain assessment tool to monitor pain levels and response to interventions. Monitor for adverse analgesic effects and notify the health care provider if they occur. Take an analgesic when the pain reaches an intolerable level. Discuss signs and symptoms and risk of addiction. Discuss the use of nonpharmacologic measures of pain control.
Use a pain assessment tool to monitor pain levels and response to interventions. Monitor for adverse analgesic effects and notify the health care provider if they occur. Discuss the use of nonpharmacologic measures of pain control. To promote self-management of pain at home, the nurse teaches the client to use a pain rating scale to monitor the level of pain in response to interventions. The client should also be taught adverse effects of medications that require medical attention. The client should be instructed to take an analgesic when pain is first felt, not when it reaches an intolerable level. Additionally, the nurse should also discuss nonpharmacologic measures to control pain, such as heat/cold, transcutaneous electrical nerve stimulation, and relaxation breathing. Since this client is not using opioid medications to control pain, there is no risk of addiction.
About which issue should the nurse inform clients who use pain medications on a regular basis?
Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.
A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?
Migraines often coincide with menstrual cycle. Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?
neuropathic and chronic 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.
