Comfort - Nursing 1430

The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate?

"Offer 'magic mouthwash' followed by a popsicle."

A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be:

"Pain threshold is the point at which a stimulus is perceived as painful." Rationale: Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful. Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain. Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate. The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?

"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain."

Pain Assessment

- Self report - Search for potential causes of pain - Observe patient behaviors - Surrogate reporting - Attempt an analgesic trial - Pain Pattern -Location -Intensity -Quality

Acute Pain

- Short lived pain -Injury, trauma, procedural pain, post-op pain -Protective mechanism -Triggers autonomic response -After cause is treated, pain usually goes away

The nurse is caring for a preschooler who is hospitalized with a suspected blood disorder and receives an order to draw a blood sample. Which approach is best?

"Why don't you sit on your mom's lap?"

The nurse is explaining the procedure of bone marrow aspiration to a 6-year-old child with leukemia. What explanation would be best to give to the child?

"You may feel pressure on your hip during the procedure." Rationale: The bone marrow aspiration is performed on the iliac crest if the child is older and on the femur if the child is an infant. Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. A lidocaine/prilocaine cream is applied to the skin anywhere from 1 to 3 hours prior to the procedure to help numb the site where the needle will be inserted. Bone marrow aspirations and biopsies are usually performed with conscious sedation. If the child is an infant or there are special circumstances the procedure may be performed under anesthesia. The child is placed on the side for the procedure so the health care provider has better access to the iliac crest. The child will need to rest after the procedure to prevent bleeding, but is not required to lay flat on the back. Children who have had a lumbar puncture may need to lie on the back and are at risk for a headache.

Two days following abdominal surgery, a client is refusing the narcotic pain medication, event though the pain rating is an 8 on a 10 scale. The client tells the nurse, " I do not want to get dependent on that stuff". Which Response is most appropriate?

"You will recover more quickly and more effectively if you take pain medication now"

Antecedents of Pain

- Effective Circulatory System - Able to discern from comfort to discomfort - Without Noxious Stimuli (actual or potential damage to the tissue) - Intact Neurological/ Sensory System (Brain, spinal cord, nerves work together during pain process)

Pain Pattern

- Onset: when pain started; hard to identify with chronic pain - Duration: how long has pain lasted

A nurse is caring for a 30-year-old client who experiences intense one-sided headaches. Which additional characteristic would support a diagnosis of cluster headaches? Select all that apply.

-Pain behind the eye -Rhinorrhea on the same side as the headache Rationale: Cluster headaches tend to affect people in their 20s and 30s. The classic onset is sudden with an intense increase of symptoms for the first 10-15 minutes. Attacks last from 15 minutes to 3 hours. The pain behind the eye radiates to the temple cheek and gum on the same side. The eyelid may droop or be edematous and the eye may tear or be reddened. Nasal congestion, rhinorrhea, and forehead or facial sweating may occur. There is no direct correlation with the menstrual cycle, nausea and vomiting, or an aura, as may be the case with migraine.

Neuropathic Pain

-Pain caused by a lesion or disease of the peripheral or central nerves -Can be phantom pain; pain occurs with amputation where receptors and nerves are absent -Can be central: pain from spinal cord injury -Frequently is chronic pain -Described as burning, numbness, tingling, stabbing (often seen in diabetic patients)****

Chronic Pain

-Pain that lasts longer than 3 months -May have periods of remission -May be difficult to describe -Can lead to withdrawal, anger, depression, and dependency -Personal biases can impact pain treatment by nurses - Must use therapeutic communication

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

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

Projected Pain

Along a specific nerve or nerves

The nurse is caring for children on a postoperative unit. Which nursing action promotes the most efficient pain control?

Anticipate when pain will occur and plan interventions to prevent it. Rationale: The mark of efficient pain control is to anticipate when pain will occur and plan interventions to prevent it rather than let it occur and then relieve it

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response?

Decompression Rationale: Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. Instillations in a nasogastric tube after surgery are done when necessary to promote patency; this is not the most common purpose of a nasogastric tube after surgery. Gavage is contraindicated after abdominal surgery until peristalsis returns. Lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding, but this is not the most common purpose of a nasogastric tube after surgery.

Radiating Pain

Diffuse around site of origin

Which intervention is helpful for the neonate experiencing drug withdrawal?

Place the isolette in a quiet area of the nursery. Rationale: Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications such as phenobarbital and paregoric should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?

Fentanyl Rationale: Opioid analgesic agents are divided into two major groups: (1) mu agonist opioids (also called morphine-like drugs) and (2) agonist-antagonist opioids. The mu agonist opioids comprise the larger of the two groups and include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone, among others. The agonist-antagonist opioids include buprenorphine (Buprenex, Butrans), nalbuphine (Nubain), and butorphanol (Stadol).

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain?

Heart rate of 110 beats/min Rationale: Pain medication can cause decreased bowel motility and cause constipation. However, pain itself can cause an increased heart rate which is indicated by the rate of 110 beats/min. Pain can cause decreased urinary output; 2500 milliliters of urine in 24 hours is an indication of increased output. Pain can increase the consumption of oxygen; an O2 saturation of 98% on room air would be a normal reading.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress? Rationale: When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.

Referred Pain

Pain perceived in an area distant from site of painful stimuli

Wong-Baker FACES Pain Rating Scale

Pain scale using drawn faces

Descriptive Pain scale

No pain, mild pain, moderate pain, severe pain, unbearable pain

Nursing Care

Primary Prevention - Preventing pain from occurring Secondary Prevention: aims to detect disease in the early stages and limits it's progression Tertiary Prevention: Aim to reduce secondary effects of those suffering from chronic pain

A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the:

Prodromal stage Rationale: The hallmark of the prodromal stage is the initial appearance of symptoms in the host that are mild and nonspecific. The other stages/symptoms would not be present.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

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

A 5-year-old child is diagnosed with acute otitis media. Which nursing intervention would be priority?

Relieving the child's pain

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Respiratory Rationale: The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much opioid or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. The cardiac system can be affect by a opioid PCA by decreasing the blood pressure and heart rate as the pain decreases. It is expected but not the priority. The neuromuscular and peripheral vascular system are not affected by the PCA.

A female client experiencing hot flashes during perimenopause asks the nurse about hormone therapy (HT). What is the appropriate response by the nurse?

Short term HT can be used to reduce symptoms.

Localized Pain

Site of origin

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications. Rationale: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.

Degenerative Disc Disease Pain Management

Treatment of the muscular dystrophies focuses on supportive care and prevention of complications in the absence of a cure or specific pharmacologic interventions The goal of supportive management is to keep the patient active and functioning as normally as possible and to minimize functional deterioration. An individualized therapeutic exercise program is prescribed to prevent muscle tightness, contractures, and disuse atrophy. Night splints and stretching exercises are used to delay contractures of the joints, especially the ankles, knees, and hips. Braces may compensate for muscle weakness.

Nonopioid analgesics

Tylenol: Mild Pain, Start low, go slow ***Ask about use of herbal meds NSAIDS: Used for mild-moderate pain - may be used as multimodal approach Monitor for side effects: liver toxicity; GI Bleeding

Transduction

activation of pain receptors; painful stimuli converted to electrical impulses that travel to spinal cord

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids. Rationale: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

A client, who travels frequently for work, reports intense ear pain during ascent from and descent into airports. The health care provider will recommend which category of medications to help alleviate this symptom?

decongestant nasal spray such as phenylephrine Rationale: Barotrauma most often occurs in people who travel while suffering from an upper respiratory tract infection. Decongestants, such as nose drops or nasal sprays, may be used 30 to 60 minutes prior to ascent or descent to reduce congestion and open the eustachian tubes. Steroids are not recommended for barotrauma. They are helpful for inflammation and nasal polyps. Antihistamines are helpful for tinnitus and vertigo.

FLACC scale

face, legs, activity, cry, consolability

transmission of pain

movement of pain impulses from the periphery to the spinal cord & then to the brain

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron Rationale: Ondansetron (Zofran) is used to treat nausea and vomiting.

The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of PRN analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?

"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." Rationale: There is little danger of addiction to pain medications used in the postoperative management of pain. This acute condition of pain will subside over time and the client needs to be educated about this. The client does not need to be told that the dependency will occur later as most clients wean themselves off pain medication as the pain subsides over time. The client does not need to be told about hospital resources as this is not appropriate at this moment. People who are addicted to drugs do become more tolerant during their recovery which means they need more medication to decrease the pain.

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply.

- Control the client's pain with prescribed medication. -Advise the client's health care provider of the client's condition. -Encourage the client to explain his or her wishes. Rationale: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.

Factors Influencing pain:

- Physiological - Environmental - Social - Religion - Psychological - Anxiety - Cultural - Family, Sex, Gender, and Age

Attributes of Pain

- Reports being comfortable -Indicates Pain scale of zero -Relaxed facial expression and body posture -Vital signs WNL for Baseline

Mixed Pain Syndromes

-Components of both nocieceptive and neuropathic pain -Poorly defined pain (generalized) -Adjuvent meds used for treatment; antidepressants; anticonvulsants (Interfere with pain signals to brain and enhance effects of pain meds)

Location of Pain

-Localized -Projected -Radiating -Referred

Pediatric assessment - QUESTT

-Question the child. -Use pain-rating scales. -Evaluate behavior and physiologic changes. -Secure parents' involvement. -Take cause of pain into account. -Take action and evaluate results

Nonpharmacologic Therapies

-Relaxation -Guided Imagery -Distraction -Herbs -Massage -Yoga

Behavioral effects of pain on patient

-Vocalizations -Facial expressions -Body movements -Social interaction

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle Rationale: Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

A 61-year-old male client is scheduled to begin chemotherapy for the treatment of his bone cancer shortly. Staff at the cancer center have educated the man and his wife about the goals, course, and expectations of his treatment. Which medications and treatments might the man anticipate needing during and after his course of treatment?

Antiemetics and packed red blood cell (PRBC) transfusions Rationale: Nausea and anemia are common side effects of chemotherapy, and may be addressed with antiemetics and PRBCs. There is no noted indication with chemotherapy for corticosteroids, antiplatelet aggregators, diuretics, or SSRIs.

Numerical Pain Scale

Assessment tool used to rate the severity of pain

The Nurse explains to the client that the main purpose of a back rub is used as therapy to relieve pain is because Massage:

Block pain impulses from the spinal cord to the brain

Postoperative Pain Management

During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia, frequently assessing the patient's physiologic status, monitoring for complications, managing pain, and implementing measures designed to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery

A G4P4 mother calls the nurse's station reporting uterine pain following birth. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Rationale: Afterpains occur most commonly in multiparous mothers and occur when the uterus contracts and relaxes at intervals. Breastfeeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the physician.

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?

L4, L5, and S1

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Providing a solution of viscous lidocaine for use as a mouth rinse Rationale: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern. Rationale: While pain is individualized, labor pain is defined and follows a pattern. Since it follows a typical path, education and planning are completed. All pain is not the same. A primigravid needs education and guidance to best navigate the process. A cesarean birth is not an option as a method of pain management.

Osteoarthritis Pain Management

The treatment for patients with PMR (without GCA) is moderate doses of corticosteroids. Longer durations of corticosteroid treatment are required with patients who have higher baseline inflammatory markers. Gradual tapering of the corticosteroid treatment should be monitored. NSAIDs are sometimes given in mild disease.

The nurse caring for a client with bilateral rib fractures explains to the client that the pain causes him to take more shallow respirations, which will contribute to feeling short of breath due to a:

decreased tidal volume. Rationale: Tidal volume is the amount of air that a person brings in the lungs with one inhalation and exhalation. The pain caused by the fractured ribs will cause a decrease in the tidal volume, due to more shallow respirations, causing the feeling of shortness of breath because less air is entering and leaving the lungs.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Rationale: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

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

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

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?

positive reinforcement Rationale: Any woman, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement.

Nociception

the ability to feel painful stimuli

Mastitis is an inflammation of the breast that can occur at any time. What is the treatment for mastitis? Select all that apply.

• Application of heat or cold • Nonsteroidal anti-inflammatory drugs Rationale: Treatment for mastitis symptoms include application of heat or cold, NSAIDS, excision, aspiration, mild analgesics, antibiotics, and a supportive brassiere or breast binder.

A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply.

• Promoting daytime exercises • Assisting with progressive relaxation • Providing a back massage