NURS 327 Ch 12 Pain Management

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.

- 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.

Which of the following is a disadvantage of using the transdermal route of opioid administration?

A delay in effect until the dermal layer is saturated A disadvantage of using the transdermal route of administration is that there is a delay in effect when the dermal layer is saturated. Advantages include a consistent opioid serum level, slightly less constipation than with oral opioids, and less cost as compared to the parenteral route.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced how often?

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

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. Pain affects individuals of every age, sex, race, and socioeconomic class

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Gabapentin The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

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

"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 nurse is assessing a client who has been taking up to 4 grams of acetaminophen every day for undiagnosed pain. What reaction due to ingestion of acetaminophen will the nurse assess for?

Abrupt onset of rash and pruritus The use of acetaminophen increases the risk of hepatotoxicity. Initial signs and symptoms of a drug-induced hepatitis include an abrupt onset of a rash and pruritus. Initial effects would not include excessive clotting of blood, shortness of breath, or sensitivity to hot and cold temperatures.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect?

Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

A client is receiving morphine sulfate intravenously (IV) every 4 hours as needed for the relief of pain related to a surgical procedure the client had 3 days previously. The physician is discontinuing the IV and will be starting the client on oral pain medication. What would provide the client with optimal pain relief when discontinuing the IV dose?

Administer an equianalgesic dose. When changing from a parenteral to an oral route, it is best to administer an equianalgesic dose, an oral dose that provides the same level of pain relief as when the drug is given by a parenteral route. Administering a lower dose of the medication will not provide the client with an adequate pain relief. Administering an IM dose may decrease the absorption and not provide the client with adequate relief. Administering a higher dose may cause side effects that would be detrimental to the client.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics every three hours Scheduling the administration of analgesics every three hours, 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.

The nurse understands that which statement is true about tolerance and addiction?

Although clients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

The client takes naproxen for arthritic pain and is now prescribed warfarin for persistent atrial fibrillation. Due to the interactions of the medications, what is the nurse's best response?

Assess the client's stool for color Clients who take NSAIDs, such as naproxen (Aleve), with warfarin (Coumadin) may experience gastrointestinal bleeding. The nurse will need to monitor for this. Clients are to ingest a consistent level of vitamin K. Administering the medications with food does not increase absorption. Ingesting food with the medications may decrease gastrointestinal upset. Clients are instructed to not ingest alcohol.

When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point?

At the same time the first patch is applied Because it takes 12 to 18 hours for the fentanyl concentrations to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The skin must be clean and dry before applying the patch; no shower is required. Respiratory assessment must be conducted before applying the fentanyl patch.

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 after an amputation?

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. Clients who have a history of amputation commonly report phantom pain in the amputated extremity.

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?

Confusion Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.

Which of the following is a physiologic response to pain?

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

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be described?

Prolonged in duration 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.

Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order?

Rectal The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option. The rectum allows passive diffusion of medications and absorption into the systemic circulation. Topical agents produce effects in the tissues immediately under the site of application. Intrathecal catheters for acute pain management are used most often to provide anesthesia or a single bolus dose of an analgesic agent. The subcutaneous route of administration is not recommended in this situation.

When caring for a patient who is receiving an opioid analgesic agent, the nurse knows to assess for the most serious side effect of:

Respiratory depression Although all listed side effects are serious, the most serious is respiratory depression since it is life-threatening in an immediate sense.

The client is taking oxycodone (Oxycontin) for chronic back pain and reports decreased pain relief when he began taking a herb to improve his physical stamina. The nurse asks if the herb is

ginseng Ginseng may inhibit the analgesic effects of an opioid, such as oxycodone. The other herbs listed (valerian, kava-kava, and chamomile) may increase central nervous system depression.

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 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. Dosing may or may not be more than twice per hour. 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.

A client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. The initial surgeries occurred more than 2 months ago, and the nurse is concerned about the repeated requests. What does the nurse suspect to be the cause of the client's frequent appeals for pain medication?

tolerance Tolerance is a condition in which a client needs larger doses of a drug to achieve the same effect as when first administered; it may not develop until an opioid drug is used regularly for 4 weeks or more. Activation of NMDA receptors is believed to decrease the effect of opioids, resulting in the need for higher doses to achieve a therapeutic effect. The development of tolerance is not an indication of addiction; rather, the client's request for pain-relieving drugs more often is a consequence of poor pain control. Addiction is a repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's mind-altering or mood-altering effects. Although opioid drugs can result in addiction, there is very little evidence that those who require narcotics for legitimate pain actually become addicted. An allergic reaction to a drug could present many symptoms, such as a rash, hives, or difficulty breathing, but it would not result in a client requesting increased medication. Most prescription drugs are manufactured using strict quality control standards, so poor quality control is not likely to be a reason for the client's request for increased medication.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply.

- I am tired of living with this nagging pain; I'm not sure how much longer I can go on." - I would love to go to church, but my back pain is too uncomfortable to make it through the service." - I used to walk every day for exercise; pain in my knee made me stop walking." A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The client's report is the most reliable indicator of pain. The client works with the nurse and doctor to establish a pain management regimen.

A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?

Administer analgesics around the clock. Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.

Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture?

Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.

The client is scheduled for surgery. The nurse is reviewing with the client about postoperative pain management. The client states her goal after receiving treatment is "0." The first action of the nurse is to

Educate the client that this goal may not be achievable. The client's goal of complete elimination of pain may be unrealistic. The nurse needs to first teach the client about setting an achievable goal. The nurse will plan to use a combination of pharmacologic and nonpharmacologic interventions for pain relief. The nurse may need to notify the surgeon of the client's goal of "0" for pain relief. The nurse does not ensure large doses of opioids are prescribed for the client. Many factors go into the prescription of medication for pain relief, including the client's response to the medication.

Which substance reduces the transmission of pain?

Endorphins Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

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 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. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch?

Postherpetic neuralgia A lidocaine 5% patch has been approved for use in postherpetic neuralgia, though research suggests that is effective and safe for a wide variety of acute and chronic pain conditions. A lidocaine 5% patch has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.