Pharmacology Chapter 29: Pain Management in Patients with Cancer

A patient with chronic pain was admitted to the hospital. The provider orders morphine PO 5 mg every 4 hours. The patient states that he usually takes his home morphine prescription 10 mg every 4 hours and has been for several months. This patient is at risk for which of these problems? Addiction Tolerance Physical dependence Abstinence syndrome

Abstinence syndrome The patient is at risk for abstinence syndrome because the order is for half of the pain medication he normally takes at home, a significant decrease in his medication. He is probably already physically dependent on the medication and has developed a tolerance to many of the side effects. With pain, patients are at a low risk for addiction.

Opioids and Neonates

Accordingly, when opioids are given to nonventilated infants, the initial dosage should be very low (about one-third the dosage employed for older children).

A patient with cancer develops mucositis from chemotherapy. Which action should the nurse take? Administer nerve blocks. Administer mouthwashes. Administer adjuvant therapy. Administer bisphosphonates.

Administer mouthwashes. Treatments for mucositis involve mouthwashes and local anesthetic rinses; opioids in transdermal, patient-controlled analgesia, intravenous, and subcutaneous routes; and antibiotics. Bisphosphonates are given for bone pain. Adjuvant drugs can be given for unacceptable side effects and neuropathic pain. Nerve blocks are therapy for movement-related pain. p. 288

A patient with cancer is experiencing neuropathic pain. Which adjuvant drugs are appropriate for this type of pain? Antihistamines Glucocorticoids Antidepressants Antiseizure drugs Antidysrhythmics Central nervous system (CNS) stimulants

Antidepressants Antiseizure drugs Antidysrhythmics Several of the adjuvants are especially useful for neuropathic pain: tricyclic antidepressants, other antidepressants, antiseizure drugs, and local anesthetics/antidysrhythmics. CNS stimulants can enhance opioid-induced analgesia and they can counteract opioid-induced sedation. Antihistamines promote drowsiness and reduce anxiety. Glucocorticoids are part of the standard therapy for tumor-induced spinal cord compression. pp. 297-298 Among these are certain antidepressants (eg, imipramine), anticonvulsants (eg, carbamazepine, gabapentin), and local anesthetics/antidysrhythmics (eg, lidocaine).

At what time does the nurse administer tricyclic antidepressants (TCAs) for neuropathic pain in a patient with cancer? At bedtime With meals In the morning In the afternoon

At bedtime Dosing at bedtime takes advantage of sedative effects and minimizes hypotension during the day. Administering the TCAs in the morning, with meals, or in the afternoon could cause the patient to feel the sedative and hypotensive effects throughout the day.

A patient with cancer receives nonsteroidal anti-inflammatory drugs (NSAIDs) for mild pain. Which adverse effects will the nurse monitor for in this patient? Multiple selection question Bleeding Gastric ulceration Acute renal failure Physical dependence Suppression of inflammation

Bleeding Gastric ulceration Acute renal failure Primary adverse effects are gastric ulceration, acute renal failure, and bleeding. In contrast to opioids, NSAIDs do not cause tolerance, physical dependence, or psychologic dependence. Suppression of inflammation is a primary beneficial effect. p. 292

A patient with cancer receives intraventricular pain medications. Which administration site will the nurse assess? Lung Brain Heart Abdomen

Brain In this procedure (intraventricular administration), morphine is delivered to the cerebral ventricles via a catheter connected to an external infusion pump (for continuous administration) or a subcutaneous reservoir (for intermittent administration). Because morphine is delivered directly to the brain, bypassing the blood-brain barrier, analgesia can be achieved with extremely low doses. The medication is not delivered to the heart, lung, or abdomen. p. 295

A patient with cancer is prescribed meperidine for chronic, severe pain. What is the nurse's most important intervention? Preparing the patient for an IM injection Making sure the patient has a patent IV Calling the provider to change the prescription Teaching the patient about potential side effects

Calling the provider to change the prescription The nurse should call the provider to change the prescription. Demerol is not a drug that is recommended for cancer pain. When the drug is taken chronically, a toxic metabolite—normeperidine—can accumulate, thereby posing a risk of adverse central nervous system (CNS) effects (dysphoria, agitation, seizures). Morphine is preferred. Teaching about side effects is not appropriate as the drug should not be given. Most cancer drugs are given orally; IV medication can be given but IM injections are to be avoided. p. 294

A patient asks the nurse why the primary healthcare provider changed the naproxen to celecoxib. When responding, the nurse will base the answer on what information? Celecoxib is addicting. Celecoxib is an opioid. Celecoxib does not cause thrombotic events. Celecoxib does not cause gastrointestinal ulceration.

Celecoxib does not cause gastrointestinal ulceration. COX-2 inhibitors (celecoxib) specifically inhibit cyclooxygenase-2, so they are not associated with adverse effects such as gastrointestinal ulcers. Unfortunately, the selective inhibitors (celecoxib) pose a greater risk of thrombotic events. Celecoxib is a COX-2 inhibitor, not an opioid; like all other nonsteroidal anti-inflammatory drugs, it is not addicting. p. 292

Acetaminophen. How does it differ from NSAIDS

Combining acetaminophen with an opioid can produce greater analgesia than either drug alone (because acetaminophen and opioids relieve pain by different mechanisms p. 293 acetaminophen with alcohol, even in moderate amounts, can result in potentially fatal liver damage. Accordingly, patients taking acetaminophen should minimize alcohol consumption. Acetaminophen also can increase the risk of bleeding in patients taking warfarin. The mechanism appears to be inhibition of warfarin metabolism, which causes warfarin to accumulate to toxic levels. Acetaminophen differs from the NSAIDs in several important ways. Because it does not inhibit COX in the periphery, acetaminophen lacks antiinflammatory actions, does not inhibit platelet aggregation, and does not promote gastric ulceration, renal failure, or thrombotic events. Because acetaminophen does not affect platelets, the drug is safe for patients with thrombocytopenia

A patient with cancer is scheduled for a neurolytic nerve block. What information in the chart confirms the rationale for this treatment? An inability to lift objects above chest level due to weakness Constant pain that is not relieved by opioids or other methods Intermittent pain that causes tingling and numbness in the extremities An impaired ability to ambulate and rise from a chair even with assistance

Constant pain that is not relieved by opioids or other methods A neurolytic nerve block is used for intractable pain (constant pain that is not relieved by opioids or other methods). An inability to lift objects or an impaired ability to ambulate are not criteria for a nerve block. Tingling and numbness will be treated with adjuvant therapy before nerve blocks. p. 298

Adjuvant analgesic

Unlike nociceptive pain, neuropathic pain responds poorly to opioid analgesics. However, it does respond to drugs known collectively as adjuvant analgesics. Among these are certain antidepressants (eg, imipramine), anticonvulsants (eg, carbamazepine, gabapentin), and local anesthetics/antidysrhythmics (eg, lidocaine). Adjuvant analgesics (eg, amitriptyline, carbamazepine, dextroamphetamine)

A patient takes oxycodone 40 mg PO twice daily for the management of chronic cancer pain. Which intervention should be added to the plan of care to minimize the gastrointestinal adverse effects? Increase fluid and fiber in the diet. Encourage the patient to void every 4 hours. Instruct the patient to move slowly when rising. Administer the medication on an empty stomach.

Increase fluid and fiber in the diet. Oxycodone is a narcotic analgesic that decreases propulsive intestinal contractions, which lead to constipation. Increasing fluid and fiber in the diet can help manage this adverse effect. Taking medications on an empty stomach causes gastrointestinal upset, so it is not advised and will not help with the constipation. Instructing the patient to move slowly when rising is for orthostatic hypotension, not constipation. Encouraging the patient to void every 4 hours is for urinary retention, not constipation.

Drugs with Anticholinergic properties

Drugs with anticholinergic properties (eg, tricyclic antidepressants, antihistamines) can exacerbate opioid-induced constipation (by further depressing bowel function), and hence should be avoided.

The patient with cancer is prescribed an analgesic with anticholinergic side effects. The nurse will monitor for which adverse effects? Itching Dry mouth Constipation Urinary retention Orthostatic hypotension

Dry mouth Constipation Urinary retention Anticholinergic effects include dry mouth, urinary retention, and constipation. Although itching, sedation, and orthostatic hypotension can be side effects, they are not anticholinergic side effects. dry mouth, blurred vision, elevation of intraocular pressure, urinary retention, constipation, anhidrosis, tachycardia, and asthma

The nurse administered an opioid medication. Which intervention is most important to perform after the medication has been administered? Assess the patient's vital signs. Teach the patient about the medication action. Discuss possible side effects with patient's family. Document the patient's response to the medication.

Document patient response to the medication.

How often does the nurse tell the patient with cancer to change a fentanyl transdermal patch? Once a week Every 24 hours Every 72 hours When pain recurs

Every 72 hours Fentanyl patches provide steady analgesia for 72 hours, and hence, are appropriate for patients with pain that is continuous and does not fluctuate much in intensity. Absorption from the patch is very slow, so it is not as effective for acute pain relief; 24 hours is too short, and once a week is too long.

Which drugs will the nurse administer to patients with cancer to control severe pain? Fentanyl Nalbuphine Oxycodone Butorphanol Buprenorphine

Fentanyl Oxycodone Fentanyl and oxycodone are full opioid agonists. These drugs do not possess any opioid antagonist properties and are administered for pain control in cancer patients. Butorphanol, nalbuphine, and buprenorphine are opioid agonists-antagonists. Opioid agonists-antagonists are drugs that have some properties of an agonist and some properties of an antagonist. These drugs have a ceiling effect and are not routinely given to cancer patients for pain control. pp. 291, 294

A patient, whose pain is normally controlled with around-the-clock analgesia administration, is experiencing intermittent, severe episodes of pain. Which drug should the nurse administer? Senna orally Hydroxyzine orally Fentanyl nasal spray Ketorolac nasal spray

Fentanyl nasal spray Fentanyl nasal spray is the drug of choice because the patient is having breakthrough pain. Breakthrough pain is both severe and self-limited; the best medication is a strong opioid with a rapid onset and short duration. For ease of administration, oral, transmucosal, and intranasal formulations are preferred. Senna is a stool softener. Hydroxyzine is an antihistamine used as adjuvant therapy for insomnia, nausea, vomiting, and anxiety. Although ketorolac is an nonsteroidal anti-inflammatory drug (NSAID), it is not a recommended NSAID for cancer patients with chronic or breakthrough pain.

Constipation is a side effect of opioid medications because of which of these pathophysiologic reasons? Increasing nonpropulsive contractions Increasing the tone of the anal sphincter Decreasing propulsive intestinal contractions Reducing fluid secretion into the intestinal lumen Developing a tolerance for gastrointestinal effects

Increasing nonpropulsive contractions Increasing the tone of the anal sphincter Decreasing propulsive intestinal contractions Reducing fluid secretion into the intestinal lumen Opioids promote constipation by decreasing propulsive intestinal contractions, increasing nonpropulsive contractions, increasing the tone of the anal sphincter, and reducing fluid secretion into the intestinal lumen. Tolerance for gastrointestinal effects does not develop as it does for other effects such as pain relief and euphoria. p. 295

The nurse is caring for a patient who is being treated with opioids for cancer pain. The patient has become agitated and is reporting visual disturbances. The nurse suspects opioid-induced neurotoxicity and anticipates which management actions? Naloxone [Narcan] Intraveous (IV) fluids Decreasing the dose of the opioid Rotating different opioids Using nonsteroidal anti-inflammatory drugs (NSAIDs) instead of opioids

Intraveous (IV) fluids Decreasing the dose of the opioid Rotating different opioids Opioid-induced neurotoxicity symptoms include delirium, agitation, myoclonus, and hyperalgesia. Management consists of hydration, dose reduction, and opioid rotation. Narcan and NSAIDs are not specific management measures for opioid-induced neurotoxicity. p. 297

A nurse administers morphine to treat the pain of a patient with cancer. What process occurs for the nurse to observe a therapeutic effect? Mu receptors are blocked. Kappa receptors are stimulated. Mu ad kappa receptors are blocked. Mu and kappa receptors are stimulated.

Mu and kappa receptors are stimulated. The pure agonists (morphine) act as agonists at mu receptors and at kappa receptors. In contrast, the agonist-antagonists act as agonists only at kappa receptors; at mu receptors, these drugs act as antagonists. p. 293

A patient with a history of opioid abuse is prescribed an opioid analgesic for cancer pain. What will the nurse expect to observe about the initial dose? Multiple choice question It will be lower than a normal dose. It will be higher than a normal dose. It will be the same as a normal dose. It will be one-half of the normal dose.

It will be higher than a normal dose Because of opioid tolerance, initial doses for drug abusers must be higher than for nonabusers. It will not be lower, the same, or one-half of normal. p. 301

A nurse advises a patient who is taking acetaminophen to avoid or minimize alcohol intake. What is the nurse trying to prevent? Bleeding Liver damage Gastric ulcers Thrombotic events

Liver damage Combining acetaminophen with alcohol, even in moderate amounts, can result in potentially fatal liver damage. Accordingly, patients taking acetaminophen should minimize alcohol consumption. Acetaminophen also can increase the risk of bleeding in patients taking warfarin. Because acetaminophen does not inhibit COX-2 in the periphery, acetaminophen lacks anti-inflammatory actions, does not inhibit platelet aggregation, and does not promote gastric ulceration, renal failure, or thrombotic events.

When assessing a client with cancer for adverse effects of morphine sulfate, which finding should a nurse expect? Miosis Diarrhea Insomnia Hypertension

Miosis Miosis is a side effect of morphine sulfate, an opioid. Opioids (ie, morphine) cause orthostatic hypotension, not hypertension. Morphine also causes constipation, not diarrhea. Morphine sulfate does not cause insomnia, but can cause sedation.

The older patient with cancer pain is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which other drug to prevent gastrointestinal ulcers might the nurse anticipate in the prescription? Multiple choice question Etidronate Methadone Misoprostol Pamidronate

Misoprostol The risk of gastric ulceration and renal toxicity from NSAIDs is increased in older patients. Gastric erosion can be reduced by concurrent therapy with misoprostol or a proton pump inhibitor (eg, esomeprazole). Methadone is an opioid, so it would not help with gastric ulceration; it has a prolonged half-live and should be avoided in older adults. Bisphosphonates, such as etidronate and pamidronate can reduce cancer-related bone pain in some patients; however, they are not used to treat gastrointestinal ulcers. p. 300

Which prescription would be the most appropriate for treating persistent cancer pain? Morphine [Duramorph] 30 mg every 3 to 4 hours Meperidine [Demerol] 100 mg orally (PO) every 4 hours Morphine [Duramorph] 10 mg orally (PO) as needed (PRN) Pentazocine [Talwin] 75 mg intramuscularly (IM) every 3 to 4 hours PRN

Morphine [Duramorph] 30 mg every 3 to 4 hours For persistent pain, medication should be given on a fixed schedule to prevent opioid levels from becoming subtherapeutic. Meperidine causes accumulation of a toxic metabolite when used on a long-term basis. Pentazocine produces a limited amount of analgesia, and IM injections generally should be avoided. Morphine 30 mg is an appropriate dose and should be given as indicated around the clock. p. 294

A patient with cancer is receiving an opioid analgesic for pain relief. The nurse follows the principle that opioid analgesics are preferred over nonsteroidal antiinflammatory drugs (NSAIDs) for cancer-related pain relief. What is the rationale for the nurse's action? NSAIDs cause respiratory depression in patients. NSAIDs are contraindicated in patients with cancer due to drug interactions. NSAIDs are prescribed for geriatric patients and not for patients younger than 40 years. NSAIDs are ineffective for treating chronic severe pain as they have rapid ceiling effects.

NSAIDs are ineffective for treating chronic severe pain as they have rapid ceiling effects. With the nonopioid and adjuvant analgesics, there is a ceiling to how much relief we can achieve. In contrast, there is no ceiling to relief with the opioids. Any increase in the dose of the NSAID beyond a certain level does not increase the therapeutic effect of the drug, but doing so increases the adverse and toxic effects, so NSAIDs are not effective during severe pain. Respiratory depression is caused by opioid analgesics, not NSAIDs. The side effects of NSAIDs are bleeding and gastrointestinal irritation. NSAIDS are not contraindicated in cancer patients or for patients younger than 40 years; they can be used to treat mild pain. p. 291

When assessing a patient with cancer for adverse effects related to opioid use, the nurse will monitor for which effects? Nausea Diarrhea Sedation Neurotoxicity Urinary retention

Nausea Sedation Neurotoxicity Urinary retention Opioid usage can cause nausea, sedation, neurotoxicity, and urinary retention. Constipation occurs, not diarrhea. pp. 296, 297

A patient with cancer experiences pain described as "burning and shooting." What type of pain is the patient experiencing based upon this assessment finding? Visceral Somatic Neuropathic Nociceptive

Neuropathic Patients describe neuropathic pain with such words as "burning," "shooting," "jabbing," "tearing," "numb," "dead," and "cold." Nociceptive pain has two forms known as somatic and visceral. Patients generally describe somatic pain as localized and sharp. In contrast, they describe visceral pain as vaguely localized with a diffuse, aching quality. p. 287

Heightened Drug Sensitivity in Older Adults

Older adults are more sensitive to drugs than are younger adults, owing largely to a decline in organ function. In particular, rates of hepatic metabolism and renal excretion decline with age.

Which assessment finding indicates that the nonsteroidal anti-inflammatory drug has been effective for a patient with cancer? Bruising is present. Circulation to legs is increased. Bleeding time is prolonged in the periphery. Pain has decreased from a 7 to a 2 on a scale of 1 to 10.

Pain has decreased from a 7 to a 2 on a scale of 1 to 10. NSAIDs produce their effects—both good and bad—by inhibiting cyclooxygenase (COX), which reduces pain. Bruising, the bleeding time, and the increased extremity circulation are not therapeutic effects of the medication. The bleeding and bruising are adverse effects. p. 292

Which factor will the nurse consider while planning pharmacologic therapy for a patient with persistent cancer pain? Pain relief is best obtained by administering analgesics around the clock. Analgesics should be administered as needed to minimize adverse effects. Adjuvant analgesics are given solely in step 3 of the analgesic ladder for cancer pain. Narcotic analgesics should not be used for more than 24 hours because of the risk of addiction.

Pain relief is best obtained by administering analgesics around the clock. For persistent pain, administer analgesics on a fixed schedule around-the-clock (ATC), and provide additional rescue doses of a short-acting agent if breakthrough pain occurs. Administering analgesics as needed is not as effective as around-the-clock. When treating cancer pain, unfounded fears of addiction cannot regulate pain control. Adjuvant analgesics can be given throughout all the steps. pp. 291-292

A nurse is assessing pain in a patient with gastric cancer. What is the essential, priority assessment? Patient states pain is gnawing in the stomach. Patient grimaces when the abdomen is palpated. Patient's family says the moaning is constant and unrelenting. Patient's magnetic resonance imaging results indicate a mass in the stomach.

Patient states pain is gnawing in the stomach. The patient's description of his or her pain is the cornerstone of pain assessment. No other component of assessment is more important! Remember, pain is a personal experience. While the other assessments are important, they are not the priority, essential assessment. While the imaging result is important, because the patient has cancer, a mass is not unexpected. p. 289 Every question is with perfect world in mind. Not crazy people. Don't read into questions

A patient receives pain medications through an indwelling IV that flows through a device allowing the patient to self-manage pain. What type of pain management delivery system will the nurse monitor? Intraspinal Acupuncture Intraventricular Patient-controlled analgesia (PCA)

Patient-controlled analgesia (PCA) atient-controlled analgesia (PCA) is a method of drug delivery that permits patients to control the amount of opioid they receive. PCA is accomplished using a PCA device to deliver opioids through an indwelling IV or subQ catheter. In an intraspinal technique, opioids are delivered to the epidural or subarachnoid space via a percutaneous catheter connected to an infusion pump or injection port. In an intraventricular procedure, morphine is delivered to the cerebral ventricles via a catheter connected to an external infusion pump (for continuous administration) or a subcutaneous reservoir (for intermittent administration). Acupuncture is performed by inserting solid needles through the skin into the underlying muscle. p. 295

Nerve Block Risks

Potential complications include hypotension, paresis (slight paralysis), paralysis, and disruption of bowel and bladder function (eg, diarrhea, incontinence). The incidence of complications ranges from 0.5% to 2%.

Which condition should the nurse anticipate when the patient has received an intraspinal opioid medication to control cancer pain? Reduced risk of nausea, vomiting, and constipation Less need for rescue medication to control breakthrough pain Greater risk of paresthesias and numbness in the lower extremities Potential for delayed respiratory depression and catheter-related infections

Potential for delayed respiratory depression and catheter-related infections Intraspinal administration of opioids carries the same risk of side effects and tolerance as administration by other routes. However, it also poses a risk of delayed respiratory depression and catheter-related infections. Because breakthrough pain may occur, patients receiving intraspinal opioids may need rescue medication. Paresthesias and numbness are not effects commonly associated with intraspinal opioid administration. p. 295

A patient with cancer is tapping to the rhythm of recorded music. What technique is the patient using? Nerve block Teletherapy Cognitive distraction Relaxation and imagery

Relaxation and imagery Actively listening to recorded music is an example of relaxation and imagery. A nerve block is invasive surgery that destroys the neurons that transmit pain, thereby causing permanent pain relief. Teletherapy is external beam radiation. Just listening to music, not actively listening, is an example of cognitive distraction. p. 299 Massage is primarily a comfort measure that provides relief through distraction and relaxation. Exercise can reduce subacute and chronic pain by increasing muscle strength and joint mobility. Additional benefits include improved cardiovascular conditioning and restoration of coordination and balance Although weight-bearing exercise is desirable, it should be avoided in patients who are at risk of fractures because of tumor invasion or osteoporosis. Acupuncture: these techniques reduce pain by stimulating peripheral nerves

When assessing for the most serious adverse reaction to an opioid analgesic, what does the nurse monitor for in the patient with cancer? Pupil size Heart rate Blood pressure Respiratory rate

Respiratory rate Respiratory depression is the most serious side effect of the opioids; death can result. While heart rate, blood pressure, and pupil size should be assessed, respiratory depression is the most important adverse effect. p. 296

The healthcare provider orders celecoxib [Celebrex] 200 mg PO every day for pain in the postoperative patient. The nurse knows that this medication is which classification? Multiple choice question Salicylate Opioid analgesic Propionic acid derivative Selective COX-2 inhibitor

Selective COX-2 inhibitor Celecoxib [Celebrex] is an NSAID and a selective COX-2 inhibitor.

The nurse is teaching a group of nursing students about pain. What information does the nurse include in the teaching session about somatic pain? Somatic pain originates from organs. Somatic pain originates from peripheral nerves. Somatic pain originates from neuropathic pain receptors. Somatic pain originates from skeletal muscles, bones, and joints.

Somatic pain originates from skeletal muscles, bones, and joints. Somatic pain results from injury to somatic tissues (eg, bones, joints, and muscles), whereas visceral pain results from injury to visceral organs (eg, small intestine). Nociceptive pain results from injury to tissues, whereas neuropathic pain results from injury to peripheral nerves. p. 287 Somatic pain results from injury to somatic tissues (eg, bones, joints, muscles), whereas visceral pain results from injury to visceral organs (eg, small intestine). Patients generally describe somatic pain as localized and sharp.

A nurse is preparing to assess an infant for pain. Which technique will the nurse choose? Use a 1-10 scale Use a FACES scale Use notes in the chart Use behavioral observation

Use behavioral observation Since preverbal and nonverbal children cannot self-report pain, a less reliable method must be used for assessment. The principal alternative is behavioral observation. FACES and 1-10 scales cannot be used since the patient is an infant. While behavioral observation is not as effective as self-reporting, it is better than notes in the chart from somebody else's assessment that was done at a different time.

A patient with cancer has metastases. After the oncologist discussed treatment options, the patient asked the nurse for clarification on the treatments just discussed. Which treatments will the nurse anticipate explaining? Acupuncture Teletherapy Brachytherapy Radiofrequency ablation Intravenous radiopharmaceuticals

Teletherapy Intravenous radiopharmaceuticals Teletherapy and intravenous radiopharmaceuticals can be used for metastases. With teletherapy, cell kill can be localized or widespread depending on the size of the beam employed; hence, the technique can be used for both localized tumors and metastases. Intravenous radiopharmaceuticals travel throughout the body, and hence, are best suited for widespread metastases. With brachytherapy, cell kill is limited to the immediate area of the implanted pellets; hence, the technique is suited only for localized tumors. Radiofrequency ablation uses a thin, needle-like probe inserted into a tumor through an incision in the skin. The probe extends electrodes that emit high-frequency electrical current, producing heat to destroy cancer cells; hence, the technique is best suited for localized tumors. Acupuncture is a technique to reduce pain but is not a treatment for metastases. p. 299

Nerve Block

The goal of this procedure is to destroy neurons that transmit pain from a limited area, thereby providing permanent pain relief. Nerve destruction is accomplished through local injection of a neurolytic (neurotoxic) substance, typically alcohol or phenol. To ensure that the correct nerves are destroyed, reversible nerve block is done first, using a local anesthetic. If the local anesthetic relieves the pain, a neurolytic agent is then applied to the same site. Neurolytic nerve block can eliminate pain in up to 80% of patients. However, even if pain relief is only partial, the procedure can still permit some reduction in opioid dosage, and can thereby decrease side effects, such as sedation and constipation. When nerve block is successful and opioids are discontinued, opioid dosage should be tapered gradually to avoid withdrawal

The nurse administers pain medication to an older adult. The nurse anticipates that this patient's renal system may have which effect on the medication? The medication will be excreted faster. The medication will be metabolized faster. The medication will be excreted more slowly. The medication will be metabolized more slowly.

The medication will be excreted more slowly. Due to a decline in renal excretion, older adults excrete drugs more slowly than do younger patients. Metabolism will be slowed due to hepatic decline, not renal. Metabolism and excretion are not quicker in older adults. p. 300

Which actions indicate the nurse is following the World Health Organization (WHO) analgesic ladder for cancer pain management? Multiple selection question The nurse administers an opioid for a pain rating of 4. The nurse administers the pain medication intramuscularly. The nurse administers meperidine when the patient has severe pain. The nurse administers benzodiazepines when the patient reports pain. The nurse administers a fixed-dose combination formula for severe pain. The nurse administers rescue doses of a short-acting agent if breakthrough pain occurs

The nurse administers an opioid for a pain rating of 4. The nurse administers rescue doses of a short-acting agent if breakthrough pain occurs. Actions that follow the World Health Organization (WHO) analgesic ladder include providing rescue doses of a short-acting agent if breakthrough pain occurs and administering opioids for a pain rating of 4 to 10. If the patient reports pain in the 4 to 10 range (as measured on a numeric rating scale), then treatment should start directly with an opioid. Intramuscular injections are to be avoided whenever possible. When pain is severe, these drugs must be given separately because, with a fixed-dose combination, side effects of the nonopioid would become intolerable as the dosage increased, and hence, would limit how much opioid could be given. Drugs that are not recommended for treating cancer pain include benzodiazepines (no demonstrated analgesic action) and meperidine (toxic metabolites accumulatewith prolonged use). p. 291

Which action indicates the nurse is following The Joint Commission's (TJC) pain management standards? The nurse assesses the fifth vital sign. The nurse monitors some high-risk patients for pain. The nurse administers adjuvants as primary pain control. The nurse focuses on the family's satisfaction with pain management.

The nurse assesses the fifth vital sign. Pain must be regarded as a fifth vital sign, and pain intensity must be quantified and recorded along with blood pressure, heart rate, respiration, and temperature. All patients must be assessed for pain, not just some. Adjuvants are not primary pain control measures; they are not intended to substitute for these drugs. The institution must monitor patient satisfaction with pain management, not the family. p. 302

A patient has been receiving chemotherapy that has caused thrombocytopenia. After reviewing the chart, which finding will alert the nurse to notify the oncologist?

The patient is taking ibuprofen. Ibuprofen should not be given when thrombocytopenia develops; therefore, the physician should be notified. Because COX-2 inhibitors (celecoxib) do not affect platelets, these drugs are safe for patients with thrombocytopenia. All conventional nonsteroidal anti-inflammatory drugs (NSAIDs), except for COX-2 inhibitors (celecoxib), should be avoided when thrombocytopenia is present. For patients undergoing chemotherapy, inhibition of platelet aggregation by NSAIDs is a serious concern. Being tired and having three children living at home are not concerns related to thrombocytopenia. Thrombocytopenia is a condition in which you have a low blood platelet count. Platelets (thrombocytes) are colorless blood cells that help blood clot. Platelets stop bleeding by clumping and forming plugs in blood vessel injuries. NSAIDs increase the risk of bruising and bleeding in patients with thrombocytopenia

Pain Assessment

The patient's description of his or her pain is the cornerstone of pain assessment. No other component of assessment is more important! Onset and temporal pattern: When did your pain begin? How often does it occur? Has the intensity increased, decreased, or remained constant? Does the intensity vary throughout the day? Location: Where is your pain? Do you feel pain in more than one place? Ask patients to point to the exact location of the pain, either on themselves, on you, or on a full-body drawing. Quality: What does your pain feel like? Is it sharp or dull? Does it ache? Is it shooting or stabbing? Burning or tingling? These questions can help distinguish neuropathic pain from nociceptive pain. Intensity: On a scale of 0 to 10, with 0 being no pain and 10 the most intense pain you can imagine, how would you rank your pain now? How would you rank your pain at its worst? And at its best? A pain intensity scale (see below) can be very helpful for this assessment. Modulating factors: What makes your pain worse? What makes it better? Previous treatment: What treatments have you tried to relieve your pain (eg, analgesics, acupuncture, relaxation techniques)? Are they effective now? If not, were they ever effective in the past? Impact: How does the pain affect your ability to function, both physically and socially? For example, does the pain interfere with your general mobility, work, eating, sleeping, socializing, or sex life?

A nurse has administered bisphosphonates to a patient with cancer. Which assessment finding indicates a therapeutic effect is taking place? The patient can sleep at night. The patient has little or no anxiety. The patient's serum calcium is decreased. The patient's neuropathic pain is decreased.

The patient's serum calcium is decreased. Calcium will be decreased. Bisphosphonates inhibit bone resorption and are approved for treating hypercalcemia of malignancy. Hydroxyzine can be useful for nausea and vomiting as well as insomnia and anxiety. Antidepressants, antiseizure drugs, and local anesthetics/antidysrhythmics are used for neuropathic pain. p. 298

Which behavior by unlicensed assistive personnel will cause the nurse to intervene? The person offers a back massage to a patient with cancer. The person avoids placing a heat pack on an area exposed to radiation. The person performs range of motion exercises for a patient with cancer. The person places a cold pack on a patient with cancer who has Raynaud's phenomenon.

The person places a cold pack on a patient with cancer who has Raynaud's phenomenon. Because cold promotes vasoconstriction, it should be avoided in patients with Raynaud's phenomenon as this disease can be exacerbated by vasoconstriction. The nurse must stop this unsafe practice. Offering a back massage, performing range of motion exercises, and avoiding heat packs on radiated areas are appropriate and safe, requiring no follow-up. Massage can provide comfort. Exercise can increase muscle strength and joint mobility. Heat may be harmful to tissues exposed to radiation and these tissues should be avoided.

A patient is prescribed oxymorphone to treat chronic cancer pain. The nurse instructs the patient to rise slowly from sitting to standing. What is the rationale for the nurse's action? To prevent the risk of sedation To prevent the risk of bone pain To prevent the risk of neurotoxicity To prevent the risk of orthostatic hypotension

To prevent the risk of orthostatic hypotension Oxymorphone is an opioid drug that can cause orthostatic hypotension. Orthostatic hypotension can be minimized by moving slowly when changing from a supine or seated position to an upright posture. Although oxymorphone can cause sedation and neurotoxicity, rising slowly will not affect either one. Opioids do not have a side effect of bone pain. p. 297

The family of a patient with cancer is concerned about the possibility of opioid addiction. What information should the nurse provide? Addiction occurs when a larger dose of medication is needed for an effect. Addiction can be verified if abstinence syndrome follows abrupt withdrawal of the drug. True addiction is rare in patients with cancer, even when physical dependence occurs. Addiction is common and unavoidable in patients with cancer who take medications for pain.

True addiction is rare in patients with cancer, even when physical dependence occurs. Addiction is not the same as physical dependence. This is a true statement and should be included. Addiction is rare in people taking cancer pain medication. Tolerance occurs when a larger dose of medication is needed for an effect. A person can have physical dependence (abstinence syndrome after abrupt withdrawal) without being addicted. p. 293

The nurse is caring for a patient with cancer who has vague, localized, right lower abdominal pain with an aching quality. What type of pain does the nurse suspect the patient has? Somatic pain Visceral pain Neuropathic pain Peripheral nerve pain

Visceral pain Visceral pain originates from organs and is described as vaguely localized with a diffuse, aching quality. Somatic pain originates from skeletal muscles, bones, and joints. Neuropathic pain results from injury to peripheral nerves. p. 287

A patient with cancer is reporting pain. Upon assessment, the nurse observes the patient is rubbing the mid-epigastric area. Which question should the nurse ask to assess the quality of the pain? When did the pain begin? What makes the pain worse? What does the pain feel like? What rating (0 to 10) would the pain be?

What does the pain feel like? Quality of the pain can be assessed through the following questions: What does your pain feel like? Is it sharp or dull? When did the pain begin is a question to assess for onset and temporal pattern. What makes the pain worse is a question to assess modulating factors. The question regarding the pain rating scale assesses pain intensity. p. 289

Drug Therapy and Ceiling

With the nonopioid and adjuvant analgesics, there is a ceiling to how much relief we can achieve. In contrast, there is no ceiling to relief with the opioids.

Anticholinergic drugs use

are used to treat OAB and are used as preanesthetic agents. They are not contraindicated in PUD.

Anticholinergic drugs contraindicated

contraindicated in patients with glaucoma because of the potential danger of increased intraocular pressure

Pain has two major forms: nociceptive pain neuropathic pain

nociceptive pain, which results from injury to tissues, and neuropathic pain, which results from injury to peripheral nerves.

WHO ladder

the World Health Organization (WHO) devised a drug selection ladder (Fig. 29-4). The first step of the ladder—for mild to moderate pain—consists of nonopioid analgesics: NSAIDs and acetaminophen. The second step—for more severe pain—adds opioid analgesics of moderate strength (eg, oxycodone, hydrocodone). The top step—for severe pain—substitutes powerful opioids (eg, morphine, fentanyl) for the weaker ones. Adjuvant analgesics, which are especially effective against neuropathic pain, can be used on any step of the ladder. Specific drugs to avoid are listed : Pure agonists Meperidine A toxic metabolite accumulates with prolonged use Codeine Maximal pain relief is limited owing to dose-limiting side effects Agonist-antagonists Buprenorphine Butorphanol Nalbuphine Pentazocine Ceiling to analgesic effects; can precipitate withdrawal in opioid-dependent patients; cause psychotomimetic reactions Opioid Antagonists Naloxone Naltrexone Can precipitate withdrawal in opioid-dependent patients; limit use to reversing life-threatening respiratory depression caused by opioid overdose Benzodiazepines Diazepam Lorazepam others Sedation from benzodiazepines limits opioid dosage; no demonstrated analgesic action Barbiturates Amobarbital Secobarbital others Sedation from barbiturates limits opioid dosage; no demonstrated analgesic action Miscellaneous Marijuana Side effects (dysphoria, drowsiness, hypotension, bradycardia) preclude routine use as an analgesic