Prep U Chapter 12
A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?
"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication."
Perception
-3rd process of nociception -you become aware and conscious of pain
Education needed for PCA pumps
-NO ONE except client may push button -instruct pt of time limits -don't wait until pain is severe to push
Classification of sources or pain
-nociceptive -neuropathic
Two basic principles of providing pain management
-preventing pain -maintaining a pain intensity that allows the patient to accomplish functional or quality or life goal with relative ease
Effects of adjuvant analgesic in older patients
-produce sedation -effects CNS -initiated with low doses and titration used
How do smaller doses help pain
-used as a preventative approach because the pain does not escalate to a level of severe intensity -helps prevent tolerance -decreases severity of side effects -reduces peaks and troughs in serum level
What may increase central nervous system depression?
-valerian -kava-kava -chamomile
How much should as ineffective dose be increase?
25-50%
A nurse is caring for a client diagnosed with depression in the mental health unit. The nurse understands that therapeutic effects of tricyclic antidepressants occur at which time point?
3 weeks
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
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.
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.
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.
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.
Visceral Pain
arises from internal organs, such as heart, kidneys, and intestines that are diseased or injured
How should pain meds be administered in patients with end-stage dementia?
around the clock because they typically cannot request pain medications when needed should not be given a PCA
Signs of unrelieved pain in elderly clients
cognitive dysfunction confusion agitation
How to assess elderly patients with cognitive impairments?
compare current behavior to previous behaviors patterns, use caregivers to help assess patients pain
Which condition is a heightened response that occurs after exposure to a noxious stimulus?
Sensitization
The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting
Severity of the pain as judged by the patient
The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?
Diaphoresis
Effects of NSAIDS when used daily over an extended period
GI bleeding hemorrhagic disorder
A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client
That medication will be prescribed for pain relief
A clinic nurse assesses a client with diabetes who reports taking naproxen (Aleve) and the herb bilberry for osteoarthtitis. To assess for an adverse reaction between naproxen and bilberry, the nurse asks the client
"Do you bleed easily?
The nurse applies a transdermal patch of fentanyl for a client with pain due to cancer of the pancreas. The client puts the call light on 1 hour later and tells the nurse that it has not helped. What is the best response by the nurse?
"It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain."
A client informs the nurse that he has been taking ibuprofen every 6 hours for 3 weeks to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is taking a proton pump inhibitor for the treatment of this disorder. What should the nurse instruct the client about the use of the ibuprofen?
"It would be best to contact the physician prior to take any over-the-counter medications."
A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client
"Only you are to push the button for medication."
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 nurse is obtaining data regarding the medication that the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?
Adjuvant drug therapy
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.
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
The nurse understands that which statement is true about tolerance and addiction?
Although clients may need increasing levels of opioids, they are not addicted.
When caring for a patient who is deaf, which of the following should be used to elicit information regarding the patient's level of pain?
An outside interpreter should be used.
A female client with sickle-cell disease is hospitalized for pain management. The client's BUN is 24 mg/dL and creatinine is 1.6 mg/dL. To assist with management of the pain, the nurse
Applies warm soaks to the extremities
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
A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement?
Assess the client's respiratory status
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
The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?
Bradypnea
When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?
Burning
Use of over-the - counter analgesic's with chronic pain
Clients should not use and over-the-counter analgesic to treat chronic pain without first consulting physician
Which of the following nursing interventions contributes to achieving a client's goal for pain relief?
Collaborate with the client about his or her goal for a level of pain relief
When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?
Confusion
Disadvantage to transdermal route of administration
Delay in effect when the dermal layer is saturated takes 12-18 hours to work
Prostaglandins are chemical substances with what property?
Increase the sensitivity of pain receptors
A client is recovering from abdominal surgery and sleeping. The client had received an opioid medication 3 hours ago. The client's son requests pain medication for the client, stating "I do not want her to wake up in pain." The first nursing action is
Instruct the son about lack of client consent.
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 an example of chronic pain.
Intervertebral disk herniation
A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?
Neuropathic pain
Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch?
Postherpetic neuralgia
Which phase of pain transmission occurs when the one is made aware of pain
Perception
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
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
A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication?
Respiratory depression
Which of the following is a true statement with regards to the preventative approach to the use of analgesics?
Smaller doses of medication are needed.
A preschool-age child is admitted for complaints of abdominal pain and vomiting. What is the best method for the nurse to collect data about the pain level of the child
The Wong-Baker FACES scale
Best pain scale for pediatric, culture diverse and mentally challenged clients
The Wong-Baker FACES scale
Which of the following is a reliable source for quantifying pain?
The client's description of the pain
The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client's pain assessment?
The nurse administers pain medication based on the client's reported pain level.
The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient
The pain medication will be administered before the pain is experienced.
An adult with severe cognitive impairment has had a surgical procedure, and the nurse is having a difficult time assessing the level of pain the client is having postoperatively. What method can the nurse use to obtain data about the client's pain?
Use behavioral comparison of the client's current and previous behavior patterns.
How does the wong- baker FACES scale assess pain
Using picture and short descriptive phrases
Deeper somatic pain
caused by trauma, produces localized sensations that are sharp, throbbing, and intense
Initial signs and symptoms for a drug induced hepatitis
abrupt onset of a rsh pruritus
Which chemicals increase the transmission of pain
acetylcholine serotonin substance P
When changing from a parenteral to an oral route it is important to
administer and equianalgesic dose to provide the same level of pain relief
How to ensure uniform level pain relief?
administering analgesic every 3 hours, around the clock
The nurse is assessing a client's level of pain. How is pain is best described?
an unpleasant sensation of physical hurt or discomfort that can be caused by disease, injury, or surgery
First line analgesic agent for neuropathic pain
anticonvulsant gabapentin
agonist-antagonist opioids include
buprenorphine (Buprenex Butrans), nalbuphine (Nubain), and butorphanol (stadol)
Which chemicals reduce or inhibit transmission of perception of pain?
endorphins and enkephalin
How often should the nurse assess the clients pain?
every time vital signs are taken it is the 5th vital sign
What to observe is patient with pain?
facial expression crying restlessness diaphoresis changes in activity
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
What inhibits the analgesic effect or an opioid?
ginseng
How does heat effect injury?
heat increased vasodilation
Sensitization
heightened response that occurs after exposure to a noxious stimuli
What to watch for with patient receiving acetaminophen?
hepatotoxicity
What are the dangers of taking Echinacea, willow, and kava with acetaminophen?
increase potential for hepatotoxicity and nephrotoxicity
What are the dangers of naproxen (NSAID) and the herb bilberry?
increased risk for bleeding
What are the dangers of GIngko and acetaminophen?
increases risk for bleeding
A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends
increasing the amount of bran and fresh fruits and vegetables
Adjuvant drug
medications ordinarily administered for reason other than treating pain
What are mu agonist opioids?
morphine like drugs larger or the two groups ex: morphine, hydromorphone, hydrocodone, fentanyl, ocycodone, methadone, & other
A nurse is caring for client receiving fentanyl through an epidural catheter. What medication should be readily available for the client who is experiencing respiratory depression
naloxone
Neuropathic pain
pain that is processed abnormally by the nervous system
a person experiences physical discomfort, known as withdrawal symptoms
physical dependence
How do prostaglandins effect pain?
prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain0provoking effect or bradykinin.
Descriptors of neuropathic pain
sharp shooting burning
Neuropathic pain
sustained by injury or dysfunction of the peripheral or central nervous system
What is a reliable source for quantifying pain?
the client's description of the pain
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
Condition which a client needs increasingly larger doses of a drug to achieve the same effect as when the drug was first administered
tolerance
Second line analgesic agent for neuropathic pain
tramadol
nociceptive pain
transmitted from a point of cellular injury to the brain
Pain that is diffuse, poorly localized and accompanied by automatic nervous system symptoms such as nausea, vomiting, pallor, hypotension and sweating
vesceral
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?
visceral
Pain alleviation in sickle cell disease patients
warm soak (cold would constrict blood vessels, increasing pain)
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 client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies
"What do you mean by the word sick?"
Acute pain can be distinguished from chronic pain by assessing which characteristic?
Acute pain is specific and localized
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
Repetitive pattern of drug seeking and drug use to satisfy a craving for a drug's mind-altering or mood-altering effects.
Addiction
A client receives hydromorphone 2 mg intravenously for report of postoperative pain. Fifteen minutes later, the nurse notes respirations are 6 breaths/minute and the client is nonresponsive. The nurse administers prescribed naloxone. The next time the client reports pain, the best nursing action is
Consult with the healthcare provider to reduce the dose
Which of the following is the appropriate intervention to avoid physical dependence on drugs in a client
Discontinue drugs gradually
Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain?
Do not administer if respirations are
Which substance reduces the transmission of pain?
Endorphins
The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain
Every time the client's vital signs are assessed
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
A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
Gastrointestinal bleeding
When taking a client history, the nurse notes that the client is taking herbal remedies in addition to acetaminophen. Which herb, when taken in conjunction with acetaminophen, enhances the risk of bleeding?
Gingko
The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective
Position the client for comfort
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
Risk for impaired gas exchange
Problems that may develop with opioid therapy
Risk for impaired gas exchange related to respiratory depression Constipation related to slowed peristalsis Risk for injury related to drowsiness and unsteady gait
What forms a baseline for pain management?
a patient's perception of pain severity should always be the primary consideration
How is pain associated with injury best treated initially?
cold application such as ice pack and chemical pacs
How does cold treatments effect injury?
cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain
Advantages to transdermal route
consistent opioid serum level less constipation than with oral opioids less cost as compared to the parenteral route
How to avoid withdrawal symptoms?
discontinue gradually
A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen?
hepatotoxicity
Bowel regimen to prevent constipation
high fiber diet a long with increased fluids should be encouraged
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
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
A client has been taking opioid analgesics for more than 2 weeks to control post-surgical pain. Although pleased with the client's progress, the surgeon decides to change the analgesic to a non-opioid drug. The surgeon prescribes a gradually lower opioid dose and increasingly larger non-opioid doses. The surgeon is changing medications in this manner to avoid:
withdrawal symptoms.
Transmission
- second process in nociception -responsible for a rapid reflec withdrawal from painful stimuli
Modulation
-4th process of nociception -final phase when brain interacts with your nerves to modulate or alter the pain experience -release of endorphins and serotonin
Chronic pain
-constant or intermittent -persists beyond the healing time -prolonged -degeneration or traumatic conditions
Acute pain
-early onset -associated with injury -pain decreases as healing occurs -specific and localized -responds well to drug therapy
Transduction
-first process in nociception - refers to the process by which noxious stimulus, such as burn, releases of a number of excitatory compounds which more pain along the pain pathway
A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every
48-72 hours.
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.
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 most 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.