Test 5 Pain Management Chapter 55

pain threshold

Lowest intensity of a stimulus that causes the subject to recognize pain

FLACC

preverbal face, legs, activity, cry, consolability depends on observational skills (toddler)

ablation

removal of tissue to destroy its function

herniated disk

rupture of the intervertebral disk cartilage, which allows the contents to protrude through it, putting pressure on the spinal nerve roots

Word graphic scale

(adult, can be used at 6+ yrs) - numbered 1-10 with 10 as worst - no pain - little pain - medium pain - large pain - worst pain possible

Types of Pain

* Acute pain or nociceptive pain * Referred pain * Cancer pain * Chronic pain or neuropathic pain - Limited, intermittent, or persistent * Neuropathic * Intractable pain * Other types of pain - Radiating pain - Phantom pain

Pharmacologic Therapy

* Analgesics provide pain relief by slowing or halting pain transmission. - Nonopioid nonsteroidal anti-inflammatory drugs (NSAIDs) - Opioids/narcotic analgesics a) Morphine - Adjuvant drugs a) Anticonvulsants and antidepressants * Ointments and liniments * Patient Controlled Analgesia (PCA)

Description of Pain

* Character * Duration - Occasional, intermittent, spasmodic, or constant * Severity - Mild, slight, moderate, severe, or excruciating * Associated factors

Alternative Techniques

* Chiropractic care * Acupuncture or acupressure * Hypnosis * Biofeedback * Homeopathy * Use of flower essences and aromatic oils * Herbal remedies

Nursing Interventions

* Comfort measures - Clean bed, clean face and hands, warm room * Encourage nutritious diet and adequate fluids * Assist with elimination * Monitor voiding and bowel patterns * Offer ordered medications to prevent constipation and diarrhea * Physical measures - Physical stimulus (cutaneous stimulation) - Heat and cold application - Exercise * Cognitive-behavioral measures - Distraction and diversion - Deep relaxation and guided imagery - Support groups and stress management - Stress management

The Nursing Process

* Data gathering * Possible nursing diagnoses * Planning * Implementation * Evaluation

Pain

* It is a subjective symptom; only the client can describe it * It is the body's signal of distress * It is a warning that tissues are being damaged

Results of the Chronic Pain Experience

* Loss of control * Decreased self-esteem and communication * Inappropriate life goals * Change in relationships, lack of sexual activity, role changes within family * Anger of family and friends over need to do client's work or "take care of " client * Decreased activity * Decreased endurance

Causes of Pain

* Mechanical stress of trauma, surgical incision, or tumor growth * Excesses in pressure, heat and cold * Chemical substances released when tissues are damaged or destroyed * Lack of oxygen to tissues Muscle spasms

Collection of Client Data About Pain

* Pain - The fifth vital sign * Document - Level of pain - Description of pain - Action taken - Results

Pain Rating Scales

* Pain Intensity Scale or Pain Distress Scale * McGill-Melzack Pain Questionnaire * Wong-Baker Faces Pain Scale * FLACC * NIPS * PAINAD * DMC Pain Assessment Behavioral Scale

Factors Affecting Pain Perception

* Pain threshold - Lowest intensity of a stimulus that causes the subject to recognize pain * Pain tolerance - The point at which a person can no longer endure pain * Endorphins - Naturally occurring substances produced by the central nervous system to relieve pain

Joint Commission Accreditation Standards: Pain

* Patients have the right to appropriate evaluation and management of pain. * On-going data collection should include the nature and intensity of pain. * Responses to evaluation of pain should be recorded so regular reassessment and follow-up occurs. * Staff must be oriented and competent in gathering data and pain management. * Policies and procedures supporting ordering of pain medications must be in place. * (Clients) and families require education about effective pain management. * Discharge planning should address the (client's) needs for pain management.

Surgical Intervention

* Surgery may be necessary to alleviate certain types of chronic pain - Herniated disk - Tumors causing pressure - Pinched nerves - Ablation surgery

What is Endorphins

* The central nervous system produces endorphins, naturally occurring substances that relieve pain. * Endorphins are released with exercise and other forms of physical stimulation. Unfortunately, endorphins dissipate rapidly. * Studies have shown that activities other than exercise, such as laughter, can also increase endorphin production. * Intake of certain chemicals and foods, including caffeine, nicotine, alcohol, salt, and sugar, decreases endorphin production.

Pain Transmission and Interpretation: Nociception

* Transduction: The nervous system changes painful stimuli in nerve endings to impulses. * Transmission: The impulses travel from their original site to the brain. * Perception: The brain recognizes, defines, and responds to pain. * Modulation: The body activates needed inhibitory responses to the effects of pain.

Route of Administration/Analgesics

- IM injections - Epidural medications delivered by infusion catheter - Continuous and perfusion to surgical site - Perineural administration - PCA pump - CCA pump - NCA pump

Documentation of Pain

- Level of pain - Description of pain - Action taken - Response to interventions

Teaching Client to Manage Chronic Pain

- Medications - Exercise - Nutrition - Recreation - Relaxation - Support - Hobbies - Rest/sleep

Adjuvant

- to assit - drugs typically used for other purposes, but also used to enhance the effect of opioids by providing additional pain relief

Pain intensity scale or Pain distress scale is use for

7 years old or older rate pain using descriptive words or numerical scale

What are the common causes of acute pain?

Accidental trauma, infection, and surgery

DMC Pain Assessment behavioral scale

Another tool used for nonverbal clients in acute care use in ICU (ventilator)

Associated factors or Related occurence (COLDSPA)

Are other symptoms associated with the pain (headache, visual difficulties, sensitivity to light, nausea)?

COLDSPA Memory Guide

Character: Describe the pain. How does it feel? Be specific. Is it constant, occasional, or recurring? Onset: When did the pain start? How long have you had it? Location: Where is the pain? Internal or external? Does it radiate? Where does it start and where does it radiate to? Is it always in the same place? Duration: How long does the pain last? Does it come back? How often? Severity: How bad is the pain? (Use an appropriate rating scale.) Pattern: Does anything relieve the pain? What? Does anything make it worse? Does anything specific seem to cause the pain? Associated Factors or Related Occurrences: Are other symptoms associated with the pain (headache, visual difficulties, sensitivity to light, nausea)?

Character (COLDSPA)

Describe the pain. How does it feel? Be specific. Is it constant, occasional, or recurring?

Pattern (COLDSPA)

Does anything relieve the pain? What? Does anything make it worse? Does anything specific seem to cause the pain?

Is the following statement true or false? Regular use of pain medication in acute pain can lead to dependence on these drugs.

False Dependence of pain medications usually does not occur when the client needs relief from acute pain. However, these medications, especially opioids, should not be used on a long-term basis.

Is the following statement true or false? The nurse should use the Pain Distress Scale to rate the pain of a 2-year-old client.

False The nurse should use the FLACC—face, legs, activity, cry, and consolability for preverbal children. The Pain Intensity Scale or Pain Distress Scale are used for children older than 7 years and for adults.

_____________ nursing is often involved with the management of cancer pain.

Hospice

Severity (COLDSPA)

How bad is the pain? (Use an appropriate rating scale.)

Duration (COLDSPA)

How long does the pain last? Does it come back? How often?

pain cycle

Injury or other insult occurs, causing pain 1. lack of knowledge predisposes to more pain 2. fear, stress, conflict, lower pain threshold 3. muscle tension 4. fatigue makes it difficult to manage pain

IASP

International Association for the Study of Pain

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

Opiods (narcotics)

Morphine- depress the medulla oblongata and can cause respiratory depression

Endorphins

Naturally occurring substances produced by the central nervous system to relieve pain

What is nociception?

Normal pain transmission and its interpretation

Analgesic provide

pain relief by slowing or halting pain transmission.

McGill-Melzack Pain Questionnaire

Rating of pain intensity questionnaire (more data questionaire)

_______________ pain originates in one body part but is perceived in another part of the body.

Referred

Modulation is

The body activates needed inhibitory responses to the effects of pain

Modulation

The body activates needed inhibitory responses to the effects of pain.

Perception is

The brain recognizes, defines, and responds to pain

Perception

The brain recognizes, defines, and responds to pain.

Transmission is

The impulses travel from their original site to the brain

Transmission

The impulses travel from their original site to the brain.

What is meant by a person's pain threshold?

The lowest intensity of a stimulus that causes the subject to recognize pain

Transduction

The nervous system changes painful stimuli in nerve endings to impulses.

Transduction is

The nervous system changes painful stimuli in the nerve endings to impulses

What does a person's pain tolerance denote?

The point at which a person can no longer endure pain

pain tolerance

The point at which a person can no longer endure pain

Is the following statement true or false? If a client with chronic pain states that he is unable to sleep, the nurse should consider that the client has depression.

True The effects of chronic pain can be destructive to a person's lifestyle and outlook. When a person fails to express feelings, suppressed anger may turn inward and cause depression. Symptoms of depression include extreme fatigue, inability to sleep or sleeping too much, lack of interest in surroundings, lack of or excessive appetite, feelings of guilt, sexual impotence, and withdrawal from social activities.

Onset (COLDSPA)

When did the pain start? How long have you had it?

location (COLDSPA)

Where is the pain? Internal or external? Does it radiate? Where does it start and where does it radiate to? Is it always in the same place?

A nurse caring for a client in pain. Which interventions would the nurse include in the care plan? Select all that apply. a. Apply a warm or cool compress to the area as ordered b. Assist the client in deep breathing and relaxing purposefully c. Encourage the client to concentrate on a specific image d. Offer a craft project, television show, or visits from staff e. Discourage exercise of the painful area/extremity

a. Apply a warm or cool compress to the area as ordered b. Assist the client in deep breathing and relaxing purposefully c. Encourage the client to concentrate on a specific image d. Offer a craft project, television show, or visits from staff

The nurse is gathering subjective data regarding pain from a client. What is important for the nurse to consider when gathering this information? a. Culture b. Physical symptoms c. Cause of pain d. Financial status

a. Culture Cognitive Level: Apply Explanation: Because pain is subjective, it is vital to listen to clients' descriptions of their symptoms. Although it cannot be measured objectively, some manifestations of pain can be observed. Also consider your clients' culture; this may affect individual clients' reactions to their pain. Physical symptoms and cause do not always correlate with the subjective data. Financial status has no relevance with subjective data related to pain.

A client reports no relief of pain after administration of an opioid analgesic. What non-pharmacologic action can the nurse provide to assist with relieving the pain? a. Give the client a back rub. b. Give another dose of the medication even though it may be too early. c. Administer an antiemetic with the medication. d. Ambulate the client in the hall.

a. Give the client a back rub. Cognitive Level: Apply Explanation: Empathic nursing can help provide pain relief. Independent nursing interventions include providing diversion, changing the client's position, bathing the client, giving a back rub, or massaging the client's hands. The provider may order the application of heat or cold or other treatments. These methods are usually used to complement, not replace, pharmacologic interventions. Giving another dose of medication and administering an antiemetic with the medication are pharmacological methods of relief. Administering a medication too early without an order from the primary care physician is considered a medication error. Ambulation in the hall may increase the client's pain level

A client is experiencing pain secondary to a sprained ankle. The healthcare provider has prescribed an ointment containing a local anesthetic. When educating the client on the medication, the nurse identifies which as the function of this ointment? a. Improves circulation in the area b. Increases production of endorphin c. Decreases temperature in the area d. Decreases transmission of pain

a. Improves circulation in the area

A client is experiencing chronic pain related to a back injury. What suggestions can the nurse make to help control pain perception? Select all that apply. a. Limit the intake of caffeine. b. Avoid smoking. c. Perform regular exercise. d. Increase sodium intake. e. Increase alcohol intake.

a. Limit the intake of caffeine b. avoid smoking c. perform regular exercise Cognitive Level: Analyze Explanation: The central nervous system produces endorphins, naturally occurring substances that relieve pain. Endorphins are released with exercise and other forms of physical stimulation. Unfortunately, endorphins dissipate rapidly. Studies have shown that activities other than exercise, such as laughter, can also increase endorphin production. Intake of certain chemicals and foods, including caffeine, nicotine, alcohol, salt, and sugar, decreases endorphin production.

A client with chronic pain has been prescribed medication. Which instruction should the nurse give the client regarding the use of medication? a. Take medication on a regular schedule b. Take medication if pain crosses the tolerance level c. Take medication before the pain starts d. Reduce the intake of medication gradually

a. Take medication on a regular schedule

A client who is to undergo surgery for lower-back pain is stressed out and complains of lack of sleep. Which should the nurse tell the client with reference to relaxation and sleep? a. Take naps during the day b. Exercise until pain is severe c. Stay in bed for a long time d. Exercise alone at own pace

a. Take naps during the day

A nurse is observing an infant for pain behaviors. The nurse notes the infant has a clenched jaw, and has drawn up legs with a rigid posture. The parent attempts to console the infant with no change in the infant's steady crying. What score would the nurse document for the infant according to the FLACC scale? a. Total score of 10 b. Total score of 2 c. Total score of 4 d. Total score of 6

a. Total score of 10

Which of the following should the nurse suggest to a client to manage stress? Select all that apply. a. Well-balanced diet b. Adequate fluids c. Recreation d. Acupuncture e. Hypnosis

a. Well-balanced diet b. Adequate fluids c. Recreation

PAINAD

advance dementia breathing, negative vocalization, facial expression, body language, consolability pain scale for older adults who have advanced dementia

IASP definition of pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

The nurse asks the client to describe the characters of the pain being reported. The nurse would further assess and provide education if the client used which terms? Select all that apply. a. "Cramping" b. "Severe" c. "Aching" d. "Fatigue" e. "Constant"

b. "Severe" d. "Fatigue" e. "Constant"

A client in chronic pain states that the pain medication does not work. What is the best response by the nurse? a. "You probably need a stronger narcotic." b. "Take your medications regularly, not waiting until pain occurs." c. "Do you think maybe the pain felt is exaggerated?" d. "The primary care provider has given you all you can have."

b. "Take your medications regularly, not waiting until pain occurs." Cognitive Level: Apply Explanation: A client should follow regular medication schedules exactly. This helps maintain an adequate blood level, rather than waiting until pain occurs. A stronger narcotic may not always be necessary if the client takes the medication appropriately. Asking the client if the pain is exaggerated implies that the nurse does not believe this subjective statement. Adjustments to pain medication and dosage are available if the intervention of taking the medication regularly does not work.

The nurse is caring for a client with chronic pain. The provider orders an antidepressant for the client. The client asks the nurse why the provider ordered an antidepressant because "I don't think I'm depressed." The nurse knows this medication is acting as what for the client? a. Liniment b. Adjuvant drug c. Opioid/narcotic analgesic d. Nonopioid non steroidal anti-inflammatory drug

b. Adjuvant drug

A nurse is caring for a client who is in pain. Which of the following are cognitive-behavioral techniques to help in pain management? Select all that apply. a. Herbal remedies b. Games and television c. Deep relaxation techniques d. Physical activity and recreatione. Essences of flowers

b. Games and television c. Deep relaxation techniques d. Physical activity and recreation

A nurse is caring for a client with a terminal illness. Which is a physical comfort measure that the nurse can provide the client? a. Assist the client in intense exercise b. Provide a gentle massage c. Provide restful music d. Arrange for a semilighted room

b. Provide a gentle massage

A client who is being cared for by a nurse at the healthcare facility is ordered to receive an adjuvant drug. Which is a function of adjuvant drugs? a. They treat moderate to severe pain b. They assist in muscle relaxation c. They treat mild to moderate pain d. They increase temperature and circulation

b. They assist in muscle relaxation

A client with chronic pain is being cared for by a nurse at the healthcare facility. Which of the following should the nurse identify as symptoms of depression associated with the chronic pain? Select all that apply. a. Sleeping for long hours b. Withdrawing from social activities c. Displaying lack of interest in surroundings d. Expressing feelings of pain and fear e. Feeling extremely exhausted

b. Withdrawing from social activities c. Displaying lack of interest in surroundings e. Feeling extremely exhausted

A client with chronic pain has been asked by the healthcare provider to exercise regularly. Which should the nurse tell the client with reference to exercising? a. Exercise should not include any discomfort b. Perform the same regime of exercise every day c. Increase activity levels gradually and steadily d. Avoid exercising with a group of people

c. Increase activity levels gradually and steadily

The physician has recommended the use of deep relaxation techniques for a client with long-term intractable pain. When educating the client on the recommended technique, the nurse identifies which as a benefit of deep relaxation technique that will help mange the client's pain? a. It helps the client develop concentration b. It helps the client express feelings about pain c. It helps the client loosen-up taut muscles d. It helps the client visualize destruction of pain

c. It helps the client loosen-up taut muscles

The client presents to the clinic for cast placement following a fractured tibia. The client reports a pain level of 6/10 at the site of the fracture with movement. The nurse knows this client is reporting which type of pain? a. Chronic pain b. Referred pain c. Nociceptive pain d. Intractable pain

c. Nociceptive pain

The nurse plans to use guided imagery with a client experiencing pain sensation. What is the goal of guided imagery? a. Complete relaxation b. Decrease in pain c. Pain relief d. Focusing in diversion activity

c. Pain relief

The nurse is preparing a client for surgery who is experiencing chronic pain. The client is likely diagnosed with which condition? a. Inflammation b. Chronic pain c. Pinched nerves d. Referred pain

c. Pinched nerves

A client with chronic pain has been ordered a regime of exercise. Which should the nurse tell the client regarding exercise? a. Maintain the same level of activity every day b. Exercise to the point of severe pain c. Push just beyond the tolerance level d. Repeat the same set of exercises each day

c. Push just beyond the tolerance level

A nurse is gathering data regarding the character of pain experienced by the client. Which question helps the nurse to determine the duration of the pain? a. "Where does the pain start?" b. "Is the pain internal or external?" c. "Is the pain always in the same place?" d. "Is the pain constant, occasional, or recurring?"

d. "Is the pain constant, occasional, or recurring?"

A client in pain experiences fatigue, stress, conflict, and a lower pain threshold. Which is next in the pain cycle? a. Fatigue b. Injury c. Lack of knowledge d. Muscle tension

d. Muscle tension

The nurse is gathering data regarding a 2-year-old child's pain level. What scale would be most effective for obtaining this information? a. Pain Distress Scale b. Wong-Baker Faces Pain Scale c. McGill-Melzack Pain Questionnaire d. The FLACC scale

d. The FLACC scale Cognitive Level: Apply Explanation: The Joint Commission requires healthcare facilities to use pain scales to help clients determine their level of pain. Clients rate their pain level, as compared with the choices on the scale. The FLACC scale is a tool that is used with preverbal children, usually those younger than 3 years. The nurse observes the child's face, legs, activity, cry, and consolability (FLACC). This tool depends on the caregiver's accurate observational skills, because the child cannot verbally describe the pain. Rating scales, such as the Pain Distress Scale usually are reserved for children older than 7 years and for adults. The Wong-Baker Faces Pain Scale (a picture scale) was developed primarily for verbal children between the ages of 3 and 7 years. However, it can also be used for adults who have difficulty expressing themselves or people who do not speak the prevailing language in the facility. Another method of rating pain intensity uses a pain questionnaire, such as the McGill-Melzack Pain Questionnaire. This would not be appropriate for a child that is 2-years-old.

The central nervous system produced _____________ a naturally occurring substance that relieves pain.

endorphins

Endorphins is

natural painkillers produced by the brain

NIPS

neonatal/infant pain scale- facial expression, cry, breathing, arms, legs, state of arousal for newborn up to 6 weeks after birth pain assessment tool for neonatals. assessment includes facial expression, cry quality, breathing patterns, arm and leg position, state of arousal

Individuals with the _______________ type of pain typically report constant burning, tingling sensations, and/or shooting pain.

neuropathic

NSAIDs

nonsteroidal anti-inflammatory drugs

The feeling of suffering or agony caused by stimulation of specialized nerve endings is called ____________.

pain

PCA

patient controlled analgesia

Wong-Baker FACES Pain Rating Scale

verbal children 3-7 years old does not speak prevailing language in the facility - no hurt (0) - hurts little bit (2) - hurts little more (4) - hurts even more (6) - hurts whole lot (8) - hurts worst (10) a pain assessment tool that uses six caricatures of a child's face representing no hurt to biggest hurt a child could ever have.