LA #9 (Palliative) Chapters 10, 12, 13 Flashcards
A 45-year-old woman has breast cancer that has spread to her liver and spine. She has been taking oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home, but she now has constant severe pain and is hospitalized for pain control and development of a pain management program. During assessment of the patient, what information related to her pain is most important for the nurse to obtain initially?
a.
The pattern, area, intensity, and nature of her pain
b.
Identification of trigger points of pain by palpation of painful areas
c.
The schedule and total dosages of the drugs she is currently taking and when breakthrough pain occurs
d.
The presence of a sympathetic response, such as tachycardia, diaphoresis, and a rise in blood pressure
A
Pain is a complex experience involving physiological, sensory (i.e., the perception of pain by the individual that addresses the pain location, intensity, pattern, and quality), affective, behavioural, and cognitive dimensions; therefore, the nurse needs to assess the pattern, area, nature, and intensity of the pain immediately.
The physician plans to titrate narcotic analgesic to provide pain relief for a patient with surgical pain. What does the nurse’s role in include?
a.
Monitoring the effects of continuous intravenous (IV) infusion of narcotic analgesics
b.
Teaching the patient to try to increase the time between doses of pain medication
c.
Assisting the patient to plan the use of a specific total dose of analgesic over a 24-hour period
d.
Determining with the patient the optimal analgesic dosage required for pain relief with attention to the side effects produced
D
The goal of titration is to use the smallest dosage of analgesic that provides effective pain control with the fewest side effects
It is determined that a step 3 drug as proposed by the World Health Organization (WHO) is necessary for a patient whose cancer pain is unrelieved by step 2 drugs. Which is an appropriate drug and route for this patient?
a.
Oral codeine
b.
Oral morphine
c.
Intramuscular meperidine (Demerol)
d.
Intravenous oxymorphone (Numorphan)
B
A step 2 drug that would be appropriate is morphine, which is the standard of comparison for all other opioid analgesics. Sustained-release preparations (e.g., MS Contin) are also available.
Which of the following is true of persistent pain?
a.
It occurs within the normal healing time.
b.
The course of pain decreases over time.
c.
It is accompanied by an increased heart and pulse rate.
d.
It is often accompanied by changes in affect and withdrawal from other people.
D
A behavioural manifestation of persistent pain is a change in affect and withdrawal from other people and social interaction.
The physician tells a patient to use ibuprofen (Motrin, Advil) to relieve the pain after treating a laceration on the patient’s forearm from a dog bite. The patient tells the nurse that he does not think ibuprofen will control his pain. The nurse’s response is based on the knowledge that ibuprofen interferes with the pain by decreasing what process?
a.
Perception
b.
Modulation
c.
Transduction
d.
Transmission
C
Therapies directed at altering either the primary afferent nociceptor (PAN) environment or the sensitivity of the PAN are used to prevent the transduction and initiation of an action potential. An example is ibuprofen.
A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use his incentive spirometer unless specifically reminded. He rates his pain severity as an 8 on a 10-point scale but tells the nurse that he can “tough it out.” To encourage the patient to use pain medication, what should the nurse explain about the effects of withholding or delaying analgesics?
a.
Very few patients become addicted to opioids when using them for pain control.
b.
He should not worry about side effects because these problems usually decrease over time.
c.
Multiple options of medications are available, and if one drug does not relieve his pain, other drugs may be tried.
d.
Unrelieved pain can be harmful because it impairs respiratory and gastrointestinal function and can impair his recovery from surgery.
D
In the acutely ill patient, unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased catabolism.
A patient with a kidney stone in her right ureter has pain in her right flank area and also complains of pain in her right inner thigh. She asks the nurse whether something is wrong with her leg. In responding to the question, on what knowledge does the nurse base the patient’s understanding of pain?
a.
Referred pain results when dorsal horn neurons receive input from both C fibres and A-beta fibres.
b.
Stimulation of the cerebral cortex by small C fibres causes muscle spasm, leading to pain perception in large muscle groups.
c.
Radiating type of pain results from activation of normally inactive receptors by repetitive nociceptive signals to the dorsal horn.
d.
Poor localization of pain occurs when PANs release neurotransmitters that inhibit nerve cells in the dorsal column.
A
Inputs from both C fibres and A-beta fibres converge on the wide-dynamic-range neurons, and when the message is transmitted to the brain, the originating area of the body is poorly localized. The concept of referred pain must be considered when interpreting the location of pain reported by the person with injury to or disease involving visceral organs.
Which of the following is a possible musculoskeletal consequence of unrelieved pain?
a.
Decreased peristalsis
b.
Hypermobility
c.
Muscle spasm
d.
Muscle protein catabolism
C
Possible musculoskeletal consequences of unrelieved pain include muscle spasm, impaired muscle function, fatigue, and immobility. Muscle protein catabolism is a consequence of unrelieved pain, but it is a metabolic consequence, not a musculoskeletal one.
Amitriptyline, a tricyclic antidepressant, is being administered to a patient with chronic cancer pain. What does the nurse recognize as the expected outcome of administration of this drug?
a.
Increased pain threshold by stimulating the release of endogenous enkephalins
b.
Decreased perception of pain by blocking opiate receptors in the brain and descending inhibitory nerves
c.
Decreased transmission of pain impulses by altering serotonin and norepinephrine activity at nerve synapses
d.
Increased pain tolerance through relief of depression by increasing the amounts of norepinephrine in the brain
C
Tricyclic antidepressants have analgesic properties at doses lower than those effective for depression. They enhance the descending inhibitory system by preventing synaptic reuptake of serotonin and norepinephrine, thereby decreasing the transmission of pain impulses.
A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. What does the nurse recognize about how these cognitive strategies work?
a.
They reduce the sensory and affective components of pain.
b.
They prevent transmission of nociceptive stimuli to the cortex.
c.
They decrease the intensity of the pain that the patient is willing to tolerate.
d.
They decrease sensitization by increasing the production of glutamate in the spinal cord.
A
Imagery is a structured technique that uses the patient’s own imagination to develop sensory images that divert focus away from the pain sensation and emphasize other sensory experiences and pleasant memories. Hypnotic therapy is a structured technique that enables a patient to achieve a state of heightened awareness and focused concentration that can be used to alter the patient’s pain perception.
A patient in a publicly funded pain clinic asks the nurse how long he will have to wait to see a health care provider who is an expert in pain. The nurse’s response is based on the fact that the average wait time in Canada for expert pain-related care is approximately how long?
a.
One month
b.
Three months
c.
Six months
d.
One year
D
Average wait times in Canada for expert pain-related care are approximately one year at more than one-third of the publicly funded pain clinics, and many regions have no access to appropriate care.
An 86-year-old man has severe degenerative arthritis in his hips. In planning care for the patient, what does the nurse recognize about chronic pain in an older adult?
a.
It is more readily tolerated than in younger patients.
b.
It does not require the use of narcotic drugs for control.
c.
It is poorly tolerated because of past experiences with pain.
d.
It is often believed by the patient to be an inevitable part of aging.
D
Older patients often believe that pain is a normal, inevitable part of aging. They may also believe that nothing can be done to relieve the pain.
In developing a concept of pain to use in working with patients experiencing pain, what does the nurse acknowledge about pain?
a.
Pain always causes suffering.
b.
All pain serves a physiological purpose.
c.
Pain is a phenomenon.
d.
Pain is present whenever nociception occurs.
C
Pain is a complex, multidimensional, and subjective experience, and its management is influenced greatly by psychosocial, sociocultural, and legal and ethical factors.
To obtain the most complete assessment data about a patient’s chronic pain pattern, what should the nurse ask the patient?
a.
“Can you describe where your pain is the worst?”
b.
“What is the intensity of your pain on a scale of 0 to 10?”
c.
“Would you describe your pain as aching, throbbing, or sharp?”
d.
“Can you describe your daily activities in relation to your pain?”
D
At a bare minimum, the effects of the pain on the patient’s sleep and daily activities, relationships with others, physical activity, and emotional well-being should be assessed.
Morphine 10 mg IV every four to six hours as needed is ordered for a patient with a pancreatic tumour who has a history of alcoholism. After three days of receiving the morphine every six hours, the patient tells the nurse that the medication is needed more frequently to control the pain. In responding to the patient’s request, what does the nurse recognize?
a.
A tolerance to the morphine is developing, and the patient should receive the drug more frequently.
b.
Administering the morphine more frequently will increase the patient’s physical dependence on the drug.
c.
Physical dependence should be avoided at all costs, and the drug should continue to be administered every six hours.
d.
The patient is becoming addicted to the morphine, and it should be administered less frequently than every six hours.
A
People with past or current substance abuse are at high risk for inadequate pain management. Health care providers must understand that adequate pain relief is a basic human right, be aware of their own biases, and ensure that all patients are treated respectfully.
A patient with extensive second-degree burns on his legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control his pain. Several times during the night, he awakens in severe pain, and it takes more than an hour to regain pain relief. What is the most appropriate nursing action at this time?
a.
Administer a dose of morphine every hour from the PCA machine while the patient sleeps.
b.
Request that the physician order a bolus dose of morphine to be given when the patient awakens with pain.
c.
Consult with the patient’s physician about adding a continuous morphine infusion to the PCA regimen at night.
d.
Teach the patient to push the button every 10 minutes for an hour before he goes to sleep, even if he has minimal pain at that time.
C
The addition of a continuous basal infusion to a PCA regimen improves nighttime pain relief and promotes better sleep postoperatively (known as PCA plus basal).
When caring for a patient who is receiving epidural fentanyl, the nurse should monitor the patient for which common side effect?
a.
Headache
b.
Agitation
c.
Urinary retention
d.
Abdominal cramping and diarrhea
C
Nausea, itching, and urinary retention are common side effects of intraspinal opioids. Drugs that are delivered intraspinally include morphine, fentanyl, and hydromorphone.
Which type of pain is caused by damage to somatic tissue?
a.
Visceral
b.
Nociceptive
c.
Neuropathic
d.
Sensory-discriminative
B
Nociceptive pain is caused by damage to somatic or visceral tissue.
What is the mechanism of action of NSAIDs?
a.
They block action potential initiation.
b.
They block prostaglandin production.
c.
They inhibit cyclo-oxygenase action.
d.
They interfere with serotonin uptake.
B
The mechanism of action of NSAIDs is to block prostaglandin production.
When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient’s pain?
a.
“How long have you had this pain?”
b.
“How would you describe your pain?”
c.
“How much medication do you take for the pain?”
d.
“How many times a day do you medicate for pain?”
B
Because pain is a multidimensional experience, asking a question that addresses the patient’s experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning “How would you describe your pain?” is the best initial question.
A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests “something for pain that will work quickly.” The nurse will document this as
a.
somatic pain.
b.
referred pain.
c.
neuropathic pain.
d.
breakthrough pain.
D
Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.
A postoperative patient asks the nurse how the prescribed ibuprofen (Motrin) will control the incisional pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the
a.
modulating effect of descending nerves.
b.
sensitivity of the brain to painful stimuli.
c.
production of pain-sensitizing chemicals.
d.
spinal cord transmission of pain impulses.
C
Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by the NSAIDs.
A patient with chronic cancer pain is receiving imipramine (Tofranil) in addition to long-acting morphine for pain control. Which information is the best indicator that the imipramine is effective?
a.
The patient sleeps 8 hours every night.
b.
The patient has no symptoms of anxiety.
c.
The patient states, “I feel much less depressed since I’ve been taking the imipramine.”
d.
The patient states, “The pain is manageable, and I can accomplish my desired activities.
D
Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication also is prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.
A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse’s reply is based on the information that these strategies
a.
impact the cognitive and affective components of pain.
b.
increase the modulating effect of the efferent pathways.
c.
prevent transmission of nociceptive stimuli to the cortex.
d.
slow the release of transmitter chemicals in the dorsal horn.
A
Cognitive therapies impact on the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.
A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which of these prescribed medications will be best for the nurse to administer?
a.
lorazepam (Ativan) 1 mg orally
b.
amitriptyline (Elavil) 10 mg orally
c.
ibuprofen (Motrin) 400 to 800 mg orally
d.
immediate-release morphine 30 mg orally
A
A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask?
a.
“Can you describe the quality of your pain?”
b.
“Has there been a change in the pain location?”
c.
“How would you rate your pain on a 0 to 10 scale?”
d.
“Does the pain keep you from doing things you enjoy?”
D
The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.
A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to
a.
administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.
b.
consult with the health care provider about using a different treatment protocol to control the patient’s pain.
c.
request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.
d.
teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.
B
PCAs are best for controlling acute pain; this patient’s history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.
When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication?
a.
The patient has cramping abdominal pain.
b.
The patient becomes restless and agitated.
c.
The patient has not voided for over 10 hours.
d.
The patient complains of a “pounding” headache.
C
Urinary retention is a common side effect of epidural opioids. Headache is not an anticipated side effect of morphine, although if there is a cerebrospinal fluid leak, the patient may develop a “spinal” headache. Sedation (rather than restlessness or agitation) would be a possible side effect. Hypotonic bowel sounds and constipation (rather than abdominal cramping) are concerns.
When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take?
a.
Inform the patient that increasing the morphine will cause the respiratory drive to fail.
b.
Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control.
c.
Tell the patient that additional morphine can be administered when the respirations are 12.
d.
Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.
D
The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient’s respiratory rate.
A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient’s home medications, which of these will be of most concern to the admitting nurse?
a.
amitriptyline (Elavil) 50 mg at bedtime
b.
oxycodone (OxyContin) 80 mg twice daily
c.
ibuprofen (Advil) 800 mg 3 times daily
d.
meperidine (Demerol) 25 mg every 4 hours
D
Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management.
Which of these prescribed therapies should the nurse use first when caring for a patient with cancer pain that the patient describes as at “level 8 (0 to 10 scale), deep, and aching.”
a.
fentanyl (Duragesic) patch
b.
ketorolac (Toradol) tablets
c.
hydromorphone (Dilaudid) IV
d.
acetaminophen (Tylenol) suppository
C
The patient’s pain level indicates that a rapidly-acting medication such as an IV opioid is needed. The other medications also may be appropriate to use, but will not work as rapidly or as effectively as the IV hydromorphone.
The nurse is caring for a diabetic patient who has chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. Which of these prescribed medications is the best choice for the nurse to administer as an adjuvant to decrease the patient’s pain?
a.
aspirin (Ecotrin)
b.
celecoxib (Celebrex)
c.
amitriptyline (Elavil)
d.
acetaminophen (Tylenol)
C
The patient’s pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain.
A patient who uses extended-release morphine sulfate (MS Contin) for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take?
a.
Wake the patient and administer the hydrocodone.
b.
Wait until the patient wakes up and reassess the pain.
c.
Consult with the health care provider about changing the MS Contin dose.
d.
Suggest the use of nondrug therapies for pain relief instead of additional opioids.
A
Since patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, the patient’s sleep is not an indicator that she is pain free. The nurse should wake the patient and administer the hydrocodone.
These medications are prescribed by the health care provider for a patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question?
a.
morphine (Roxanol)
b.
pentazocine (Talwin)
c.
celecoxib (Celebrex)
d.
dexamethasone (Decadron)
B
Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient.
The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider?
a.
The patient complains of nausea after eating.
b.
The patient’s respiratory rate is 10 breaths/minute.
c.
The patient has not had a bowel movement for 3 days.
d.
The patient has a distended bladder and has not voided.
B
The patient’s respiratory rate indicates a need to decrease the PCA dose or change the medication in order to avoid further respiratory depression. The other information also may require intervention, but is not as urgent to report as the respiratory rate.
A patient who has chronic musculoskeletal pain tells the nurse, “I feel depressed because I ache too much to play golf.” The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan?
a.
The patient will exhibit fewer signs of depression.
b.
The patient will say that the aching has decreased.
c.
The patient will state that pain is at a level 2 of 10.
d.
The patient will be able to play 1 to 2 rounds of golf.
D
For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse also should assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.
