Flashcards in Ch 30 Pain Mgmt Deck (64):
What is pain?
Unpleasant sensory/emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Can have destructive effects (cause sleep loss, irritability, cognitive impairment, functional impairment and immobility)
Can warn of potential injury (touch hot stove, tells you to remove hand)
A multidimensional experience (can affect hob performance, social life, sexual intimacy, sleep rest, exercise and ADLs)
T or F: Pain is objective and can be measured.
False! It is subjective. Although the pt can give you a number between 1-10, you cannot measure it like HR or BP
T or F: Pain can be classified by the origin of pain, cause, duration and quality.
By origin: subcutaneous, radiating, etc...
By cause: Nociceptive or Neuropathic
By quality: Stabbing, radiating, pinching
By duration: Acute, Chronic, Intractable – 24 hr/7day pain; MS; Fibromyalgia
The origin of pain refers to the site where pain is felt and not necessarily the source of pain. List examples:
Superficial/cutaneous: skin or subcutaneous; paper cut!
Visceral: ORIGINATES IN ORGAN; stimulate deep internal pain receptors; usually abd cavity , cranium, thorax
Examples: menstrual cramps, labor pain, GI Infections, etc.
Somatic: MUSCULOSKELTAL;originates in ligaments, tendons, nerves, blood vessels, bones. Causes-fracture or sprain, arthritis, bone cancer (osteosarcoma).
Radiating: PAIN MOVES; starts at origin, extends to other locations. Example: sore throat extends to ears and head.
Referred: occurs in area distant from the original site; Example: pain from heart attack is experienced down the arm.
Phantom: perceived to originate from an area surgically removed. Amputees who lost leg, have leg pain in the limb that isn't there.
Psychogenic: pain arising from the mind (PSYCH PAIN LIKE PTSD, FROM TRAUMATIC EXP); no cause can be identified.
Review Figure 30-1
_______ pain is the most common type of pain. It occurs when pain receptors respond to stimuli that are potentially damaging. Can occur as a result of trauma, surgery or inflammation.Two types of this pain are visceral and somatic.
______ pain is complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli. This type of pain is described as burning numbness, itching and pins and needles.
It is most important for the nurse to understand the various ways in which pain is classified
a. so that he can document the client’s pain using accurate terms
b. so that he can be clear in his communication with the physician
c. so that he can develop an effective pain management plan
d. so that he can educate the client thoroughly
Correct answer: C
Different modalities are used in the treatment/ management of pain and are often based on how the pain is classified (e.g., acute vs. chronic).
What is the difference between acute, chronic, and intractable pain?
Acute - short duration, associated with injury or surgery. Can last up to 6 months, but is brought on suddenly.
Chronic - 6 months or longer, interferes with ADLs, Can be related to progressive disorder. Can come and go. May lead to anger, frustration and dependence.
Intractable -Pain is 24 hr/7day; Highly resistant to relief, Examples: MS,Fibromyalgia
Name some adjectives for describing the quality of pain...
Sharp, dull, aching, throbbing, stabbing, burning, ripping, searing, tingling.
The length of time: episodic, intermittent or constant.
Intensity: mild, distracting, moderate, sever or intolerable.
_____ is the process of nociceptor activation by perception (by noci) of potentially damaging mechanical (friction against body/incisions), thermal (extreme heat/cold), and chemical stimuli (internal-chest pain from MI/external-lemon juice in a cut).
Transduction - activation of nociceptors by stimuli/perception of potentially damaging mechanical, thermal & chemical stimuli
Pain sensitive nociceptors found in skin(highest level),subcutaneous tissue, joints, wall of arteries & most internal organs(lowest level)
Mechanical stimuli: external forces that result in pressure or friction against the body (bleeding, swelling, surgical incisions, friction from sheets, pressure from cast
Thermal stimuli: exposure to extreme heat or cold
Chemical stimuli: lemon on an open cut causes sharp, sudden pain
When tissue is damaged, it triggers the release of substances like _______, histamine, prostaglandins. These activate nociceptors. ________ also is a powerful vasodilator that triggers a release of inflammatory chemicals causing signs of inflammation in injured area
Remeber the signs of inflammation:
Calor, Dolor, Tumor, Rubor
(Heat, pain, swelling, redness)
Peripheral nerves carry the pain message to the dorsal horn of the spinal cord in a process known as ________.. Pain across synapses require neurotransmitters (esp Substance P)
The pain transmits a signal to the brain!
A delta fibers: (fast pain impulse)
Initial sharp pain from knee bump or massage
(Ay! that was fast)
C fibers: (slow pain impulse)
Lingering ache in tissue of bumped knee
(See...it still hurts)
________ involves recognizing and defining pain in the frontal cortex. The point at which the brain recognizes and defines a stimulus as pain is called ______ threshold.
perception - brain perceives stimulus
pain threshold - brain defines stimulus as pain; some people have higher pain threshold. what makes me say ow, might make my sister cry.
The duration and intensity of pain a person is willing to endure is ______ _______
A parent donating a kidney might not report as much pain as someone who had a cancerous kidneyr emoved.
Extreme sensitivity to pain is called ...
A process called modulation changes the perception of pain by either facilitating or inhibiting pain signals. There are two mechanism that allow this. Name and describe them:
EAS - endogenous analgesia system (trigger release of endogenous opioids and other substances to block the pain impulse, providing relief)
Side note: Nonpharmacological measures: exercise, meditation, visualization & music therapy can prompt the release of endogenous opioids
GCT - Gate Control Theory (The reason for using TENS)
(As impulses travel to brain - gate either allows or blocks pain signal to brain; If non painful - gate blocks. If noxious, keeps gate open) p.729
T or F: Pain is influenced by emotions, age, socio-cultural factors, and communication and cognitive impairments.
Factors that influence pain:
Past experience with pain (If pt had good/bad experience with pain, can change how they handle it. If bad, will be anxious of treatment. If good, will be less anxious)
Emotions (fear of injury being fatal, drugs being addictive, being judged for using drugs, etc.; confusion/helplessness/anger/depression)
Developmental stage (neonates will grimace, twitch, cry, won't eat etc.; Older adults-labored breathing, altered gait, withdrawal of activity)
Sociocultural factors (some people are stoic while others cry it out)
Communication skills and Cognitive impairments (may not be able to report. look for signs: withdrawal of activity, facial expressions, profanity/noisy breathing, confusion, BP/Resp/Pulse, )
Other illnesses contributingto pain
Unrelieved pain can cause harmful effects in various body systems such as: endocrine, cardiovascular, musculoskeletal, respiratory, genitourinary, and GI. GIve some examples of issues that arise:
endocrine - ongoing triggers causes exceseive release of hormones; Insulin and testosterone levels decrease; can result in weight loss, tachycardia, fever, inc resp rate, and death
cardiovascular - leads to hypercoagulation and increase in HR/BP/Cardiac workload/O2 demand; symptoms chest pain, clots, heart attack
respiratory-Splinting (reduction of tidal vol due to shallow breathing); Increases insp/exp pressures leadin to pneumonia/underventilation/resp acidosis.
genitourinary - excessive hormone release leads to decreased urinary output/retention. fluid overload, hypokalemia, HTN, and inc CO.
GI - intertinal secretions and smooth muscle tone increase; gastric emptying and motility decrease
What are the steps to assess pain? What do you include in theRN Dx?
Obtain a complete pain history; use oldcart. Watch body language. Check vitals for hints.
When writing a pain nursing diagnosis specify location/precipitating factors/deficits found when using oldcart. p. 735
T or F: Pain if the fifth vital sign and should be assessed for intensity whenever you take a full set of vital signs.
Perform pain assessments routinely but not limited to:
1. on admission
2. before/after each painful procedure/treatment
3. When pt is at rest/and when active
4. before administering pain med and 30 minutes after (60 at most)
5. with each vital sign check (is pain actual or potential prob?)
6. when pt complains about pain
T or F: when assessing pediatric pain, you should consult with parents about the child's stress signals
Nonverbal signs of pain
Elevated pulse/blood pressure - acute
Decreased BP - chronic pain
ashen - of the pale gray color of ash. (of a person's face) very pale with shock, fear, or illness.
Morphine or Norco?
Choose norco first, if that doesn’t work go IV morphine.
PO works longer but takes longer. IV is quick but stops working quick.
What are some common pain scales used?
Pain Scales (0 to 10):
Visual Analogue Scale (VAS)
Numeric Rating Scale (NRS)
Simple descriptor scale
Wong-Baker Faces Pain Rating Scale
The nurse is assessing the confused client. In trying to determine the client’s level of pain, the nurse should
a. be aware that confused clients don’t feel as much pain due to their confusion
b. observe the client carefully for changes in behavior or vital signs
c. ask the client’s family how much pain the client normally has
d. use only pain scales that feature numbers or “faces” the client can point to
Correct answer: B
The nurse should observe the confused client for nonverbal cues to pain.
T or F: NAP may assist in caring for pt w/pain. They may assess the pain and monitor response to medication.
False!!! They cannot assess/monitor pain or pain med
They may help with pain mgmt as follows:
Reposition, back massage, turning lights out, straighten sheets, mouth care, soft music, using distraction.
p.736 box 30-3
These are examples of ______ _______:
1. Cutaneous stimulation: (TENS/PENS/Spinal cord stimulator/Acupuncture/Accupressure/Massage (effleurage-long slow strokes)/heat cold pack/contralateral stiumlation)
2. Immobilization (using splints - prevent someone from moving or operating as normal.)
3. Cognitive-Behavioral Interventions (altering neg thoughts through distraction, relaxation tech, guided imagery, hypnosis, therapeutic touch, humor, expressive writing)
T or F: When using heat and cold to treat pain you should apply directly to skin and leave on intermittently for an hour at a time.
1. Avoid direct contact; cover with washcloth or fitted sleeve.
2. Apply for no more than 15 minutes at a time to avoid injury.
3. Check skin frequently for redness, blistering, cyanosis, blanching.
4. Discontinue if see any of #3 and immediately notify provider!
KNOW SAFETY BOX; use of heat and cold pg. 737 (GREEN!!!!)
Moist heat and moist cold intensifies treatment, take precautions!
______ _______ is when you stimulate the skin in opposite area to painful site. It includes scratching, rubbing, applying heat or cold. It is helpful if the affected area is painful to touch, under bandages or in a cast. It also provides some relief with phantom pain after amputation.
Contra - against/opposite/contrasting
lateral - of, at, toward, or from the side or sides.
Distraction techniques include:
visual - watch tv
tactile - massage, hugs, petting animals
intellectual - crossword puzzle
auditory - music therapy (totally works. visual + Audio -Katy Perry's DVD took my pt from completely freaking out -crying, rocking, shaking - to completely relaxed)
More examples from ppt
Progressive muscle relaxation or Sequential Muscle Relaxation (SMR) - sit comfortably--> tense muscles for 15 sec--> relax.
Reduce pain (Chronic)
Uses auditory & imaginary process to affect emotion & help keep calm & relax
Therapeutic touch - NOT ACTUALLY TOUCHING, levy mentioned this... directing energy fields.
WHen using pharmacological measures, you can use the three step ladder to assist in choosing the right treatment. There are three steps. Pts in severe pain should start at the ____ step. These type of pts include those going through cancer treatment.
remeber to apply corectly, you need to know interactions and side effects of all drugs recommended in each step
Non opioid analgesics include NSAIDs and Acetaminophen. They may reduce fever and inflammation. Why would you use these in combination with opioids?
THe combo of these with opioids allows for a lower does of opioid to be administered and reduces the incidence of side effect.
Combining reduces side effect of nausea and vomiting/pruritis/resp depression
T or F: NSAIDs interfere with production of prostaglandins, so they should be avoided when possible.
False! This is why we take them (to interfere). Prostaglandins sensitize pain receptors.
Take with food to avoid gastric upset. Use with caution in renal disease, GI bleeding, ulcers and impaired clotting.
The inability to feel pain is called ______
Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse?
a. "If you take more morphine, it will not change your pain relief."
b. "I'll call the physician and ask for an increased dose."
c. "The amount you are taking now is all I can give you."
d. "I'm worried if we increase your dose that you will stop breathing.”
Correct answer: B
There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a TOLERANCE to the effects, which often necessitates an increase in the dose.
Severe pain that erupts while a patient is already medicated with a long-acting painkiller is called?
______ _______ includes IV, IM, transdermal, and epidural forms and client-controlled pumps.
Opioid effectiveness varies based on metabolism. Different people need different doses. They are most effective for ______ which is generalized vs neurological origin which are more resistant to opioids.
T or F: Psychological dependence is common so addiction should be taken into consideration before using opioids.
False! Only 1% go through this. It should not be a factor in deciding. People who are addicts or become addicted typically have tendencies toward abuse (not necessarily the opioid). You can use ORT or SOAPP to assess (see pg 741)
Physical dependence can occur and result in withdrawal, therefore we should lowly reduce the amount used over time.
T or F: Adding fruits and vegetables, increasing exercise and fluid intake can reduce side effects of opioids.
True! It will help with the constipation. Better to try these measures before administering stool softeners/laxatives.
Other side effects include: nausea/vomiting/pruritus/respiratory depression/drowsiness
After adminsitering opioid, if a pt is unresponsive (slows breathing, etc.), immediately give an antagonist. Most commonly used and typically a part of standing orders is
0.5mg 3X every 5 minutes (it is metabolized quicker than opioids so it may require multiple doses)
pg.708 vol2 has rating scale for when to administer.
What is a paradoxical reaction?
when opioids cause greater pain vs less pain.
T or F: you should monitor postoperative pt who have received opioids for sedation and rep depression every 1-2 hours during for 12-24 hours after surgery.
An example of _________ is when 5mg does of parentral morphine is equivalent to 60mg of parenteral codeine or 100mg oral codeine in terms of effects on pain.
Opioid Oral route is used for ___- to ____ pain.It is preferred unless rapid onset of analgesia is desired. For immediate pain relief, ___ is the preferred method. The best method for infants and children is _______. We avoid IM in children because .....
mild to severe;
IM avoided because children often refuse pain med to avoid needles
p.743 box 30-6
T or F: WHen using PCA, 1 or 2 additional nurses should double check the setup before pt use.
True. It never hurts to have a add'l set of eyes and experience!
at least one other to check it before administering.
Also have two nurses verify before discontinuing it, change of shift, and when wasting med (remember to doc narcotic waste!)
_______ treatment is an addition designed to help reach the ultimate goal. ______ analgesics reduce the number of opioid pt requires.
Again, used in neuropathic pain because opioids don't treat it.
Drugs in this category include: anticonvulsants, antideoressants, local anesthetics, topical agents , psychostimulants, muscle relaxants, neuroleptics, corticosteroids, and others.
A letter carrier uses his left arm to hold mail while using his right to put the letters in the box. He does this for thirty years. Just before retirement, his elbow starts giving him trouble. It becomes very painful to hold the mail. When he goes to the dr, the dr gives him an injection. What is the injection? How does it work?
An anesthetic agent is injected into or around the nerve that supplies sensation to a specific part of the body (the elbow due to tennis elbow). It blocks the plexus (nerve network) to relieve short term pain until the elbow heals.
Cordotomy, Rhizotomy, neurectomy, and sympathectomy are all examples of ....
surgically interrupted pain.
Nerves are permanently destroyed.
Cordotomy - done for trunk and leg pain (memory tool: cut the cord/cut below the cord umbillical cord height)
Rhizotomy- used to stop spastic movement that accompany paraplegia/to relieve head&neck pain caused by cancer. (Rhizo Spazzo)
neurectomy- eliminate intractable localized pain
sympathectomy-improves vascular blood supply and elimination of vasospasm, used to treat raynaud's disease.
a disease characterized by spasm of the arteries in the extremities, especially the fingers ( Raynaud's phenomenon ). It is typically brought on by constant cold or vibration, and leads to pallor, pain, numbness, and in severe cases, gangrene.
T or F: A person's report of pain is the "gold standard." Although most people don't have pain from a particular illness or procedure does not mean a person cannot endure pain from that illness or procedure. You should be open to the patient's description of pain.
There are many difficulties in treating pain of the elderly. List some...
Common: degenerative spine conditions, arthritis, nightly leg pain or pain due to cancer
CAN OVERDOSE EASILY
Have at least one chronic condition with multiple medications, making adding an analgesic difficult because it increases likelihood of drug interactions
pt and caregiver reluctant to administer analgesic= fever of confusion, excessive sedation, drug interaction & respiratory depression
Pain not recognized due to dementia, coexisting conditions, sensory impairment, unable to communicate pain quality or intensity
Distribution changes due to body composition, blood flow and protein binding.
T or F: Pain is a normal component of aging.
p.746 Persistent pain is NOT normal in aging pt and should not be ignored.
______ is a state of psychological dependence in which a person uses a drug compulsively and will engage in self destructive behavior to obtain the drug.
The following are signs of what?
1. Repeated requests for injection of opioid or atypcail high dosing when pain would normally be diminished
2. Refusal to try oral med for pain
3. Doctor/Pharmacy shopping
behaviors that may indicate substance abuse or addiction
When managing pain in clients with addictions, use non judgemental approach
T or F: Placebos work for many people and should be used for pain management.
False! They are not suitable for PM. It is considered deceitful and may not work on a separate occasion.
During the _____ phase of the nursing process, compare your findings with the expected outcomes set in order to determin whether the PM strategy is effective.
-Are pt pain scores same, better, worse?
-Is pt behavior, mobility, ROM, mood, and affect consistent with relief?
-What is pt quality of life according to pt standard?
A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
3) Deep somatic
3) Deep somatic
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
Which pain management task can the nurse safely delegate to nursing assistive personnel?
1) Asking about pain during vital signs
2) Evaluating the effectiveness of pain medication
3) Developing a plan of care involving nonpharmacologic interventions
4) Administering over-the-counter pain medications
1) Asking about pain during vital signs
The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse.
Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric irritation with bleeding
1) Hepatitis B (patient safety!)
Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used for those with a history of gastric irritation and bleeding.
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate.
3) Assess the patient's respiratory status.
Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate.
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?
1) Caution the patient to limit the number of times he presses the dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively impaired.
2) Ask another nurse to double-check the setup before patient use.
As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain?
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
4) In 60 minutes
(Book says 30-60 minutes)
Immediately, 10 and 15 not long enough for med to work!
Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)
3) Aspirin (Ecotrin)
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.