Pain

Question 1

what is pain?

Answer 1

*“Whatever the experiencing person says it is, existing whenever the
experiencing person says it does” (pg. 1233-1234).
*Human body’s defensive mechanism that indicates the person is
experiencing a problem.
*Physical suffering or discomfort, unpleasant sensory, emotional experience
*Chronic pain is the most common reason to seek healthcare
*Linked to restrictions in mobility and daily activities, dependence on opioids, anxiety and
depression, and poor perceived health or reduced quality of life
*Fifth vital sign
*According to the AMA, gives pain equal status with blood pressure, heart rate,
respiratory rate and temperature as vital signs. Consider assessing your patient’s pain
once V/S are taken and documented.
*Relief of pain is a client rightGreat resource:
https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm

Question 2

peripheral nervous system

Answer 2

*Composed of sensory and motor neurons
*Pain perceived through sensory neurons
*Responded to through motor neurons
*Connections occur within spinal cord
*Nociceptors located at ends of small afferent neurons
*All tissues except brain
*Especially numerous in skin, muscles

Question 3

the pain process

Answer 3

*Transduction: activation of pain
receptors
*Transmission: conduction along
pathways (A-delta and C-delta fibers)
*Perception of pain: awareness of the
characteristics of pain
*Modulation: inhibition or
modification of pain

Question 4

bradykinin

Answer 4

powerful vasodilator that causes vasodilation and increases capillary permeability and constricts smooth muscles

Question 5

prostaglandins

Answer 5

hormone like substance that send pain stimulation to the brain/CNS

Question 6

substance P

Answer 6

sensitizes pain receptors on nerves to feel pain and also increases the rate f firing nerves.

Question 7

origin of pain

Answer 7

Physical: cause of pain can be identified
Psychogenic: cause of pain cannot be identifiedHeadaches, back pain, stomach pain
Referred: pain is perceived in an area distant from its point
of originPain associated with a heart attack is often referred to the chest, arms, neck or
shoulders.
Pain from a gallbladder attack may be felt in the back of the shoulder.

Question 8

signs of pain in infants/newborn

Answer 8

Challenging to distinguish
cause of discomfort and
to conduct an actual
assessment of pain, watch for the facial expression.

Question 9

children/adolescents

Answer 9

Like infants, can be
difficult to assess and
determine.
Children’s capability to
describe pain increases
with age and experience.
Types of pain changes
throughout their
developmental stages

Question 10

older adults

Answer 10

may have a higher pain tolerance, cognitive impairment is something we should watch for.

Question 11

ethnicities

Answer 11

. Could be
considered a sign of
weakness or could be a
standard of accepting the
pain without complaint.
Cognitive level &
impairment
Some children may grow
up to “be brave” and
ignore the pain

Question 12

acute pain

Answer 12

*Acute
*Sudden onset; varies in intensity from mild to severe
*Typically lasts less than 3-6 months. Could be as short as weeks
*Surgical pain
*“Protective in nature”-subjective.
*Warns an individual of tissue damage or disease.

Question 13

chronic pain

Answer 13

*Persists greater than 6 months; lasts beyond the normal healing process
*Varying severity
*Periods of remission or exacerbation are common
*May or may not be localized
*May be limited, intermittent, or persistent
*Examples: frequent headaches, arthritis, back pain, fibromyalgia
1/3 of americans suffer from chronic pain

Question 14

describe your pain? what does it feel like?

Answer 14

Described in terms of:*Location
*Site
*Radiation (spreads or extends to other areas)
*Referred- appears to arise in different areas of the body
*Phantom pain- can last for years & is normal. (BKA, AKA, etc)
*Intensity/Severity
*Mild, moderate, severe
*Standard 0-10 Scale
*1-4=mild pain
*5-6=moderate pain
*7-10=severe pain
*Visual Scale  Faces
*Quality
*Stabbing, burning, itchy, aching, cold, dull, tender, shooting, numbness, throbbing, radiating, heavy, tender, cramping
*Duration/Onset
*When?
*How long has the pain been there?
*Timing
*Is it constant, intermittent? Both?

Question 15

nociceptive pain

Answer 15

pain from a noxious stimuli being percieved as painful. sunburn, cuts, burns, bladder distention.

Question 16

cutaneous pain

Answer 16

usually from cuts, the subcutaneous tissue is involved. and is superficial

Question 17

somatic pain

Answer 17

*Is diffuse or scattered and originates in the tendons, ligaments, bones, blood vessels, and nerves. Common with everyday
injuries

Question 18

visceral pain

Answer 18

*Poorly localized, and originates in the body organs in the thorax, cranium, and abdomen.
*Most common type of pain produced by disease (Examples:
constipation, menstrual cramps, gall stones, pain caused by cancer)

Question 19

neuropathic pain

Answer 19

*Pain caused by a lesion or disease of the peripheral or central nerves
*Commonly described as burning, shooting or tingling (Examples: Phantom leg pain, spinal cord injury)
*Trigeminal neuralgia, diabetic neuropathy, phantom limb pain

Question 20

gate control theory of pain

Answer 20

Proposed by Melzack and Wall, 1965Most widely accepted pain theory; most practical
*Describes the transmission of painful stimuli and recognizes a
relationship between pain and emotions.
*Small- and large-diameter nerve fibers conduct and inhibit pain
stimuli toward the brain.
*Gating mechanism determines the impulses that reach the brain.
*Other factors that have impact of this gate are past experiences,
the cultural and social environment, personal expectations,
beliefs about pain and etc.
*Factors that control gates: physical, emotional and behavioral
(responses to pain). See Box 35-1

Question 21

patient self report of pain

Answer 21

*Identify pathologic conditions or procedures that may be
causing pain; consider physiologic measures (increased blood
pressure and pulse)
*Report of family member, other person close to the patient or
caregiver familiar with the person

Question 22

nonverbal behaviors

Answer 22

*Nonverbal behaviors: restlessness, grimacing, crying, clenching
fists, protecting the painful area
*Physiologic measures: increased blood pressure and pulse
*Attempt an analgesic trial and monitor the results

Question 23

A patient who has bone cancer is most likely
experiencing which of the following types of pain?

Answer 23

somatic Rationale: Deep somatic pain is diffuse or scattered and originates
in tendons, ligaments, bones, blood vessels, and nerves.
Cutaneous pain usually involves the skin or subcutaneous tissue.
Visceral pain is poorly localized and originates in body organs.
Referred pain is pain that originates in one part of the body and is
perceived in an area distant to that part.

Question 24

perception of pain

Answer 24

Pain thresholdPain tolerance is the maximum level of pain that a person is able to
tolerate.
*Regular exposure to painful stimuli will increase pain tolerance
*Pain tolerance is distinct from pain threshold (the point at which
pain begins to be felt)
AdaptationLeads to protection of pain or injury
Modulation of painNeuromodulators
*Endorphins, dynorphins, enkephalins
https://i.pinimg.com/736x/2b/16/2a/2b162aafbda2866129f1abf41aa6c2a9–pharmacology-mnemonics-massage-therapy.jpg
Do not be judgmental…..

Question 25

chronic pain

Answer 25

Greater than 6 months

Question 26

acute pain

Answer 26

sudden onset, less than 3-6 months, postsurgical pain.

Question 27

breakthrough pain

Answer 27

moderate to severe pain due to temporary flare up. Transient exacerbation of pain that occurs spontaneously or in relation to a specific predictable or unpredictable trigger*End-of-dose medication failure

Question 28

central pain

Answer 28

Caused by damage to nerves in CNS due to stroke, MS, Parkinson disease, or trauma. May occur immediately or be delayed May be less able to feel normal touch Described as burning, pins and needles, aching, or lacerating

Question 29

phantom pain

Answer 29

Pain felt in amputated limb or body part even though it is absent. Usually recurring vs. constantDescribed as shooting, stabbing, squeezing, throbbing, or burning Associated with neurological activity in portions of brain once connected to amputated body part

Question 30

psychogenic pain

Answer 30

Pain associated with psychological factors vs. physiological factors Treatment should include interventions for pain and emotional distress

Question 31

general assessment of pain

Answer 31

*Patient’s verbalization and description of pain *Duration of pain *Location of pain *Quantity and intensity of pain *Quality of pain *Chronology of pain *Aggravating and alleviating factors *Physiologic indicators of pain *Behavioral responses *Effect of pain on activities and lifestyle *Visual assessment *Especially important in newborns

Question 32

nursing considerations with pain

Answer 32

Physical Assessment -Vital Signs (b/p, pulse, respiratory rate) -Visual Exam: Inspection for injuries, etc -Palpation of specific location (is the patient guarded?) -Testing motor functions -Heart, lungs, breath sounds

Question 33

factors affecting pain throughout the lifespan

Answer 33

Culture-Lifespan considerations*Age and developmental stage affect ability to describe pain *Special considerations for assessing discomfort and promoting comfort for each stage *Cultural differences in expressions of pain *Ethnic variables *Family, sex, gender, and age variables *Religious beliefs *Environment and support people *Anxiety and other stressors *Past pain experience

Question 34

children and pain

Answer 34

*Infants, children less able to articulate pain, display behavioral responses. *Visual assessment important Body movement, posture, crying *Physiological considerations *Untreated pain may result in: Decreased growth and development Decreased immune function Lack of appetite Hypertension Increased sensitivity to future pain

Question 35

children and pain

Answer 35

*Infants, children less able to articulate pain, display behavioral responses. *Visual assessment important Body movement, posture, crying *Physiological considerations *Untreated pain may result in: Decreased growth and development Decreased immune function Lack of appetite Hypertension Increased sensitivity to future pain

Question 36

developmental aspects of pain expression

Answer 36

*Infant: intense cry, unable to sleep or eat *Toddler: verbal or physical aggression or withdrawal, guarding the site or pain *Preschooler: can verbalize but much “magical thinking”, see pain as punishment *School-age: can verbalize but very influenced by cultural behaviors associated with pain *Adolescent: can verbalize but may choose to be “tough” in front of peers; regression

Question 37

pain and adults

Answer 37

Pain and Adults *Chronic pain widespread among adults *In 2016, an estimated 20.4% of U.S. adults had chronic pain and 8.0% of U.S. adults had high- impact chronic pain. (CDC) *Both were more prevalent among adults living in poverty, adults with less than a high school education, and adults with public health insurance (CDC) *More prevalent among women than men *Women more likely to develop pain-causing diseases *Lower pain threshold and tolerance than men *Men more susceptible to pain from: - Headaches, coronary heart disease, gout, duodenal ulcer, pancreatic disease

Question 38

pain and older adults

Answer 38

*Most older adults have chronic pain *Physiological changes of aging affect perception of pain *Drug interactions *Barriers to pain management *Inadequate knowledge of healthcare providers *Fear of pain medication dependence *Noncompliance, financial barriers

Question 39

cultural and ethnic influences

Answer 39

Cultural and ethnic influences: *Variation in meaning of pain *Variation in verbal and behavioral response to pain *Culture plays critical role in pain expression and management *Nurses have own attitudes, expectations but must provide culturally competent care

Question 40

the meaning of pain

Answer 40

*Positive view of pain may result in higher tolerance *Decreases possible development of depression and anxiety about pain *Negative view of pain may bring feelings of hopelessness, depression and anxiety *Preventing enjoyment of life *Lower quality of life physically, emotionally, socially

Question 41

cultural

Answer 41

*Environmental and social support *Strange environment can compound pain *Lonely person without support network *Perceives pain as severe *Family education can positively affect perceived quality of life *Caregiver, client *Expectations of significant others *Previous experience with pain *Clients who have undergone procedure without adequate pain management *Clients who have seen a loved one suffer *Influences how clients perceive efficacy of future treatments

Question 42

pain assessment tools

Answer 42

*Numerical Scale- Most common *Wong-Baker FACES *Adults and children (>3 years old) in all patient care settings) *Beyer Oucher pain scale *Used in young patients, combines a 0-100 scale with 6 photographs of children in pain *CRIES pain scale *Neonates & infants 0-6 months *https://prc.coh.org/pdf/CRIES.pdf *FLACC scale *Infants and children (2 months–7 years) who are unable to validate the presence of or quantify the severity of pain *COMFORT scale *Infants, children and adults who are unable to use the numeric rating *Cognitive impairment or temporarily impaired due to illness or medication

Question 43

Which following pain assessment tool is recommended for use with neonates ages 0 to 6 months?

Answer 43

Answer: D. CRIES pain scale Rationale: The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months.

Question 44

nursing interventions for pain

Answer 44

*Establishing trusting nurse–patient relationship *Manipulating factors affecting pain experience *Initiating nonpharmacologic pain relief measures *Managing pharmacologic interventions *Reviewing additional pain control measures, including complementary and alternative relief measures *Considering ethical and legal responsibility to relieve pain *Teaching patient about pain

Question 45

manipulating factors with pain

Answer 45

*Remove or alter cause of pain. *Alter factors affecting pain tolerance. *Initiate nonpharmacologic relief measures.*Distraction *Humor *Music *Imagery *Relaxation *Cutaneous stimulation *Acupuncture *Hypnosis *Biofeedback *Therapeutic touch *Animal-facilitated therapy

Question 46

invasive therapy

Answer 46

*Nerve block (steroid injection) *Chemical interruption of nerve pathway *Injection of local anesthetic around nerves

Question 47

complimentary/alternative pain control

Answer 47

*Independent nursing interventions- positioning *Acupuncture *Herbal supplements *Guided imagery *Support, laughter, focus on others *TENS unit- *uses electrical stimulation to inhibit transmission of painful impulses

Question 48

relaxation therapy

Answer 48

*Reduce stress, induce sleep, reduce pain, calm emotions *Four main categories (often combined) *Breathing exercises *Muscle relaxation *Imagery *Movement techniques *Other forms: massage, acupuncture, meditation, biofeedback *Allow for lower doses of medications for pain.

Question 49

nonopiods anelgesics and NSAIDS

Answer 49

*Ibuprofen, acetaminophen, naproxen, celebrex

Question 50

opiods and narcotic anelgesics

Answer 50

*Morphine, codeine, oxycodone, meperidine, hydromorphone, methadone *Typically in a double locked drawer and requires “a count” *Witness required for any “waste” of a drug

Question 51

adjuvant anelgesic drugs

Answer 51

*Anticonvulsants, antidepressants, multipurpose drugs *Escitalopram (Lexapro), Prednisone (Steriods), Gabapentin (Neurontin)

Question 52

nonopiod anelgesics and NSAIDS

Answer 52

Analgesic and antipyretic Acetaminophen and NSAIDs (ibuprofen, aspirin, naproxen, celebrex) Vary in anti-inflammatory properties Have ceiling effect and narrow therapeutic index Well tolerated take with food to avoid upset stomach Comparable to morphine in providing pain relief Fewer adverse events than with morphine Liver and kidney toxicity with high dose, long-term use Combining medications may lead to inadvertent overdose Major side affect: GI UPSET and/or bleeding (particularly with NSAIDS)

Question 53

antiflammatory drugs

Answer 53

Anti inflammatory Drugs: Advantages: *Effective anti-inflammatory and treatment for bone pain *Avoid side effects of opioids Disadvantages: *Inhibit platelet function *Renal and gastrointestinal toxicity

Question 54

acetaminophen

Answer 54

Advantages: *Does not interfere with platelet function *No gastrointestinal toxicity or renal toxicity *Readily available and inexpensive Disadvantages: *Weak anti-inflammatory *Liver toxicity *Dose: 15 mg/kg PO q4h with max of 4000 mg/day

Question 55

What is the max dose of acetaminophen that you can give an adult patient in a 24 hour period?

Answer 55

4000mg

Question 56

What is the max dose of ibuprofen that you can give an adult patient in a 24 hour period?

Answer 56

3200mg

Question 57

narcotics

Answer 57

*Potential for abuse; addictive *Action = 4 hours; require frequent repeat dosing *Most common: Morphine Sulfate (used PO, IV, or Epidural) *Treats acute and chronic pain *Constipation-common side effect

Question 58

opiods with nonopiods

Answer 58

*Work better than either type alone *Can take in lower doses *Watch for Tylenol dosing- 4,000 mg in 24 hr

Question 59

what to considor with opioids

Answer 59

*Physical dependence *Body physiologically becomes accustomed *Withdraw symptoms; sweats, shakes, tremors, pain, N/V and GI upset *Tolerance *Body is accustomed and needs a larger dose (up to 10 times the original dose)

Question 60

full agonists

Answer 60

Full agonists (oxycodone, morphine, hydrocodone) *High affinity to mu receptors in PNS and CNS *Most potent pain relievers *No ceiling effect (“top limit of pain management potential”) *Euphoria, respiratory depression, tolerance

Question 61

mixed agonist - antagonist

Answer 61

*Act as agonist at one opioid receptor, antagonist at a different opioid receptor (less respiratory depression and addiction potential) *Give only as first opioid *Not used for severe pain or if terminally ill *Some examples of these drugs are pentazocine or Talwin, nalbuphine or Nubain, and butorphanol or Stadol

Question 62

side effects of opioids

Answer 62

*Respiratory depression (bradypnea) commonly feared *Sedation *Nausea/vomiting *Constipation *Urinary retention *Pruritus *Sexual dysfunction *REVERSAL AGENT: naxolone HCL (Narcan) given IV or Intra-nasal

Question 63

what caused 93,000 deaths in 2020

Answer 63

Lethal doses of Fentanyl caused 93,000 deaths in 2020 and ~108,000 in 2021

Question 64

methods of opioid administration

Answer 64

*Oral (PO): preferred *Long-acting for continuous pain *Short-acting/immediate release for intermittent pain or breakthrough pain while on continuous *Intramuscular (IM): not recommended *Intravenous (IV): *Intermittent scheduled or continuous infusion (basal) for continuous pain *PRN doses only for intermittent pain *Patient controlled analgesia (PCA) *Acute and chronic pain usage

Question 65

IV vs IM vs Po

Answer 65

IV: Typically 5-10 minutes IM: 15-30 minutes PO: Typically 30-60 minutes

Question 66

coanelgesics

Answer 66

*Have analgesic properties-typically used for other purposes *Potentiate effects of pain medications *Reduce pain medication side effects *Effective at reducing neuropathic pain *Fibromylagia, diabetic neuropathy *Include antidepressants, anticonvulsants, antihypertensives, antipruritics, corticosteroids, local anesthetics and bisphosphonates. *Can be used to treat pain after surgery (post-op), burns, or trauma *Be cognizant of max Tylenol dose and Ibuprofen dose in a 24 hr period

Question 67

examples with drugs

Answer 67

Antianxiety Lorazepam Antiemetic Ondansetron Steroids Prednisone Insomnia Ambien Anti-gas Simethicone Examples: Neuropathic pain Neurontin Antianxiety Lorazepam Antiemetic Ondansetron Steroids Prednisone Insomnia Ambien Anti-gas Simethicone

Question 68

the anelgesic ladder

Answer 68

Step 1  mild pain Nonopioid analgesic (with/without coanalgesic) Step 2  mild - moderate pain Weak opioid, combination of opioid and nonopioid (with/without coanalgesic) Step 3  moderate - severe pain Strong opioid administered around the clock Titrated until pain relieved

Question 69

numeric sedation scale

Answer 69

*S: sleep, easy to arouse: no action necessary *1: awake and alert; no action necessary *2: occasionally drowsy, but easy to arouse; no action necessary *3: frequently drowsy, drifts off to sleep during conversation; reduce dosage *4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

Question 70

normal respiration rates

Answer 70

Normal respiration rate: Adults is 12-18 breaths per minute School aged is 18-30

Question 71

examples of long acting opioids

Answer 71

A. Fentanyl patch B. OxyContin C. Methadone

Question 72

PCA pump

Answer 72

VPatient-controlled analgesia (PCA)*Can be used for post-surgical pain or chronic pain syndromes *Patient pushes the button and gets the medication as ordered

Question 73

epidural anelgesia

Answer 73

*Used for pain relief during postoperative phase *Used for children with terminal cancer or children or adults under going surgery. *Preparing for delivery

Question 74

local anesthesia

Answer 74

*Anesthetic agents may be applied topically to the skin, mucous membranes or injected *Nerve blocks common in dental work, surgery, wound closure and minor procedures

Question 75

osteoarthritis

Answer 75

Osteoarthritis (OA) A degenerative joint disease that is the most common chronic condition of the joints Effects about 31 million Americans 50,000 children in the United States have OA: Juvenile rheumatoid arthritis most common Often referred to as "wear and tear" Occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling. Most effected parts of the body: Hips Knees Fingers Feet

Question 76

OA symptoms

Answer 76

*Symptoms:*Pain and stiffness (most common) *Affected joints may get swollen; particularly after lots of activity *Limited range of motion depending on where its located *Clicking or cracking sound *Fatigue *Tenderness *Bone spurs on imaging

Question 77

OA risk factors

Answer 77

*Risk Factors: No specific cause Women; although not clear why >45 years of age Rare in children Factors that lead to OA: *Obesity (BMI) *Injury (fractures, ligament tears) *Overuse (athletes) *Family history *Diabetes

Question 78

OA examination and diagnosis

Answer 78

OA Examination & Diagnostics Diagnosis after healthcare examination *Assessing for range of motion, tenderness, signs and symptoms of joint damage *PMH and risk factors Diagnostic tests *Joint aspiration-insertion of needle into joint for fluid to assess for crystals or joint deterioration *X-ray-can help show any damage to the joints or bone spurs *MRI-obtains a better view of the cartilage and other joint structures https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925 If the cartilage wears down completely, bone will rub on bone.

Question 79

OA treatment

Answer 79

No cure *Manage symptoms (pain) *NSAIDS *Analgesics *Corticosteriods *Hyaluronic acid. Occurs naturally in joint fluid, acting as a shock absorber and lubricant. However, the acid appears to break down in people with osteoarthritis. The injections are done in a doctor’s office. *Duloxetine (Cymbalta) Typically used as an antidepressant, but approved to help treat chronic pain, including osteoarthritis pain. *Nonpharmocological approach- massage, acupuncture, vitamins, relaxation techniques *Improve joint mobility (physical activity) *Weight management *Stretching *Surgery *joint surgery can repair or replace severely damaged joints, especially hips or knees. *PT/OT *Tens Unit-provides some short term relief

Question 80

postsurgical pain overview

Answer 80

*“Post-Op” pain: response to tissue trauma during surgery *“Post Surgical” Refers to both inpatient and outpatient patients *Post-op pain typically lasts 4-6 weeks. This can vary depending on the type of surgery *Length of stay also varies (type of surgery, pain control, complications, etc) *Post Anesthesia Care Unit (PACU) *Holding area for patients after their procedure *Important to monitor safety- Side rails need to be up and bed in low position. Bed alarm should also be on. Help assist your patients with ambulation while on heavy narcotics and post-anesthesia. *PRN pain medications- be timely! Often ordered every 2-4 hours *Pain assessment is done prior to administering pain medications and 30 minutes after to assess effectiveness *Consider route of administration