Pain

Question 1

Pain

Answer 1

Universal, complex personal experience

Pain is inadequately treated in all health care settings

One major reason people seek health care
Nurses have a central role in assessment and management

Question 2

Populations at highest risk for inadequate pain control:

Answer 2

Older adults
Substance abusers
Those whose primary language differs from that of the health care professional

Question 3

Definitions of Pain

Answer 3

Unpleasant sensory/emotional experience associated with actual or potential tissue damage
Whatever person experiencing it says it is; exists whenever person says it does
Self-report always most reliable indication of pain

Question 4

Types of Pain

Answer 4

Acute pain
Short-lived
Results from sudden, accidental trauma; surgery; ischemia; inflammation
Chronic (persistent) pain-More than 3 months
Cancer pain
Non-cancer pain

Question 5

Acute Pain

Answer 5

Major distinction from chronic pain is the effect on biologic responses
Acts as warning sign
Activation of sympathetic nervous system
“Fight-or-flight” reactions

Question 6

Acute Pain Responses

Answer 6

Increased heart rate
Increased blood pressure
Increased respiratory rate
Dilated pupils
Sweating

Question 7

Chronic (Persistent) Pain

Answer 7

Persists or recurs for indefinite period (more than 3 months)
Onset is gradual
Character and quality can change over time
Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness

Question 8

Categorization of Pain by Underlying Mechanisms

Answer 8

Nociceptive pain
Somatic-
Visceral
Neuropathic pain

Question 9

Nociceptive Pain

Answer 9

Damage to somatic or visceral tissue
Surgical incision, broken bone, or arthritis
Usually responsive to opioids and nonopioid medications

Question 10

Somatic Pain

Answer 10

Superficial or deep
Localized
Arises from bone, joint, muscle, skin, or connective tissue

Question 11

Visceral Pain

Answer 11

Tumor involvement or obstruction
Arises from internal organs such as the intestine and bladder

Question 12

Neuropathic Pain

Answer 12

Damage to peripheral nerve or CNS-Neurontin
Numbing, hot-burning, shooting, stabbing, or electrical in nature
Sudden, intense, short-lived, or lingering

Question 13

Pain Transmission

Answer 13

Painful stimuli often originate in extremities
If pain is not transmitted to the brain, person feels no pain
Two specific fibers transmit periphery pain:
A delta fibers
C fibers

Question 14

Pain Assessment

Answer 14

Patient’s self-report is “gold standard” for pain existence and intensity assessment
Nurse’s role
Accept patient self-report
Serve as advocate
Act promptly to relieve pain
Respect values and preferences of patient

Location
Intensity
Quality
Onset and duration
Aggravating and relieving factors
Effect of pain on function and quality of life
Comfort-function outcomes
Patient’s acceptable level of pain

Question 15

Areas of Referred Pain

Answer 15

Question 16

What is breakthrough pain?

Answer 16

Beyond the treated pain
Transient, moderate to severe
Occurs beyond treated pain
Usually rapid onset and brief duration with variable frequency and intensity

Question 17

What is End-of-dose failure

Answer 17

Dosage is not holding patient such as fentanyl patch good for 72 hours. Stops working after 48 hours

Question 18

Associated symptoms of Pain

Answer 18

Can worsen pain
Anxiety
Fatigue
Depression

Question 19

Psychosocial Assessment

Answer 19

All pain holds unique meaning for the

person experiencing it

Remain objective; advocate for proper pain control

Ask open-ended questions

Question 20

Pain Reassessment

Answer 20

Critical to reassess at appropriate intervals, guided by
Pain severity
Physical and psychosocial condition
Type of intervention
Risks of adverse effects- IE- opioids check resp
Institutional policy

Question 21

Assessment Challenges

Answer 21

Patients who cannot self-report pain are at highest risk for undertreated pain
Hierarchy of Pain Measures
Checklist of Nonverbal Pain Indicators (CNPI)
Pain Assessment in Advanced Dementia Scale (PAINAD)- Used a lot
CPOT-Critical care pain tool

Question 22

Pharmacologic Management of Pain

Answer 22

Analgesic agents are first-line therapy
Individualized treatment plan based on comprehensive assessment
Clarify desired outcomes
Discuss options and preferences with patient and family
Re-evaluate as needed

Question 23

Pharmacologic Management of Pain

Three categories of medications

Answer 23

Nonopioid- Tylenol, NSAIDS,
Opioid
Adjuvant

Question 24

Nonopioids

Answer 24

Analgesic ceiling
Increasing dose above upper limit produces no greater analgesia.
Do not produce tolerance or addiction
Many are OTC.

Aspirin and other salicylates (Trilisate)

Acetaminophen

NSAIDs

Some NSAIDs are equal to aspirin.

Others have better efficacy

Decrease production of pain –sensitizing chemicals .

Side effects include GI problems, renal insufficiency, and hypertension.

Question 25

Pharmacologic Management of Pain Epidural and PCA

Answer 25

Multimodal analgesia Preemptive analgesia Multiple routes of administration- ***_epidural-Respiratory depression, constipation, URINARY RETENTION_*** Around-the-clock dosing ***_Patient-controlled analgesia (PCA)-Respiratory status-double sign when handing off patient_***

Question 26

Analgesics by Classification: Non-Opioids Health Teaching

Answer 26

Ask about use of non-opioids Clarify brand names vs. over-the-counter names Inform patients about combination products containing non-opioids Advise not to exceed safe maximum daily dose due to adverse side effects Full or mu agonists Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone Mixed agonists antagonists Butorphanol, nalbuphine Partial agonists Buprenorphine

Question 27

Physical Dependence, Tolerance, and Addiction

Answer 27

Physical dependence: Normal response Tolerance: Normal response Opioid addiction: Chronic neurologic and biologic disease Pseudoaddiction: Mistaken diagnosis of addictive disease

Question 28

Side Effects of Opioids

Answer 28

***_Constipation Urinary retention_*** Nausea Vomiting Pruritus Sedation Respiratory depression (less common, most feared)

Question 29

Adjuvant Analgesics

Answer 29

Anticonvulsants and antidepressants Local anesthetics

Question 30

Considerations for Older Adults: Opioids

Answer 30

Start with low doses and titrate slowly Systematic assessment of patient response Teach caregivers measures to reduce falls and accidents Home safety assessment is recommended

Question 31

Nonpharmacologic Interventions

Answer 31

Should be used to complement, not replace, pharmacologic therapies Physical modalities Cognitive-behavioral strategies

Question 32

Physical Interventions

Answer 32

Physical therapy Occupational therapy Aquatherapy Functional restoration-Patients with chronic conditions and are improving in the ADL type skills Acupuncture Low-impact exercise such as walking or yoga Cutaneous stimulation – for example, TENS

Question 33

Cognitive/Behavioral Strategies

Answer 33

Prayer Relaxation breathing Artwork Meditation Hypnosis Virtual reality

Question 34

Community-Based Care

Answer 34

Home care management Self-management education Health care resources

Question 35

The patient is receiving the first dose of an opioid analgesic for pain. The nurse expects the patient will also be ordered a(n):

Answer 35

Antacid agent Anti-anxiety agent ***_Laxative or stool softener_*** Breakthrough pain reliever

Question 36

Which patient would benefit most from the use of a patient-controlled analgesia pump?

Answer 36

75-year-old woman with confusion who is in the last stages of the dying process 15-year-old girl who is recovering from a head injury from an automobile accident ***_42-year-old man who is mentally alert and is recovering from a fractured femur_*** 60-year-old man who is mentally alert and is experiencing left-sided weakness after a stroke