Pain - Chap 15 Flashcards
The nurse is caring for a patient who is a devout Orthodox Jew. The patient is on a patient-controlled analgesia (PCA) pump. What accommodations might the nurse have to make to conform to the patient’s cultural needs?
a.
Ask the patient whether he will need alternative forms of medication for the Sabbath.
b.
Ask the patient specific questions because Jews tend to be stoic regarding pain.
c.
Medicate the patient “around the clock” instead of as needed (“prn”).
d.
Understand that Jews believe that suffering is a consequence of actions in a previous life.
Orthodox or Observant Jews may not use electrical equipment during the Sabbath and on Holy Days; therefore, the staff should program the PCA to achieve optimum pain relief. Alternative methods will be needed during these times. Cultures vary regarding when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desirable. Russians, Asians, and Native Americans tend to be stoic, whereas Italians, Puerto Ricans, and Jews tend to be more expressive. The nurse should ask the patient about his preferences. Some Hindu patients believe that suffering is a consequence of actions in a previous life. For example, a belief in the concept of Karma motivates the patient to bear the pain, refuse pain medications, and suffer in silence. Some Jews view pain as a communal suffering that they should share with others to affirm their life experience.
The patient is admitted with chronic pain. She states that nothing takes the pain away totally, but that “Dilaudid works best.” The fact that the patient calls the medication by name should alert the nurse to:
a.
suspect that the patient is drug seeking.
b.
expect that the patient may need smaller doses than normal.
c.
assess the patient’s acceptable level of comfort.
d.
accept the fact that nothing will help this patient’s pain.
ANS: C
It is important to assess the patient’s acceptable level of comfort so that both you and the patient are striving for the same outcome. Some patients with prior pain conditions can alert the nurse to pain-relieving measures that were successful. Patients with chronic/persistent pain are often familiar with the names and actions of medications, including opioid medications. This should not cause you to view the patient negatively or with suspicion. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new pain. Do not accept that “there is nothing that will help this patient’s pain.” Learn the institutional policy for how to proceed in this situation.
The nurse frequently must assess a patient who is experiencing pain. When assessing the intensity of the pain, the nurse should:
a.
ask whether there are any precipitating factors.
b.
question the patient about the location of the pain.
c.
offer the patient a pain scale to objectify the information.
d.
use open-ended questions to find out about the sensation.
ANS: C
Descriptive scales are an objective means of measuring pain intensity. Use a pain intensity scale appropriate to the patient’s age, developmental level, and comprehension, and ask the patient to rate the pain. An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity. Asking the patient what precipitates the pain does not assess intensity, but rather assesses the pain pattern. Asking the patient about the location of pain does not assess the intensity of the patient’s pain. To determine the quality of the patient’s pain, the nurse may ask open-ended questions to find out about the sensation experienced (e.g., “Tell me what your pain feels like”). This approach assists in identifying the underlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity.
The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic. Which of the following interventions is most appropriate? a. Straighten the bed linens. b. Change the saturated surgical dressing. c. Administer prescribed pain medications. d. Check for displaced equipment underneath the patient.
ANS: C
Administer pain-relieving medications as ordered. Analgesics are the cornerstone of pain management. Smoothing wrinkles in bed linens may reduce pressure and irritation to the skin; however, pain-relieving medication should be given first. Changing a wet surgical dressing might not be needed if the patient has received a wet-to-dry dressing as treatment, or if not changing the dressing will reduce irritation to the skin but will not address the discomfort. Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces. Removing these stimuli may maximize the response to pain-relieving interventions such as medication, but pain-relieving medication should be administered first.
The patient’s family is concerned that the patient may get too much pain medication after surgery and become addicted to the medication if he is placed on a PCA pump. They also voice concern about the effectiveness of the PCA. The nurse should instruct the family and the patient that:
a.
pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time.
b.
pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more.
c.
because the device provides medication as soon as the patient needs it, he will probably use less of the medication.
d.
the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate.
ANS: C
Because the device provides medication on demand as soon as the patient feels the need, the total amount of opioid use is reduced. Because the blood level stays within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. The PCA has several advantages. It allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus. An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief.
The nurse caring for a patient who has a PCA knows that it:
a.
allows the family to participate in pain management for the patient.
b.
prevents mistakes in medication administration.
c.
can be used by all hospitalized patients.
d.
provides a more constant level of medication.
ANS: D
PCA allows more constant serum levels of the opioid, and, as a result, it avoids the peaks and troughs of a large bolus. Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. Potential concerns involving PCA use are pump failure, and operator errors. Patients may misunderstand how PCA therapy works, may mistake the PCA button for the nurse call button, or may have family members who operate the demand button. Instruct the family not to push the timing device for the patient unless the patient is unable to push the button himself, and the nurse has instructed the family to do so. Use of a PCA pump does not prevent mistakes. The pump may fail to deliver drug on demand, may have a faulty alarm or a low battery, or may lack free-flow protection. Operators may incorrectly program the dose, concentration, or rate. Not all patients are candidates for PCA. Assess the patient’s cognitive ability to determine the appropriateness of PCA pain management.
When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse. What step should the nurse take next? a. Insert an airway. b. Turn patient to the side. c. Stop the PCA. d. Expect this as a patient outcome of the therapy.
ANS: C
If the patient is sedated and is not readily arousable, stop the PCA. As long as the patient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for the presence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient.
The patient is scheduled for surgery late in the afternoon. His postoperative orders include PCA therapy. Which of the following nursing interventions is appropriate to perform?
a.
Teach the patient about PCA after the patient comes out of recovery.
b.
Teach the patient about PCA before surgery and before preoperative medication administration.
c.
Tell the patient not to use PCA unless he can no longer tolerate the pain.
d.
Inform the patient’s family to watch him carefully and to depress the PCA administration button whenever they think he needs it.
ANS: B
Instruct surgical patients preoperatively. Encourage the patient to push the button on the timing unit whenever he feels pain. Tell the patient not to delay if he is experiencing pain. Pain is easier to prevent than to treat. Inform the patient and family that the patient cannot overdose with PCA if only the patient pushes the button. The family should not push the button unless instructed to do so by the nurse.
The nurse knows that an advantage of intraspinal analgesia is the:
a.
smaller doses of epidural than intrathecal medication.
b.
lack of significant patient complications.
c.
systemic distribution of morphine faster than fentanyl.
d.
ability to achieve appropriate analgesia with smaller dosages.
ANS: D
Because opioids are delivered close to their site of action, the central nervous system (CNS), they have greater bioavailability and thus require much smaller doses to achieve adequate pain relief. Epidural and intrathecal doses are not equivalent. Intrathecal doses are much smaller than epidural doses. As an example, the epidural dose of morphine is 10 to 20 times greater than that required for an intrathecal dose. The catheter poses a threat to patient safety because of its anatomical location, its potential for migration through the dura, and its proximity to spinal nerves and vessels. Migration of an epidural catheter into the subarachnoid space can produce medication levels too high for intrathecal use. Fentanyl and sufentanil are hydrolipid, which causes them to have a quicker onset and a shorter duration of action (2 hours). Morphine and hydromorphone are hydrophilic, resulting in a longer onset and a longer duration of action (up to 24 hours with a single bolus dose).
The patient is in the hospital undergoing major abdominal surgery. When the patient returns from the recovery room, the nurse expects that he most likely will be receiving pain medication: a. by mouth. b. intramuscularly. c. via the epidural route. d. intravenously.
ANS: C
Research shows the epidural route to be most effective in managing postoperative pain from thoracic and abdominal surgeries.
While reviewing a patient’s medication history, the nurse determines that intraspinal analgesia is contraindicated as a result of: a. previous spinal anesthesia. b. recent administration of anticoagulants. c. a history of cardiac problems. d. a diagnosis of advanced cancer.
ANS: B
Recent anticoagulants sometimes contraindicate the placement of an epidural catheter because of the risk for epidural hematoma at the insertion site. Certain conditions may make epidural analgesia the method of choice for pain control: following surgery, for patients with trauma or advanced cancer that is not responsive to other pain management modalities, and those predisposed to cardiopulmonary complications because of a preexisting medical condition or surgery. Previous spinal anesthesia is not a contraindication for receiving subsequent spinal anesthesia.
A nurse checks the continuous IV infusion for the intraspinal analgesia. The IV setup should be changed if: a. tubing with a Y-port is attached. b. an infusion pump is attached. c. the tubing connections are all taped. d. a diluted, preservative-free medication is used.
ANS: A
Use tubing without Y-ports for continuous infusions. Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space. Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports. Catheter and injection cap or infusion pump tubing should be securely taped and labeled. Closed, intact systems prevent entry of pathogens and disruption of the flow of medication. Medication should be prediluted, preservative-free opioid or local anesthetic as prescribed by the physician and prepared for use in an IV infusion pump (usually prepared by pharmacy). Preservatives may be toxic to nerve tissue.
Before administering an epidural medication, the nurse aspirates and suspects that the catheter has migrated into the subarachnoid space when: a. clear drainage is noted. b. no drainage is noted. c. purulent drainage is noted. d. redness, warmth, and edema are noted.
ANS: A
Aspiration of more than 1 mL of clear fluid or bloody return means that the catheter may have migrated into the subarachnoid space or into a vessel. Do not inject the drug. Notify the physician. Purulent drainage is a sign of infection, indicating that local inflammation and superficial skin infection at the insertion site have occurred.
The nurse is preparing to administer a bolus of epidural medication. The nurse must remember to:
a.
clean the injection cap of the epidural catheter with an anti-infective according to agency policy.
b.
clean the injection cap of the epidural catheter with alcohol.
c.
inject opioids quickly and smoothly.
d.
flush with saline after the injection.
ANS: A
Clean the injection cap of the epidural catheter with povidone-iodine, or substitute anti-infective according to agency policy. Alcohol causes pain and is toxic to neural tissue. Inject opioid at a rate of 1 mL over 30 seconds. Slow injection prevents discomfort by lowering the pressure exerted by fluid as it enters the epidural space. The catheter is in a space, not a blood vessel; thus flushing with saline is not required.
A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal catheter has punctured the dura when \_\_\_\_\_ noted. a. clear drainage is b. bloody drainage is c. purulent drainage is d. redness, warmth, and swelling are
ANS: A
Clear drainage may indicate puncture of the dura. Bloody drainage may indicate that the catheter has entered the blood vessel. Purulent drainage is a sign of infection. Redness, warmth, and swelling are signs of inflammation. Local inflammation and superficial skin infection can occur at the insertion site.
