Pain Interventions Flashcards by Madison North

Pharmacological therapies help

actual tissue damage

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Non-pharmacological therapies

sensory and emotional experiences associated with tissue damage

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Who is the single most powerful nonpharmacologic method of pain relief if available to children?

Parents

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Non-pharmacologic interventions help reduce the

perception of pain
- sense of control (more tolerable)
- decreases anxiety
- enhance effective analgesics
- learn prior to need

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Non-pharmacological therapies can affect the pain pathway at the

point of perception and modulation

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Specific Nonpharmacological therapies are categorized into what 3?

sensory
cognitive behavioral and relaxation
imagery

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Sensory techniques are used to

alter one’s perception of pain by stimulaing recptors involved with the senses
(sight, smell, taste, feel, hear)

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Sensory techniques include

Tactile stimulation
Distracting

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Tactile stimulation of cutaneous fibers to

compete with perceived painful sensations

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Distracting technique does what?

refocuses attention away from the pain
- iPad, TV, bubbles, games

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Tactile stimulation examples

rubbing
stroking
patting
hugging
hand-holding
squeeze soft object (stress balls)
vibrating device (i.e. Buzzy® Bee)

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Buzzy Bee uses

cold
vibration

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Buzzy Bee uses what to confuse the body’s own nerves?

gat control pain relief
- dulling or eliminiating sharp pain

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The Buzzy Bee needs to between

brain and the pain

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The tactile stimulation uses alternate application of

heat and cold

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If direct application to painful area is contraindicated then you can apply to

opposing extremities

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TENS is a

trancutaneous electricl nerve stimulation

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TENS uses what stimulation

tactile

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TENS sends

low voltage electrical current to the nerves, preventing pain signals from being transmitted

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The TENS device will stimulate the production of

endorphins which similarly aid in pain mgmt

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Distraction of infants and young children use

objects move or change in shapes and colors
(pinwheels, kaleidoscopes, videos, and magic wands)
pop-up books; seek and find books
puppets
rocking
non-nutritive sucking
music and/or singing
play and art therapy

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Distraction of older children and adolescents

electronic activity (video games or TV)
books/reading
music
art
aromatherapy

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Cognitive Behavioral and Relaxation Techniques

bubble blowing
counting (backwards or patterns)
deep breathing
progressive music relaxation
biofeedback
MBSR and/or meditation

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MBSR means

Mindfulness-based stress reduction

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MSBR is a program that teaches

pt to calm their mind and body as a method to help control pain and stress **(similar to meditation)**

Imagery Techniques is a form of

**distraction** allowing redirect attention away from pain to mental representation of an image

Imagery techniques use this as a key to alleving pain

choose image or setting to ensure joy and find relaxation

Guided imagery (cognitive) includes

taking a trip pain switch magic gloves happy place

Is hynosis a type of imagery?

yes, cognitive stimulation

Storytelling and pretending re what type of nonpharmacologic examples

cognitive imagery

Guided imagery is used to distract what age groups

children to adolescents

T/F: Guided imagery can only be done in person.

false, or several recording available online apps purchase podcasts

The process of "taking a trip" imagery technique

Ask to relax, deep breaths, close eyes and imagine you are in a place you desire to be in their mind Place without pain Lead them using calm gentle voice and describe every detail senses on the trip Transportation, weather, encounter along the way When the trip is complete, open their eyes and return to the room

It is important that the trip tecnhique encounters what?

NO PAIN

How does the pain switch work

visualize pain as an electrical current and describe the switch to turn off the pain -slow (dimmer) or instant (light or pull chain) whne off do you feel numb, tingles, or warmth

The magic gloves technique is useful in children from

3-12 years old (easy and slow to warm up)

Magic gloves explains to a child a feeling of

comfort to the body where the procedure will occur by placing/visualing a magic glove of no pain on that body part

Magic gloves process

instruct the child on the color and texture of the glove practice putting it on one finger at a time leave on to help protect the body part remove when ended and assess normal sensation returned to the body part

Whata re the 7 Rights of medications?

Pt Time Drug Dose Route Reason Approach Documentation

Other interactive non-pharmacological therapies

Yoga Tai Chi Physical Therapy Massage Accupuncture/Accupressure Energy Therapies Aromatherapy

Yoga helps

breathing control postures relaxation and meditation

Tai Chi

musculoskeletal strength joint stability mood and pain perception

posture positioning exercise and strengthen massage, joint mobility **TENS unit**

Massage

inhibit pain messages

Acupuncture

suppress pain stimulation pain relief

Aromatherapy

alter one's perception of anxiety, pain, and enhance health

Non-opioids used in conjuction with opioids require _______ opioid usage.

less

Pain control is better received through

combination method of no-opioid and opioids

The patient will experience **fewer adverse side effects from opioids**, since

amount of opioid dose needed for pain control is lessened

Non-opioid drugs are used for what type of pain

mild to moderate peripheral nervous system

Ceiling effect dosage

**maximum therapeutic dosage** is given, increasing the dose may produce side effects but **no further beneficial effects with pain relief**

Non-opioid drugs target

peripheral nervous system

What are the most common non-opioids given

acetaminophen (Tylenol) ibuprofen (Motrin, Advil)

What is IV Acetaminophen called?

Ofirmev

Opioids are given for

moderate to severe pain

Opioids target

central nervous system

Opioids affect the CNS which is why what is a serious adverse reaction to it?

respiratory depression

T/F: Opioids have a ceiling effect.

no, more is always better with pain

Should you question an order if the drug is more than the therapeutic range on the first dose?

yes, unless they are developing a drug tolerance for several days

Most effective Opioids

morphine sulfate (Morphine) fentanyl citrate (Sublimaze) hydromorphone hydrochloride (Dilaudid) Oxycontin

What is a 100 times more potent than morphine?

fentanyl citrate (Sublimaze)

What is 6 times more potent than morphine?

hydromorphone hydrochloride (Dilaudid)

MS Contin MEANS

controlled release

Methadone is used for

wean pts off of opioids tx severe and chronic pain

Other effective medications for pharmacologic tx for pain relief

Oxycodone / OxyContin (extended release) Hydrocodone combined with acetaminophen or ibuprofen

Hydrocodone combined with acetaminophen or ibuprofen brand names include

Norco, Lortab, Vicoden, Vicoprofen

Anticonvulsants

gabapentin (Neurontin)

Anticonvulsants are used for in pain

neuropathic pain

NSAIDs for antiinflammatory before or after medical procedural surgery

Ketorolac (Toradol)

Tricyclic antidepressants include

amitriptyline, imipramine (Tofranil)

Tricyclic antidepressants are used for

Neuropathic pain trigeminal neuroalgia

Trigeminal neuroalgia

severe pain from inflammation of the nerve

Sedatives include

Versed

Sedatives like Versed are used for

Relaxation or sedation prior to medical procedures/surgery (conscious)

Skeletal muscle relaxants include

baclofen (Lioresal)

Skeletal muscle relaxants do what?

alleviate musculoskeletal pain and spasms **reduce spasticity** Cerebral palsy

Antianxiety Medications

lorazepam (Ativan)

Antianxiety Medications are used to

muscle relaxant **lessen anxiety before medical procedure or surgery** (Closed MRI with claustrophobia)

Corticosteroids include

methylprednisolone (Solu-Medrol)

Corticosteroids are used for

reducing pain and inflammation

Placebos _________ recommended by the American Society of Pain Mgmt Nursing

not

Placebos are considered

unjustified and unethical raise serious ethical and legal questions

Therapeutic Range

safe starting dose titrate upwward to achieve optimal pain relief different safe, staring ranages based on Dx

The usual Morphine Sulfate Safe Starting Dosage is

0.05 - 0.1 mg/kg/dose

The usual starting dose of morphine is allowed higher in a child with what diseases?

sickle cell crisis cancer

Range order example: 1-2 mg every 3 hours for pain How long would you wait to give the medication again?

3 hours

If you have a range order and this is the first dose to be administered, it is advisable to start with what dose first

smallest dose and reevaluate pain relief again and give more if needed

What is the preffered route if tolerating PO intake?

Oral

What route has the longer duration and least invasive?

oral

What are the different forms of Oral medications?

liquid pill Lollipop (transmucosal)

Should you assume a child can swallow pills based on their age?

no, maybe has never swallowed them before - give with sweet juices

What are the different transmucosal forms of oral medications?

fentanyl oralet (Actiq) tetracaine lollipop – POST OP tonsillectomy

IV is recommended in a child when they are

brief, moderate to severe pain unable to take oral medications

IV can be given in what ways

Bolus - IVP continous

PCA is administrated

self (bolus, basal, infusion, or combination)

PCA is used for what age of children

5-6

PCA is used when a child understands what developmental concept?

cause and effect

PCA uses lock outs to prevent

overdosing

Can a family or nurse push the PCA button for the patient, if the policies are not preventing them from doing it?

Yes, ONLY WITH POLICIES on family or nurse-controlled analgesia WITH CERTAIN STEPS example) palliative

Which method of administering pain control is not recommended for children?

IM should be avoided if possible **causes pain and variability in absorption**

The rectal administration of medication should be avoided because of these reasons.

traumatic absorption affect by stool however drugs can be compounded into rectal suppositories

Intradermal is used primarily for

skin anesthesia

Local anesthetics includeing Lidocaine may be buffered with

sodium bicarbonate

ID Lidocaine blocks are used in what procedures?

LP Bone marrow aspirations arterial punctures skin bx

Inhalation for pain control is used to produce

partial or complete analgesia for painful procedures

Anesthetic for inhalation common

nitrous oxide

Transdermal fentanyl (DURAGESIC) should be given only to

12+ years old

Transdermal fentanyl (DURAGESIC) is used for what

continuous pain control not initial relief of acute pain

Transdermal fentanyl (DURAGESIC) used on what type of skin

intact

Transdermal fentanyl (DURAGESIC) onset

12-24 hours

Transdermal fentanyl (DURAGESIC) duration per patch

72 hours

J-Tip is what

needle-free jet injection with buffered lidocaine **numbs the area**

Topical Anesthetics for Intact Skin

EMLA LMX4 Transdermal patches (lidocaine-tetracaine (Synera, S-Caine) Vapo-coolent (Refrigerant sprays)

Topical Anesthetics for Non-intact Skin

LAT-gel (lidocaine-adrenalin-tetracaine)

EMLA means what

Eutectic Mixture of Local Anesthetics

EMLA is a combination of drugs

lidocaine and prilocaine

EMLA is applied when would it be used in the ED?

1-2 1/2 hours before painful event **not useful in ED only scheduled or non-emergent interventions**

EMLA causes

vasoconstriction in the 1st hour - not IV start during that time

LMX4 name application prior to procedure duration

4% lidocaine cream **30 minutes before duration of 60 minutes**

Lidocaine-tetracaine brand names

Synera, S-Caine

Lidocaine-tetracaine apply for

20-30 minutes

Lidocaine-tetracaine should not be applied on _________ skin

broken

Lidocaine-tetracaine is administered for

topical analgesia before painful procedures

Lidocaine, EMLA, and LMX4 are great for procedures

IV Insertion Lumbar Puncture Accessing PortaCaths Lab Draws PICC Line Insertion IM Injections/Immunizations

Vapo-coolant is a

refrigerant sprays Pain Ease (ethyl chloride)

Pain Ease (ethyl chloride) is what type of topical anesthetic

instant (brief minute) to temporarily control pain

Pain Ease (ethyl chloride) is used on

intact skin minor open wounds intact mucous membranes

Vapocollent procedures for analgesia

needle procedures minor surgical procedures

Does vapocollent ( Pain ease- ethyl chloride) cause vasoconstriction?

Vapocollent works within

seconda to freeze and numb skin

Vapocoolent works for how long?

1 minute

Does vapocollent require a physician's order?

Vapocollent is used for what ages

4 years and younger

Vapocollent is used for what procedure in children younger than 4?

Immunizations IV starts Joint injections Blood draws Incision and drainage of small abscesses* Foreign body removal Suturing and suture removal

LAT stands for

lidocaine-adrenalin-tetracaine

LAT is used on what type of skin

non-intact (suturing)

What topical agent is usen on non-intact skin?

LAT

Anesthesia for LAT occurs in

10-15 minutes

If the topical anesthetic causes vasoconstriction, it should not be used on

end of extremities (fingers, penis tip, nose, ears, toes) - lose circulation and death of tissue

Adrenaline is not used on ends of __________ because of ___________

arterioles vasoconstriction

Which type of pain medication regimen is preferred?

scheduled to keep pain at bay with PRN given for breakthrough pain

Side effects increase markedly if the rate of injection is too

fast

What is the most serious adverse effect of pain medications? (whether it is rare or not)

respiratory depression

Respiratory depression is most likely to occur with which doses

initial

Respiratory depression is most likely to occur when there is

no hx of previous exposure

Opioid-induced Respiratory Depression Intervention steps

Assess sedation level If continuous infusion, then STOP infusion Stimulate pt Admin O2 support respirations

Opioid-induced Respiratory Depression If a client cannot be **aroused or apneic**,

Initiate resuscitation efforts **Admin Narcan (naloxone)**

What do you need to remember when administering Narcan to respiratory depression?

Duration of Narcan is shorter than opioid **requiring repeated doses of Narcan**

Respiratory depression due to benzodiazepines can be reversed with

flumazenil (Romazicon)

N/V and constipation is what type of side effects

common

What are non-sedating antiemetics for N/V?

ondansetron (Zofran) promethazine (Phenergan)

Nausea and vomiting subside with opioid administration after

2 days

In terms of Constipation, what is more effective than tx?

prevention

Treatment/prevention for constipation

stool softeners/laxatives **docusate sodium (Colace)** - increases fiber and fluids - an increase in activity

Pruritis

itching

Treatment of Pruritis as an adverse effect

diphenhydramine (Benadryl) ondansetron (Zofran) is shown effective for opioid and epidural pruritis

With the right approach, what should be told to the pt when giving the medication?

therapeutic responses and verbalize expectations

Which therapeutic response is appropriate to say? “By now you shouldn’t need so much pain medication.” “ You will feel the pain going away as this medicine goes into your body.”

“ You will feel the pain going away as this medicine goes into your body.”

A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Numeric

B. FLACC

A nurse is assessing an infant. Which of the following are manifestations of pain in an infant? Select all that apply. A. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body E. Pushes away stimulus

B. Loud cry C. Lowered eyebrows D. Rigid body

A nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include in the plan of care? Select all that apply. A. Offer a pacifier B. Use guided imagery C. Use swaddling D. Initiate a behavioral contract E. Encourage kangaroo care

A. Offer a pacifier C. Use swaddling E. Encourage kangaroo care

What is kangaroo care?

skin to skin contact with mom and baby

A nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care? A. Administer non-opioids for pain greater than 7 on a scale of 0-10 B. Administer pain medications prn for pain C. Administer IM analgesics for pain D. Administer IV analgesics on a schedule

D. Administer IV analgesics on a schedule

The nurse is caring for a 10-year-old boy with autism on the pediatric unit, immediately after a spinal fusion with titanium rods implanted. The child is able to communicate a little verbally and attends special classes for children with autism. He has a short attention span, according to the mother. The child’s pain management is of great concern to his mother. What information about this child should the nurse take into account when providing medication for pain? A. Children with autism do not perceive pain as do regular children. B. Children with neurologic disorders, such as autism, are at greater risk than other children for undertreatment of pain. C. EMLA cream would be contraindicated for use prior to restarting the child’s intravenous line. D. Distraction and guided imagery can be used to help make this child comfortable.

B. Children with neurologic disorders, such as autism, are at greater risk than other children for undertreatment of pain.

What pain scale would be most appropriate for the nurse to use for the child with autism? A. The FLACC Pain Assessment Tool B. The Comfort Scale C. The Wong-Baker FACES Pain Scale D. The Oucher Pain Scale

A. The FLACC Pain Assessment Tool

The child’s mother asks about her son’s dependence on large doses of pain medication and whether it will cause addiction later in life. What response by the nurse is most appropriate? A. “The risk for addiction is extremely low. The child would not want to take this medication if there was no pain.” B. “As long as he uses the pain medication for less than 2 weeks, there shouldn’t be any problem.” C. “It will be easier for him to become dependent upon this medication if he needs it later in life.” D. “This is something you really need to address with his surgeon because she ordered the pain medication dosage.”

A. “The risk for addiction is extremely low. The child would not want to take this medication if there was no pain.”

The child has patient-controlled analgesia (PCA) of morphine with an 8-minute lockout. Teaching by the nurse has been effective if what behavior is seen in this child? A. He pushes the button on the PCA whenever he wants. B. He waits 8 minutes until pushing the button again. C. The nurse pushes the PCA button whenever she is turning him. D. The mother pushes the PCA button whenever the child moans or makes a strange face.

A. He pushes the button on the PCA whenever he wants.

1. Which of the following statements best verifies that an eight-year-old patient admitted for Sickle Cell Crisis is experiencing pain? A. Her parents tell you that she has had trouble sleeping. B. She appears uninterested in you caring for her. C. She looks like she is in pain. D. She tells you her chest hurts “really bad” when she tries to take a deep breath.

D. She tells you her chest hurts “really bad” when she tries to take a deep breath.

2. Select the most appropriate pain intensity scale for a developmentally normal 3-year-old patient. A. COMFORT Scale B. CRIES Scale C. FLACC Scale D. Numeric Rating Scale E. Revised FLACC Scale F. Wong-Baker FACES Scale

F. Wong-Baker FACES Scale

3. Select the most appropriate pain intensity scale for a 9-year-old cognitively impaired patient. A. COMFORT Scale B. CRIES Scale C. FLACC Scale D. Numeric Rating Scale E. Revised FLACC Scale F. Wong-Baker FACES Scale

E. Revised FLACC Scale

4. Select the most appropriate pain intensity scale for a developmentally appropriate 9-year-old patient. A. COMFORT Scale B. CRIES Scale C. FLACC Scale D. Numeric Rating Scale E. Revised FLACC Scale F. Wong-Baker FACES Scale

D. Numeric Rating Scale

5. Which of the following scales would be the most appropriate pain assessment tool to use for Will? A. COMFORT B. CRIES C. FLACC D. Numeric Rating

D. Numeric Rating

Name: Jack Age: 12 years Diagnosis: Sickle cell pain crisis Notes: Jack has frequent hospitalizations with pain crisis related to his sickle cell disease. He is developmentally appropriate. 6. One hour after receiving his ordered pain medication for pain rated as a 10 on a 1-10 numeric scale, Jack tells the clinician he is still hurting. Which of the following would be the correct next step by the clinician? A. Call the physician and request a different pain medication. B. Reassess Jack’s pain level using a numeric rating scale. C. Reassess Jack’s pain using a different scale. D. Tell Jack he will have to wait three hours for more medication.

B. Reassess Jack’s pain level using a numeric rating scale.

Name: Elizabeth Age: 6 months Diagnosis: Post-op intussusception repair Notes: Had emergency abdominal surgery 12 hours ago. Parents are at the bedside. 7. Which of the following pain intensity scales is appropriate for assessing Elizabeth’s pain level? A. CRIES B. FLACC C. Numeric Rating D. Wong-Baker FACES

B. FLACC

8. Which of the following statements is an example of the element to “identify a pain relief goal”? A. “Do you want Tylenol or Morphine?” B. “This medication will decrease your pain rating to 3”. C. “What is an acceptable pain rating for you?” D. “You should be feeling better now”.

C. “What is an acceptable pain rating for you?”

9. Which of the following physiologic measures noted on assessment would be most indicative of a need to further assess for increased pain? A. Decreased blood pressure B. Decreased heart rate C. Increased appetite D. Increased heart rate

D. Increased heart rate

10. Which of the following cultural considerations plays an important role in pain assessment? A. The culture of the clinician. B. The language spoken by the family. C. The region of the country where the patient resides. D. The type of diet the patient eats.

A. The culture of the clinician. AND PATIENT

11. The patient must understand the ordering of numbers to effectively use which of the following pain-assessment scales? A. CRIES Scale B. FLACC Scale C. Numeric Rating Scale D. Wong-Baker FACES Scale

C. Numeric Rating Scale

12. The clinician recognizes that a 4-year-old child that had abdominal surgery yesterday has pain related to actual tissue damage. The clinician is also aware that pain is: A. Always relieved by medication. B. Impossible for a young child to describe. C. Only a physiologic experience. D. Whatever the child says it is.

D. Whatever the child says it is.

13. One hour after providing Tylenol to 5-year-old Jacob, you reassess and record his pain level using the Wong-Baker FACES scale. This is an example of which accreditation standard of pain assessment and management? A. Defines criteria to screen, assess and reassess pain consistent with patient age, condition and ability to understand. B. Develops pain treatment plan based on evidence-based practices, patient condition, past medical history and pain-management goals. C. Reassesses and responds to pain. D. Treats or refers patient for treatment.

C. Reassesses and responds to pain.

14. You are caring for a 12-year-old patient, status post–motor vehicle accident. The patient is mechanically ventilated and receiving sedation and neuromuscular blocking agents. As you are preparing the patient for surgery to repair a broken femur, you administer a PRN opioid pain medication. Monitoring his pain level is important due to which of the following: A. Critical judgment should be used in addition to pain scales due to the child’s condition. B. It can be assumed the patient is not in pain because he is mechanically ventilated. C. The patient is receiving a neuromuscular blocking agent and will not need additional pain medication. D. You assessed the patient using the FLACC scale and determined additional pain medication was needed.

A. Critical judgment should be used in addition to pain scales due to the child’s condition.

Raphael is a 17-year-old male who was seen in ED. Patient was hit by a car and driver did not stop. Reported brief LOC at scene. He was transported from scene to ED via EMS. Upon arrival in the ED, he was AAOx3, GCS was 15. He has complaints of left leg and left arm pain. 1. Upon arrival to the ED, Raphael is complaining of 9/10 pain in his left leg. After his assessment and he is stabilized what should you do? A. Give IV Ketorolac. B. Give IV morphine 0.05mg/kg. C. Give PO acetaminophen. D. Wait to see if his pain gets better.

B. Give IV morphine 0.05mg/kg.

2. Raphael arrives back from the OR. He is using his pain medication, hydromorphone, appropriately with no side effects. However, to optimize his pain medication, the provider adds IV acetaminophen. What is important to understand about IV acetaminophen? A. It has a ceiling effect. B. It is an adjuvant therapy. C. It is opioid sparing. D. All of the above

D. All of the above

3. A few days after his second surgery Raphael complains of burning pain in his left foot. He has multiple medications ordered for pain. Based on your knowledge, which medication could assist in alleviating this type of pain? A. Acetaminophen B. Clonidine C. Gabapentin D. Morphine

C. Gabapentin

4. Raphael has been on hydromorphone for over seven days, and he reports that he feels like the medication is not helping as much as it was a few days ago. He is scheduled for one more surgery tomorrow. You know that he is building up a tolerance. What can you do to help Raphael? Select all that apply. A. Call the provider to change the hydromorphone to an equianalgesic dose of another opioid. B. Call the provider to increase the dose. C. Do nothing; he will be okay. D. Tell him that he is imagining that the medication is not helping.

A. Call the provider to change the hydromorphone to an equianalgesic dose of another opioid. B. Call the provider to increase the dose.

5. Raphael has been taking opioids for over one month. He is healing well from his surgeries and is ready to go into inpatient rehab. What is an important point to remember about taking opioids longer than seven days? Select all that apply. A. A weaning plan needs to be initiated. B. Dependence may develop. C. Discontinue the pain medication as he is progressing. D. Repeated doses of opioid medication can lead to addiction. Raphael is becoming addicted.

A. A weaning plan needs to be initiated. B. Dependence may develop.

6. Raphael is now completely healed and no longer requires opioid medication for pain. What is the best way to dispose of his extra medication? A. Flush it down the toilet. B. Give it to his friend who recently had knee surgery. C. Keep it in his medicine cabinet at home for future use. D. Throw it in the trash can.

A. Flush it down the toilet.

7. The clinician is caring for Jackie, a 12-year-old that is one day post-op from a posterior spinal fusion. Jackie is NPO and is rating her pain as a 7 on a 0 to 10 pain scale. The clinician is aware that the first line of pharmacologic pain management for this child should include: A. Adjuvant analgesics B. Opioids C. Non-opioids D. Anti-inflammatory

B. Opioids

8. The mother of a child being treated with opioids for sickle cell pain crisis reports to the clinician that the child is still in significant pain after being treated with morphine but is also experiencing severe itching as a side effect of the morphine. The clinician suggests adding a non-opioid medication in combination with the morphine rather than increasing the amount of morphine. This is an effective strategy because of which of the following characteristics of non-opioids? A. Ceiling of analgesia B. Equianalgesic C. Opioid-sparing effect D. Tolerance

C. Opioid-sparing effect

9. The clinician has been assigned to take care of a 17-year-old male recently diagnosed with chronic musculoskeletal pain. He has been prescribed the antidepressant duloxetine, but states that he doesn’t think it is doing anything to help him feel better. His first dose was taken five days ago. Based on your knowledge of how drugs work in the body, you expect that he won’t reach full effect of the medication until which of the following occurs? A. Another medication is added to create synergy. B. The medication reaches steady state. C. The active metabolites of the drug are managed. D. The half-life decreases allowing for more drug to remain in his system.

B. The medication reaches steady state.

10. A 13-year-old has been receiving morphine for two weeks for intractable cancer pain. The current dose of morphine is no longer relieving the child’s pain. The mother tells the clinician she is afraid her child is addicted to morphine. The clinician explains to the mother that the child is experiencing which of the following: A. Addiction B. Ceiling of analgesia C. Dependence D. Tolerance

D. Tolerance

11. A 10-year-old male is on the unit post-ATV accident. He has had multiple surgeries; incisions and drainages for an open tibia-fibula fracture and multiple open wounds. The patient has been receiving opioids for about two weeks. He has been transitioned from IV morphine to oral oxycodone. It is one week later, and the fracture is healing well, and wounds are closed. He is now taking a non-opioid for his pain; however, he is experiencing irritability, sweating and diarrhea. These are symptoms of which of the following? A. Ceiling of analgesia B. Tolerance C. Dependence D. Withdrawal

D. Withdrawal

12. The clinician is caring for a child with chronic pancreatitis and kidney failure. The child requires opioids for management of her pain. The clinician should consider which of the following when administering pain medication? A. The child may require a higher than usual dose. B. The child may require a lower than usual dose. C. The child should require the usual recommended dose. D. The child should not be receiving opioids.

B. The child may require a lower than usual dose.

13. Brendan is a 9-year-old post-clavicle fracture repair patient. He is tolerating meals without any complaints of nausea or vomiting. What is the preferred route for administering opioids for pain management? A. Intramuscular B. Intravenous C. Oral D. Transdermal

C. Oral

14. Madeline is a 13-year-old who had a Nuss procedure done to correct pectus excavatum. Her pain has been managed well with IV morphine and now with PO oxycodone and acetaminophen. She is ready for discharge. She will be sent home with a prescription for oxycodone. Her mom would like to know how to dispose of the unused medication if there is any left over. A. Give the medication away. B. Throw the medication in the trash. C. Mix with coffee grounds or cat litter and then throw in trash. D. Keep to use next time.

C. Mix with coffee grounds or cat litter and then throw in trash.

Adarius is a 7-year-old boy who presents to the emergency department (ED). He was climbing a fence on the playground during recess and cut his leg. Upon arrival to the ED, accompanied by a school aide, Adarius is fearful and appears to be in pain. The ED clinician assesses the cut on his knee and asks Adarius about his pain; he says that his leg pain is the worst pain he has ever had. The assessment reveals that his leg wound will require sutures. Adarius is upset and wants his mom. 1. When determining pain-management strategies, it is important to understand which of the following concepts about pain? Select all that apply. A. It may not be possible for a 7-year-old to accurately describe the amount of pain he is actually experiencing. B. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. C. Pain is whatever the person experiencing it says it is, existing whenever the experiencing person says it does.

B. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. C. Pain is whatever the person experiencing it says it is, existing whenever the experiencing person says it does.

Adarius' leg hurts (sensory experience), and he says that it is the worst pain he has ever experienced (subjective). He is upset and wants his mom (emotional experience). Let’s consider the best treatment approach for the sensory, subjective, and emotional aspects of Adarius' pain. 2. What is the best approach for the pain associated with actual tissue damage? A. Non-pharmacologic therapy B. Pharmacologic therapy

B. Pharmacologic therapy

3. What treatment approach will be best for sensory, subjective and emotional aspects of his pain? A. Non-pharmacologic therapy B. Pharmacologic therapy

A. Non-pharmacologic therapy

Adarius is in the ED with a laceration of his knee. He was brought in by a school aide. It has been determined that his laceration will require sutures. You are preparing him to have his laceration sutured. Consider the following questions regarding general non-pharmacologic strategies that might be helpful to Adarius at this time. 4. Adarius' parents arrive at the ED and ask to be in the procedure room with him during the suturing. Which of the following would be the most appropriate way to respond to Adarius’ parents? A. “Adarius may get more upset if you are in the room; someone from the ED will stay with him throughout the procedure.” B. “It will help Adarius for you to be with him; I can share some coping strategies that might be helpful to him.”

B. “It will help Adarius for you to be with him; I can share some coping strategies that might be helpful to him.”

5. Which of the following statements would be appropriate when preparing Adarius for the procedure? A. “Adarius, the cut on your knee will need to be stitched up; it is not going to hurt. Close your eyes and try to relax.” B. “Adarius, the cut on your knee will need to be stitched up; the doctor will give you some medicine to take the hurt away. Your parents will stay with you.”

B. “Adarius, the cut on your knee will need to be stitched up; the doctor will give you some medicine to take the hurt away. Your parents will stay with you.”

6. What is the best strategy for positioning Adarius in order to immobilize the leg while it is being sutured? A. Allow Adarius to sit and hold a parent’s hand. B. Ask one of the parents to restrain the leg being sutured.

A. Allow Adarius to sit and hold a parent’s hand.

The clinician is preparing for Adarius to have his knee sutured. Answer the following questions about appropriate non-pharmacologic pain management strategies to use with Adarius during the procedure. 7. Which of the following would be a helpful tactile stimulation technique? A. Playing music B. Singing songs C. Squeezing clay D. Taking a trip

C. Squeezing clay

8. Adarius tells the clinician that he loves comic books. The clinician recognizes that this activity could be used as which of the following non-pharmacologic strategies? A. Distraction B. Guided imagery C. Relaxation

A. Distraction

9. The clinician guides Adarius in imagining taking a trip to his favorite place in his mind, describing how he will get to this place and what he will see, hear, touch, and smell while he is there. What type of non-pharmacologic strategy is this activity? A. Distraction B. Guided imagery C. Relaxation D. Tactile stimulation

B. Guided imagery

Desiree is a 1-week-old infant. She is hospitalized with hyperbilirubinemia. She requires phototherapy and daily blood tests. Answer the following question considering developmentally appropriate strategies for pain management during Desiree’s blood draws. 10. Which of the following non-pharmacologic interventions would be the most age-appropriate pain management techniques to use for Desiree during blood draws? Select all that apply. A. Guided imagery B. Kangaroo care C. Oral sucrose D. TENS

B. Kangaroo care C. Oral sucrose

Lynae is a 13-year-old girl who had an exploratory laparotomy and bowel resection yesterday. She reports abdominal pain, which she rates as a six on a zero to 10 numerical rating scale. She is also upset about missing school and her friends. The clinician would like to identify some non-pharmacologic strategies to utilize as adjunct to pharmacologic interventions to improve Lynae's pain level. Answer the following questions about developmentally appropriate non-pharmacologic interventions for Lynae. 11. Which of the following is a developmentally appropriate sensory technique the clinician could utilize? A. Blowing bubbles B. Music C. Oral sucrose

B. Music

Lynae is a 13-year-old girl who had an exploratory laparotomy and bowel resection 12. Which of the following might be an effective imagery technique for Lynae? A. Count to 100 by twos B. Pain switch C. TENS

B. Pain switch

13. The clinician would also like to implement a cognitive behavioral strategy for non-pharmacologic pain management. Which of the following would be an age-appropriate cognitive behavioral strategy? A. Arts and crafts B. Blowing bubbles C. Swaddling

A. Arts and crafts

14. Which of the following statements describes the appropriate use of non-pharmacological pain-management strategies? A. Used to avoid giving children narcotic agents. B. Used to decrease the amount of pain medications required. C. Used for patients that do not tolerate pharmacological agents. D. Used in conjunction with medications to improve pain management.

D. Used in conjunction with medications to improve pain management.

15. The clinician is caring for a 2-year-old child with a laceration requiring sutures. When should the clinician talk to the child about the procedure? A. After the numbing medication is administered B. Before preparing the supplies in the child's room C. Immediately prior to the procedure D. Up to two hours before the procedure

C. Immediately prior to the procedure

16. A clinician is talking with the parent of a school-aged child that is scheduled for a lumbar puncture. The parent tells the clinician that the child loves to tell imaginary stories. What strategy for pain management could the clinician implement that would best utilize this information? A. Hypnosis B. Magic Glove C. Taking a trip D. Videos

C. Taking a trip

17. Guided imagery is an appropriate non-pharmacological pain-management strategy for which of the following age groups? A. Infant B. Toddler C. Preschooler D. School-aged

D. School-aged

18. A 14-year-old is being prepared for scoliosis surgery in a few weeks. The child says he is feeling anxious about the procedure. Which of the following would be an appropriate imagery technique to teach this patient in preparation for surgery? A. Hypnosis B. Music C. Progressive muscle relaxation D. Video games

A. Hypnosis

19. When positioning a 5-year-old to have his foot sutured, which of the following would be an appropriate position? A. Lying down with someone lying across his chest B. Reclining with someone lying across his legs C. Sitting with someone hugging him D. Wrapped up tightly in blanket.

C. Sitting with someone hugging him

20. The clinician would like to include non-pharmacological pain management in a plan of care for a child who had an appendectomy yesterday. Which of the following is a good example of a sensory technique? A. Art therapy B. Bubble blowing C. Deep breathing D. Hypnosis

A. Art therapy

21. A 4-month-old infant needs to have an IV started. Which of the following is the best preparation strategy for an infant? A. Ask the mother to wait in the waiting area. B. Give oral sucrose prior to procedure. C. Perform the procedure in child's own bed. D. Turn on the television in the background.

B. Give oral sucrose prior to procedure.