Pain Management Chapter 36 Unit 9/10

Question 1

1. When assessing the patient for pain, which factors should the nurse consider? (Select all that apply.)
   a. Previous medical history
   b. Physical appearance
   c. Age, gender, and culture
   d. Lifestyle and loss of appetite
   e. Hair color and style

Answer 1

Answer: a, b, c, d
Medical history, physical appearance, age, gender, culture, lifestyle, and loss of appetite should be considered when conducting a pain assessment. Hair color and style are not necessary components of a pain assessment.

Question 2

2. Which statement best describes the dose of prescribed pain medication that a nurse should administer given pharmacologic treatment considerations?
   a. The smallest dose possible to avoid opioid addiction
   b. The smallest dose possible to decrease adverse effects
   c. A dose that best manages pain with fewest side effects
   d. A large dose initially to decrease the initial level of pain

Answer 2

Answer: c
Based on the patient’s report of pain, the nurse administers the dose of medication that is effective in relieving pain without causing adverse side effects. Administering too small of a dose does not relieve pain. Administering a large dose may result in unwanted side effects. Addiction to narcotics is rare.

Question 3

3. Which method is the most accurate way to determine the pain level of a patient who is alert and oriented?
   a. Evaluate whether the patient is crying or grimacing.
   b. Assess the patient’s heart rate and blood pressure.
   c. Consider the seriousness of the patient’s condition.
   d. Ask the patient to describe the pain and rate its level.

Answer 3

Answer: d
Because pain is defined as what a patient says it is, a patient’s report based on the pain scale is currently the most accurate way to determine the pain level of a cognitively alert patient. Crying or grimacing may be considered on a noncognitive scale for a nonverbal patient. Vital signs and the patient’s condition contribute to a pain assessment, but they may not be the most accurate determinants.

Question 4

4. A patient who has a serious back injury received intravenous medication for pain approximately 1 hour earlier. The patient practices relaxation techniques but still is reporting pain at a level of 9 of 10. What is the next action that should be taken by the nurse?
   a. Report the lack of pain relief to the primary care provider.
   b. Tell the patient to give the medication more time.
   c. Reposition the patient and try diversion activities.
   d. Document in the nurse’s notes that the patient has a low pain tolerance.

Answer 4

Answer: a
If the patient with a serious injury is not obtaining pain relief from pharmacologic and nonpharmacologic interventions, the primary care provider should be notified. Waiting longer and using more nonpharmacologic interventions are not likely to relieve pain in this situation.

Question 5

5. The nurse recognizes which cue from the patient as a physiologic response to acute pain?
   a. Increased blood pressure
   b. Decreased pulse
   c. Increased temperature
   d. Restlessness

Answer 5

Answer: a
Acute pain can increase blood pressure and pulse rate but may not affect temperature. Restlessness is a psychological response, not physiologic.

Question 6

6. When administering analgesics to elderly patients, what information does the nurse need to understand?
   a. Start with a low dose, and increase the dose as needed for pain relief.
   b. Start with a high dose and decrease the dose as pain is relieved.
   c. Start with a midrange dose and increase or decrease the dose as needed for pain.
   d. Start with a low dose and decrease the dose every other day.

Answer 6

Answer: a
Due to decreased metabolism and clearance of medications, start with a lower dose and increase as indicated for pain relief. A high dose may result in drug toxicity. Too low of a dose will not relieve pain.

Question 7

7. The nurse administered intravenous morphine at 0830. At what time will the nurse evaluate the patient for pain relief?
   a. 1000
   b. 1030
   c. 0900
   d. 0930

Answer 7

Answer: c
After administering intravenous medication, check the patient in 15 to 30 minutes for relief from pain. Intravenous medication is injected directly into the bloodstream and bypasses the gastric system metabolism.

Question 8

8. The endocrine system releases excessive hormones during episodes of acute pain. The nurse should monitor patients experiencing acute pain for which potential problem?
   a. Hyperglycemia
   b. Migraine headache
   c. Hypokalemia
   d. Diarrhea

Answer 8

Answer: a
Release of hormones causes the blood glucose level to increase, causing hyperglycemia. Hypokalemia may result from the metabolic effects of genitourinary injury. Constipation results from decreased intestinal motility. Migraine headaches are not a result of hormone release during acute pain.

Question 9

9. The patient who had a below-the-knee amputation 3 days ago complains of pain from the amputated extremity. Which response by the nurse best explains what the patient is experiencing?
   a. “Your phantom pain will subside when the brain realizes the lower extremity is no longer there.”
   b. “Your radiating pain will continue for months because the lower extremity is no longer there.”
   c. “You are suffering from referred pain, which you will always have, but it will lessen with time.”
   d. “You are experiencing psychogenic pain because loss of an extremity is an emotional loss.”

Answer 9

Answer: a
Phantom pain occurs when the brain continues to receive messages from an area of amputation. Over time, the brain will adapt to the loss of the limb. Radiating pain extends from the source of pain to an adjacent area of the body. Referred pain originates in one area of the body but hurts in another area of the body. Psychogenic pain is pain perceived by the patient but has no physical pain.

Question 10

10. A patient who has type 2 diabetes is admitted to the hospital with a fractured left femur. What are the two highest-priority actions for the nurse to implement? SELECT TWO THAT APPLY
    a. Starting an intravenous solution of lactated Ringer solution
    b. Administering ordered pain medication after taking vital signs
    c. Glucometer testing to monitor the patient’s blood glucose level
    d. Giving the ordered prophylactic antibiotic to prevent infection
    e. Encouraging assisted ambulation to avoid blood clot formation

Answer 10

Answer: b, c
The highest-priority actions are to administer the patient’s prescribed pain medication and checking the patient’s blood glucose level. Pain control and blood glucose monitoring are very important as stress caused by pain can cause an increase in blood glucose. Starting an ordered IV solution and administering prophylactic antibiotics can follow analgesia administration and glucometer testing. Encouraging assisted ambulation is not indicated at this time. A sequential compression device (SCD) may be ordered for the patient’s right, uninjured leg to prevent blood clot formation before the patient has surgery to repair the fractured femur.

Question 11

THE CONCEPT OF PAIN

Answer 11

The International Association for the Study of Pain (2018) defines pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This is the most widely used definition today.

Pain has physical and emotional aspects.

Pain is whatever the person with the pain says it
is and it exists whenever the person says it does

Pain may prevent injury or results from injury

Pain is the most subjective of all symptoms that
patients experience.

Cognitive, affective, behavioral, and sensory
factors can influence pain.

Cognitive, affective, behavioral, and sensory
factors can influence pain

Question 12

Does it make sense to educate a patient while they are suffering in severe pain?
A. Yes
B. No

Answer 12

B. No

Patients that are currently going through pain may become delirious due to the amount of pain they are experiencing, the best way to make sure your patient is all ears through out your teaching, is to make sure you relief they’re pain with an IV PO, IM, SUB, TOPICAL, TRANSDERM med then teaching them after they’re pain is relief .

IV pain meds take about 15-30 minutes to be distributed to relief pain in the body.

Question 13

Who’s responsibility is it to relieve the patients’ pain?
A. Registered Nurse
B. Environmental Health
C. Certified Nursing Assistant
D. Patient Care Tech

Answer 13

A. Registered Nurse

Question 14

Nurses and Pain Management

Answer 14

Pain should be assessed and documented to provide comfort at a level acceptable to each patient. In 2018, the American Nurses Association (ANA) published a position statement on pain management to guide nursing practice. The ANA believes:

• Nurses have an ethical responsibility to relieve pain and the suffering it causes.
• Nurses should provide individualized nursing interventions.
• Multimodal and interprofessional approaches are necessary to achieve pain relief.
• Pain management modalities should be informed by evidence.
• Nurses must advocate for policies to assure access to all effective modalities.
• Nurse leadership is necessary for society to appropriately address the opioid epidemic. (ANA, 2018).

Question 15

Analgesic

Answer 15

(pain-reducing) medication

Question 16

As a nurse should pain be assessed on a regular basis?

Answer 16

Yes!

In 2001 The Joint Commission (TJC) developed a standard of pain management for the care of hospitalized patients. This standard resulted from the undertreatment of pain. Since that time, TJC has required that pain be assessed on a regular basis.

Question 17

Nursing and Pain Management Assessment Part 2

Answer 17

Pain should be assessed and
documented to provide comfort.

In addition to assessing for pain, the
nurse:

Question 18

Types of PAIN

Answer 18

Acute pain- labor, trauma, surgery, acute disease
* Chronic pain- arthritis , neuropathy, fibromyalgia
* Nociceptive pain- surgery, inflammation, trauma
* Visceral- pain in organs (heart, bladder, bowels,lungs kidneys)
* Somatic- pain in skin, bone, muscles and joins (
* Referred- pain in an area other than. the area that causing the pain (jay and left arm pain with myocardial infraction - heart attack
* Radiating-Radiating pain extends from the source to an adjacent area of the body. For example, in gastroesophageal reflux, pain in the stomach radiates up the esophagus
* Neuropathic pain- Neuropathic pain results from nerve injury, and the pain continues even after the painful stimuli are gone. Sometimes referred to as pathologic pain, neuropathic pain may stem from injury to nerves in the central or peripheral nervous system (Baron, Binder B, & Wasner, 2017).
* Dysesthesia- Patients may have dysesthesia (unpleasant, abnormal sensation), allodynia (pain from noninjury stimuli),
* Allodynia
* Hyperalgesia- hyperalgesia (excessive sensitivity), or hyperpathia (greatly exaggerated pain reaction to stimuli).
* Hyperpathia- hyperalgesia (excessive sensitivity), or hyperpathia (greatly exaggerated pain reaction to stimuli).
* Phantom pain- Phantom pain occurs when the brain continues to receive messages from the area of an amputation.
* Plasticity- Over time, the brain adapts to the loss of the limb, and the pain stops. This adaption is called plasticity
* Psychogenic pain- Pain that is perceived by an individual but has no physical cause is called psychogenic pain. It may be caused, increased, or prolonged by mental, emotional, or behavioral factors. Some patients may report headaches, back pain, or stomach pain that is psychogenic pain.

Question 19

Nociceptors

Answer 19

Nociceptors are the free endings of afferent nerve fibers, which are sensory neurons sensitive to noxious thermal, mechanical, or chemical stimuli. These pain receptors are distributed throughout the body, with the highest density found in the skin, making the skin extremely sensitive to pain.

Question 20

Pain threshold

Answer 20

The pain threshold is the lowest intensity at which the brain recognizes the stimulus as pain

Question 21

Pain tolerance

Answer 21

Pain tolerance is the intensity or duration of pain that a patient is able or willing to endure. Tolerance varies from person to person and from one injury to another. For example, one patient in early labor may request pain medication as soon as possible because she has a low tolerance for pain.

Question 22

Nociceptive pain

Answer 22

Nociceptive pain is the most common type of pain. This type of physiologic (physical) pain occurs when nociceptors are stimulated in response to trauma, inflammation, or tissue damage from surgery.

example, Characteristically, nociceptive pain may be sharp, burning, aching, cramping, or stabbing. Nociceptive pain originates in visceral and somatic locations.

“Can occur with menstrual cramping”

Question 23

Visceral pain

Answer 23

Visceral pain arises from the organs of the body and occurs in conditions such as appendicitis, pancreatitis, inflammatory bowel disease, bladder distention, and cancer.

Question 24

Somatic Pain

Answer 24

Somatic pain results from injury to skin, muscles, bones, and joints. Somatic pain occurs in conditions such as sunburn, lacerations, fractures, sprains, arthritis, and bone cancer.

Question 25

Acute pain

Answer 25

most frequently is defined as pain lasting less than 3 to 6 months.

Rapid, onset short duration

Question 26

Chronic Pain

Answer 26

Chronic pain is identified as persisting longer than 3 months postoperatively (Gilron, Vandenkerhof, Ka , et al., 2017), longer than 6 months, or beyond a normal healing period (Jamison & Edwards, 2012).

Question 27

Referred Pain

Answer 27

Referred pain originates in one area but hurts in another area, such as pain from a myocardial infarction (i.e., heart a ack) (Fig. 36.3). The pain is caused by lack of oxygen to the heart muscle, but the pain may be felt in the jaw or down the left arm.

The pain occurred in one place but you are feeling it somewhere else,

Question 28

Radiating Pain

Answer 28

Radiating pain extends from the source to an adjacent area of the body. For example, in gastroesophageal reflux, pain in the stomach radiates up the esophagus.

example
if you have a herniated disc, you may have pain in your lower back. This pain might travel along the sciatic nerve, which runs down your leg

Question 29

Neuropathic pain

Answer 29

Neuropathic pain results from NERVE INJURY, and the pain continues even after the painful stimuli are gone. Sometimes referred to as pathologic pain, neuropathic pain may stem from injury to nerves in the central or peripheral nervous system

Sources of neuropathic pain include neuropathies, tumors, infection, and chemotherapy. Examples of disease processes that may invoke or involve secondary neuropathic pain are diabetes mellitus, cerebrovascular accident (such as brain a ack or stroke), viral infections, carpal tunnel syndrome, and phantom limb pain.

Question 30

Phantom Pain

Answer 30

Phantom pain occurs when the brain continues to receive messages from the area of an amputation. Over time, the brain adapts to the loss of the limb, and the pain stops. This adaption is called plasticity

Question 31

safe practice alert

Answer 31

When treating an elderly patient for pain, start with a low dose within the prescribed range and slowly increase the dosage to relieve pain. Opioid doses should start 50% to 75% lower than the normal adult dose to avoid oversedation (

Question 32

How would a pt with acute pain present , vital signs

Answer 32

Vital signs may vary according to how the patient perceives pain. Elevated pulse and blood pressure values may indicate acute pain and a need for pain medication.

Question 33

how would a pt present with chronic pain, vital signs

Answer 33

A decrease in blood pressure and pulse rate may indicate chronic pain.

EXAMPLE ARTHRITIS

Question 34

Physiologic Responses to Pain

Answer 34

Physiologic Responses to Pain
Multiple systems of the body may be affected by pain, depending on its severity and duration. For instance, if a patient is in acute pain, the patient’s heart rate, respiratory rate, and blood pressure increase above the patient’s normal baseline due to a response by the sympathetic nervous system. With chronic or prolonged pain, the parasympathetic nervous system responds with a decrease in the systolic blood pressure and a decrease in the pulse rate below the patient’s normal baseline. Table 36.4 contains a list of the clinical manifestations commonly associated with each body system.

Question 35

Behavioral Response & Psychological Response to Pain

Answer 35

Behavioral and Psychological Responses to Pain
While assessing the patient, the nurse may notice behaviors that the patient is exhibiting in response to pain, including facial grimaces, clenched teeth, rubbing or guarding of the painful area, agitation, restlessness, and withdrawal from painful stimuli. A patient in labor may use effleurage (rhythmic massaging of the abdomen with her hands) and immobilization to help deal with uterine contraction pain. Vocalizations of pain may be expressed as crying, moaning, or screaming.

Question 36

Psychological Response to Pain

Answer 36

Patients may exhibit psychological responses to pain, including anxiety, fear, depression, anger, irritability, helplessness, and hopelessness. When a patient is anxious, fearful, or angry, the nurse addresses the patient’s physical needs first. The nurse provides a comfortable environment and privacy for the patient. Then the nurse communicates with clear, simple validating statements to relieve the stress of the situation and develop a trusting relationship with the patient. The nurse needs to allow time for the patient to verbalize feelings and concerns regarding pain relief to assess the patient’s coping abilities. The nurse acknowledges the patient’s pain experience and expresses acceptance of the patient’s response to pain. After pain has been assessed, the nurse uses nursing diagnoses to develop a plan of care for the patient.

Question 37

Endocrine Systems Response to Pain

Answer 37

Endocrine system: Pain triggers the release of excessive amounts of hormones, including cortisol, adrenocorticotropic hormone (ACTH), antidiuretic hormone (ADH), growth hormone, catecholamines, glucagon, insulin, and testosterone. The release of these hormones results in carbohydrate, protein, and fat catabolism (breakdown), and poor use of glucose, leading to hyperglycemia (high blood glucose levels).

Question 38

Cardiovascular system response to Pain

Answer 38

• Cardiovascular system: Pain increases cardiac workload and oxygen demand. Decreased oxygen delivery to the cells leads to increases in the heart rate and force of contraction. Blood pressure increases, and increased workload may cause plaque formation, narrowing of the arteries, possible blood clot formation, and increased risk for myocardial infarction (heart a ttack). In situations of prolonged or unrelieved pain, blood pressure and pulse may decrease due to parasympathetic stimulation.

Question 39

• Respiratory system response to Pain :

Answer 39

: Pain reduces tidal volume (air exchange) and increases inspiratory and expiratory pressures. The respiratory rate increases and becomes irregular in an attempt to distribute more oxygen to the cells. Prolonged pain may cause a reluctance to breathe deeply, which limits thoracic expansion. If this continues, pneumonia and atelectasis may occur.

Question 40

Musculoskeletal Response to Pain

Answer 40

• Musculoskeletal system: Pain impairs muscle function and the capacity to perform activities of daily living (ADLs). The patient experiences muscle spasms, muscle tension, and fatigue. A withdrawal response is initiated by the patient’s prolonged pain.

Question 41

Genuitary System’s response to Pain

Answer 41

• Genitourinary system: Pain causes the release of ACTH, catecholamines, aldosterone, angiotensin II, cortisol, and prostaglandins. Blood pressure increases through activation of the renin- angiotensin system. Urine output decreases, and urinary retention increases. Fluid overload and hypokalemia may result.

Question 42

• Gastrointestinal system response to Pain

Answer 42

Pain decreases gastric emptying and motility, increases gastrointestinal secretions, and increases smooth muscle tone. Metabolism is slowed, resulting in indigestion from the slow movement of food in the gastrointestinal tract. Constipation may develop from decreased intestinal motility, anorexia, and weightloss.

Question 43

• Immune system response to Pain

Answer 43

• Immune system: The inflammatory response is initiated by painful stimuli. Inflammatory mediators are released in an a ttempt to prevent further tissue injury, fight infection, and reduce pain. Some of the inflammatory mediators that are released may contribute to persistent pain.

Question 44

Pain Assessment

Answer 44

S: Site (Where is the pain located?)
O: Onset (When did the pain start? Was it gradual or sudden?) C: Character (What is the quality of the pain? Is it stabbing,
burning, or aching?)
R: Radiation (Does the pain radiate anywhere?)
A: Associations (What signs and symptoms are associated with the
pain?)
T: Time course (Is there a pa ern to when the pain occurs?)
E: Exacerbating or relieving factors (Does anything make the pain
worse or lessen it?)
S: Severity (On a scale of 0 to 10, what is the intensity of the pain?

Because pain is a very individual, subjective experience, nurses cannot objectively assess pain in patients. Completing a thorough pain assessment requires nurses to ask patients about several critical areas of concern: pain location, onset, quality, intensity, and pa ttern; precipitating and alleviating factors; and associated symptoms. The mnemonics SOCRATES, PQRST, and OLDCARTS are used by many health care personnel to help them remember each area of pain assessment. The le ers in SOCRATES have the following meanings:

Question 45

Who is the Won Baker intended for?

Answer 45

Descriptors of pain are denoted verbally in the Verbal Descriptor Scale and the Wong-Baker FACES Pain Rating Scale. Use the FACES scale or behavioral observations to interpret expressed pain when patients have difficulty communicating their pain intensity. These tools can be used worldwide for assessing pain. for children, verbally impaired.

Question 46

Pain Management - Nonpharmacologic

Answer 46

Nonpharmacologic pain management and complementary and alternative therapies are recommended for patients with mild pain who do not want to use medication to control pain.

NO MEDICATION AT ALL

Question 47

What is Nonpharmcalogic therapy

Answer 47

no use of drugs to relieve patients pain

Question 48

Complementary Therapy

Answer 48

Complementary therapies are implemented to enhance the effect of pharmacologic treatment, and alternative therapies take the place of pharmacologic interventions

Question 49

Alternative Therapy

Answer 49

alternative therapies take the place of pharmacologic interventions

NO MEDICATIONS JUST ALTERNATIVE THERAPY

Question 50

Examples of Complementary and Alternative Therapy

Answer 50

Herbal remedies: The use of certain herbal mixes relieves pain; examples are ginger, rosehips, feverfew, and black cohosh.
* Yoga: Slow stretches and deep breathing build strength, release muscle tension, and improve flexibility to bring the body into balance and the mind into a focus on something other than pain.
* Biofeedback: Taking control of body responses to pain is achieved through voluntary control over physiologic body activities, such as relieving muscle tension.
* Meditation: Meditating (sometimes referred to as mindfulness) restores the body to a calm state through controlled breathing and relaxation to decrease stress and pain.
* Aroma therapy: Breathing the fragrance of essential oils that contain oxygenating molecules can help transport nutrients to the cells in the body.
* Hypnosis: Used for all types of pain, hypnosis alters the state of consciousness to modify memory and perception of pain and reduces cortical activation associated with painful stimuli.
* Reiki and therapeutic touch: Hand placement to correct or balance energy fields restores health by restoring communication between cells, thereby diminishing pain.
* Traditional Chinese medicine:
* Acupuncture: The insertion of fine needles into the skin at
various depths causes secretion of endorphins and
interferes with transmission of pain impulses.
* Acupressure: The application of pressure at acupuncture
sites interferes with transmission of pain impulses.
* Cupping: The application of plastic or glass cups with
suction over muscle areas increases local circulation and promotes muscle relaxation and pain reduction.

Question 51

Multimodal Pain Medications

Answer 51

Multimodal analgesia is the use of more than one means for controlling pain. When more than one type of agent is used, analgesia is more effective, requires lower doses of each agent, and produces fewer side effects. Multimodal analgesia may be two medications (e.g., acetaminophen with codeine, morphine sulfate with gabapentin) or a medication used in combination with a complementary therapy (e.g., topical ointment with massage therapy, essential oils)

Question 52

Preemptive analgesia

Answer 52

Preemptive analgesia is the administration of medications before a painful event to minimize pain. Medications administered before surgery or before dressing changes are examples of preemptive analgesia.

Question 53

Nonpharmacologic pain management
and complementary and alternative
therapies

Answer 53

• Positioning, splinting, massage, progressive
  relaxation techniques, guided imagery,
  meditation
• Distraction (television, music, and
  conversation)
• Spiritual support (prayer and meditation)
• Neurologic and neurosurgical pain therapies

Question 54

Non-opioid analgesics

Answer 54

Nonopioid analgesics include acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and aspirin.

These drugs are used in the treatment of many types of mild to moderate pain. Mild pain is rated as 1 to 3 on a numeric pain scale; it may be an achy feeling to the patient. Moderate pain is classified as 4 to 7 on a numeric pain scale; it may be the type of pain a patient experiences on day 3 after surgery. Nonopioids are not addictive and are safer for the patient to use than opioid analgesics, although patients may become dependent on nonopioids for pain relief.

Question 55

What medication is an example of an NSAID
a. Ibuprofen
B. Zofran
C. Senna
D. Docusate

Answer 55

a. Ibuprofen

nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and aspirin.

Question 56

What properties does acetaminophen have?

Answer 56

Acetaminophen has analgesic and antipyretic capabilities and is a safe pain relief agent for most patients, including those with liver disease, if monitored closely and administered within the safe dosage range. Special caution should be taken when giving acetaminophen to infants, children, and the elderly. Long-term use may result in hepatotoxicity, renal damage, or leukopenia.

Acetaminophen is used for fever reduction and for mild to moderate pain from conditions such as a mild headache or general achiness.

Question 57

What would be a toxic level of acetaminophen ingested

Answer 57

The total daily dose should not exceed 3,000 mg.

Question 58

NSAID NON-STERIDOL ANTI INFLAMMATORY DRUGS

Answer 58

NSAIDs are more useful than acetaminophen in treating inflammatory pain and bone pain. NSAIDs have antiinflammatory effects in addition to analgesic and antipyretic qualities. Aspirin is also an effective agent for decreasing platelet aggregation in patients who are prone to blood clots or at risk for myocardial infarction.

ASPIRIN - IBRUPHOPHEN
Unfortunately, NSAIDs have significant side effects, including possible gastrointestinal upset and bleeding and cardiac and renal complications. These side effects may be avoided by taking the drugs with food and taking the prescribed dose. Proton pump inhibitors (PPIs) or histamine H2-receptor blockers are often prescribed for
patients who are on long-term NSAID therapy to help reduce the incidence of stomach ulcers.

Question 59

OPIOID ANALGESIC

Answer 59

Opioid analgesics are the most effective agents for relief of moderate to severe pain. These narcotic medications work by binding to the opioid receptors in the nervous system, which are sites of endorphin action. There are many types of opioid analgesics, including agonist analgesics and agonist-antagonist analgesics.

Question 60

Agonist-antagonist analgesics

Answer 60

Agonist-antagonist analgesics include pentazocine, butorphanol, dezocine, and nalbuphine. These medications are used for moderate to severe pain. They depress the pain-impulse transmission at the spinal cord by acting with opioid receptors. They are normally administered by the intramuscular or intravenous route. Dosing is every 1 to 4 hours, depending on the drug. The nurse needs to be aware of patient drowsiness, dizziness, nausea, vomiting, itching, and respiratory depression. Treatment for these adverse effects is the same as that for the adverse effects associated with agonist analgesics.

Question 61

Agonist analgesics

Answer 61

Agonist analgesics, such as morphine, hydromorphone, oxycodone, fentanyl, and meperidine, are the most effective agents for relief of severe pain, which is rated 7 to 10 on a numeric pain scale.

They may change the patient’s perception of pain while relieving the pain. Routes of administration include oral, transdermal, intramuscular, or intravenous. Research continues to identify the best methods for pain relief in various situations (Box 36.10). When administered intramuscularly or intravenously, these medications may be given every 1 to 3 hours, depending on the dose administered. The nurse needs to be aware of adverse effects such as respiratory depression, seizures, nausea, vomiting, constipation, itching, and urinary retention. The nurse may administer an antagonist analgesic for the respiratory depression, antiemetics for the nausea and vomiting, and an antihistamine for itching. Dizziness, blurred vision, confusion, and orthostatic hypotension may occur.

Question 62

Antagonist Analgesics

Answer 62

Antagonist analgesics such as naloxone are used for the treatment of opioid analgesic overdose. They compete with opioids at the opioid receptor sites, decreasing the side effects of opioids. They are administered intravenously, intramuscularly, subcutaneously, or into an endotracheal tube every 2 to 3 minutes until symptoms of opioid overdose subside. Signs of opioid withdrawal, such as vomiting, hypertension, and anxiety, may occur up to 2 hours after administration.

Question 63

Patient-controlled analgesia (PCA)

Answer 63

Patient-controlled analgesia (PCA) is a system in which an electronically controlled infusion pump immediately delivers a prescribed amount of analgesic to the patient when he or she activates a bu tton, without the need for a nurse to administer it.

The purpose of PCA is improved pain control. PCA uses more frequent but smaller doses of medication, usually opioids (i.e., morphine sulfate, fentanyl, or hydromorphone), and provides more even levels of medication in the patient’s body. The PCA pump can deliver medicine into a vein (intravenously, the most common method), under the skin (subcutaneously), or between the dura mater and the spinal cord (epidurally). When the medication is delivered intravenously, the site must be monitored for infiltration and phlebitis.

Question 64

The following are additional methods by which opioids are delivered:

Answer 64

On-Q infusion pump provides continuous infusion of local anesthesia through an antimicrobial catheter, which destroys or inhibits microorganism growth on the catheter. It is most often used for postoperative pain control after abdominal surgery.

• Transdermal administration consists of a
  medicated adhesive patch (e.g., fentanyl ITS) that is placed on the skin to deliver a specific dose of medication through the skin, allowing absorption into the bloodstream.
• Intrathecal injection or infusion of a narcotic or local anesthetic into the subarachnoid space through a needle or catheter provides pain relief to a large area of the body. It may be used as spinal anesthesia for surgery, cancer pain, or relief from spasms that occur with spastic cerebral palsy.
• Epidural analgesia is continuous infusion of a narcotic or local anesthetic into the epidural space by insertion of a needle or catheter for relief of acute or chronic pain. It is used for labor pain, surgery, and cancer pain because it numbs the nerve endings in a local area of the body.
• Nerve block is an injection of a local anesthetic into or near spinal nerves for temporary pain control. The anesthetic can be injected into the cervical, thoracic, lumbar, and sacral areas of the spinal column. Nerve blocks can be used for migraine headaches, dental work, back pain, herniated disks, and cancer pain.

Question 65

Accidental Ingestion

Answer 65

Accidental Ingestion
In addition to individuals dying from accidental overdose and substance use disorder, children are in danger of accidental ingestion when narcotics are not kept secure and out of reach. Approximately 60,000 young children are taken to the emergency department because of taking medications left unsecured (Up & Away.org, 2018). Nurses can be instrumental in reducing accidental overdose by minors by educating patients, family members, and care providers of prevention strategies (Box 36.12). Research findings indicate that when a primary care provider (PCP) failed to discuss safe disposal of analgesics, twice as many parents kept leftover pain medication at home, vulnerable to child access (C.S. Mo Children’s Hospital, 2016).

Question 66

Palliative care

Answer 66

Goal: to help relieve pain caused by serious
illness regardless of the patient’s prognosis

Another option for pain relief is palliative nursing care. The goal of palliative care is to help relieve pain caused by serious illness, regardless of the patient’s prognosis. Palliative care is appropriate for patients of any age and for any stage of serious illness. Typically, a group of physicians, nurses, and social workers work as a team to provide the appropriate treatment for the patient. Palliative care improves the quality of life of patients and families who face a life- threatening illness by providing pain and symptom relief and supplying spiritual and psychosocial support from diagnosis to the end of life and bereavement.

Question 67

Adjuvant or Coanalgesic Medications

Answer 67

Adjuvant medications, or coanalgesic medications, work synergistically with standard pain medications to enhance pain relief and to treat side effects of the medication.

Question 68

Example of Adjuvant or Coanalgesic Medications

Answer 68

For example, tricyclic antidepressants and anticonvulsants may be used together to treat neuropathic pain.

Antiemetics are often administered with opioid analgesics to counteract the nausea and vomiting.

Laxatives or stool softeners (e.g., senna, docusate) are prescribed to prevent constipation,

Antihistamines (e.g., diphenhydramine) are given to decrease the itching side effect of morphine.

Ketorolac (Toradol) is an NSAID used along with opioid analgesics to enhance pain relief.

Caffeine is used with analgesics to treat migraine headaches.

Question 69

Therapeutic Decision Making

Answer 69

The nurse evaluating and administering care to the patient makes the therapeutic decision about best treatment based on knowledge of pain relief techniques and the PCP orders

After vital sign and pain scale assessments are completed, the nurse determines the level of intervention the patient needs.

When the PCP has ordered a range of pain medication for a patient, the nurse can titrate the dose on the basis of the patient’s pain assessment.

If the pain is severe, the nurse may begin with a higher dose or stronger opioid to obtain pain relief. If the patient complains of moderate pain, the nurse may try giving a nonopioid pain medication, such as acetaminophen or ibuprofen. For mild pain, the nurse may try nonpharmacologic interventions before administering a nonopioid pain medication if ordered. Helpful information from the American Society of Pain Management Nurses and the American Pain Society on range dosing of opioid analgesics for pain management is available at

Question 70

Assessing pain relief

Answer 70

To determine whether pain relief methods are effective, the nurse evaluates the patient’s level of pain relief and documents the results in the patient’s chart. The WHO’s (2018) pain relief ladder to treat cancer pain is a tool that helps health care providers determine which pain medication and adjuvant therapy may be most effective on the basis of the intensity of the reported pain (Fig. 36.5). Although criticism of the pain ladder has emerged in recent years, it remains a framework on which to determine analgesic dosing in a variety of situations (ACOG, 2018).

Question 71

Around the Clock medications admin

Answer 71

The timing of pain medication administration can be critical in providing adequate pain relief. There is strong support for providing around-the-clock dosing of analgesia to prevent pain levels from ge ing too high. Consistent analgesia helps maintain medication blood levels and prevent pain recurrence. If a patient delays asking for pain medication until the pain is severe, the nurse may need to administer higher doses of analgesia or stronger medications to initially get the patient’s pain under control. Relief from pain may take longer.

Question 72

Barriers to Adequate Pain Management

Answer 72

Patient barriers: fear of addiction,
cost of medication, and no
access to health care
* Health care provider barriers:
poor pain assessment skills,
inaccurate beliefs, prejudicial
attitudes

Question 73

Barriers within the health care system

Answer 73

• Pain not a priority, systematic pain
  management approaches and pain
  management teams not in place, inadequate
  reimbursement for pain medications,
  regulations may restrict access to
  medications
• Patients have a right to pain relief.
• Inadequate pain management may lead to
  detrimental outcomes.

Question 74

2. The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective?
   a. The patient is sleeping quietly.
   b. The patient states a reduction of the pain.
   c. The patient’s respirations are slow and regular.
   d. The patient’s blood pressure has returned to baseline.

Answer 74

ANS: B
The best way for the nurse to determine that the pain medication was effective is for the patient to state a reduction of the pain. The other assessment findings cannot definitively determine whether the patient is still in pain.

Question 75

3. The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. The nurse recognizes which type of pain is this patient experiencing?
   a. Visceral pain
   b. Somatic pain
   c. Radiating pain
   d. Referred pain

Answer 75

a. Visceral pain

Visceral pain arises from the organs of the body and occurs when inflammation and tissue damage occur, such as with cholecystitis. Somatic pain occurs when there is tissue damage to skin, muscle, joints, and bones. Referred pain occurs when the discomfort is felt at a location other than the origin of the pain. Radiating pain extends to another area of the body.

Question 76

4. The nurse knows which is the best pain medication option for a patient to manage severe long-term cancer pain at home?
   a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours
   b. Meperidine (Demerol) 50 mg IM q 6 hours
   c. Hydromorphone (Dilaudid) 0.2 mg q 10 minutes IV via PCA pump
   d. Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter

Answer 76

ANS: A
An opioid transdermal patch is the best pain management option for home use with patients who have long-term, severe cancer pain as no injections are required and the opioid is slowly released. Epidurals and PCA pumps are intended for hospital use. Frequent IM injections require nursing administration, are not comfortable for the patient and are not optimal for chronic long-term pain.

Question 77

5. The nurse is caring for a patient with severe chronic pain and applied the first 50 mcg transdermal fentanyl (Duragesic) patch 2 hours ago. The patient states that the pain is presently rated at 9 on a 1 to 10 scale. What is the nurse’s best action?
   a. Instruct the patient that the fentanyl patch will start to work soon.
   b. Check the provider’s orders for a short-acting narcotic medication to administer
   for breakthrough pain.
   c. Give the patient a gentle back rub and encourage guided imagery.
   d. Apply a second 25-mcg transdermal fentanyl patch now.

Answer 77

b. Check the provider’s orders for a short-acting narcotic medication to administer
for breakthrough pain.

Transdermal administration of medication does not become effective for 12 to 16 hours after application. Short-acting narcotic medication should be given in the meantime to make the patient comfortable.

Question 78

6. The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for the last several months to relieve knee pain from arthritis. Which assessment finding must be reported by the nurse to the provider promptly?
   a. The patient has abdominal pain and pale skin.
   b. The patient has constipation and takes stool softeners daily.
   c. The patient enjoys a glass of wine every Friday and Saturday evening.
   d. The patient has gained 15 lb in the last 3 months.

Answer 78

ANS: A
Ibuprofen (Motrin) is an NSAID and NSAIDs have significant side effects, including possible gastrointestinal upset and bleeding and cardiac and renal complications. Abdominal pain with pale skin in this patient may be indicative of a bleeding ulcer and should be reported to the provider promptly.

Question 79

7. The nurse is caring for a patient who just underwent laparoscopic appendectomy. The patient complains of severe postoperative pain between the shoulder blades. Which term best describes the pain that this patient is having?
   a. Referred pain
   b. Phantom pain
   c. Neuropathic pain
   d. Psychogenic pain

Answer 79

ANS: A
Referred pain is pain that occurs when discomfort is felt in a different area than the source of the pain. Phantom pain occurs in amputees when pain is felt in the missing limb. Neuropathic pain occurs in the nervous system and often feels like burning or tingling. Psychogenic pain is discomfort felt by the patient that has no physical cause.

Question 80

8. The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 a.m. to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained?
   a. 10:30 a.m.
   b. 11:00 a.m.
   c. 11:30 a.m.
   d. 12:00 noon

Answer 80

ANS: A
Sublingual pain medications should be working well 15 to 30 minutes after administration, so the nurse should reassess the patient’s pain at 10:30 a.m.

Question 81

9. The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient’s care plan related to this pump?
   a. Assess the patient’s respiratory status frequently after PCA pump started.
   b. Review patient’s medication profile to check for interactions with
   hydromorphone.
   c. Teach the patient how to use PCA pump when the pain level is still tolerable.
   d. Keep naloxone (Narcan) available at the bedside in case of respiratory depression.

Answer 81

ANS: A
For patient safety, the nurse would check the patient’s respirations frequently after the pump has been initiated due to possible respiratory depression. Reviewing the medication profile would occur prior to initiating the pump. Teaching the patient how to use the pump is important, but not the priority. Naloxone should be close by to treat respiratory depression but monitoring the respirations frequently would hopefully prevent depression.

Question 82

12. The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain. Which nursing diagnosis is the highest priority for this patient?
    a. Impaired mobility r/t patient’s need to use a cane or walker with ambulation.
    b. Impaired health maintenance r/t sedentary lifestyle and poor physical condition.
    c. Anxiety r/t mistrust of health care personnel.
    d. Chronic pain r/t ongoing inflammatory tissue damage and joint destruction.

Answer 82

ANS: D
Chronic pain is the highest priority diagnosis for this patient becauSE it is severe. The other diagnoses may be addressed once the patient’s pain is controlled.

Question 83

14. The nurse identifies which patient to be best suited for PCA analgesia?
    a. A patient who is confused after a head injury.
    b. A patient recovering from total hysterectomy surgery.
    c. A patient who has severe psychogenic pain.
    d. A patient with arthritis who is unable to push the nurse call button.

Answer 83

ANS: B
Patients recuperating from surgery are often good candidates for PCA analgesia. Confusion, inability to push the PCA button, and psychogenic pain are all contraindications for PCA analgesia.

Question 84

15. What is the priority nursing assessment for a patient who is receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?
    a. Respiratory rate, depth, and pattern
    b. Skin underneath the epidural dressing
    c. Bladder scanning to check for urinary retention
    d. Itching on the trunk and/or extremities

Answer 84

ANS: A
The respiratory system is the priority nursing assessment for patients receiving narcotic pain medication via any route. This is because narcotics can cause respiratory suppression. The other assessments are a lower priority and may be done after a respiratory assessment is completed.