UNIT 1 CHAPTER 5 PAIN MANAGEMENT

Question 1

What is Pain?

Answer 1

the unpleasant sensory and emotional experience associated with tissue damage that results from acute injury, disease, or surgery.

Question 2

What is Breakthrough pain?

Answer 2

additional pain that “breaks through” the pain being managed by the mainstay analgesic drugs.

Question 3

What is Persistent Pain/Chronic Pain?

Answer 3

(also called chronic pain) pain that persists or recurs for an indefinite period, usually for more than 3 months, often involves deep body structures, is poorly localized, and is difficult to describe.

Question 4

What is Nociceptive Pain?

Answer 4

nociceptive pain the result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral.

Question 5

What is pain?

Answer 5

pain an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The most reliable indication of pain is the patient’s self-report.

Question 6

Is a patient blood pressure high or low when they have Persistent Pain/ Chronic Pain?

Answer 6

“LOW”

it persists for an extended period, it can interfere with personal relationships and performance of ADLs. Persistent pain can also result in emotional and financial burdens, depression, and hopelessness for patients and their families. It is important to remember that the body adapts to persistent pain; thus vital signs such as pulse and blood pressure may actually be lower than normal in people with persistent pain.

Question 7

Affects of Acute/Short Term Pain

Answer 7

Short-term
– Fight or flight response (All body systems elevates, HR UP ,RR UP, PUPIL DIALTION, DIAPHORESIS,HIGH BLOOD SUGAR, CORTICORSTERIOOS IN BLOOD, ANTI DIUERECTIC HORMONE ELEVATED)
– Causes body to address pain and stress caused by pain, rather than healing
(Delayed healing)
– Can lead to long-term issues
SYMPATHETIC SYSTEM ACTIVATED

Question 8

Affects of Chronic/Persistent/ Longterm Pain

Answer 8

– Physiologic
◦ Immobility
◦ Decreased immune response
◦ Delayed healing

– Quality of life
◦ Impaired ADLs
◦ Depression
◦ Impaired relationships

-Financial
◦ Increased hospital stays
◦ Longer hospital stays
◦Loss of income for patient and
family

Question 9

The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching?
A. “Persistent pain is a warning in my body that alerts the sympathetic nervous system.”
B. “Acute pain has a quick onset and is usually isolated to one area of my body.”
C. “My frozen shoulder causes musculoskeletal or somatic pain.” D. “Nociceptive pain follows a normal and predictable pa ttern.”

Answer 9

A. “Persistent pain is a warning in my body that alerts the sympathetic nervous system.”

Question 10

What are the 3/8 categories of Pain?

Answer 10

• Acute
• Chronic
• Neuropathic
• Nociceptive
• Localized
• Projected
• Radiating
• Referred

Question 11

What is Acute Pain?

Answer 11

Acute pain
most frequently is defined as pain lasting less than 3 to 6 months.
Rapid, onset short duration

Question 12

What is Chronic Pain?

Answer 12

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 13

What is Neuropathic Pain?

Answer 13

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 attack or stroke), viral infections, carpal tunnel syndrome, and phantom limb pain.

Abnormal function due to damage or destruction of
systems in the nervous system
– Phantom limb pain
– May be described as burning or numbness

Asking patients to describe it is the best way to identify the presence of neuropathic pain. Common distinctive descriptors include “burning,” “shooting,” “tingling,” and “feeling pins and needles.” Much is unknown about what causes and maintains neuropathic pain; it is the subject of intense ongoing research.

GABAPENTIN FOR NERVE PAIN (PT WITH DIABETES, AND AMPUTEES)

Question 14

What is Nociceptive Pain?

Answer 14

nociceptive pain the result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral.

Nociception is the term that is used to describe how pain becomes a conscious experience. It involves the normal functioning of physiologic systems that process noxious stimuli, with the ultimate result being that the stimuli are perceived to be painful.

Somatic –
◦ Cutaneous or superficial
◦ Deep: Bone or muscle
– Visceral
◦ Typically originates at the organ level

Question 15

What is Reffered Pain

Answer 15

Referred pain originates in one area but hurts in another area, such as pain from a MYOCARDIAL INFRACTION (HEART ATTACK) (i.e., heart attack) (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 16

What is the first step of the nursing process when you suspect a patient is experiencing Pain?

A. Intervention
B. Assess
C. Plan
D. Diagnose

Answer 16

B. Assess

All accepted guidelines identify the patient’s self-report as the gold standard for ASSESSING the existence and intensity of pain (ANA, 2018). Because pain is such a private and personal experience, it may be difficult for the person to describe or explain it to others.

Question 17

What is the nurses primary role first when it comes to managing a patient’s pain?

A. accepting the patient’s report of pain and advocating for them
B. Dismissing their pain
C. Telling the charge nurse that the patient repeatedly ask for pain medications
D. Try to find an alternative methods to relieve their pain

Answer 17

A. accepting the patient’s report of pain and advocating for them

The primary role of the nurse in pain management is to advocate for patients by accepting their reports of pain and acting promptly to relieve it while respecting their preferences and values.

Question 18

As a nurse when assessing your patient for pain what should you take into consideration? Select all that Apply

A. Verbal Cues
B. Non Verbal Cues
C. Nail color
D. Hair color
E. Age
F. Pain Scale Rating

Answer 18

A. Verbal Cues
B. Non Verbal Cues
E. Age
F. Pain Scale Rating

Question 19

What are the 0-10 Numeric Pain Rating Scale used for?

A. To specify the quality/intensity of pain through a 0-10 scale
B. To specify the quantity of pain through a 1-10 scale
C. To describe the location of pain
D. To describe the region of pain

Answer 19

A. To specify the quality/intensity of pain through a 0-10 scale

Question 20

What would be the best way to manage a patients pain in steps?

Answer 20

starting with non pharmacological therapy , then moving on to non-opioid analgesics, giving the patient a stronger dose of the non-opioid analgesic, then finally moving on to an opiod analgesic to relieve the patients pain

Question 21

What are the Non-opiod Analgesics? Select all that Apply
A. Morphine
B. Acetaminophen
C. Codeine
D. Ibuprophen
E. Heroin
F. Aspirin(Non- Selective)
G. Celecoxib (Celebrex)(Selective)

Answer 21

B. Acetaminophen
D. Ibuprophen
F. Aspirin
G. Celecoxib (Celebrex)

Question 22

When a patient is receiving Non- Selective NSAID’s to reduce moderate pain what should you educate them about?
A. NSAID’s are best effective when you take them on an empty stomach
B. Non-selective NSAID’s put you at risk at for stomach ulcers and getting an upset stomach, when you are taking this , make sure you take with food to avoid the side effects
C. NSAID’s such as acetaminophen should be taken with food to avoid side effects of stomach ulcers.
D. NSAID’s will not relieve your pain but will reduce inflammation.

Answer 22

B. Non-selective NSAID’s put you at risk at for stomach ulcers and getting an upset stomach, when you are taking this , make sure you take it with food to avoid the side effects.

NSAIDs have analgesic, antipyretic, and anti- inflammatory properties.

Ibuprofen, naproxen, and celecoxib are the most widely used oral NSAIDs in the United States and Canada.

NSAIDs have more adverse effects than acetaminophen, with gastric toxicity and ulceration being the most common

An important principle of NSAID use is to administer the lowest dose for the shortest time necessary.

Question 23

What are examples of Non Opioids

Answer 23

Acetaminophen (Tylenol)
* NSAIDs (nonselective)
– Aspirin, ibuprofen (Motrin), naproxen (Naprosyn)
* NSAIDs (selective) - causes ulcers cannot be taken without food
– Celecoxib (Celebrex)SELECTIVE- can be taken without food safe option

Question 24

What are examples of Opioids

Answer 24

Examples of Opioids
Pure agonists
– Morphine, Oxycodone, Hydrocodone
* Patient Controlled Analgesia (PCA)
Examples of Opioids

Question 25

What is the antagonist drug for opioid overdoses?
A. Nalaxone
B.Nazan
C. LSD
D. Diazepam

Answer 25

A. Nalaxone

Question 26

Are Patient Controlled Analgesics controlled by patients or family members?
A. Family
B. Patient

Answer 26

B. Patient

Patient-controlled analgesia (PCA) is an interactive method of management that allows patients to treat their pain by self-administering doses of analgesics

The primary benefit of PCA is that it recognizes that only the patient can feel the pain and only the patient knows how much analgesic will relieve the pain. This fact reinforces that PCA is for patient use only and that unauthorized activation of the PCA butt on (called “PCA by proxy”) can be very dangerous. Instruct staff, family, and other visitors to contact the nurse if they have concerns about pain control rather than pressing the PCA butt on for the patient.

Question 27

Which NSAID would be preferred to decrease GI bleeding and stomach ulcers?
A.Celecoxib
B. Aspirin
C. Ibuprophen
D.Naproxen

Answer 27

A.Celecoxib

NSAIDs can cause GI disturbances and decrease platelet aggregation (clott ing), which can result in bleeding. Therefore observe the patient for gastric discomfort or vomiting and for bleeding or bruising. Tell the patient and family to stop taking these drugs and report these effects to the primary health care provider immediately if any of these problems occur. Celecoxib has no effect on bleeding time and produces less GI toxicity compared with other NSAIDs.

Question 28

What should be considered when administering acetaminophen to a patient

Answer 28

The most serious complication of acetaminophen is hepatotoxicity (liver damage) as a result of overdose. A patient’s hepatic risk factors must always be considered before administration of acetaminophen. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults.

Question 29

Patient Controlled Analgesic Guidelines

Answer 29

The primary benefit of PCA is that it recognizes that only the patient can feel the pain and only the patient knows how much analgesic will relieve the pain. This fact reinforces that PCA is for patient use only and that unauthorized activation of the PCA bu on (called “PCA by proxy”) can be very dangerous. Instruct staff, family, and other visitors to contact the nurse if they have concerns about pain control rather than pressing the PCA bu on for the patient.

Patients who use PCA must be able to understand the relationships among pain, pressing the PCA bu on and taking the analgesic, and pain relief. They must also be cognitively and physically able to use any equipment that is used to administer the therapy.

Teach patients how to use the PCA device and to report side effects such as dizziness, nausea and vomiting, and excessive sedation. As with all opioids, monitor the patient’s sedation level and respiratory status at least every 2 hours. Promptly decrease the opioid dose (i.e., discontinue basal rate) if increased sedation is detected.

Question 30

What should you take into consideration when your patient is taking and OPIOD ANALGESIC?

Answer 30

Constipation
* Nausea
* Urinary retention
* Vomiting
* Pruritus- Itchy skin is an irritating sensation that makes you want to scratch
* Sedation
– Accidents from sedation
* Respiratory depression
Effects with Opioid Administration
Reversal agent - Naloxone

If an opioid is ordered for your patient you always want to make sure there is also an order of Naloxone in case of an overdose.

naloxone, naltrexone). If an antagonist is present, it competes with opioid molecules for binding sites on the opioid receptors and has the potential to block analgesia and other effects. They are used most often to reverse opioid effects such as excessive sedation and respiratory depression

CNS DOWN

Question 31

3 Categories of Analgesics

Answer 31

Analgesics are categorized into three main groups: (1) nonopioid analgesics, which include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs); (2) opioid analgesics such as morphine, hydrocodone, hydromorphone, fentanyl, and oxycodone; and (3) adjuvant analgesics (sometimes referred to as co-analgesics), which make up the largest group and include a variety of agents with unique and widely differing mechanisms of action. Examples are local anesthetics, muscle relaxants, and some anticonvulsants and antidepressants.

Question 32

Adjuvants

Answer 32

SSRIs-Selective serotonin reuptake inhibitor
– Block chemical transmitters
* Anti-epileptic drugs (AEDs)
– Decrease pain transmission
– Good choice for neuropathic pain
* Local anesthetics
– Block nerve impulses
Examples of Adjuvants

Question 33

SPECIAL CONSIDERATIONS FOR OLDER ADULTS

Answer 33

“Start low & go slow”; half recommended dose to start
* Evaluate patient response, drug effectiveness, side effects
 Polypharmacy, pharmacokinetics, pharmacodynamics
* Older adults feel pain as much as younger adults
* Greater risk for under treated pain
Special Considerations for the Older Adult

For older adults the guideline is to “start low and go slow” with all drug dosing. For example, the starting opioid dose may need to be reduced by 25% to 50% in older adults because they are more sensitive to opioid side effects than are younger adults.

Question 34

Pharmacological Management of Pain

Answer 34

Basic principle – Prevent and control
* Multimodal – Use 2 or more types of drugs-NSAID & OPIOD
* Post operative – combination therapy
* Pre-medicate – Before procedures or activity

Question 35

PCA INFUSION PUMPS

Answer 35

Can deliver pain medication via IV or epidural
* Useful for around the clock pain control
– Post-surgical
– Basal rate
– Demand dosing
* Careful monitoring of
– Vital signs
– Oxygenation
* Nursing responsibilities
– Education
– Verification(2 NURSES NEED TO BE PRESENT FOR PCA CHECK OFF)

Question 36

Cognitively impaired patients , how would you assess their pain?

Answer 36

• Assess using a reliable and valid behavioral pain assessment tool.
  -GRIMACING
  -CLENCHING OF TEACH

Question 37

EPIDURAL ADMINISTRATION CONCERNS

Answer 37

Assess patients receiving epidural local anesthetic for their ability to bend their knees and lift their bu ocks off the ma ress (if not prohibited by surgical procedure). Ask them to point to any areas of numbness and tingling. Mild, transient lower-extremity motor weakness and orthostatic hypotension may be present, necessitating assistance with ambulation. Most undesirable effects can be managed with a reduction in local anesthetic dose. Promptly report areas of numbness outside of the surgical site, inability to bear weight, and severe hypotension to the anesthesia provider. Do not delegate assessment of local anesthetic effects to assistive personnel!

HYPOTENSION*
OXYGENATION*

Question 38

EPIDURAL ADMINISTRATION MONITORING

Answer 38

Can deliver pain medication via IV or epidural
* Careful monitoring of
– Vital signs
◦ Hypotension (report 25% changes)*
◦ Oxygenation***
– Infection
– Headache
Epidurals

The most commonly administered analgesics by the epidural route are the opioids morphine, hydromorphone, and fentanyl in combination with a long-acting local anesthetic such as bupivacaine or ropivacaine. This multimodal approach allows lower doses of both the opioid and local anesthetic and produces fewer side effects.

Question 39

Nursing Intervention for OPIOD ADMININ SIDE EFFECT - CONSTIPATION

Answer 39

Assess previous bowel habits.
* Keep a record of bowel movements.
* Remind patients that tolerance to this side effect does not develop, so a preventive
approach must be used; administer a stool softener plus mild stimulant laxative for duration of opioid therapy; do not give bulk laxatives because these can result in obstruction in some patients.
* Provide privacy, encourage adequate fluids and activity, and give foods high in roughage(FIBER).
* If ineffective, try suppository or Fleet’s enema.
* For long-term opioid-induced constipation (OIC) in patients with chronic pain,
drug therapy may be used (e.g., lubiprostone, methylnaltrexone).

Question 40

Nursing Intervention for OPIOD ADMININ SIDE EFFECT- NAUSEA AND VOMMITTING

Answer 40

• Use a multimodal antiemetic preventive approach (e.g., dexamethasone plus ondansetron in moderate- to high-risk patients).
• Assess cause of nausea and eliminate contributing factors if possible.
• Reduce opioid dose if possible.
• Reassure patients taking long-term opioid therapy that tolerance to this side effect
  develops with regular daily opioid doses.
• Consider switching to another opioid for unresolved N/V.

Question 41

Nursing Intervention for OPIOD ADMININ SIDE EFFECT-
SEDATION

Answer 41

Sedation
* Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy.
* Use a simple sedation scale to monitor for unwanted sedation (see Table 5.9).
* If excessive sedation is detected, reduce opioid dose to prevent respiratory depression.
* Eliminate unnecessary sedating drugs such as antihistamines, anxiolytics, muscle relaxants, and hypnotics. If it is necessary to administer these drugs during opioid therapy, monitor sedation and respiratory status closely.
* Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses.
* Be aware that stimulants such as caffeine may counteract opioid-induced sedation. * Consider switching to another opioid for unresolved excessive sedation during
long-term opioid therapy.

Question 42

Nursing Intervention for OPIOD ADMININ SIDE EFFECT- RESPIRATORY DEPRESSION

Answer 42

Respiratory Depression
* Be aware that counting respiratory rate alone does not constitute a comprehensive respiratory assessment. Proper assessment of respiratory status includes observing
the rise and fall of the patient’s chest to determine depth and quality in addition to
counting respiratory rate for 60 seconds.
* Recognize that snoring indicates respiratory obstruction and is an ominous sign
requiring prompt intervention.
* Remember that sedation precedes opioid-induced respiratory depression; identify
patient and iatrogenic risk factors and monitor sedation level and respiratory status
frequently during the first 24 hours of opioid therapy (see Sedation section). * Stop opioid administration immediately for clinically significant respiratory
depression, stay with patient, continue att empts to arouse patient, support respirations, call for help (consider Rapid Response Team or Code Blue), and consider administration of naloxone.

Question 43

NALOXONE DRUG ALERT

Answer 43

Unless the patient is at the end of life, promptly administer the opioid antagonist naloxone IV to reverse clinically significant opioid-induced respiratory depression, usually when the respiratory rate is less than 8 breaths per minute or according to agency protocol. When giving the opioid antagonist naloxone, administer it slowly until the patient is more arousable and respirations increase to an acceptable rate. The desired outcome is to reverse just the sedative and respiratory depressant effects of the opioid but not the analgesic effects. Giving too much naloxone too fast can not only cause severe pain but also lead to ventricular dysrhythmias, pulmonary edema, and even death. Continue to closely monitor the patient after giving naloxone because its duration is shorter than that of most opioids and respiratory depression can recur. Sometimes more than one dose of naloxone is needed.

Question 44

NONPHARMACOLOGICAL TREATMENTS

Answer 44

Nonpharmacologic therapies may be effective alone for mild pain and are used to complement, not replace, pharmacologic interventions for moderate- to-severe pain.

Many patients find that the use of nonpharmacologic methods helps them cope be er and feel greater control over the pain experience

• Physical therapy
• Occupational therapy
• Aquatherapy
• Functional restoration (also has cognitive-behavioral components) * Acupuncture
• Low-impact exercise programs such as slow walking and yoga

Application of Hot/Cold Therapies

Massages

Transcutaneous electrical nerve stimulation TENS UNIT

Question 45

Transcutaneous electrical nerve stimulation TENS UNIT

Answer 45

TENS is used as an adjunctive treatment for pain. Although there are several types of transcutaneous electrical nerve stimulation (TENS) units, each involves the use of a baTT ery-operated device capable of delivering small electrical currents through electrodes applied to the painful area (Fig. 5.5). The voltage or current is regulated by adjusting a dial to the point at which the patient perceives a prickly “pins-and-needles” sensory perception rather than the pain. The current is adjusted based on the degree of desired relief.

Is effective when patient feels tingling or pins/needles sensation
* Placed directly over site of pain
* Starts to work immediately, may take up to 30 minutes for desired effect
* May be used as long as desired – usually 30 minutes to 2 hours
* Can cause minor skin irritation

Question 46

Cognitive & Behavioral Measures

Answer 46

• Distraction
• Guided Imagery
• Relaxation techniques
• Hypnosis
• Distractions
  – Reading, TV, speaking with
  friends/family/support groups
• Prayer
• Aromatherapy/Music therapy/ Art
  therapy
• Humor
• Meditation

Question 47

What is the best Assessment of Pain?
A. patients self report
B.

Answer 47

B. Patient report

Question 48

Do you use pregablin ( gabapentin ) for phantom pain or nueropathic pain for an amputee patient ?

Answer 48

Yes