Ch. 43 – Pain Management (Potter and Perry) – Flashcards

improves quality of life; reduces physical discomfort; promotes earlier mobilization and return to previous activity levels; results in fewer hospital visits and decreases hospital lengths of stay, resulting in lower healthcare costs

The pain experience is complex, involving physical, emotional, and cognitive components. Pain is subjective and highly individualized. It is not the responsiblity of patients to prove that they are in pain; it is a nurses responsibility to accept their report.

Four physiological processes of normal (nociceptive) pain: 1. Transduction 2. Transmission 3. Perception 4. Modulation

Thermal, chemical, or mechanical stimuli usually cause pain. Transduction converts energy produced by these stimuli into electrical energy. Transduction begins in the periphery when a pain-producing stimulus sends an impulse across a sensroy peripheral pain nerve fiber (nociceptor), initiating an action potential.

Pain impulse begins.

Prostaglandins, bradykinin, substance P, histamine. "Inflammatory soup", spreading the pain message and causing an inflammatory response.

The point at which a person is aware of pain

Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids, which work to hinder the transmissions of pain and help produce an analgesic effect.

Clenched teeth, facial expressions, holding the painful area, bent posture, grimacing. Some patients cry or moa, are restless, or make frequent requests to the nurse.

protective, short duration. identifiable cause Physiological responses are usually from the SNS (fight or flight) tachycardia, anxiety, diaphoresis, muscle tension Behavioral responses include grimacing, moaning, flinching, and guarding

not protective and thus serves no purpose. lasts longer than 6 months and is constant recurring with mold-severe intensity. (arthritis, low back pain, myofascial pain, headache) usually non-life threatening. Physiological responses do not usually alter vital signs, but clients may have depression, fatigue, and a decreased level of functioning.

a person with chronic pain will seek numerous health care providers to alleviate pain.

Assessment of common characteristics of pain helps you form an understanding of the type of pain, its pattern, and the types of interventions that bring relief. 1. Onset and Duration 2. Location 3. Intensity (Scale) 4. Quality 5. Pain pattern 6. Relief Measures 7. Contributing Symptoms 8. Effects of Pain on the Patient

Requires an individualized approach. The nurse, patient, and frequently the family are partners in pain management. Usually try the least invasive or safest therapy first along with previously successful patient remedies.

Can lessen pain but are to be used with and not in the place of pharmacological measures. Nonpharmacological measures include: 1. Cognitive-behavioral and physical approaches. 2. relaxation and guided imagery 3. Distraction 4. Cutaneous stimulation (cold and heat) 5. Herbals 6. elevation of edematous extremities to promote venous return and decrease swelling 7. acupuncture

Analgesics: Most common and effective method of pain relief.

1. Nonopioids (Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs) 2. Opioids (Narcotics) 3. Adjuvants (variety of medications that enhance analgesics or have analgesic properties that were originally unknown)

drug delivery system, is a safe method for pain management that many patients prefer. Allows patients to self administer opioids (morphine, hydromorphone, and fetanyl) with minimal risk of overdose.

1. Pain is purely subjecrtive and psychosocial experience 2. Misconceptions about pain often result in doubt about the degree of the patient's suffering and unwillingness to provide relief 3. Knoweldge of the nociceptive pain processes of the pain experience - transmission, transduction, perception, and modulation provides guidelines for selecting pain-relief measures 4. An interaction of psychological and cognitive factors affect pain perception. 5. A person's cultural background influences the meaning of pain and how it is experssed. 6. It is common for older patients not to report pain. 7. Patients who are in chronic pain are unlikely to show behavioural changes 8. The difference between acute and chronic pain involves the concept of harm. Acute pain is protective, thus preventing harm; chronic pain is no longer protective. 9. Do not collect an in-depth pain history when the patient is experiencing severe discomfort. 10. Pain causes physical signs and symptoms similar to those of other diseases. 11. Using a regular around the clock (ATC) for analgesic administration is more effective than as-needed schedule in pain control. 12. Sedation is an adverse effect of opioids that always precedes respiratory depression (which is rare) 13. A PCA device gives patients pain control with low risk of overdose. 14. Addictions rarely occur in patients who take opioids to relieve pain. 15. The goal of pain management is to anticipate and prevent pain rather than treat it. 16. Pain evaluation includes measuring the changing character of pain, the patient's response to interventions and the patients perceptions of the effectiveness of therapy.

1. Substance P 2. PRostraglandins 3. Bradykinin 4. Histamine

1. Serotonin 2. Endorphins

Arises from damage to or inflammation of tissue other than that of the peripheral central nervous system. It is usually throbbing, aching, and localized this pain typically responds to opioids and nonopioid medications.

Arises from abnormal or damaged pain nerves. It includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy pain typically responds to adjuvant medications (antidepressants, antiplasmodic agents, skeletal muscle relaxants)

cultural and societal attitudes, lack of knowledge, fear of addiction, exaggerated fear of respiratory depression

infants, children, Older Adults, clients who have substance abuse disorder

age (infants cannot verbalize or understand their pain) older adults may have multiple pathologies that cause pain and limit function. Fatigue which can increase sensitivity to pain genetic sensitivity, which can increase or decrease pain tolerance Cognitive function-clients who are cognitively impaired may not be able to report pain or report it accurately.

A. Presence of associated symptoms (CORRECT) B. Location of pain C. Pain quality D. Aggravating and relieving factors (A. Nausea and vomiting are common symptoms clients have when they are in pain)

A. Asking what precipitates the pain B. questioning the client about the location of the pain C. offering the client a pain scale to measure his pain D. using open-ended questions to identify the sensation (C. A pain scale can help the client measure the amount of pain he has and its intensity)

A. some clients exaggerate their level of pain B. pain must have an identifiable source to justify use of opioids C. objective data are essential in assessing pain D. pain is whatever the client says it is (D. Pain is subjective and the client is the best source of information about it)

C. I should tell the nurse if the pain doesn't stop after I use the device." . PCA method of delivering pain medication through an electronic infusion device that allows the client to self administer pain meds on as prn basis. IF the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan.

A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea C,D, E Respiratory depression which can cause respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia; dizziness or light-headeness when changing positions is a common adverse effect, nausea and vomiting are common, constipation, and urinary retention. (THINK PARASYMPATHETIC -- everything slows down)

Answer: A, B, D, E Rationale: The characteristics of pain that the nurse should assess are onset, duration, location, intensity, and quality.

Answer: false Rationale: Neuropathic pain is burning, shooting, or electric like. Pain from a surgical incision that is dull, throbbing, or aching is nociceptive pain.

Answer: D Rationale: Opioids can cause respiratory depression in some patients who are not used to taking them. Monty's safest action is to see if he can use nonsteroidal antiinflammatory drugs (NSAIDs) and nonpharmacological pain-relief interventions to try to decrease Mrs. Lewis' pain. He should also alert the health care provider to Mrs. Lewis' respiratory status.

Answer: B Rationale: Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Drug tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time.

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Difficulty arousing the patient Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.

Calls the health care provider, and questions the order Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.

Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation. Awarded 0.0 points out of 1.0 possible points.

The time interval Controlled- or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.

The amount of daily acetaminophen The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control.

Physical dependence. Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Assess patient's vital signs every 15 minutes for 2 hours Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory depression may return.

Only the patient should push the button. Patient preparation and teaching are critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to "push the button" for the patient.

Request to have the ordered changed to ATC for the first 48 hours. The American Pain Society (2003) states that, if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.

Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.

he patient's report of pain is the best method for assessing the pain.

TENS electrodes are applied near or directly on the site of pain. TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain.

Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation.

The sedative administered may have helped him sleep, but assessment of pain is still needed. Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment.

Respirations 26 per minute on room air HR 114 Crackles heard on auscultation

Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.

Promote venous return to the heart. Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.

"I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. " Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.

80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.

Risk for activity intolerance Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.

Coffee ground-like aspirate from the feeding tube When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.

The three-legged stool on wheels in The braided throw rugs in the entry hallway and between the bedroom and bathroom

Cream of broccoli soup with whole wheat crackers and tapioca for dessert The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.

Patient's weight Patient's level of cooperation Patient's ability to assist Presence of medical equipment

The muscle fibers become shortened because of disuse. The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.

Using an objective, valid scale to assess patient's risk for pressure ulcer development Using a device to relieve pressure when patient is seated in chair Teaching patient how to shift weight at regular intervals while sitting in a chair A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

The patient received an injection of morphine 30 minutes ago for pain. The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.

"By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint. Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.

Maintain independence with activities of daily living (ADLs). The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.

Answer: C Rationale: Footdrop is the inability to dorsiflex and invert the foot because of peroneal nerve damage.

Answer: A, B, D Rationale: Virchow's triad contributes to venous thrombus formation. The three factors of Virchow's triad are damage to the vessel wall, alterations in blood flow, and alterations in blood constituents.

Answer: Muscle atrophy Rationale: Muscle atrophy is the loss of muscle tone and joint stiffness as a result of immobilization.