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H&S Chapter 11- CARE OF THE CLIENT WITH PAIN
Terms in this set (85)
Origin of pain
Cutaneous or superficial pain - cause short term pain
Visceral pain - Abdominal cavity, cranium, or thorax
Deep somatic pain - in ligaments, tendons, nerves, blood vessels, and bones
Radiating pain - start at the origin and extend to other locations (e.g., severe sore throat may extend to ears and head)
Referred pain - occur in an area that is distant from the original site (e.g., pain from heart attack may be experienced down the left arm, through back, or into jaw)
Phantom pain - pain is perceived to originate from an area that has been surgically removed
Psychogenic pain - pain arises from mind
Duration of pain
Definition: Acute Pain
Short duration - hours to weeks
Linked with tissue injury or damage
Acts as warning sign - alerts and prompts withdrawal, avoidance, and protective responses
Results from sudden, accidental trauma; surgery; ischemia; inflammation
Physiological response: Acute Pain
R/t Sympathetic response
Increase HR - tachycardia
Increase BP - hypertension
Sweating - diaphoresis
Behavioral Response: Acute Pain
Grimacing - an ugly, twisted expression on a person's face, typically expressing disgust, pain, or wry amusement.
Flinching - make a quick, nervous movement of the face or body as an instinctive reaction to surprise, fear or pain
Guarding - abdominal
Definition: Chronic Pain
Persists or recurs for indefinite period (months to years) not always linked to identified tissue injury or damage
Unpredictable - intensity can change over time
Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness
Physiological responses: Chronic Pain
no change in vital signs
decreased level of function
Cause of pain
Definition: Nociceptive Pain
Most common type of pain
Arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems
Usually throbbing, aching, localize
pain typically response to opioids and non-opioids medication.
Two types of nociceptive pain
Somatic: Nociceptive Pain
in bones, joints, muscles, skin, or connective tissues
Visceral: Nociceptive Pain
internal organs such as the stomach or intestines
can be sharp or dull and difficult to localize
Cutaneous: Nociceptive Pain
in skin or subcutaneous tissue
Definition: Neuropathic Pain
arises from abnormal or damaged pain nerves (Phantom limb pain, pain below the level of a spinal cord injury, diabetic neropathy)
usually intense, shooting, burning, numbness, itching, or "pins and needles"
Difficult to localize
A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain?
Acute pain typically has a short duration and a rapid onset.
Chronic pain lasts longer than 6 months and interferes with daily activities.
Intractable pain is chronic and highly resistant to relief.
Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves.
Processing Pain Messages
In early stages of injury damaged cells release chemicals including histamine, bradykinin, and prostaglandins.
Cause activation of nociceptors (neurons that respond to stimuli) that transmit pain messages to brain and spinal cord.
Other chemicals stimulate the inflammatory response
How does the body react to pain?
Onset of acute pain activates SNS to minimize blood loss, maintain perfusion to vital organs, prevent infections, and promote healing
If pain continues, the body adapts, and PNS take over
Unrelieved pain trigger Endocrine system by
ACTH = Adrenocorticotropic hormone
ADH = antidiuretic hormone
GH = growth hormones
Insulin and testosterone decrease
Results = activate carbohydrate, protein, and fat catabolism (breakdown); hyperglycemia; and poor glucose use
Unrelieved pain trigger cardiovascular system by
increase HR, BP, cardiac workload, an oxygen demand
Combination of hypercoagulation and increase cardiac workload =
* unstable angina (chest pain)
* intracoronary thrombosis (clot formation in vessels that supply heart)
* Myocardial ischemia and infarction (heart attack)
Unrelieved pain trigger musculoskeletal system by
impaired muscle function
Prevent ADLs and physical therapy
Unrelieved pain trigger respiratory system by
breath shallowly - limit thoracic and abdominal movement - in an effort to reduce pain. This is called Splinting
Definition of Splinting
reduces tidal volume (air exchanged with each breath)
Increase inspiratory and expiratory pressures
Result = pneumonia and atelectasis and respiratory acidosis
Unrelieved pain trigger genitourinary system by
Release of excessive amount of
decrease urinary output
increase cardiac output
Unrelieved pain trigger GI system by
Intestinal secretions and smooth muscle tone increase
Gastric emptying and mobility decrease
Factors the Shape the Pain Experience
Prior experience with pain
Expectations of pain
Situational meaning of pain for a particular patient (laboring mom)
Very powerful influences on the pain experience are
Gender Determinants of Pain
women have lower thresholds for pain, rate noxious stimuli are more painful and have lower tolerance for intense pain do men
May discourage men for reporting pain or seeking medical care
Women are more likely to have ongoing relationship with a medical professional
Gender responses to analgesia
Men required more opioid dosing to achieve pain relief
Men report more analgesic relief with ibuprofen
Older Adults and Pain
Older patients in pain may be reluctant to report pain because of cognitive impairment
Older adults use analgesia agents longer than younger adults and pain is likely to slow recovery from surgery
A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing for?
Presence of associated symptoms
A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by
offering the client a pain scale to measure his pain.
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statement indicates that the client knows how to use the device?
"I should tell the nurse if the pain doesn't stop after I use this device
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (ALL THAT APPLY)
A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client's health history would lead the nurse to consult with the provider over the choice of medication?
a. 25-pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin (Coumadin)
The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
When evaluating a patient's response to acute pain, the nurse assesses for the presence of physiologic responses associated with the pain experience.
1. Decreased urinary output
3. Increased cardiac output
4. Increased metabolic rate
The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does all of the following:
1. consults with the healthcare provider about the client's report
2. evaluates the pain level using the established pain scale
3. assesses respirations, pulse, and blood pressure
The family practice physician group, where you practice nursing, treats a high number of older adult clients. Many of these older adults use nonopiod pain medications on a regular basis. Which of the following client education principles should you teach to these clients? Choose all correct options.
Avoid OTC analgesics consistently without consulting a physician
Inform the primary healthcare provider about the use of salicylates before any procedure
The client reports chest pain. The nurse uses which of the following questions to assess the pain further.
1. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain."
2. "What aggravates your chest pain?"
3. "How long have you experienced this pain?"
4. "Please point to where you are experiencing pain."
Populations at highest risk for inadequate pain control
Those whose primary language differs from that of the health care professional
Definitions of Pain
Unpleasant sensory/emotional experience associated with actual or potential tissue damage
Self-report always most reliable indication of pain
Physiological Impact by pain
Increases heart rate, blood pressure and O2 demand
Decreases GI motility
Decreases immune response
Increased risk of development of chronic pain
Quality of Life Impact by pain
ADLs, anxiety, depression, hopelessness fear, anger, insomnia and relationships
"gold standard" for pain existence and intensity assessment
Nurse's role in pain assessment
Accept patient's self-report
Serve as advocate
Act promptly to relieve pain
Respect values and preferences of patient, family members, and significant others
Physical assessment techniques to help understand patient's pain
Palpation and ROM
Verbal and non-verbal response
NSAIDS (Motrin Advil, Toradol, Dolobid, Aleve)
Use of Aspirin and NSAIDS (Anti-inflammatory)
reduce pain by inhibiting local prostaglandin synthesis.
Released at site of injury and stimulates inflammation
Use of Tylenol
has few anti-inflammatory effects
Activates one of body's own natural pain-inhibiting neurochemical systems
Used to treat Acute inflammation and pain following nerve and spinal cord injuries
Used as adjuvant (aid) therapy for pain control in cancer patients
Increases effectiveness of other medication
Side effects of Corticosteroids
myopathies (Muscle disease)
mental status changes
Eliminate sensation and pain without LOC
Relax vascular muscle walls bringing increased blood flow into region
Lidocaine (Xylocaine) most common
Used for nerve blocks and epidural anesthetic
Greater risk for CNS and cardiac toxicity
Side effects of Opioids
Nausea and vomiting
Use of Opioids
Autonomic effects include pupil constriction, dry mouth, reduced sensitivity to cold
Mutes activity of sympathetic nervous system causing relaxation, sedation, slowed breathing, and reduction in anxiety
Opioid receptors Delta, Kappa, Mu
Physical dependence of opioid
Withdrawal symptoms occur when opioid is suddenly stopped
Not the same as addiction
Tolerance of opioid
Effects of analgesia decrease; client may require higher dose
Not the same as addiction
Addiction of opioid
compulsive behavioral pattern to take medication for its psychic effects without regard for negative consequences
Health teaching of non-opioid
Ask about use of non-opioids
Clarify brand names vs. over-the-counter names
Inform patients about combination products containing non-opioids (Tylenol and Percocet)
Advise not to exceed safe maximum daily dose due to adverse side effects
The patient is receiving the first dose of an opioid analgesic for pain. The nurse expects the patient will also be ordered a(n):
A. Antacid agent
B. Anti-anxiety agent
C. Laxative or stool softener
D. Breakthrough pain reliever
Rationale: Opioids inhibit peristalsis in the GI tract. Patients who take regular doses of opioids frequently become constipated. Interventions such as diet modifications and laxative agents may be needed to prevent or minimize the problem of constipation. Other common side effects of opioid administration include nausea and vomiting, sedation, and respiratory depression.
Which patient would benefit most from the use of a patient-controlled analgesia pump?
A. 75-year-old woman with confusion who is in the last stages of the dying process
B. 15-year-old girl who is recovering from a head injury from an automobile accident
C. 42-year-old man who is mentally alert and is recovering from a fractured femur
D. 60-year-old man who is mentally alert and is experiencing left-sided weakness after a stroke
Rationale: The mentally alert, physically able patient is the best candidate to receive PCA. When a patient is cognitively impaired or unable to push the PCA button, another method of administration should be considered.
The nurse is caring for a hospitalized patient whose home medications include daily acetaminophen for headaches. Which associated assessment finding should the nurse report to the healthcare provider immediately?
A. Pain level of 4/10
B. Urinary output 75 mL/hr
D. Dark urine
Which of these outcomes would be most appropriate to establish for a patient who is being treated for post-operative pain following an open abdominal procedure? Select all that apply.
A. Patient reports pain level of 2/10 on 0-10 scale.
B. Patient's blood pressure is 162/81 mm Hg.
C. Patient monitor displays sinus tachycardia.
D. Patient will be free from pain during hospitalization.
E. Oxygen saturation remains above 94% on room air.
The nurse should include which questions when assessing a patient's pain following a fractured ankle injury? Select all that apply.
C. How much weight he is able to bear
E. What makes it better or worse
An older adult has suffered a stroke and exhibits expressive aphasia. When assessing for pain, which tool is best for the nurse to utilize with this patient?
A. Numerical scale
B. FACES scale
C. Wong-Baker Faces
D. Verbal scale
patient's pain level is subjective mean ?
This means that only the patient can determine the amount of pain he or she is experiencing. It is not an objective sign that the nurse can definitively measure or observe.
Purpose of Positioning
a tried-and- true non-pharmacologic pain management method.
The nurse helps the patient find a position that promotes comfort and alleviates pain
Side lying positions or head elevations can minimize stress on muscle groups or incisions
Upright sitting positions that encourage forward leaning improve pain caused by shortness of breath
Application of heat or cold is help to
reduce pain associated with underlying muscle, skeletal, or neurological pathology
Ice packs, cold water baths, and cold-emitting chemical packs can help alleviate
low back pain with spasticity ( muscles are continuously contracted)
activity induced muscle pain
pain associated with obstetric and gynecologic procedures
Either wet or dry heat can be used to
manage lower back pain present without spasm
manage N/V and diarrhea caused by peristalsis and acid production
reduce reflex muscle spasms associated with menstrual cramps
Other applications to reduce pain
Active and passive range-of-motion exercises can help alleviate pain. The nurse can use passive exercises with patients who are immobile.
Relaxation, massage, acupressure, and controlled breathing techniques
Pharmacologic methods of pain control include
narcotic analgesics such as oxycodone and morphine
non-narcotic analgesics such as aspirin and acetaminophen
corticosteroids such as prednisone
atypical analgesics, such as antidepressants, which can be effective for neuropathic pain
the best combination of treatment is recommended
using a combination of pharmacologic and nonpharmacologic techniques
You are responsible for providing care to Mr. Jones, a 58-year-old salesman who was admitted to the surgical unit for a left total knee replacement surgery. Mr. Jones is 12 hours post-op. During shift report, the assigned nurse shares the following information with you:
• Pain rating of an 8 of 10 during initial assessment
• Prescribed pain medication (morphine) administered per order
• Post-medication administration assessment revealed pain rated at 5 of 10.
Patient was restless most of the overnight. You enter Mr. Jones' room to complete a shift assessment. Which is your priority action?
A. Palpating a radial pulse
B. Monitoring blood pressure
C. Conducting a pain assessment
D. Inspecting the surgical incision
Rationale: Pain assessment and management is your priority based on the information shared during the shift assessment, which portrays the concern that the patient's pain has not been controlled with morphine alone. The American Pain Society champions this relatively straightforward way to improve pain management, since inclusion of a pain assessment when assessing vital signs (blood pressure, pulse, and respirations) gives the pain assessment clinical priority.
Which tool should you use to assess Mr. Jones' current level of pain?
A. FACES pain scale
B. FLACC pain scale
C. Numerical pain scale
D. Neonatal infant pain scale
Rationale: A numerical pain scale allows the patient to rate current level of pain on a scale of 1 to 10. This unidimensional measurement is designed to assess treatment response to both pharmacologic and non-pharmacologic interventions for many forms of acute pain, including burns, postoperative pain, and chronic non-cancer pain. Evidence suggests that this unidimensional scale may be less effective as a measure of chronic pain or of mixed acute and chronic pain. The FACES scale is more appropriate for a pediatric patient. The FLACC pain scale is more appropriate when assessing pain for an infant patient. The neonatal infant pain scale, referred to as NIPS, is designed for a neonate.
Which questions should you ask Mr. Jones in order to conduct a focused pain assessment? Select all that apply.
A. "When did your pain begin?"
B. "Can you describe your pain for me?"
C. "Are there any activities that make your pain worse?"
D. "When was the last time you received pain medication?"
E. "Can you trace your pain for me?"
ANS: A, B, C, and E
Rationale: OPQRST-AAA is a useful mnemonic the nurse can use to evaluate pain symptoms, with each letter representing an important line of questioning:
• O - Onset of pain
• P - Provocation
• Q - Quality of pain
• R - Region or radiation
• S - Severity
• T - Time and duration
• AAA - Aggravating/alleviating factors and associated symptoms.
It is not necessary to ask the patient when he last received pain medication. This information is provided during shift report and can be verified with the medication administration record (MAR). A brief interview using the OPQRST-AAA mnemonic can be conducted in less than 5 minutes and can occur simultaneously with other assessment activities. The information gained through this structured questioning approach clarifies the nature of pain experienced by the patient and informs the clinician's review and selection of effective therapeutic interventions.
The nurse assesses Mr. Jones' current level of pain and finds that it is back to an 8 on a 1 to 10 scale. He describes the pain in his left knee as "stabbing and angry." Which prescribed pain medication should you administer to Mr. Jones?
Rationale: Mr. Jones' is experiencing acute, severe pain; therefore, it is appropriate to administer an intravenous opioid to address his pain. While morphine and hydromorphone are both intravenous analgesics, the patient's pain has not been addressed by morphine thus far; therefore, hydromorphone is the most appropriate pain medication to administer at this time. Hydromorphone is eight times more potent than morphine. Aspirin is often contraindicated after a surgical procedure due to the risk for bleeding. Ibuprofen, a non-steroid anti-inflammatory drug (NSAID), is appropriate to treat chronic pain due to inflammation.
You administer the prescribed IV hydromorphone to Mr. Jones. Which is your priority assessment based on the current data?
B. Heart rate
D. Blood pressure
Rationale: While it is important to reassess Mr. Jones' level of pain, the priority assessment after administering an IV opioid drug such as hydromorphone is to monitor the patient for the adverse reaction of respiratory depression. Heart rate and blood pressure are not priority assessments for this patient based on the current data.
The hydromorphone administered at the beginning of the shift worked well to address Mr. Jones' pain. Thirty minutes post administration, he rated his current level of pain at a 3 on a 1 to 10 scale. It is now early afternoon and Mr. Jones is preparing for physical therapy. Which nursing action is most appropriate at this time?
A. Assessing the patient's current level of pain
B. Monitoring the patient for respiratory depression
C. Asking the therapist to initiate therapy on the next shift
D. Administering a prn dose of prescribed oral pain medication
Rationale: Physical therapy often causes an exacerbation in the level of pain experienced by the patient. It is important for you to assess Mr. Jones' current level of pain and implement an intervention to manage his pain in preparation for physical therapy. There is no indication that you have administered an opioid pain medication necessitating an assessment for respiratory depression. While administering a pain medication prior to physical therapy may be appropriate, you cannot make this determination prior to conducting a pain assessment.
Mr. Jones received a dose of acetaminophen with codeine prior to the physical therapy session. After the session Mr. Jones states, "I am very uncomfortable now that therapy is over. I don't want a strong pain medication because it made me really drowsy. What else can I have to treat my pain?" You review Mr. Jones' medication prescriptions and find that he cannot receive anything for two more hours. Which nursing actions are appropriate based on the current situation? Select all that apply.
A. Using acupressure on the affected knee
B. Initiating guided imagery with Mr. Jones
C. Applying cold therapy to Mr. Jones' left knee
D. Repositioning Mr. Jones and elevating his left knee with a pillow
E. Implementing passive range of motion to the lower left extremity
ANS: B, C, and D
Rationale: Mr. Jones is not due to receive another dose of pain medication for two more hours. You should implement nonpharmacological pain management strategies to address his pain at this time, including guided imagery, cold therapy, and repositioning the patient and elevating his left knee. These interventions have been proven to address the type of pain that Mr. Jones is experiencing after a physical therapy session. Acupressure and implementing passive range of motion may further aggravate Mr. Jones' current level of pain.
Mr. Jones is now three days postoperative. His pain is being managed with scheduled doses of ibuprofen (800 mg every 8 hours by mouth) and prn doses of acetaminophen with hydrocodone. Mr. Jones has not had a bowel movement since surgery. Which nursing action is appropriate based on the current data?
A. Notify the healthcare provider immediately.
B. Administer the prn dose of docusate sodium.
C. Assist the patient in a guided imagery exercise.
D. Place the patient on a bedpan and provide privacy.
Rationale: Constipation is a known side effect for patients who are receiving opioid analgesics in the treatment of acute pain. The most appropriate nursing action based on the current data is to administer the prn dose of docusate sodium, a stool softener. There is no reason to notify the healthcare provider immediately regarding the patient's constipation. Guided imagery is a nonpharmacological intervention to treat pain and is not effective in treating constipation. Placing the patient on a bedpan and providing privacy is not indicated at this time.
When a patient is suffering from acute pain, the nurse should anticipate which patient complaints Select all that apply.
A. Insidious onset of pain in the lumbar region
B. Phantom limb pain following amputation
C. Pain present for several months' duration
D. Guarding of a midline abdominal incision
E. Sharp, stabbing pain in a specific area
The nurse recognizes that which pharmacologic agents may be prescribed for a patient suffering from chronic pain? Select all that apply.
A. Narcotic analgesics
B. Nonsteroidal anti-inflammatory drugs
D. Loop diuretics
The nurse should anticipate that cold therapy is most effective for which patient ailments? Select all that apply.
A. Spastic lower back pain
B. Dull, throbbing headache
C. Muscle pain after ambulation
D. Post-gynecologic procedures
E. Pleuritic chest pain
A patient with a respiratory rate of 26 breaths/minute and an oxygen saturation of 92% on room air complains of pain as a 10/10 following a motor vehicle crash. What is the nurse's priority of care for this patient?
A. Patient verbalizes a tolerable level of pain.
B. Patient remains free from further injury.
C. Patient demonstrates improved respiratory status.
D. Patient uses incentive spirometer hourly as instructed.
A patient complains of pain due to shortness of breath. What is the nurse's best action to alleviate the patient's discomfort?
A. Assist patient into a side-lying position.
B. Encourage an upright, forward-leaning position.
C. Apply heating pad to anterior chest.
D. Administer narcotics intravenously.
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