Chapter 12: Pain Management
Which is a true statement regarding placebos?
Placebos should never be used to test a client's truthfulness about pain.
Perception of pain is highly individualized.
A placebo effect is a true physiologic response.
A placebo should never be used as a first line of treatment.
Reduction in pain as a response to placebo should never be interpreted as an indication that the person’s pain is not real.
The client is taking continuous-release oxycodone (Oxycontin) for chronic pain and now reports constipation. The first question the nurse asks is
"When was your last bowel movement?"
Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.
A client receives hydromorphone 2 mg intravenously for report of postoperative pain. Fifteen minutes later, the nurse notes respirations are 6 breaths/minute and the client is nonresponsive. The nurse administers prescribed naloxone. The next time the client reports pain, the best nursing action is:
Consult with the healthcare provider to reduce the dose.
The nurse consults with the health care provider about reducing the dose of an opioid temporarily, because doing so may prevent deep sedation. The nurse assesses the client and administers the prescribed dose of an opioid. The nurse does not withhold or change the prescribed dose of the medication unless client safety is immediately compromised. The nurse will ensure naloxone (Narcan)is available when an opioid is again administered to the client.
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?
- neuropathic and chronic
When classified according to its source, pain can be categorized as nociceptive or neuropathic. When classified according to its onset, intensity, and duration, pain can be categorized as either acute or chronic. Because the client is without breakthrough pain at this time, he has no acute pain. Nociceptive pain is transmitted from a point of cellular injury to the brain. This is not the type of pain related to long-term diabetes mellitus. Neuropathic pain sustained by injury or dysfunction of the peripheral or central nervous systems. This type of pain is related to long-term diabetes mellitus. Acute pain is pain or discomfort of short duration: from a few seconds to less than 6 months. This is not the type of pain related to long-term diabetes mellitus.
A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?
- Ensure the client knows to taper down the dose if it is discontinued by the care provider.
Corticosteroids must be tapered slowly in order to prevent an adrenal crisis. These medications do not normally cause dependence and they do not pose a risk for GI bleeding. Grapefruit is not contraindicated.
Which of the following nursing interventions contributes to achieving a client’s pain relief?
- Collaborate with the client about his or her goal for a level of pain relief.
The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.
How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?
- Administering the analgesics on a regular basis
Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.
A client with appendicitis has had an appendectomy. After surgery, what type of pain does the nurse anticipate the client will have?
- Acute pain
Acute pain is a discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identifiable etiology. The characteristics of chronic pain, discomfort that lasts longer than 6 months, are almost totally opposite from those of acute pain. An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Referred pain is a term used to describe discomfort that is perceived in a general area of the body, but not in the exact site where an organ is anatomically located.
The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client’s pain assessment?
- The nurse administers pain medication based on the client’s reported pain level.
Clients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated blood pressure or heart rate does not mean the absence of pain. The ability of an individual to give a report of pain, especially its intensity, is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain medication should not routinely be administered to a client upon admission to the unit.
The advance practice nurse is treating a client experiencing a neuropathic pain syndrome. Which statements by the client demonstrates an understanding of concepts related to neuropathic pain?
- "My phantom limb pain serves no purpose, and I may need to take antidepressants to help."
Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the tricyclic antidepressants despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for treatment of neuropathic pain.
The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain?
- Every time the client's vital signs are assessed
The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain should not be assessed only on admission and discharge of the client.
A nurse is employed at a healthcare facility with a recent influx of many clients from a particular culture. The nurse is presenting information about the effect of one's culture on pain perception to a group of unlicensed assistive personnel (UAP). The nurse evaluates that the students need reteaching when one of them states
- "A client from this culture always exaggerates his or her pain."
Nurses should not stereotype clients based on culture by believing that those from a specific culture will exhibit more or less pain. Clients do learn from others how to respond to pain. Factors, such as age and gender, may explain differences about pain perception among cultural groups. The nurse needs to recognize that his or her values differ from those of other cultures.
A physician orders morphine sulfate 1 mg IV stat for chest pain. The drug is available in 2 mg per 1 mL syringe. How many mL does the nurse administer? Enter the correct number ONLY.
The dose ordered is 1 mg. The dose available is 2 mg. The quantity is 1 mL. 1 mg/2 mg x 1 mL = 0.5 mL.
A client is being taught to self-administer a narcotic analgesic by means of an intravenous pump system. Which of the following would help prevent accidental overdosage?
- Programming the dosage and time interval into the device
When the client is being taught to self-administer a narcotic analgesic, the dosage and time interval between doses are programmed into the intravenous pump system to prevent accidental overdosage. The frequency or dosage of the narcotic analgesic need not be reduced. Although a schedule chart is useful to the client, it does not effectively prevent accidental overdosage.
An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?
- Follow a bowel regimen.
The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. The client should not reduce fiber intake because this increases the risk for constipation. Exercising regularly or avoiding harsh sunlight have no effects on the drug therapy.
Acute pain can be distinguished from chronic pain by assessing which characteristic?
- Acute pain is specific and localized.
Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.
Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing?
- Older clients should receive a reduced dose.
A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.
A 64-year-old client is experiencing joint pain on a regular basis and asks the nurse what the options are beyond heat and the yoga exercises the client has been doing. What does the nurse describe as the cornerstone treatment modality for pain?
- drug therapy
Drug therapy is the primary method used for pain management. Physical therapy is often used as a co therapy, along with prescription or nonprescription drugs. It can help to strengthen muscles weakened by disuse. Acupuncture is a pain management technique that involves the insertion of very thin needles at strategic points on the body. It is not a primary therapy in conventional Western medicine. Psychological counseling may be recommended in some cases to help clients deal with depression and anxiety associated with pain. It is not a primary therapy.
Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission?
- A child quickly removing a hand when touching a hot object
Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.
The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?
Opioid analgesic agents are divided into two major groups: (1) mu agonist opioids (also called morphine-like drugs) and (2) agonist-antagonist opioids. The mu agonist opioids comprise the larger of the two groups and include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone, among others. The agonist-antagonist opioids include buprenorphine (Buprenex, Butrans), nalbuphine (Nubain), and butorphanol (Stadol).
A client recovering from hip surgery is receiving morphine through a patient–controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement?
- Assess the client's respiratory status
A basal rate is a continuous infusion of the medication. Assessment of the client's respiratory status is a major nursing responsibility and the most important one listed per Maslow's hierarchy of needs. The nurse will instruct the client about bolus doses for increased pain or painful activities and assess pain status. There is no information in the stem of the question to support the need for consent for PCA by proxy.
When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?
Patients should be informed about signs and symptoms of fentanyl overdose such as shallow or difficulty breathing, extreme sleepiness, confusion, sedation. Hyperalertness, hyperventilation, and insomnia would not occur.
According to The Joint Commission’s pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?
- location, onset, alleviating factors, and aggravating factors
Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards. Family history is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Nutritional deficiencies are not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Range of motion is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards.
A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client’s pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing?
- neuropathic pain
Neuropathic pain can affect cancer patients due to nerve damage from chemotherapy or radiation therapy. Somatic pain is caused by damage or disorders that affect bones, joints, muscles, skin, or other structures. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is pain felt in the body in a location that is different from the actual source of the pain.
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?
- Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration.
The most appropriate action by the nurse would be to consult with the physician regarding the need for an increased dose of the drug and not to reduce its frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50%. Informing the client that he will not be able to receive more medication is not acting as a client advocate nor acting in the best interest of the client. Suggesting a psychiatrist consultation would not be an appropriate action because the client has a chronic illness that requires medication. Taking a non-narcotic analgesic would not provide the client with the pain relief that he has.
A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?
- Ice bag
Pain associated with injury is best treated initially with cold applications such as an ice bag or chemical pack. The cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain. Heat will increase vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the scope of practice for the nurse to inject steroids into the joint space.
What does the nurse understand is the advantage of using intraspinal infusion to deliver analgesics? (Select all that apply.)
- Side effects of systemic analgesia are reduced.
- Effects on pulse, respirations, and blood pressure are reduced.
- The need for injections decreases in frequency.
Some of the more invasive methods used to manage pain are accomplished via catheter techniques such as intraspinal analgesia, sometimes referred to as “neuraxial” analgesia. Delivery of analgesic agents by the intraspinal routes is accomplished by inserting a needle into the subarachnoid space (for intrathecal [spinal] analgesia) or the epidural space and injecting the analgesic agent, or threading a catheter through the needle and taping it in place temporarily for bolus dosing or continuous administration (Pasero, Quinn et al., 2011). Intrathecal catheters for acute pain management are used most often for providing anesthesia or a single bolus dose of an analgesic agent. Temporary epidural catheters for acute pain management are removed after 2 to 4 days. Epidural analgesia is administered by clinician-administered bolus, continuous infusion (basal rate), and patientcontrolled epidural analgesia (PCEA). The most common opioids administered intraspinally are morphine, fentanyl, and hydromorphone (Dilaudid).
When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain.
- Intervertebral disk herniation
Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain.
A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:
- Prolonged in duration.
A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.
Regarding tolerance and addiction, the nurse understands that
- although clients may need increasing levels of opioids, they are not addicted.
Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.
Which substance reduces the transmission of pain?
Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.
A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect?
Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
- Risk for impaired gas exchange
Problems that may develop with opioid and opiate therapy include risk for impaired gas exchange related to respiratory depression, constipation related to slowed peristalsis, and risk for injury related to drowsiness and unsteady gait.
Which medication should be readily available for patients receiving epidural opioids who are experiencing respiratory depression?
Opioid antagonist agents such as naloxone must be available for IV use if respiratory depression occurs. Diphenhydramine is used for opioid induced pruritus. Aspirin and ibuprofen would not be used.
Which phase of pain transmission occurs when the one is made aware of pain?
Problems that may develop with opioid and opiate therapy include Risk for Impaired Gas Exchange related to respiratory depression, Constipation related to slowed peristalsis, and Risk for Injury related to drowsiness and unsteady gait.
The nurse is administering a narcotic analgesic for the control of a newly postoperative client’s pain. What medication will the nurse administer to this client?
- Fentanyl (Duragesic)
Opioid and opiate analgesics such as morphine and fentanyl (Duragesic) are controlled substances referred to as narcotics. The other medications are not opioid analgesics and should not be given for a newly postoperative client.
The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?
Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient (“pain signature”). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures.
The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?
- Older people experience reduced sensory perception.