Nursing Care of the Patient with Pain Exam 62 Questions with Verified Answers
Acute Pain - CORRECT ANSWER Short duration usually r/t tissue damage
... [Show More] (cut, abraison, swelling, pressure from inside or outside, chemical, heat, multiple causes)
Usually of limited time period
Often reduced by intervention
Chronic Pain - CORRECT ANSWER Acute pain that increased tissue damage may delay or prevent healing, stimulating nerve to respond to a long term discomfort
Usually longer than 6 months duration
May or may not respond to intervention
Somatic Pain - CORRECT ANSWER Comes from the skin & deep tissues
Visceral Pain - CORRECT ANSWER Originates in the internal organs
Neuropathic Pain - CORRECT ANSWER Burning
Prickling
Tingling
Shock-like
Paresthesia
May be associated with: Allodynia, Hyperalgesia, Referred pain, More intense at noc
Hyperalgesia - CORRECT ANSWER Increased response to a painful stimulus
Allodynia - CORRECT ANSWER Painful response to a normally innocuous stimulus
Post Mastectomy Pain Syndrome (PMP) - CORRECT ANSWER A type of chromic pain that occurs after breast cancer surgeries such as mastectomy, lumpectomy, & axillary lymph node dissection.
Burning sensation
Shooting, stabbing pain
Throbbing, aching, or oppressing pain
Can develop up to several months after surgery & persist for 3-6 or more years
Fibromyalgia - CORRECT ANSWER Widespread musculoskeletal pain accompanied by fatigue, sleep, memory & mood issues
Painful sensations are amplified due to the way the brain processes pain signals
Hemiplegia Associated Shoulder Pain - CORRECT ANSWER Occurs after a stroke that hampers functional recovery and can lead to disability
Can begin as early as 2 weeks post-stroke but typically occurs within 2-3 months post-stroke
Contributing factors:
Subluxation
Contracture's
Complex regional pain syndrome (CRPS)
Rotator cuff injury
Spastic muscle imbalance of glenohumeral joint
Sickle Cell Disease Pain - CORRECT ANSWER Deep, gnawing, & throbbing
Skin may be tender to touch, red, and warm in painful areas
Pain severity may range from mild to severe
Can start as early as 6months old continuing throughout their lives
Can be very unpredictable when pain starts
**AVOID: swimming in cold water, being out in cold weather, getting too hot, dehydrated, colds & infections, over-exerting yourself, alcohol, smoking, menstruation, stress, second-hand smoke**
AIDS related pain - CORRECT ANSWER Can result from the virus itself, various forms of treatment, opportunistic infections & cancers
Effects all parts of the body & can significantly affect quality of life
Often left untreated
**causes: inflammatory response caused by the infection, complications of poorly managed HIV, SEs of meds, damage caused by HIV meds, lowered immunity**
Burn Pain - CORRECT ANSWER The degree of pain is not related to the severity of the burn, as the most serious burns can be painless
Can be one of the most intense & prolonged types of pain
It has changing patterns & various components that effect it making it hard to manage
Pain is involved in treatment of burns, as the wounds must be cleansed & dressings changed
**aggressive treatments for pain are needed with severe burns**
Gullian-Barre Syndrome (GBS) - CORRECT ANSWER A condition where the immune system attacks the nerves
Pain area is in the muscles
Symptoms:
Muscle weakness
Abnormally walking
Problems with coordination or weakness of the arms & legs
Fatigue
High BP
SOB
Difficulty swallowing
**Pain symptoms: uncomfortable tingling & burning, presents 2-4 weeks following a benign respiratory or GI illness with c/o finger dysesthesias & proximal muscle weakness of lower extremities**
Can progress over hours to days to involve the arms, truncal muscles, cranial nerves, & muscles of respiration.**
**Variants of GBS may present as pure motor function or acute dysautonomia**
Phantom Limb Pain - CORRECT ANSWER Refers to ongoing painful sensations that seem to be coming from the part of the limb that is no longer there
The limb is gone but the pain is real
Onset of pain often occurs soon after surgery
Complex Regional Pain Syndrome (RSD) - CORRECT ANSWER A chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb
Causes: damage to, or malfunction of the PNS & CNS
Characterized by: prolonged or excessive pain & mild/dramatic changes in the skin color, temp, &/or swallowing in the affected area
2 types (CRPS-1 & CRPS-2)
CRPS-2 - CORRECT ANSWER Formerly called Causalgia
Is the term used for patients with confirmed nerve injuries
Symptoms of CRPS - CORRECT ANSWER Prolonged pain that is constant and severe
Burning
"Pins & needles"
Some report squeezing sensation of the limb
Pain may spread to the entire arm or leg even though the precipitating injury might only be a finger or toe
Pain can sometimes travel to the opposite extremity
Theres often an increased sensitivity in the affected area, such that light touch or contact is painful (allodynia)
Assessments, Dx testing, lab values - CORRECT ANSWER Obtain:
History (general health & focused pain assessment)
Physical exam
Measurement of pain (NRS, other scale)
Imaging (X-ray, CT scan, MRI, bone scan)
Blood testing (check: Ca++, renal function, infection)
Pain assessment (documentation) - CORRECT ANSWER Onset & pattern
Location
Description
Intensity
Aggravating & relieving factors
Previous treatment
Effect of previous/current treatment
Pain rating scales - CORRECT ANSWER Number Rating Scale (NRS): 0-10
Faces Pain Scale: smiley faces
Word description scales
Pieces of Hurt tool: poker chips to qualify pain for small children
McGill Melzack Pain questionnaire
Figures to locate exactly where pain is
FLACC scale for non-verbal/child
Checklist of Non-verbal Pain Indicators (CNPI)
Pain Assessment tools for an infant (objective) - CORRECT ANSWER Neonatal Infant Pain Scale (NIPS)
Neonatal Pain, Agitation, & Sedation Scale (NPASS)
Pain Assessment Tool (PAT or FLACC)
Pediatric Pain Assessment tools (objective) - CORRECT ANSWER FACES scale
Poker chips
Number rating scale
Color matching
Checklist for Non-verbal Pain Indicators (CNPI) - CORRECT ANSWER **behavior with movement at rest**
1) Vocal complaints (NON-VERBAL): sighs, gasps, moans, groans, cries
2) Facial Grimaces/Winces: furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expressions
3) Bracing: clutching or holding onto furniture, equipment, or affected area during movement
4) Restlessness: constant or intermittent shifting or position, rocking, intermittent or constant hand motions, inability to keep still
5) Rubbing: massaging affected area
6) Vocal Complaints: (VERBAL): words expressing discomfort or pain (i.e. "Ouch", "that hurts", cursing during movement; exclamations of protest such as, "stop", "that's enough")
***and then tally total score***
CNPI scoring - CORRECT ANSWER Score of 0 if the behavior is not observed
Score of 1 if the behaviors observed at rest, with movement, & overall
There are no clear cutoff scores to indicate severity of pain; instead, the presence of any of the above behaviors may be indicative of pain, warranting further investigation, treatment, & monitoring by the practicioner
EVP/collaborative care for pain management - CORRECT ANSWER 1) Health promotion (be aware of risk for injury to self, children, & elders)
2) Safety & Prevention (safety in work & play; first aid, 911 assistance)
3) Initial Treatment:
Protect injury
First aid
Cold
NSAIDS
Treatment (determine injury)
WHO pain relief ladder
Acute Pain Interventions - CORRECT ANSWER Assess q2 & PRN
Remove cause if possible
Comfort measures (reposition, ice, massage, distraction, etc)
Meds as needed based on WHO pyramid for appropriate level
Reassess after intervention & prn
**Keep ahead of the pain**
Chronic Pain Interventions - CORRECT ANSWER Assess q2-4 & PRN
Remove cause or factor that worsens pain
Comfort measures (reposition, heat, ice, massage, distraction, etc)
Meds prn based on WHO pyramid for appropriate level
Reassess after intervention & prn
**Routine schedule to provide 24 hr relief**
WHO pain ladder - CORRECT ANSWER Mild pain (0-3) use acetaminophen
Moderate pain (4-6) use codeine
Severe pain (7-10) use morphine
***By the mouth, by the clock, by the ladder***
Chronic pain 24 hour protocol - CORRECT ANSWER Giving meds at same intervals can provide adequate relief
Waiting too long between meds makes pain levels rise, requiring stronger pain meds to be effective
Maintaining stable blood levels of meds keeps pain levels more constant
**Goal for pain management: <4**
Pharmacological/Parenteral pain management strategies - CORRECT ANSWER Non-narcotic
Narcotics
Sedatives/anesthetics
Local anesthetics
Pain pumps
Epidural implants
End of life care
Morphine equivalency table
Conscious sedation
Why do pain meds work? - CORRECT ANSWER Increase vascular permeability
Plasma extravasation
Vasodilation
Leukocyte chemotaxis
Nociceptor activation
Sensitization of sensory nerves
Opioid receptors - CORRECT ANSWER Usually opioids are active on CNS receptors found on:
Peripheral neurons
Immune cells
Inflamed tissue
Respiratory tissue
GI tract
Patient & Caregiver Education regarding pain management - CORRECT ANSWER Diagnosis, prognosis, natural history of underlying disease
Communication & assessment of pain
Explanation of drug strategies
Management of potential side-effects
Explanantion of non-drug strategies
Serotonergic effect - CORRECT ANSWER Symptom onset is usually rapid, often occurring within minutes
Potentially life-threatening drug reaction that may occur following:
Therapeutic drug use
Inadvertent interactions between drugs
Overdose of particular drugs
Recreational use of certain drugs
**Symptoms: described as a clinical triad of abnormalities: cognitive, autonomic, & somatic effects**
Cognitive effects - CORRECT ANSWER HA
Agitation
Hypomania
Mental confusion
Hallucinations
Coma
Autonomic effects - CORRECT ANSWER Shivering
Sweating
Hyperthermia
HTN
Tachycardia
Nausea
Diarrhea
Somatic effects - CORRECT ANSWER Myoclonus (muscle twitching)
Hyperreflexia (manifested by clonus)
Tremors
Considerations for opioids - CORRECT ANSWER Reduce dose
Rotate opioids
Hydration
Ambulate patient
Stool softeners
Opioids relieve agony
Key Teaching Points-Patient - CORRECT ANSWER Careful of mix up between long acting & short acting with same mg amount (ex: MS Contin & MSIR)
Remove old patch before new one put on
Safe disposal issues
Drinking, causes driving issues
Tell all of your health care providers everything that you take ALWAYS
Careful about buying on the internet
Sleepers, sedatives
Be aware of s/s of addiction/withdrawal
IV push meds - CORRECT ANSWER -Requires a VAD
-If IV fluid infusing, med must be compatible with IV solution infusing
-Admin med at correct rate & dilution
-If IV fluid NOT infusing (saline lock) or if med is NOT compatible, use saline flush to determine if IV patent. (May have to piggy back compatible solution to give med)
-Use SAS procedure
-If central line may have to use SASH with Heparin flush solution & special push technique (per facility policy)
**Note patient response: pain, LOC, VS, especially respiratory status or anything else**
**Usual pain meds: morphine, dilaudid, ketorolac**
S-A-S IV procedure - CORRECT ANSWER Saline flush prior to slow administration of drug (timed), flush VAD with saline at medication rate otherwise remains in tubing (also, saline keeps VAD from clotting)
Epidural Analgesia for Post-Op Pain - CORRECT ANSWER **Epidural space is an area between walls of the vertebral canal & dura matter of spinal cord**
-Contains BVs, fat & nerves, NO FLUIDS
-Surrounds spinal meninges & extends from foremen magnum to sacral hiatus
-Analgesics can be injected with a needle that has been inserted into the epidural space
-Catheter may be threaded through the needle & taped in place for use during acute pain period of 2-4 days
Epidural Analgesia for Post-op Pain Benefits - CORRECT ANSWER -Appropriate first line for moderate-severe acute >24 hrs
-20 yrs research demonstrated superior pain relief & improved functional outcomes after major surgery even over IV PCA
-All systems responded better: mobility, GI, pulmonary, circulatory
Administration of Meds via Epidural (3 methods) - CORRECT ANSWER 1) Bolus: injecting single bolus
Intermittent Bolus: for moderate/severe pain >24 hrs. Small around the clock doses provide more even control than PRN doses
2) Continuous Infusion: more consistent control with pump to deliver continuous basal rate (dose).
**Supplemental bolus doses for breakthrough pain can be given by clinician
3) PCA: patients self-admin doses with PCA pump complement a continuous infusion
PCA - CORRECT ANSWER -Contains a syringe of pain med connected to IV line
-Machine is set to deliver a small, constant flow of pain medication
-The patient can press a button to give themselves additional medication (can check history to see use)
-Machine controls size & amount of bolus medication
-Machine is locked to prevent tampering
Interruption of Pain Pathways - CORRECT ANSWER -Injection of steroids via epidural (#1 anti-inflammatory drug)
-Specialty blocks such as a celiac plexus blockade
-Cordotomy (lateral pathways cut in spinal cord)
-Rhizotomy (nerve root cut)
-Epiduroscopy (inserting a small flexible fiberoptic catheter into epidural space, scar tissue is then removed from nerve roots, decreasing pain)
End of life Care - CORRECT ANSWER -Many people comply with medical treatment because they are afraid of they don't, they will not have adequate pain management especially when it is severe
-Palliative care
-Hospice Care
-Non-Hospice care
Procedural Sedation Indications - CORRECT ANSWER Suturing
Fracture reduction
Abscess I&D
Joint relocation
Major wound treatment/dressing
Colonoscopy & other out-patient procedures
**Assessment: obtain info about allergies, last oral intake**
midazolam/Versed - CORRECT ANSWER **most commonly used for conscious sedation**
-Provides sedation & pain control during medical or dental procedures
-Called "conscious" b/c the pt is aware of where he/she is & can talk with the doctors & nurses during the procedure
-Usually pt is very sleepy, but can be easily awakened with touch or talking
-May feel like speech is slurred
-May not remember the procedure after it is over b/c some meds given for conscious sedation cause amnesia
-Routinely used for medical procedures such as: cardiac catheterization, upper & lower bowel exams, dental procedures & outpatient surgeries
-Not under a general anesthetic
-Pt aware of his/her surroundings but doesn't care much about them
Criteria used to assess the adequacy of sedation include: - CORRECT ANSWER -Sleepiness with response to commands
-Slurred speech
-Respiratory depression
-Drooping eyelids without loss of protective reflexes (cough, gag, or glottic closure)
**The above are all expected positive responses**
Depth of Conscious Sedation allows... - CORRECT ANSWER Patient cooperation
An intact gag reflex
Arousal response during procedure
Agent also used in conscious sedation - CORRECT ANSWER Valium
**Valium & Versed are both benzodiazapines**
What is the goals of conscious sedation? - CORRECT ANSWER -Amnesia (not mandatory but does cause a lack of recall which is considered a positive experience for patients)
-Decreased pain response
-Altered mood state
-Enhanced patient cooperation
-Cardiovascular stability
-Rapid return to pre-procedure mental status
diazepam/Valium - CORRECT ANSWER -Indicated for conscious sedation prior to short diagnostic or surgical procedures, either alone or with a narcotic
-It may be admin IV, IM, or PO. **IM admin very painful & not recommended**
-10mg PO often for adults <50
-IV dose may range from 2-20mg in a healthy adult, although 10mg or less is usually sufficient
-Decreased dosage in children or elderly
-Admin in 1-2mg increments IV q2 mins until desired effect is achieved
Side Effects: Narcotics & Conscious Sedation Agents - CORRECT ANSWER Half-life: 2-4 hrs (pts should not do any activities that require fine motor or cognition skills such as: driving, cooking)
Rapid IV administration can lead to a rigid chest wall & difficulty breathing
**Narcotics: SEs can be reversed with naloxone (Narcan) or may require a depolarizing muscle relaxant & intubation**
Nursing Implications during Procedures - CORRECT ANSWER -IV access must be continuously maintained in the patient receiving IV conscious sedation
-All pts receiving IV conscious sedation will be continuously monitored throughout the procedure as well as the recovery phase by physiologic measurements including (RR, O2 sat, BP, cardiac rate & rhythm, pt's LOC)
-The pt should be monitored at 5min intervals during the procedure, & at 5-15 min intervals during the recovery phase, & at any significant event in the either phase
Nursing Implications during Procedures - CORRECT ANSWER -O2 with continuous pulse ox
-Constant one-on-one supervision (Key: RR & verbal responsiveness)
-Requires uninterrupted observation & monitoring if the pt from time to time of conscious sedation until time of discharge)
-Provisions must be in place for ACLS staff to be present
Patient with pain management issues (Role of the Nurse) - CORRECT ANSWER Asses the patient (obtain both subjective & objective data)
Organize the data, determine cause
Determine nursing diagnosis
Determine goal
Patient with pain management issues (Role of the Nurse) - CORRECT ANSWER Interventions:
Continue assessment
Nursing actions for comfort, medication
Teach patient how to help themselves
Plan for interventions outside of health care system
Refer for pain management organizations
Evaluations:
Continuous re-evaluation process
Patient/Family Education & Referral - CORRECT ANSWER Safety:
Education, safe use, complications of long term use, addiction & drug use
Family participation in pain management
Keep meds safe in home, observe for safe use, monitor use & side effects.
**support patient**
Key Education Points - CORRECT ANSWER Know patient's knowledge base
Address patient's priorities first
Individualize plan to patient (social & education level)
Current, accurate info
Use available resources
Involve family & caregivers
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