Chapter 8 - Pain

Pain has been defined as "whatever the person experiencing the pain says it is, existing whenever the patient says it does."
This definition is problematic for the nurse when caring for which type of patient?

a. A patient placed on a ventilator
b. A patient with a history of opioid addiction
c. A patient with decreased cognitive function
d. A patient with pain resulting from severe trauma

c. Because the patient's self-report is the most valid means of pain assessment, patients who have decreased cognitive function, such as those who are comatose, have dementia, or are mentally disabled, might not be able to report pain. In these cases, nonverbal information and behaviors are necessary considerations in pain assessment.

On the first postoperative day following a bowel resection, the patient complains of abdominal and incisionalpain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse's action have on the patient?

a. Protects the patient from addiction and toxic effects of the drug
b. Prevents hastening or causing a patient's death from respiratory dysfunction
c. Contributes to unnecessary suffering and physical and psychosocial dysfunction
d. Indicates that the nurse understands the adage of "start low and go slow" in administering analgesics

c. Administering the smallest prescribed analgesic dose when given a choice is not consistent with current pain management guidelines and leads to undertreatment of pain and inadequate pain control. Without reassessing the pain within 30 minutes of the IV analgesic the nurse is unsure how well the previous dose of medication worked for the patient to determine the current dose needed.
Unnecessary suffering, impaired recovery from acute illness, increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, and other physical dysfunction can occur.

Once generated, what may block the transmission of an action potential along a peripheral nerve fiber to the dorsal root of the spinal cord?

a. The transmission may be interrupted by drugs such as local anesthetics.
b. Nothing can stop the action potential along an intact nerve until it reaches the spinal cord.
c. The action potential must cross several synapses, points at which the impulse may be blocked by drugs.
d. The nerve fiber produces neurotransmitters that may activate nearby nerve fibers to transmit pain impulses.

a. Although a peripheral nerve is one cell that carries an impulse directly from the periphery to the dorsal horn of the spinal cord with no synapses, transmission of the impulse can be interrupted by drugs known as membrane stabilizers or sodium-channel inhibitors, such as local anesthetics and some antiseizure drugs. The nerve fiber produces neurotransmitters only at synapses, not during transmission of the action potential.

A patient comes to the clinic with a complaint of a dull pain in the anterior and posterior neck. On examination, the nurse notes that the patient has full range of motion (ROM) of the neck and no throat redness or enlarged head or neck lymph nodes. What will be the nurse's next appropriate assessment indicated by these findings?

a. Palpation of the liver
b. Auscultation of bowel sounds
c. Inspection of the patient's ears
d. Palpation for the presence of left flank pain

a. The right neck and flank are common areas of referred pain from liver damage and examination of the liver should be considered when pain occurs without other findings in these areas. Other common referred areas are midscapular and left arm for cardiac pain, inner legs for bladder pain, and shoulders for gallbladder pain.

While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient's heel. During care of the ulcer, what is the nurse's understanding of the patient's perception of pain?

a. The patient will have a behavioral response if pain is perceived.
b. The area should be treated as a painful lesion, using gentle cleansing and dressing.
c. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
d. All nociceptive stimuli that are transmitted to the brain result in the perception of pain

b. It is known that the brain is necessary for pain
perception but because it is not clearly understood where in the brain pain is perceived, pain may be perceived even in a comatose patient who may not respond behaviorally to noxious stimuli. Any noxious stimulus should be treated as potentially painful.

List in order the nociceptive processes that occur to communicate tissue damage to the CNS. No. 1 is the first process and No. 4 is the last process.
a. Perception
b. Modulation
c. Transmission
d. Transduction

a. 3; b. 4; c. 2; d. 1

Amitriptyline (Elavil) is prescribed for a patient with chronic pain from fibromyalgia. When the nurse explains that this drug is an antidepressant, the patient states that she is in pain, not depressed. What is the nurse's best response to the patient?

a. Antidepressants will improve the patient's attitude and prevent a negative emotional response to the pain.
b. Chronic pain almost always leads to depression, and the use of this drug will prevent depression from occurring.
c. Some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain.
d. Certain antidepressant drugs are metabolized in the liver to substances that numb the ends of nerve fibers, preventing the onset of pain.

C.

antidepressants affect the modulatory systems
by inhibiting the reuptake of serotonin and norepinephrine in descending modulatory fibers, thereby increasing their availability to inhibit afferent transmission of pain impulses. Although chronic pain is often accompanied by anxiety and depression, the antidepressants that affect the physiologic process of pain modulation are used for pain control whether depression is present or not.

A patient with trigeminal neuralgia has moderate to severe burning and shooting pain. In helping the patient to manage the pain, the nurse recognizes what about this type of pain?

a. Treatment includes the use of adjuvant analgesics
b. Will be chronic in nature and require long-term treatment
c. Responds to small to moderate around-the-clock doses of oral opioids
d. Can be well controlled with salicylates or nonsteroidal antiinflammatory drugs (NSAIDs)

a. Damage to peripheral or cranial nerves causes neuropathic pain that is not well controlled by opioid analgesics alone and often includes the adjuvant use of tricyclic antidepressants or antiseizure drugs to help inhibit pain transmission. Salicylates and NSAIDs are not effective for the intensity of neuropathic pain.

A patient with colorectal cancer has continuous, poorly localized abdominal pain at an intensity of 5 on a scale of 0 to 10. How does the nurse teach the patient to use pain medications?

a. On an around-the-clock schedule
b. As often as necessary to keep the pain controlled
c. By alternating two different types of drugs to prevent tolerance
d. When the pain cannot be controlled with distraction or relaxation

a. Analgesics should be scheduled around the clock for patients with constant pain to prevent pain from escalating and becoming difficult to relieve. If pain control is not adequate, the analgesic dose may be increased or an adjunctive drug may be added to the treatment plan

A patient who has been taking ibuprofen (Motrin) and imipramine (Tofranil) for control of cancer pain is having increased pain. What would the health care provider recommend as an appropriate change in the medication plan?
a. Add PO oxycodone (Oxycontin) to the other medications
b. Substitute PO propoxyphene (Darvon), a mild opioid, for imipramine
c. Add transdermal fentanyl (Duragesic) to the use of the other medications
d. Substitute PO hydrocodone with acetaminophen (Lortab, Vicodin) for the other medications

a. As cancer pain increases, stronger drugs are added to the regimen. This patient is using a nonsteroidal antiinflammatory drug (NSAID) and an antidepressant. A stronger preparation would be an opioid but because an NSAID is already being used, a combination NSAID/opioid is not indicated. An appropriate stronger drug would be an oral opioid, in this case oral oxycodone, and this still leaves stronger drugs for expected increasing pain. Propoxyphene is not recommended in analgesic guidelines because of its limited efficacy and toxicities.

A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what?

a. Pruritus

b. Dizziness

c. Constipation
d. Nausea and vomiting

c. Although tolerance to many of the side effects of opioids (nausea, sedation, respiratory depression, pruritus) develops within days, tolerance to opioid-induced constipation does not occur. A bowel regimen that includes a gentle-stimulant laxative and a stool softener should be started at the beginning of opioid therapy and continue for as long as the drug is taken.

A postoperative 68-year-old opioid-naive patient is receiving morphine by patient-controlled analgesia (PCA) for postoperative pain. What is the rationale for not initiating the PCA analgesic with a basal dose of analgesic as well?
a. Opioid overdose
b. Nausea and itching

c. Lack of pain control

d. Adverse respiratory outcomes

d. Use of a basal dose may increase the risk of serious respiratory events in opioid-naive patients and those at risk for respiratory difficulties (older age, existing pulmonary disease, etc.). Overdose is not expected, as the dosages are calculated and the PCA pump is programmed to prevent this. Nausea and itching are common side effects but not related to a basal dose of analgesic. A lack of pain control would not be expected with or without a basal dose. The nurse would be assessing the patient and notify the physician if a lack of pain control occurs but, again, this is not related to receiving a basal dose of analgesic via PCA pump

Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)?

a. Distraction
b. Corticosteroids
c. Epidural opioids

d. Local anesthetics

e. Antiseizure medications

f. Nonsteroidal antiinflammatory drugs (NSAIDs)

b, d, e, f. Distraction is effective in the perception stage. Epidural opioids are effective in the transmission stage

A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery.Which actions should the nurse include in the plan of care (select all that apply)?

a. Label the catheter as an epidural access.
b. Assess the patient's pain relief frequently.
c. Use sterile technique when caring for the catheter.
d. Monitor the patient's level of consciousness (LOC).
e. Monitor patient vital signs (blood pressure, heart rate, respirations).
f. Assess the motor and sensory function of the patient's lower extremities

a, b, c, d, e, f. The major complications of epidural analgesia are catheter displacement and migration, accidental infusions of neurotoxic agents, and infection. These actions will help to reduce those risks.

A patient with multiple injuries resulting from an automobile accident tells the nurse that he has "bad" pain but that he can "tough it out" and does not require pain medication. To gain the patient's participation in pain management, what should the nurse explain to the patient?

a. Patients have a responsibility to keep the nurse informed about their pain.
b. Unrelieved pain has many harmful effects on the body that can impair recovery.
c. Using pain medications rarely leads to addiction when they are used for actual pain.
d. Nonpharmacologic therapies can be used to relieve his pain if he is afraid to use pain medications.

b. When a patient wants to be stoic about pain, it is
important that he or she understand that pain itself can have harmful physiologic effects and that failure to report pain and participate in its control can result in severe unrelieved pain. No evidence that indicates fear of taking the medication is present in this situation.

The patient has chronic pain that is no longer relieved with oral morphine. Which medication would the nurse expect to be ordered to provide better pain relief for this patient?

a. Duragesic
b. Oramorph SR
c. Hydrocodone
d. Intranasal butorphanol (Stadol)

a. Duragesic is frequently used for chronic pain in patients who are not opiate-naive. Oramorph SR given buccally will have the same absorption as morphine, so it would not be expected to be more effective than oral morphine. Hydrocodone is used for acute and short-term pain, not chronic pain. Intranasal butorphanol (Stadol) is used for acute headaches and recurrent, not chronic pain. The route used will depend on the swallowing ability of the patient.