NUR 3480 Exam 3: Pain Assessment and Scales

Definition of pain used on the slides

Whatever the person says it is, existing whenever the experiencing person says it does.

Single most reliable indicator of pain

The patient's self-report.

Three pain myths (all FALSE)

1) All real pain has an identifiable physical cause. 2) Patients in pain always have observable signs. 3) Addiction is a common problem in patients taking opioids for pain.

A patient laughing with visitors rates pain 8/10. What do you do?

Accept the rating and treat it. Self-report is the best indicator; observable signs are not required.

OLDCARTS

Onset, Location, Duration, Characteristics/quality, Aggravating and alleviating factors, Radiating/referred, Time of day, Severity.

Question that assesses functional status in pain

"What does the pain keep you from doing?" Use those meaningful activities as the treatment goals.

Three times to assess pain intensity around an analgesic

At initiation of the medication, with a dose increase, and at the peak of the analgesic.

Joint Commission: what a pain REASSESSMENT must include

Response to the intervention; progress toward goals including functional ability; side effects; risk factors for adverse events. A numeric score alone is inadequate.

Which scale: adult with advanced dementia who cannot self-report

PAINAD: breathing, negative vocalization, facial expression, body language, consolability. Each scored 0-2 by the nurse.

Which scale: infant or nonverbal child

FLACC: Face, Legs, Activity, Cry, Consolability. Each scored 0-2 by the nurse.

Wong-Baker FACES: who chooses the face?

The PATIENT points to the face. The nurse does not assign a score based on how the patient's face looks. [DB]

What does the POSS measure?

Opioid-induced SEDATION, not pain intensity. Levels S, 1, 2, 3, 4.

POSS S, 1, and 2

Acceptable. S = asleep but easy to arouse; 1 = awake and alert; 2 = slightly drowsy, easily aroused. No action needed; opioid may be increased if needed.

POSS 3: what it looks like and what you do

Frequently drowsy, drifts off to sleep during conversation. UNACCEPTABLE: monitor respirations and sedation closely, decrease opioid dose 25-50% or notify the prescriber, consider a nonopioid (acetaminophen or NSAID).

POSS 4: what it looks like and what you do

Somnolent, minimal or no response to verbal and physical stimulation. UNACCEPTABLE: stop the opioid, consider naloxone, notify the prescriber, monitor closely.

Nociceptive pain

Damage or inflammation of tissue outside the nervous system; NORMAL pain processing. Localized, throbbing, aching. Treated with opioids and nonopioids.

Neuropathic pain

Abnormal or damaged pain nerves; ABNORMAL processing. Pins and needles, burning, shooting. Treated with adjuvants: antidepressants and anticonvulsants.

Somatic vs visceral pain

Somatic: bones, joints, muscles, skin, connective tissue. Visceral: internal organs (stomach, intestines); can cause referred pain.

Examples of neuropathic pain

Phantom limb pain, diabetic neuropathy, pain below a spinal cord injury, postherpetic neuralgia, trigeminal neuralgia, poststroke pain.

Acute pain: the body's response

Sympathetic fight-or-flight: tachycardia, hypertension, anxiety, diaphoresis, muscle tension. Protective, temporary, usually self-limiting. Treat the cause.

Chronic pain: definition and effect on vital signs

Persists or recurs beyond expected healing time (beyond 3 months). Usually does NOT raise vital signs. Can lead to depression, anger, fatigue, disability, suicide.

A patient with chronic pain has a normal HR and BP. Does that rule out pain?

No. Vital signs do not usually increase with chronic pain. Believe the self-report.

Breakthrough pain: key facts

Transient moderate-to-severe flare on top of persistent pain. More than 60% of patients. Peaks within 3 minutes, lasts about 30 minutes. Triggered by activity (incident pain) or unpredictable.

Treatment of breakthrough pain

Short-acting opioids, immediate-release opioids, NSAIDs.

Post-op patient is asleep when pain reassessment is due

Wake the patient to assess and treat. Stay ahead of the pain.

When are analgesics scheduled around the clock?

When high pain is anticipated, such as after surgery.

Why treat pain early (proactive pain management)?

Minor pain is easier to control, needs lower doses and lower-risk drugs, fixed intervals prevent wearing off, and the patient can take part in PT and ambulation. Pain stress delays healing.

Pain pyramid Tier 1 (the base)

Nonpharmacological: warm/ice, compression, elevation, mobilization, rest, repositioning, distraction, music, lower lights and noise. Foundational, NOT optional.

Pain pyramid Tier 2

Tylenol or an NSAID given on a SCHEDULE, plus adjuvants (muscle relaxants, antidepressants, anxiolytics).

Pain pyramid Tiers 3 and 4

Tier 3: opioid such as oxycodone or hydrocodone. Tier 4: stronger opioid such as hydromorphone, IV options.

Therapies stack, not swap

When an opioid is added, keep nonpharmacological measures and scheduled non-opioid to prevent rebound pain.

Best route for acute pain vs chronic pain

Parenteral (IV) for acute pain; oral for chronic, nonfluctuating pain.

Six opioid side effects

Respiratory depression, drowsiness/confusion, nausea/vomiting, constipation, urinary retention, pruritus.

Bowel regimen for a patient on opioids

Prophylactic and scheduled stimulant plus osmotic laxatives for unforced BM at least every other day.

Patient-controlled analgesia (PCA)

Patient controls IV doses via button; pump settings limit doses and record attempts for adjustments.

Ethical stance on placebos in pain

Placebos should never be used to assess or manage pain in any patient.

Addiction vs tolerance

Addiction involves psychological dependence and compulsive use; tolerance means needing higher doses for the same effect.

Nonverbal indicators of pain

Grimacing, guarding, restlessness, confusion, combativeness, moaning, tachycardia, elevated BP, diaphoresis.

Constipation definition and threshold

Abnormal infrequency or irregularity of defecation; fewer than 3 bowel movements per week.

Priority assessment in constipation

The patient's usual bowel pattern (baseline).

Drug classes causing constipation

Opioids, GLP-1s, anticholinergics, and chronic laxative use.

Order of treatment for constipation

Dietary fiber, then osmotic agents, then stimulant laxatives.

Long-term strategy for chronic constipation

Bowel habit training, exercise, and increased fiber and fluids, avoiding long-term senna.

Complications of constipation

Hypertension, fecal impaction, hemorrhoids, fissures, megacolon, and vagal stimulation from straining.

Psyllium (Metamucil)

Bulk-forming fiber supplement that facilitates stool passage.

Docusate (Colace)

Stool softener that moves water and fats into the stool.

Polyethylene glycol and Milk of Magnesia

Osmotic agents that retain water in stool to soften it and increase bowel movements.

Bisacodyl (Dulcolax)

Stimulant laxative that causes intestinal contractions to move stool through the colon.

Bristol Stool Chart types

Types 1-2 indicate constipation, 3-4 are ideal, and 5-7 indicate diarrhea and urgency.

Diarrhea definition

More than 3 bowel movements per day, increased stool amount, or abnormally liquid stool.

Priority in diarrhea management

Rehydration, oral before IV, while closely monitoring serum electrolytes.

Tube feeding diarrhea lab abnormality

Hypokalemia.

Diarrhea diet restrictions

Avoid caffeine, carbonated drinks, and temperature extremes; limit milk, fats, whole grains, and fresh produce.

Fecal incontinence nursing priorities

Identify the underlying cause, implement scheduled bowel retraining, and provide meticulous skin care.

Irritable Bowel Syndrome (IBS)

Functional disorder of intestinal motility with no inflammation, mucosal changes, or red flags.

IBD vs IBS differences

IBD is inflammatory, requires endoscopy/labs, and uses immunosuppressants; IBS needs no scope and focuses on diet and stress.

Classic IBS pain pattern

Pain precipitated by eating and relieved by defecation, associated with altered bowel habits.

IBS teaching guidelines

Keep food diaries, reduce stress, maintain high fiber, eat slowly, avoid drinking with meals, and limit trigger foods.

Hallmark of malabsorption

Steatorrhea: frequent, loose, bulky, foul-smelling gray stools containing fat.

Lower UTI (cystitis) cues

Dysuria, burning, frequency, urgency, nocturia, incontinence, suprapubic or pelvic pain, gross hematuria.

Older adult with new confusion and incontinence

Evaluate for a lower urinary tract infection. Older adults present atypically.

Pyelonephritis cues

Flank pain, CVA tenderness, fever, chills, nausea, vomiting, malaise; leukocytosis, bacteriuria, pyuria.

Pyelonephritis antibiotic and hydration goal

To prevent end-stage renal disease.

UTI prevention teaching

Wipe front to back, void after intercourse, drink liberal fluids, limit coffee/tea/soda/alcohol, shower rather than bathe, void every 2-3 hours, take all the antibiotic.

Urinary incontinence aging factor

Not a normal part of aging, though aging predisposes to it; often reversible and treatable.

Incontinence treatment order

Behavioral therapies first; medication as an adjunct; surgery when both have failed.

Stress incontinence action

Leakage with coughing, sneezing, or position change. Start pelvic floor muscle (Kegel) exercises.

Kegel exercise prescription

Contract 5-10 seconds, relax completely, 3 sets of 10 daily.

Urge incontinence actions

Leak after a sudden strong urge. Timed voiding every 1-2 hours then lengthen; urge suppression; cut caffeine, alcohol, artificial sweeteners, spicy foods.

Overflow incontinence actions

Dribbling from an overdistended bladder that does not empty. Bladder scan/PVR, clean intermittent self-catheterization, double voiding.

Functional incontinence actions

Cannot reach the toilet in time. Scheduled toileting, clear path, lighting, bedside commode, easy clothing, prompt call-light response.

DIAPPERS transient incontinence

Delirium, Infection, Atrophic vaginitis/urethritis, Pharmacologic agents, Psychological factors, Excessive urine production, Restricted activity, Stool impaction.

Urinary retention post-void residual

More than 200 mL. (50-100 mL is considered normal at age 60 and older.)

Dobbie's post-void residual ranges

Under 50 normal; 50-100 borderline; 100-200 elevated; over 200 high/abnormal; over 400-500 severe, often needs catheterization.

Acute urinary retention intervention

Decompression with a urethral catheter. A patient who cannot void at all still has retention; look for the cause.

Kidney stone pain location

Renal pelvis: intense deep ache in costovertebral region. Ureter: acute, excruciating, colicky, wavelike pain radiating down thigh to genitalia.

Kidney stone prevention diet

Limit high-oxalate foods; eat enough dietary calcium but avoid extra calcium supplements; moderate protein; avoid high salt and high-dose vitamin C.

Kidney stone fluid goal

Enough to produce at least 2 liters of urine per day.

Active kidney stone home teaching

Strain the urine and bring the stone in for analysis.

Small kidney stone first-line treatment

Watchful waiting, high fluid intake, NSAIDs or acetaminophen for pain, and tamsulosin to relax the ureter.

Reflex vs iatrogenic incontinence

Reflex: involuntary loss due to hyperreflexia. Iatrogenic: due to extrinsic medical factors, mainly medications.

Insulin vs glucagon source

Beta cells secrete insulin, which lowers blood glucose. Alpha cells secrete glucagon, which raises it.

Type 1 diabetes problem and treatment

Destruction of pancreatic beta cells. Treated with insulin ONLY; no oral medications.

Type 2 diabetes problem and treatment

Insulin resistance and impaired insulin secretion. May be treated with oral medications and insulin.

Type 2 diabetes risk factors

Family history, BMI over 25, ethnicity, age 45 or older, prior impaired glucose, hypertension 140/90 or higher, low HDL or high triglycerides, gestational diabetes or baby over 9 lb.

Metabolic syndrome criteria

Three needed: fasting glucose over 100; waist over 40 in (men) or 35 in (women); triglycerides over 150; HDL under 40 (men) or 50 (women); BP over 130/85.

Three Ps of diabetes

Polyuria, polydipsia, polyphagia.

Fasting plasma glucose diagnostic thresholds

Diabetes: 126 mg/dL or higher. Prediabetes: 100-125. Normal: under 100.

Type 2 diabetes: problem and treatment

Insulin resistance and impaired insulin secretion. May be treated with oral medications and insulin.

Risk factors for type 2 diabetes

Family history, BMI over 25, ethnicity, age 45 or older, prior impaired glucose, hypertension 140/90 or higher, low HDL or high triglycerides, gestational diabetes or a baby over 9 lb.

Metabolic syndrome: criteria (three needed)

Fasting glucose over 100; waist over 40 in (men) or 35 in (women); triglycerides over 150; HDL under 40 (men) or 50 (women); BP over 130/85.

The three Ps of diabetes

Polyuria, polydipsia, polyphagia.

Fasting plasma glucose: diabetes and prediabetes

Diabetes: 126 mg/dL or higher. Prediabetes: 100-125. Normal: under 100.

A1C: diabetes, prediabetes, and what it reflects

Diabetes: 6.5% or higher. Prediabetes: 5.7-6.4%. Reflects average glucose over about 3 months.

Random plasma glucose that diagnoses diabetes

200 mg/dL or higher WITH classic symptoms of hyperglycemia.

2-hour oral glucose tolerance test

Diabetes: 200 mg/dL or higher. Prediabetes: 140-199.

Abnormal glucose test but no symptoms: next step

Confirm it: repeat the same test on a different day, or use two different tests.

Five components of diabetes management

Nutrition, exercise, monitoring, medication, education.

Nutrient with the greatest effect on blood glucose

Carbohydrates. Keep the amount consistent at each meal.

"I guess I can never eat carbs again." Best response?

You do not need to eliminate carbohydrates. Track them consistently and choose complex carbs with high fiber.