Exam Review
Chapter 9: Pain Management
Pain is whatever the patient says it is.
Patient self-report is the most reliable pain indicator.
Unrelieved pain affects nearly every system.
Acute pain usually follows tissue injury and improves with healing.
Chronic pain persists and may involve nervous system changes.
Breakthrough pain = temporary severe flare despite baseline pain control.
Nociceptive pain = normal pain from tissue injury.
Neuropathic pain = abnormal processing from nerve damage/disease.
Somatic pain = skin/bone/muscle/joint; usually localized.
Visceral pain = organs; often poorly localized/cramping.
Nociception has 4 parts: transduction, transmission, perception, modulation.
NSAIDs block prostaglandins through COX inhibition.
Acetaminophen relieves pain/fever but is not anti-inflammatory.
Local anesthetics block sodium channels.
A-delta fibers = fast, sharp, localized pain.
C fibers = slow, dull/aching/burning pain.
Allodynia = pain from nonpainful stimulus.
Hyperalgesia = exaggerated response to painful stimulus.
Patient self-report is the gold standard for pain.
Pain is subjective and cannot be proved or disproved.
Personal opinions do not guide professional nursing care.
Assess pain on admission, with new pain, and when condition/treatment changes.
Comprehensive pain assessment includes: location, intensity, quality, onset/duration, aggravating/relieving factors, function/QOL, comfort-function goal, culture/history/comorbidities.
FACES scales are self-report tools; do not match the patient’s facial expression to the scale.
Treat obvious pain before teaching the pain scale.
Patients unable to self-report are at high risk for undertreated pain.
Neuromuscular blockers paralyze but do not relieve pain or provide sedation.
Behavioral tools show possible pain presence, not exact pain intensity.
Absence of pain behaviors does not mean absence of pain.
Vital signs are the least sensitive pain indicators.
Reassess pain after analgesia: 15–30 min parenteral, 1–2 hr oral.
Pain goals should be tied to function, not only a number.
For acute pain: can the patient cough, deep breathe, ambulate?
For chronic pain: can the patient perform meaningful life activities?
Goal of pain management = effective and safe analgesia with improved function.
Multimodal analgesia is the standard of care because it targets multiple pain mechanisms and reduces opioid requirements.
Oral route is preferred whenever feasible.
IV route is first-line immediately post-op for rapid analgesia.
Topical ≠ Transdermal: topical acts locally; transdermal enters systemic circulation.
Epidural = epidural space; Intrathecal = subarachnoid (CSF) space.
Continuous peripheral nerve blocks primarily block sensory fibers first, allowing pain relief while preserving more motor function.
ATC dosing is for continuous pain; PRN dosing is for intermittent or breakthrough pain.
Breakthrough pain (BTP) = transient flare despite baseline pain control.
Only the patient should press the PCA button.
Never allow PCA by proxy unless specifically authorized under institutional policy.
Basal PCA infusions are discouraged in opioid-naive IV PCA patients due to increased risk of oversedation and respiratory depression.
Increasing sedation is often the earliest warning sign of opioid-induced respiratory depression.
PCA allows the patient to self-administer preprogrammed analgesic doses.
The patient must be cognitively and physically capable of using PCA.
IV PCA is recommended when postoperative pain requires parenteral analgesia.
PCA dose/demand dose is delivered when the button is pressed and the lockout permits.
The lockout interval prevents doses from being delivered too close together.
A basal rate is a continuous infusion.
Basal rates are generally discouraged in opioid-naïve IV PCA patients because of oversedation and respiratory depression.
Increasing sedation is an early warning sign of opioid toxicity.
Monitor respiratory rate, depth, level of consciousness, and ventilation, not SpO₂ alone.
Only the patient presses the PCA button.
Family members must call the nurse rather than press it.
PCA by proxy is unsafe.
Authorized Agent Controlled Analgesia is a formal, protocol-driven exception.
Neuromuscular weakness does not automatically eliminate PCA candidacy if an authorized-agent protocol is appropriate, but standard PCA requires independent activation.
Pain control should improve function: coughing, deep breathing, ambulation, sleep, and rehabilitation.
Naloxone can reverse opioid respiratory depression, but re-sedation can occur after naloxone wears off.
The preferred term is opioid analgesic, not narcotic.
Opioids are divided into mu agonists and agonist–antagonists.
Mu agonists include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone.
Agonist–antagonists include buprenorphine, nalbuphine, and butorphanol.
Major opioid receptors are mu, delta, and kappa.
Opioid receptors are abundant in the dorsal horn of the spinal cord.
Opioid binding reduces pain transmission but can also cause constipation, nausea, sedation, and respiratory depression.
First-line opioids in this section are primarily mu agonists.
Agonist–antagonists activate kappa receptors and weakly block mu receptors.
Agonist–antagonists may precipitate severe pain and withdrawal in patients on long-term mu agonists.
Withdrawal signs include rhinitis, abdominal cramping, nausea, agitation, and restlessness.
Opioid antagonists bind receptors but produce no analgesia.
Naloxone may reverse respiratory depression and sedation but also removes analgesia.
Respiratory depression may recur after naloxone if the opioid lasts longer than the antagonist.
Increasing sedation is a major warning sign.
A normal oxygen saturation does not prove adequate ventilation.
The nurse must assess breathing, alertness, pain relief, bowel function, and medication compatibility.
Opioid treatment must be individualized.
Goals should include pain relief, function, and adverse effects.
Titration means adjusting the dose according to response.
Cancer pain may require upward titration; postoperative pain should usually be titrated downward as healing occurs.
Mu agonists have no fixed analgesic ceiling, but adverse effects limit dosing.
Always consider onset and peak before increasing a dose.
Multimodal analgesia can reduce opioid requirements.
Persistent pain and chronic opioid use must be assessed before surgery.
Preemptive analgesia may reduce pain-pathway sensitization.
Give analgesia before painful procedures.
Use the least invasive effective route.
ATC dosing is appropriate for continuous pain; PRN dosing is appropriate for intermittent or breakthrough pain.
Increasing sedation is an early warning of respiratory depression.
Constipation should be prevented, not treated only after it becomes severe.
Opioids may need tapering after more than a few days to prevent withdrawal.
Equianalgesia means approximately equal pain relief.
Opioid doses are not equal milligram for milligram.
Morphine 30 mg oral is approximately equal to 10 mg parenteral in the chart.
Hydromorphone is much more potent than morphine.
Fentanyl is measured in micrograms.
Short-acting opioids begin working in about 30 minutes and last about 3–4 hours.
Modified-release opioids provide prolonged control and are not intended for rapid breakthrough relief.
Chapter 4- adult assesment-
Holistic assessment examines physical, psychological, social, cultural, spiritual, nutritional, functional, and environmental factors.
Assessment is the first step of the nursing process.
Subjective data are reported by the patient or informant.
Objective data are observed or measured.
Nursing assessment focuses on human responses, function, safety, comfort, coping, and treatment response.
Rapport improves honest communication and data accuracy.
Anxiety may reduce concentration, memory, and ability to communicate.
Nurses must adapt communication for education, language, culture, disability, and impairment.
Medical jargon should be replaced with understandable language.
Summarizing and clarifying validate assessment information.
Culture is learned, shared, influenced by resources, and dynamic.
Ethnicity is group affiliation based on shared racial, national, tribal, religious, linguistic, or cultural background.
Cultural competence requires individualized care and recognition of personal bias.
Cultural awareness must not become stereotyping.
Patients have the right to know why information is collected and how it will be used.
Participation in assessment is voluntary.
Privacy protects the patient’s space and information during care.
Confidentiality protects information from inappropriate disclosure.
HIPAA gives patients rights to view, obtain, and request correction of their records.
EHRs support communication and trend recognition but do not replace direct assessment.
Maintain interaction with the patient while documenting electronically.
Home assessment includes the environment, resources, support systems, and ability to cope.
The physical assessment techniques used in the home are similar to those used in healthcare facilities.
A safe care plan must be realistic for the patient’s actual living environment.
Every intervention must be followed by reassessment.
A health history primarily collects subjective data.
Nursing assessment focuses on human responses, function, safety, coping, and self-care.
Functional status is the ability to perform usual physical, mental, and social activities.
The informant may be someone other than the patient.
Reliability must be assessed and documented objectively.
Older adults may present with subtle symptoms or functional decline instead of classic symptoms.
Sensory impairment can mimic confusion.
Polypharmacy increases risk for interactions, toxicity, falls, and confusion.
Obtain patient permission before including family in the interview.
Urgent physiologic problems take priority over routine biographical questions.
Record the chief complaint in the patient’s own words when appropriate.
The history of present illness includes onset, setting, manifestations, course, treatment, and patient interpretation.
Sudden onset may suggest an acute vascular, obstructive, or rupture event.
Associated manifestations help determine origin, severity, and urgency.
Significant positive and negative findings must both be documented.
Allergy documentation must include the reaction.
Past health history includes illnesses, injuries, hospitalizations, surgeries, and screenings.
Family history identifies genetic, environmental, communicable, and behavioral patterns.
A genogram displays family relationships and disease patterns.
Review-of-systems checklists improve completeness but do not replace follow-up assessment.
Chapter 8: communication
Effective communication is as essential as clinical skill.
Communication affects patient assessment, care planning, teamwork, documentation, safety, and outcomes.
Healthy work environments use open communication, respect, collaboration, and problem-solving rather than blame.
Communication begins with a stimulus or patient need.
The sender encodes and sends the message.
The message travels through an auditory, visual, or kinesthetic channel.
The receiver decodes and interprets the message.
Feedback provides evidence of understanding.
Noise can interfere at any point.
Pain, discomfort, television, emotions, experiences, and sociocultural differences may alter communication.
Communication is reciprocal; both participants send and receive messages.
Verbal communication uses spoken and written words.
Language depends on shared definitions and word organization.
Nonverbal communication occurs without words.
When verbal and nonverbal messages conflict, the nurse must assess further.
Do not assume the meaning of eye contact, silence, gestures, or touch without considering culture and context.
Touch may communicate comfort or may be experienced as intrusive.
Facial expression, posture, gait, gestures, appearance, grooming, sounds, and silence provide assessment data.
Nonverbal cues are clues that require clarification, not automatic proof of a conclusion.
Social media can support education and professional networking but creates serious privacy risks.
Omitting a patient’s name does not guarantee confidentiality.
Room numbers, diagnoses, photographs, or distinctive patient details may still identify a patient.
Deleted posts may remain available.
Privacy settings do not guarantee privacy.
Inappropriate social media use may cause employment consequences, board discipline, fines, licensure loss, and civil or criminal penalties.
E-mails and text messages should be concise, professional, secure, and consistent with facility policy.
Avoid informal text abbreviations.
Patient e-mails may require authorization and must become part of the health record.
Telehealth does not reduce professional nursing standards.
Effective telehealth requires privacy, reduced distractions, professional appearance, verbal and nonverbal engagement, and active listening.
Communication must be adapted to developmental level.
Children need simple explanations that promote cooperation without unnecessary fear.
Adolescents can receive more detailed explanations because abstract thinking is developing.
Adult communication may be influenced by previous health experiences and inaccurate information.
With older adults, assess hearing, vision, confusion, and depression before concluding the patient cannot communicate.
Culture includes learned lifestyles, languages, behavior patterns, traditions, and beliefs.
Cultural competence requires awareness of the nurse’s own beliefs, prejudices, and attitudes.
Do not stereotype patients based on cultural background.
Limited English proficiency can interfere with instructions, diagnoses, test results, and treatment decisions.
Low health literacy can further reduce understanding.
Use lay terminology and avoid unnecessary medical jargon and abbreviations.
Assess language proficiency, support system, cultural preferences, and socioeconomic circumstances.
A patient’s social or professional role should never be used to assume how much teaching or support is needed.
Quiet or independent patients may still have unmet needs.
Territoriality is the desire to maintain control over personal space.
Proxemics is the study of distance zones during communication.
Approximately 18 inches to 4 feet may be appropriate for many intake interviews.
Take individual cues about preferred distance.
Ask permission before entering personal or intimate space.
Greater privacy is required for more private body areas.
Pain, fear, anxiety, confusion, and physical discomfort can interfere with communication.
Address urgent physical distress before lengthy interviewing or teaching.
Agitation in a cognitively impaired patient may indicate pain or another unmet need.
AAC methods include voice aids, handwriting, pictograms, and gestures.
Nurse and patient values affect motivation and communication.
Communication works best in a calm, private, nonthreatening environment with minimal distractions.
Sensitive topics should not be discussed where privacy is inadequate.
Continual assessment requires accurate documentation.
Documentation must be placed in the correct section of the record.
No single nurse provides all care, so significant information must be handed off.
Documentation and reporting support coordination and continuity.
Progress notes and care plans are communication tools.
Cooperation, coordination, and collaboration are essential to safe team care.
A handoff transfers responsibility from one caregiver or team to another.
Handoff includes both accurate presentation and acceptance of information.
Poor handoff communication contributes to wrong-site surgery, delayed treatment, falls, and medication errors.
Structured communication reduces incomplete and inaccurate information.
Standardized tools must still be flexible for the patient and situation.
SBAR means Situation, Background, Assessment, and Recommendation.
Situation states the current problem.
Background provides relevant context.
Assessment includes findings and clinical interpretation.
Recommendation states what action is needed.
Do not end an urgent provider call without a clear request or recommendation.
Electronic templates may improve documentation but do not replace nursing judgment.
I-SBAR-R adds identification and readback.
Readback helps prevent misunderstanding of orders and critical information.
The Hand-off TST identifies causes of communication failure and targeted solutions.
CUS means Concerned, Uncomfortable, and Unsafe.
CUS is used to escalate patient-safety concerns.
Assertive communication focuses on evidence and safety, not personal attacks.
Nurses are responsible for speaking up when care appears unsafe.