MS CH 10 Nursing Care of Patients in Pain PDF

4068_Ch10_147-170 17/11/14 10:01 AM Page 147 10 Nursing Care of Patients in Pain SHERIA GRICE ROBINSON, APRIL HAZARD VALLERAND, AND KAREN P. HALL LEARNING OUTCOMES 1. Describe current definitions of pain. 2. Identify common myths and barriers to the effective management of pain. 3. Differentiate amo...

4068_Ch10_147-170 17/11/14 10:01 AM Page 147 10 Nursing Care of Patients in Pain SHERIA GRICE ROBINSON, APRIL HAZARD VALLERAND, AND KAREN P. HALL LEARNING OUTCOMES 1. Describe current definitions of pain. 2. Identify common myths and barriers to the effective management of pain. 3. Differentiate among addiction, physical dependence, and tolerance. 4. Explain current understanding about the basic physiology of the pain response. 5. Differentiate between nociceptive and neuropathic pain. 6. Perform a basic pain assessment. 7. Use the World Health Organization analgesic ladder for the treatment of pain. 8. Describe the three classes of analgesics and their uses. 9. Identify commonly used pain medication treatment modalities and their appropriate use. 10. Recognize appropriate use of nonpharmacological pain management techniques. KEY TERMS addiction (uh-DIK-shun) adjuvant (ad-JOO-vant) agonist (AG-un-ist) analgesic (AN-uhl-JEE-zik) antagonist (an-TAG-on-ist) breakthrough (BRAYK-THROO) ceiling effect (SEE-ling ee-FEKT) endorphins (en-DOOR-fins) enkephalins (en-KEFF-e-lins) equianalgesic (EH-kwee-AN-uhl-JEE-zik) hyperalgesia (HYPER-al-JEE-zee-ah) malingerer (muh-LING-gur-er) neuropathic (NEW-roh-PATH-ik) nociception (NOH-sih-SEP-shun) opioid (OH-pee-OYD) pain (PAYN) patient-controlled analgesia (PAY-shunt kon-TROHLD AN-uhl-JEE-zee-ah) physical dependence (FIZZ-ik-uhl dee-PEN-dense) prostaglandins (PRAHS-tah-GLAND-ins) pseudoaddiction (soo-doh-ah-DIK-shun) psychological dependence (SY-ko-LAW-jik-al dee-PEN-dense) somatic (so-MAT-ik) suffering (SUH-fur-ing) tolerance (TAWL-ur-ens) transdermal (trans-DER-mal) visceral (VISS-er-uhl) 147 4068_Ch10_147-170 17/11/14 10:01 AM Page 148 148 UNIT TWO Understanding Health and Illness THE PAIN PUZZLE Have you ever been in pain? If you have, then you know that pain is unpleasant. Not only does it hurt physically, but it can also make us feel emotionally sad or angry and lead to social isolation. Pain is a sensory and emotional experience that can affect every aspect of the person’ s being and how he or she relates to the environment. Pain management is the most common reason patients seek medical advice. Ho wever, despite the widespread nature of the problem and the millions of dollars spent on care, pain often remains untreated or under treated. Nurses can make a difference in pain management. Nurses often w orry about overmedicating patients and may think that they are “doing good” (beneficence) or “doing no harm” (nonmaleficence) by withholding medication from a patient whom the y do not belie ve is in pain (see “Ethical Considerations—Controlling Pain” on DavisPlus). So how can we know what pain is, and ho w can we truly tell when others are experiencing it? DEFINITIONS OF PAIN According to Margo McCaffery (1968), a well-known consultant in the care of patients with pain, “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” This is a reminder to nurses to accept the patient’s report of pain. The International Association for the Study of Pain (IASP) describes pain in a bit more detail by noting it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (2011).This definition indicates that pain is comple x and is not only physical b ut has emotional and other components as well. Why does pain exist? It is a protective mechanism or a warning. In the presence of injury, pain may help to prevent further injury. Consider the patient who has a fracture and holds it still to prevent further damage or a child who touches a hot sto ve and pulls his or her hand away before a serious burn occurs. Suffering, or feelings of continuous distress, often accompanies pain. In a study of suffering, Ferrel and Coyle (2008) concluded, “suffering is not synon ymous with pain b ut is closely associated with it. Physical pain is closely related to psychological, social, and spiritual distress. Pain that persists without meaning becomes suffering” (p. 246). Persistent pain can diminish patients’ quality of life. It can mak e them feel as though their health is getting w orse and take away their motivation for self-care. Suffering can often be relieved if patients believe they can achieve comfort. A good assessment and individualized, culturally congruent approaches to care increase the likelihood of comfort. RISKS OF UNCONTROLLED PAIN Why is untreated or undertreated pain a bad thing? Complications can occur when pain is e xperienced. The body produces a stress response to pain that causes harmful substances to be released from injured tissue. Reactions include breakdown of tissue, increased metabolic rate, impaired immune function, and negative emotions. In addition, pain pre vents the patient from participating in self-care acti vities such as walking, deep breathing, and coughing. Consider the patient who has had chest sur gery and then has to cough and deep breathe. It hurts! P ain may make the patient w ant to avoid coughing, turning, or e ven moving. Retained pulmonary secretions and pneumonia can develop. If the patient is less active, return of bowel function is delayed, and an ileus (disruption of normal propulsive gastrointestinal [GI] activity) can result. When pain is well controlled, complications can be avoided, and patients are able to do what they need to do to get well and go home from the hospital or continue with recovery activities. PAIN AND CULTURE Cultural differences can affect patient responses to pain. People from various cultures have different ways of expressing pain (see “Cultural Considerations”). Some may be dramatic and emotional; others tend to be stoic and quiet. Knowledge of widely accepted information about different ethnic and cultural groups can be useful in understanding a patient’s experience and what care might be considered acceptable pain responses. It is important, however, to assess a patient’s pain care needs individually and pay careful attention to the ethical principles that influence patient care rather than making assumptions based on culture or ethnicity alone. WHO’S THE BOSS IN PAIN MANAGEMENT? The patient is at the center of the health team. Providing accurate information and offering relevant choices helps patients to maintain autonomy. Just as risks, benef its, and alternatives to surgery and anesthesia are discussed with the patient, so too should pain management options be discussed in the process of obtaining informed consent. It is important to learn as much as you can about pain and pain management so you can effectively advocate for your patients and help with patient education. The entire health team is responsible for pain management. All must provide care in the most cost-effective manner possible while continuing to provide the best quality. Effective pain management helps to reduce costs by minimizing the side effects of opioids, preventing complications related to inadequate pain control, and reducing the length of hospital stay or period of recovery. Various regulatory bodies have also recognized the importance of good pain management and ha ve incorporated a review of organizational pain management practices into accreditation and review processes. These standards support the importance of appropriate and effective management of pain. They address assessment and the safe pharmacological management of pain, as well as patient and family teaching, 4068_Ch10_147-170 17/11/14 10:01 AM Page 149 Chapter 10 Nursing Care of Patients in Pain 149 Cultural Considerations The pain experience may differ between and among individuals of differing cultural, ethnic, or religious groups. Remember that people within groups vary, and not all fit the general descriptions provided here (see Chapter 4). Culture Expression and Meaning of Pain Patient Preferences Assessment Interventions Compare verbal and nonverbal characteristics of pain to determine degree of pain. Engage family to help with distraction and relaxation techniques. Administer medication promptly. Prefer oral or IV pain Observe for nonverbal medications. signs of pain. Incorporate traditional healing methods as much as possible. Arab American See pain as something Intramuscular or IV to be controlled. May usually preferred over express pain openly to oral medications. family with elaborate verbal expressions, less so with caregivers. May use terms such as fire, hot, and cold. Asian American Chinese and Koreans tend to be stoical and describe pain in terms of diverse body symptoms instead of locally. May like warm compresses. For Koreans, intraFilipinos may view muscular injections pain as a part of living may be seen as an an honorable life. invasion of privacy. Vietnamese may not understand numerical scale of rating pain. Observing facial expression may provide an indicator of pain. Offer and encourage pain medicines to promote healing. Some view this as an Vietnamese maintain opportunity to reach a self-control as a fuller life and to atone means of pain relief. for past transgressions. Frequently stoic and tolerate pain to a high degree. Some moan as an expression of pain. For Asians, bearing pain is a virtue and a matter of family honor. Some, especially older individuals, may fear addiction. African American May openly and publicly display pain, but this is highly variable. Many, especially older adults, fear that medication may be addictive. Many believe that suffering and pain are inevitable and should be endured. May focus on spiritu- Observe for verbal and ality and religious nonverbal expressions beliefs to endure of pain. pain. Use of pain scales is Prayers and the layhelpful. ing on of hands may be believed to relieve pain if the client has enough faith. Offer pain medication as needed. Allow meditation and prayer along with pain medication. Support patient’s spiritual practices. Continued 4068_Ch10_147-170 17/11/14 10:01 AM Page 150 150 UNIT TWO Understanding Health and Illness Cultural Considerations—cont’d Expression and Meaning of Pain Patient Preferences European American Strong sense of stoicism, especially in men. Fear of being dependent may decrease use of pain medicine. Many have fear of addiction. May continue to work and carry out daily activities and minimize pain. Hispanic American Puerto Ricans tend to be expressive of pain and discomfort. Moaning, groaning, and crying are culturally accepted ways of dealing with and reducing pain. Culture Assessment Interventions May prefer relaxation and distractions as means of pain control. Observe for nonverbal signs of pain. Use visual analog or numerical pain scales to assess severity of pain. Encourage use of pain medicine as needed. Prefer oral or IV medication for pain. Visual analog and numerical scales may be helpful. Incorporate distraction and relaxation techniques. Heat, herbal teas, and prayer are used to Observe and compare manage pain. verbal and nonverbal behaviors indicating pain. Mexicans may bear pain stoically because it is “God’s will.” Many feel that pain and suffering are a consequence of immoral behavior. For men, expressing pain shows weakness. The Spanish word for pain is dolor. Native American Frequently do not request pain medicine and are undertreated. May not realize that they can ask for pain medicine. Many believe pain is something that must be endured. May describe pain in general terms such as “not feeling good.” The word for pain varies according to the tribal language. Many prefer traditional herbal medicines. May mention pain to family member or visitor, who relays message to caregiver. Frequently ask patient and family members or visitors if patient has pain. Observe for nonverbal clues of pain. Incorporate traditional practices as permitted. For individuals who are stoic about pain, encourage pain medicine frequently. Explain that pain control can hasten healing. Explain that the control of pain can promote healing. Offer pain medicine as needed. Allow adequate time for response; silence is valued. Maintain a calm, relaxing environment. Incorporate traditional practices for pain relief if not harmful. 4068_Ch10_147-170 17/11/14 10:01 AM Page 151 Chapter 10 postoperative pain, management of opioid-induced side effects, discharge planning, and process improvement. Examples of these guidelines are a vailable through the Joint Commission website at www.jointcommission.org and the Centers for Medicare and Medicaid Services (CMS) website at www.cms.gov. For more information on pain management, visit the following websites. For some sites, you may need to type “pain” in the search window. www.ahrq.gov www.ampainsoc.org www.cancer.org www.geriatricpain.org www.pain-topics.org The care of patients with pain is challenging, ho wever, with a systematic and holistic approach to assessment and treatment, good pain management can be achie ved. In this chapter, the difficulties of pain assessment and treatment are discussed. Some of the tools needed to effectively deal with these challenges are presented. Common myths and barriers that continue to affect nursing practice are clarified. MYTHS AND BARRIERS TO EFFECTIVE PAIN MANAGEMENT A number of factors, including the nurse’s personal experiences with pain, influence how patients with pain are treated. Why are some patients not belie ved when they report pain? Why do some nurses and other health care team members insist that patients beha ve a certain w ay before they are believed? Common myths about pain can impair the nurse’ s ability to be objective about pain and may create barriers to effective treatment. Because there are few objective measure for pain, many nurses rely on assumptions rather than f acts. Note the following myths. Myth: A person who is laughing and talking is not in pain. Fact: A person in pain is likely to use laughing and talking as a form of distraction. This can be effective in managing pain, especially when used with appropriate drug therapies. Patients may be more easily distracted when they have visitors and may ask for pain medication as soon as their family or significant other goes home. Myth: Respiratory depression is common in patients receiving opioid pain medications. Fact: Respiratory depression is uncommon in patients receiving opioid pain medications. If patients are monitored carefully when they are at risk, such as with the first dose of an opioid or when a dose is increased, respiratory depression is preventable. A patient’s respiratory status and level of sedation (LOS) should be routinely monitored using an LOS scale. Myth: Pain medication is more effective when given by injection. Nursing Care of Patients in Pain 151 Fact: Oral administration is the first choice if possible, or whenever the IV route is not an option. The IV route has the most rapid onset of action and is the preferred route for postoperative administration. Intramuscular (IM) injections are not recommended because they are painful, have unreliable absorption from the muscle, and have a lag time to peak effect and rapid falloff compared with oral administration. Myth: Teenagers are more likely to become addicted than older patients. Fact: Addiction to opioids is uncommon in all age groups when taken for pain by patients without a prior drug abuse history. Myth: Pain is a normal part of aging. Fact: Although many older adults have medical conditions that cause pain, pain is not a normal or anticipated part of aging and should be treated proactively. Effective pain treatment for older people helps them to maintain their mobility longer and improve overall health. OPIOID ADDICTION Nurses often express concern about patients who need large amounts of pain medication or know exactly when their next dose of pain medication is due. Nurses may worry that such patients are addicted or that they are “clock watchers,” but do we really know what that means? Patients are expected to be informed about their medications and involved in their care, but when they know when their medications are due, we may become suspicious. In truth, if a patient is watching the clock, the most likely reason is because he or she is in pain. The most common reason that patients ask for more pain medicine is because they have increased pain. Similarly, patients are expected to know the effects of other medications the y take, such as blood pressure medications and insulin. Yet when they ask for a specif ic analgesic, concern that the patient is “drug seeking” is sometimes raised. CRITICAL THINKING Mrs. Smithers and Mr. Brown Mrs. Smithers had an abdominal hysterectomy and is sitting up in bed the morning after sur gery, putting on her makeup. On morning rounds she is smiling but reports that her pain is at 6 on a scale of 0 to 10. Mr. Brown has just been transferred from the surgical intensive care unit the day after sur gery for multiple injuries. He is moaning and reports his pain at 6 on a scale of 0 to 10. Which of these patients is really having as much pain as the y say they are? How can you make this judgment? Suggested answers are at the end of the chapter. 4068_Ch10_147-170 17/11/14 10:01 AM Page 152 152 UNIT TWO Understanding Health and Illness It is important to understand the differences among addiction, tolerance, and physical dependence. When talking with patients and teaching them about their medications, it is important to help them understand these differences as well. Addiction is something many patients fear. Tolerance is a normal biological adaptation. Exposure to a drug induces changes that result in a decrease of one or more of the drug’ s effects over time. Simply put, this means it takes a larger dose to pro vide the same le vel of pain relief. Physical dependence is a normal physiological phenomenon that most people experience after a few weeks of continuous opioid use. If an opioid is discontinued abruptly after a few weeks of use or if an opioid antagonist such as naloxone (Narcan) is administered, the patient experiences a withdrawal syndrome that includes such symptoms as sweating, tearing, runn y nose, restlessness, irritability, tremors, dilated pupils, sleeplessness, nausea, vomiting, and diarrhea. These symptoms can be prevented by weaning a patient slo wly from an opioid rather than stopping it suddenly. According to the American Society of Addiction Medicine (2011), addiction or psychological dependence is a disease of the brain that causes the compulsi ve pursuance of a substance, or behavior to obtain reward or relief. Addictive behaviors are characterized by impaired control over drug use and continued use despite harm. Patients with uncontrolled pain who desire treatment are not addicts. Sadly, patients with a history of addiction are more lik ely to have unmet pain needs due to medication tolerance and health provider bias. Careful assessment and monitoring of treatment is essential for all patients receiving treatment for pain—particularly patients who are prescribed opioid analgesics. Pseudoaddiction has been described in patients who are receiving opioid doses that are too low or spaced too far apart to relieve their pain, and certain behavioral characteristics resembling psychological dependence, such as drug-seeking behaviors, have developed. In contrast to the addicted patient, a patient with pseudoaddiction stops drug-seeking behaviors when the pain is relieved. CRITICAL THINKING Janet Janet is hospitalized with pancreatitis and has severe abdominal pain. She has a history of IV drug abuse. She is receiving IV morphine every 3 hours. Two hours after her last dose, she puts on her call light and says she is in severe pain, which she rates as “15” on a 0 to 10 scale. You feel like you have given her enough morphine to kill a horse, yet she keeps requesting more. 1. How is it possible for Janet to be in pain when she is receiving so much morphine? 2. It’s not time for more medication. What should you do? 3. You speak to the health care provider (HCP), who prescribes acetaminophen (Tylenol) 1000 mg for breakthrough pain (between morphine doses). When you take it to Janet, she rolls her eyes and says, “You must be kidding me.” How do you respond? 4. What communication with Janet is important at this time? MECHANISMS OF PAIN TRANSMISSION Many theories of how pain is transmitted and perceived (called nociception) are described in the literature. The specificity theory, developed by Descartes in 1644, proposed that body trauma sends a message directly to the brain, causing a sort of “bell” to ring, prompting a response from the brain. In 1965, Melzack and Wall proposed the gate control theory, which describes the dorsal horn of the spinal cord as a gate, allowing impulses to go through when there is a pain stimulus and closing the gate when those impulses are inhibited. The gate control theory stimulated massive research on the physiology of pain and is still considered in current research. However, much more is now known about the transmission of pain. Pain is transmitted through four distinct processes, transduction, transmission, perception, and modulation: 1. Transduction represents the initiation of the stimulus and conversion of that stimulus into an electrical impulse at the time of the injury. Chemical neurotransmitters are released from damaged tissue. These substances include prostaglandins, bradykinin, serotonin, and substance P. 2. Transmission is the process of moving a painful message from the peripheral nerve endings through the dorsal root ganglion and the ascending tract of the spinal cord to the brain. 3. The third process is perception, or actually feeling the pain. During perception, the hypothalamus activates and controls emotional input and also generates purposeful goal-directed behavior while the cerebral cortex receives the pain message. 4. Last in the process of nociception is modulation, or the body’s attempt to interrupt pain impulses by releasing endogenous (naturally occurring) opioids. Endorphins are endogenous chemicals that act like opioids, inhibiting pain impulses in the spinal cord and brain. Endorphins are the chemicals that stimulate the long-distance runner’s “high.” Unfortunately, they degrade too quickly to be considered effective analgesics. Enkephalins are one type of endorphin. WORD BUILDING pseudoaddiction: pseudo—false + addiction—psychological dependence 4068_Ch10_147-170 17/11/14 10:01 AM Page 153 Chapter 10 Pain Transmission: Nociceptive or Neuropathic? Pain transmission can be nocicepti ve and neuropathic. Nociception refers to the body’s normal reaction to noxious stimuli, such as tissue damage, with the release of pain-producing substances. Nociceptive pain may be somatic or visceral. Somatic pain is localized in the muscles or bones. P atients can often point to the exact location of pain and will describe it as throbbing or aching. Cancer patients may e xperience somatic pain when the cancer has spread to the bone or a tumor has invaded soft tissue. Visceral pain, or organ pain, is not well localized and is often described as cramping or pressure. Bowel obstructions and tumors in the lung can cause visceral pain symptoms. Pain may also be felt in parts of the body a way from the pain source, such as the low back/flank pain that often accompanies a bladder infection. This is called referred pain (Fig. 10.1). Neuropathic pain is pain associated with injury to either the peripheral or central nervous system. Unlike nociceptive pain, neuropathic pain is poorly localized and may in volve other areas along the nerv e pathway. Neuropathic pain is common in cancer patients following chemotherapy or radiation therapy, patients with diabetic neuropathy, and patients who have had shingles. The pain is often described as numbness, tingling, sharp, shooting, or shocklike. TYPES OF PAIN Acute Pain Pain is also categorized according to the length of time it has been present. Acute pain is immediate and follows injury to the body, prompts an inflammatory response, and subsides as healing takes place. It is often associated with short-term, objective, physical signs, such as increased heart rate and elevated blood pressure. As pain continues, the physiological responses that accompany acute pain cannot be sustained without harm to the body. As the body adapts, vital signs return to normal. The nurse must guard against labeling such a patient a malingerer (pretending to be in pain) or drug Nursing Care of Patients in Pain seeker simply because vital signs are no longer altered. Examples of acute pain include pain related to childbirth, sur gery, burns, or other trauma. Persistent acute pain may become chronic. Chronic Pain Chronic pain typically lasts 3 months or longer , persisting beyond the time when healing usually takes place. Examples are neck pain that continues years after an accident, pain that accompanies diseases such as arthritis, and phantom limb pain. Patients with chronic pain may ha ve both nociceptive and neuropathic components that require a combination of medications and nonpharmacological treatments. Because of the body’s ability to adapt, patients with chronic pain may not appear to be in pain. OPTIONS FOR TREATMENT OF PAIN There are many pharmacological and nonpharmacological treatments available for the effective management of pain. Medications that relieve pain are called analgesics. Analgesics make up the largest piece of the pain management puzzle and encompass three main classes of medication: opioids, nonopioids, and adjuvants. Opioids bind to opioid receptors in the brain, spinal cord, and other areas of the body, inhibiting the perception of pain. Nonopioids include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (e.g., Tylenol). Adjuvants are different from opioid and nonopioids in that they include categories of medications that were originally approved by the Federal Drug Administration for purposes other than pain relief (such as depression). Some patients may require a combination of opioids, adjuvants, and NSAIDs to effectively manage their pain. Nurses should have WORD BUILDING nociception: noci—pain + ception—reception neuropathic: neuro—nerves + pathy—disease, suffering analgesic: an—not + gesia—pain Gallbladder Liver Lungs and diaphragm Heart Pancreas Stomach Liver Small intestine Ovaries Colon Bladder Appendix Kidneys Bladder Ureters FIGURE 10.1 Sites of referred pain. Anterior 153 Posterior 4068_Ch10_147-170 17/11/14 10:01 AM Page 154 154 UNIT TWO Understanding Health and Illness a good understanding of these pharmacological treatment options. Let’s begin the discussion with nonopioids. Nonopioid Analgesics Nonopioids are typically the f irst class of drugs used to treat mild pain (Table 10.1). They can be useful for acute and chronic pain from a variety of causes, such as surgery, trauma, arthritis, and cancer. These drugs are limited in their use because the y have a ceiling effect to analgesia. A ceiling effect means that there is a dose be yond which there is no impro vement in the analgesic effect, but there may be an increase in adverse effects. When used with opioids, care must be taken to ensure that the nonopioid dose does not exceed the maximum safe dose for a 24-hour period. For example, if a patient receiving two Vicodin (acetaminophen and hydrocodone) tablets e very 4 hours continues to experience pain, the dose cannot be increased because of the potentially toxic effects of acetaminophen at that dosage. (See Table 10.1 for side ef fects and nursing implications.) Nonopioids do not produce tolerance or physical dependence. Most do have antipyretic (fever-reducing) effects. Nonopioids work mainly peripherally, at the site of injury, rather than in the central nervous system, as opioids do. The exception in this class is acetaminophen, which is believed to act on the central nervous system. NSAIDs block the synthesis of prostaglandins, one of man y chemicals needed for pain transmission. In general, it is helpful to include a nonopioid agent in any analgesic regimen, even if the pain is se vere enough to require the addition of an opioid (see the section later in this chapter titled “BalancedApproach to Analgesia”). Opioid Analgesics Opioids are drugs that have actions similar to those of morphine. Opioids are classified by how they affect receptors in the nervous system. They may be full agonists (stimulators), partial TABLE 10.1 ANALGESIC AGENTS Medication Class/Action Salicilates Peripherally acting analgesics; reduce pain, fever, inflammation NSAIDs Peripherally acting analgesics; reduce pain, fever, inflammation COX-2 Inhibitors Reduce pain and inflammation, no effect on platelet aggregation Acetaminophen Relieves pain and fever; no anti-inflammatory or antiplatelet effect Opioids and Opioid Combination Agents Bind to opioid receptors in the central nervous system to alter perception of pain Examples Nursing Implications aspirin Give with food. Decrease platelet aggregation; watch for bruising or bleeding. ibuprofen (Motrin) ketorolac (Toradol) naproxen (Naprosyn, Aleve) Give with food. Decrease platelet aggregation, so watch for bleeding. Do not give ketorolac longer than 5 days. celecoxib (Celebrex) Give with food. acetaminophen (Tylenol) Maximum safe dose is 4 g per day; less for those who use alcohol. Be aware of other drugs that contain acetaminophen, such as cold remedies, to prevent accidental overdose. codeine (in Tylenol 2, 3, 4)* fentanyl (Sublimaze, Duragesic) hydromorphone (Dilaudid, Exalgo) meperidine (Demerol) methadone (Dolophine) morphine (MS IR, MS Contin) oxycodone (OxyIR, OxyContin) hydrocodone and acetaminophen (Vicodin, Lortab) May be combined with nonopioid (e.g., acetaminophen). Monitor vital signs, level of sedation, and respiratory status. Avoid fentanyl patch in patient with fever; heat increases absorption. Encourage fluids and fiber to prevent constipation. Meperidine should be avoided in older adults and those with renal dysfunction. * Tylenol #2 = Tylenol 300 mg + codeine 15 mg; Tylenol #3 = Tylenol 300 mg + codeine 30 mg; Tylenol #4 = Tylenol 300 mg + codeine 60 mg 4068_Ch10_147-170 17/11/14 10:01 AM Page 155 Chapter 10 agonists or mixed agonists, or antagonists (blockers). Full agonists have a complete response at the opioid receptor site; a partial agonist has a lesser response.A mixed agonist/antagonist activates one type of opioid receptor while blocking another. Morphine, a full agonist, is often the drug of choice for treating moderate to severe pain. It is the standard to which all other analgesics are compared (see Table 10.2 for equianalgesic doses of medications). Morphine is long acting (4–5 hours) and available in many forms, making it convenient and affordable for patients. It also has a slower onset than many other opioids. Other examples of opioids include controlled-release drugs such as oxycodone (OxyContin) and hydromorphone (Exalgo), which are effective for prolonged, continuous pain. BE SAFE! Never crush a controlled- or time-release tablet. Because the tablet is designed to deliver a dose of medication over time, crushing it could deliver the entire dose at once, resulting in overdose. Opioids alone have no ceiling ef fect to analgesia. This means that doses can safely be increased to treat w orsening pain if the patient’s respiratory status and level of sedation are stable. However, inappropriate prescribing can lead to hyperalgesia, or increased sensitivity to pain. Patients with hyperalgesia have pain at the slightest touch, such as the moving of sheets, and require further medical interv ention. Institutions must have policies and procedures in place related to opioids to prevent medication errors and reduce the risk of serious side effects. It is especially important to be vigilant for side effects in patients unaccustomed to opioids, the most common of which are constipation, confusion, and fatigue, which can increase a patient’s risk for falls. Although respiratory depression is not a common side ef fect, it is a life-threatening one, and respiratory rate should be monitored. See Table 10.1 for additional information and adverse effects of opioids. TABLE 10.2 EQUIANALGESIC CHART Drug Morphine Parenteral Dose* 5 mg Oral Dose 15 mg Codeine 60 mg 100 mg Hydromorphone 1.5 mg 4 mg Methadone 5 mg 10 mg Meperidine 50 mg 150 mg Oxycodone Not applicable 10 mg Note. Approximate doses of medications in milligrams to equal same amount of pain relief between drugs or same drug, different route. Consult pharmacist and physician before changing drugs or routes. *Intramuscular, IV, subcutaneous. Nursing Care of Patients in Pain 155 Although opioids are extremely important in pain management, they are also on a short list of “high alert” drugs that can harm or even kill patients if they are not administered carefully (Institute for Safe Medication Practices, 2012). Institutions must ha ve policies and procedures in place related to opioids to pre vent medication errors and reduce the risk of serious side ef fects. It is especially important to be vigilant for side ef fects in patients unaccustomed to opioids. Such patients are sometimes called “opioid-naïve.” Opioids are added to nonopioids for pain that cannot be managed effectively by nonopioids alone. The use of a centrally acting opioid with a peripherally acting non-opioid can increase pain relief and reduce the amount of opioid needed. Controlled-release opioids such as oxycodone (OxyContin) and morphine (MS Contin) are effective for prolonged, continuous pain. Whenever a controlled-release form of medication is used, it is important to ha ve an immediaterelease medication available for breakthrough pain (transient pain that arises during generally effective pain control), such as oral morphine solution, oxycodone immediate-release (OxyIR), or hydromorphone immediate-release (Dilaudid). CRITICAL THINKING Mrs. Zales Mrs. Zales, a 32-year-old woman, was admitted for a hysterectomy after being treated for painful endometriosis for 12 months. After her surgery, she had a patientcontrolled analgesia (PCA) pump with hydromorphone, which was effective in relieving her pain. F orty-eight hours after surgery, the surgeon discontinued the PCA pump and ordered oral hydrocodone with acetaminophen. It was ineffective, so an order w as added for hydromorphone 2 mg orally every 3 to 4 hours, as needed. The nurses gave only one dose of the hydromorphone. Then, thinking that her pain should be lessening, switched Mrs. Zales back to the hydrocodone with acetaminophen. By the next morning she was in severe pain, and the on-call physician ordered IM meperidine and promethazine (Phenergan). Mrs. Zales’s discharge was delayed until her pain could be controlled. 1. What do you think happened? 2. How could the delayed discharge have been avoided? 3. Who were the important team members in this scenario? Suggested answers are at the end of the chapter. WORD BUILDING antagonist: ant—against + agonist—stimulates receptor site equianalgesic: equi—equal + analgesic—relieving pain 4068_Ch10_147-170 17/11/14 10:01 AM Page 156 156 UNIT TWO Understanding Health and Illness Meperidine (Demerol) was at one time a commonly used opioid, but is no longer recommended in most cases. Meperidine is an opioid agonist, and when brok en down in the body, it produces a toxic metabolite called normeperidine. Normeperidine is a cerebral irritant that can cause adv erse effects ranging from dysphoria and irritable mood to seizures. Normeperidine has a long half-life even in healthy patients, so those with impaired renal function are at increased risk. Meperidine use should be a voided in patients o ver age 65, patients with impaired renal function, and patients taking a monoamine oxidase inhibitor (MA OI) antidepressant. In general, the use of meperidine should be limited to young, healthy patients who need an opioid for a short period and to those who have unusual reactions or aller gic responses to other opioids. The effective dose of oral meperidine is three to four times the parenteral dose and is never recommended. Fentanyl (Sublimaze, Duragesic) can be given parenterally, intraspinally, or by transdermal patch (Duragesic). Fentanyl is commonly used IV with anesthesia for surgery. It also is used to relieve postoperative pain via the IV route, PCA pump, or epidural route (discussed later in this chapter). IV fentanyl has a short duration of action and must be gi ven more often than other opioids to maintain an ef fective level of analgesia. The fentanyl patch is useful for a patient with stable cancer pain. CRITICAL THINKING Mrs. Shepard Mrs. Shepard is 92 years old and has undergone an open cholecystectomy. Her continuous epidural infusion of analgesic is discontinued at 1400 on her second postoperative day. The physician orders oral acetaminophen with hydrocodone every 3 to 4 hours as needed for pain. At 1700 Mrs. Shepard refuses to get out of bed because her pain is 7 on a scale of 0 to 10. The nurse checks the medication administration record and notes that she has not yet received a dose of acetaminophen and hydrocodone. 1. Why is Mrs. Shepard in so much pain? 2. What complications can occur as a result of her pain? 3. Each analgesic tablet contains 500 mg of acetaminophen and 5 mg of hydrocodone. The maximum daily dose of acetaminophen is 4 g. If she takes one tablet every 3 hours, is her dose safe? 4. What can be done to relieve her pain and better prevent it in the future? Suggested answers are at the end of the chapter. Opioid Antagonists BE SAFE! BE VIGILANT! It is important to monitor the patient’s level of sedation and respiratory status when administering opioids. Increased sedation, decreased respiratory effort, and constricted pupils can be signs of opioid overdose. Careful monitoring and dosage adjustments of opioids can prevent opioid-induced respiratory depression. Methadone (Dolophine) is a potent analgesic that has a longer duration of action than morphine. It has a long half-life and accumulates in the body with continued dosing. Dosing intervals may be extended after pain relief has been achieved. Methadone is well absorbed from the GI tract and is effective when given orally at doses similar to the parenteral dose. Methadone is also used in drug treatment programs during detoxification from heroin and other opioids. Patients on methadone maintenance can present a unique challenge when admitted to the hospital. It is important to continue the maintenance dose even if additional pain medications are required after surgery or trauma. See Table 10.1 for examples of opioids. Naloxone (Narcan) is a pure opioid antagonist that counter acts, or antagonizes, the effect of opioids. It is often used in emergency departments for treating the effects of opioid overdose, such as sedation and respiratory depression. Caution must be used when gi ving naloxone to a patient who is receiving opioids for pain control. If too much naloxone is given too fast, it can reverse not only the unwanted effects— such as respiratory depression and sedation—but the desired effect of analgesia as well. Some antagonists are shorter acting than the opioid that is being used. If the antagonist is gi ven because of respiratory depression, the dose may need to be repeated because its effect may wear off before the opioid wears off. Some analgesics are classified as combined agonists and antagonists or partial agonists. These drugs bind with some opioid receptors and block others. The most commonly used drugs in this class are butorphanol (Stadol) and nalbuphine (Nubain). How does this information translate into nursing practice? Consider, for example, a patient who receives sustained-release morphine every 12 hours to control metastatic bone pain, b ut the patient develops breakthrough pain between doses. You observe that butorphanol has been ordered for pain by another doctor and administer it. The butorphanol will antagonize, or counteract, some of the effects of the morphine, and the patient may experience acute pain. It is important to be informed about the actions of all drugs that are administered and to be aware of possible drug interactions that may interfere with patient care. Analgesic Adjuvants WORD BUILDING transdermal: trans—across + dermal—skin Adjuvants are classes of medications that are given in addition to other medications. Analgesic adjuvants can potentiate 4068_Ch10_147-170 17/11/14 10:01 AM Page 157 Chapter 10 Pain that is predictable can be more effectively treated, or prevented, with scheduled doses of medication. Aroundthe-clock (ATC) dosing is an ef fective way to schedule doses evenly over a 24-hour period to pre vent pain from becoming unbearable. It is important to use ATC dosing after surgery or trauma, with chronic pain, or in any other circumstance in which pre venting pain will allo w the patient to participate in daily or other recovery activities. Patient-Controlled Analgesia Patient-controlled analgesia (PCA) involves an opioid on an IV controller. The patient has a button on a cord that can be pushed to activate a dose of IV medication. The registered nurse (RN) programs the pump to the dose and dosing interval ordered by the HCP. A “lockout” mechanism prevents the patient from receiving the medication more often than or dered. PCA is an e xcellent option after surgery because it gives the patient some control over pain management. Teach the patient and family that only the patient should push the button, never the nurse or a family member. If the patient is too sedated to push the button, a dose of opioid is not likely needed and could even be dangerous. World Health Organization Analgesic Ladder In 1990, the World Health Organization (WHO) developed the WHO analgesic ladder to help clinicians to select appropriate medications for pain management based on pain intensity (Fig. 10.2). Although many organizations today use algorithms or flowcharts to help clinicians make appropriate medication choices, the WHO analgesic ladder remains a classic reference. g tin is rs ing pe as in re Pa inc or Op io to s id fo ⫾ N ever r mod e ⫾ A onop pain erate dju ioid van t Balanced Approach to Analgesia Op i mo oid fo d ⫹ N erat r mild e ⫾ A onop pain to dju ioid van t g tin is rs ing pe a s in re Pa inc or A balanced analgesia approach should be used, combining analgesics and adjuvants from different classes to minimize the adverse effects of opioids, such as nausea and v omiting or sedation, while maximizing pain relief. F or example, an opioid and a nonopioid given together can provide pain relief with an overall lower dose of each medication than if each was given alone. Because these drugs have different mechanisms of action and different adverse effects, it is possible to safely use them together. If doses can be reduced in this manner, additional sedating medications such as antiemetics and antihistamines (to treat side effects) may not be needed. 157 m fro m in do pa ee er Fr nc ca the effects of opioids or nonopioids, ha ve analgesic activity themselves, or counteract the unwanted effects of other analgesics. They may be called off-label medications because they are being used in a way not specifically approved by the Food and Drug Administration; that is, they were not initially developed to treat pain. Adjuvants may have pain-relieving properties for certain conditions. Although the use of adjuvants is common, nurses must be mindful of the side effects of these medications, which often affect the central nervous system. Examples of adjuvants are corticosteroids, benzodiazepines, antidepressants, and anticonvulsants. Corticosteroids can be used to treat a v ariety of painful conditions, including acute and chronic cancer-related pain. They may be used as part of actual cancer treatment because of their toxicity to some cancer cells, or they may reduce pain by decreasing inflammation and the resulting compression of healthy tissues. Benzodiazepines such as midazolam (Versed) or diazepam (Valium) are effective for treating anxiety or muscle spasms associated with pain. These drugs do not pro vide pain relief alone but are ef fective in treating pain caused by muscle spasms. Benzodiazepines can cause sedation, which limits the amount of opioid that can be safely given at the same time. Tricyclic antidepressants such as amitriptyline, imipramine, desipramine, and doxepin can help relieve neuropathic pain. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that is also effective for nerve pain. These drugs must be taken for days to weeks before they are fully effective, and patients must be told to continue the medication e ven if it seems ineffective at first. Additional benefits of this class of medications may include mood elevation and improved ability to sleep, but significant side effects often limit their use. Anticonvulsants such as carbamazepine (T egretol) and gabapentin (Neurontin) are often used to relieve neuropathic pain. Again, these medications must be taken regularly to realize their full benefit. Stimulants such as methylphenidate hydrochloride (Ritalin) or caffeine-containing medications may be used to counteract the sedating effects of opioids in some patients. Nursing Care of Patients in Pain 3 2 No n ⫾ A opio dju id van t Pa in 1 Scheduling Options Analgesics of an y kind can be administered either as needed (prn) or on a scheduled basis. Intermittent, unpredictable pain may be best treated with as needed doses. FIGURE 10.2 World Health Organization three-step analgesic ladder. 4068_Ch10_147-170 17/11/14 10:01 AM Page 158 158 UNIT TWO Understanding Health and Illness At the first level, nonopioid analgesics are recommended for mild pain (a verbal rating of 1–3). Typically, at this intensity, patients can perform usual daily activities. When pain is unrelieved by maximum ATC dosing, the treatment moves up the ladder to Level 2, moderate pain, and adds a lo w dose of an opioid analgesic. A patient with moderate pain (a v erbal rating of 4–6) may have trouble working and staying focused. She or he may also begin to have difficulty with usual care activities such as walking, bathing, and dressing. If pain severity increases to se vere pain (a v erbal rating greater than 6), stronger opioids may be needed. Moderate to severe pain affects the quality of the patient’ s life. Addition of adjuvant agents should be considered at all levels. Best practice mandates the scheduling of pain medications ATC to prevent breakthrough pain, especially for patients with cancer and chronic pain. F or patients with surgical or traumatic pain, analgesics should be gi ven ATC until the pain decreases to a level that allows medications to be given less often (e.g., as needed, such as before physical therapy). When using the WHO ladder, it is important to keep in mind that it is not necessary to start at Level 1 if the patient is having severe pain. Analgesics from Level 3 on the WHO ladder may be the starting point for some patients. CRITICAL THINKING Ms. Jackson Ms. Jackson had abdominal surgery 2 days ago. She has been receiving morphine via IV PCA at an average of 2.5 mg per hour for the past 6 hours. She rates her pain at 3 on a scale of 0 to 10. She is to be dischar ged today. Her physician has ordered codeine 30 mg with acetaminophen (Tylenol with codeine No. 3), one or two tablets every 4 hours as needed for pain at home. Will Ms. Jackson be comfortable at home? Why or why not? Suggested answers are at the end of the chapter. Other Interventions Other pain treatments include radiation therap y or antineoplastic chemotherapy to help shrink tumors that are causing pain for a patient with cancer. Chemotherapy is also used for treating pain associated with connective tissue disorders such as rheumatoid arthritis and systemic lupus erythematosus (SLA). Topical local anesthetics such as lidocaine/prilocaine cream (EMLA) decrease the pain of procedures such as venipuncture and lumbar puncture. A lidocaine patch may be effective for patients with postherpetic or other nerv e pain. In patients with osteoporosis, drugs that promote calcium uptake by the bones can aid in pain relief. These may include hormonal agents and medications that decrease calcium reabsorption from bone. Placebos Use of placebos involves the administration of an inacti ve substitute such as normal saline in place of an active medication. In the past, placebos were sometimes given in an attempt to determine whether a patient’s pain was “real.” This is unethical and inappropriate unless the patient has given written consent. The use of placebos is a denial of the patient’s report of pain. If a placebo is ordered for a patient, discuss concerns with the physician and nurse supervisor. Placebos are only to be used in drug studies (clinical trials) to compare a new drug with an inactive substance. In this situation, patients are informed that they may be receiving a placebo. Routes for Medication Administration Analgesics can be administered by almost any route. The oral route is desired in most instances because it is easy and painless for the patient and can be used at home. See Table 10.3 for a comparison of the various routes. Nonpharmacological Therapies Nonpharmacological treatments are usually classified as either cognitive-behavioral interventions or physical agents. The goals of these two groups of treatments differ. Cognitivebehavioral interventions can help patients understand and TABLE 10.3 ROUTES FOR ANALGESIC ADMINISTRATION Uses Oral Preferred route in most cases Rectal May be used to provide local or systemic pain relief Advantages Disadvantages Nursing Considerations Convenient Less expensive than other forms Immediate- and controlled-release forms available Slower onset than IV form Can provide consistent blood levels when given around the clock. Controlled-release form recommended for long-term use in chronic pain. Can be used when patient cannot take oral medication May be difficult for patient or family to self-administer Some oral preparations can be given rectally. (Place in empty gel cap for ease of use.) Check with HCP or pharmacist. 4068_Ch10_147-170 17/11/14 10:01 AM Page 159 Chapter 10 Nursing Care of Patients in Pain 159 TABLE 10.3 ROUTES FOR ANALGESIC ADMINISTRATION—cont’d Uses Transdermal Patch Chronic pain Intramuscular Acute pain IV Preferred route for postoperative and chronic cancer pain in patients who cannot tolerate oral route Patient-Controlled IV Allows patient some control over administration schedule Subcutaneous May be used if IV route is problematic Advantages Disadvantages Nursing Considerations Easy to apply Delivers pain relief for several days without patch change May take up to 3 days before maximum effective drug level reached, and delay in excreting once removed. Patient must be closely monitored and alternative routes may be needed when starting and stopping therapy. May be less effective in smokers and very thin people. Absorption may be erratic. Absorption may be increased with fever. Avoid heat application over patch. Avoid touching medication when applying patch. Keep used patches away from pets and children. Rapid pain relief, although slower than IV Painful administration Inconsistent absorption Use only if other routes cannot be used. Provides rapid relief Continuous infusion to achieve steady drug level Difficult to use in home care setting Requires training and special equipment Follow drug manufacturer’s instructions for administration. Patient pushes a button to administer a dose of opioid Requires special training Pump must be programmed correctly An hourly limit and lockout interval are programmed into the pump to keep the patient from receiving too much drug. Caution patient and family that only the patient should push the button. Can deliver effective pain relief Some opioids may be given as continuous infusion. Injection may be painful May be effective for treatment of chronic cancer pain. Requires single or continuous injection in back May be associated with intense itching Motor function must be assessed especially when local anesthetic is used Steroids may be given with opioid to reduce pain by treating inflammation. Local anesthetic may be paired with opioid to enhance pain relief. Avoid use of anticoagulant and antiplatelet agents (including aspirin) because of risk of epidural hematoma. Intraspinal (Epidural or Subarachnoid) May be able to control Catheter into epidural pain with lower or subarachnoid doses of opioid space used for because relief is traumatic injuries delivered closer to or chronic pain site of pain unrelieved by other Fewer systemic side methods effects May also be used for orthopedic, chest, and abdominal surgical procedures 4068_Ch10_147-170 17/11/14 10:01 AM Page 160 160 UNIT TWO Understanding Health and Illness cope with pain and take an active part in its assessment and control. The goals of physical agents may include providing comfort, correcting physical dysfunction, or altering physiological responses. Nonpharmacological therapies should be used in conjunction with drug therapies and are not expected to relieve pain on their own. Cognitive-Behavioral Interventions Included in this group are interventions such as educational information, relaxation exercises, guided imagery, distraction (e.g., music, television), and biofeedback. These treatments require e xtra time for detailed instruction and demonstration. The use of these modalities must be acceptable to the patient to be useful. Educating patients about what to expect and how they can participate in their own care has been shown to decrease patients’ reports of postoperative pain and analgesic use. Relaxation can be accomplished through a v ariety of methods. The patient may prefer a scripted relaxation e xercise that can be practiced and used the same w ay each time or simply the use of a f avorite piece of music that allo ws a state of muscle relaxation and freedom from anxiety. Guided imagery uses the patient’ s imagination to tak e the patient away from the pain to a f avorite place, such as a beach in Tahiti. The success of guided imagery does not mean that the pain is in any way imaginary. See Chapter 5 for more information on relaxation and imagery. As noted earlier, distraction is commonly used by patients to focus their attention on something other than the pain. They may watch a favorite television program or laugh with visitors when they are in pain. When the program is over or the visitors leave, the patient may focus on the pain again and ask for a dose of pain medication. Biofeedback is sometimes used in chronic-pain programs to teach patients how to train their bodies to respond to dif ferent signals. Biofeedback has been v ery useful in patients with migraine headaches. When an aura (a w arning sign) occurs before a migraine headache, patients are prompted to begin the exercise that relaxes them and may allow them to prevent the headache. APPLICATION OF COLD. Cold can reduce swelling, bleeding, and pain when used to treat a new injury. Cold can be applied by a variety of methods, such as cold wraps and cold packs, as well as localized ice massage. P atients often choose heat over cold if the y have the choice, because cold can be uncomfortable. Cold may be better tolerated over a small area. Alternating heat and cold therapies is most ef fective if not contraindicated. MASSAGE AND EXERCISE. Massage and exercise are used to stretch and regain muscle and tendon length and to relax muscles. Massage pressure can be superf icial or deep. It is im portant that massage is acceptable and not of fensive to the patient. Immobilization is used after a v ariety of orthopedic procedures, as well as fractures and other injuries w orsened by movement. Acupressure has also been shown to be beneficial for pain reduction (See “Evidence-Based Practice”). Physical agents are readily available, inexpensive, and require little preparation or instruction. But always remember, it is important to use nonpharmacological treatments to enhance appropriate drug treatments, not as a substitute. EVIDENCE-BASED PRACTICE Clinical Question Can acupressure help relieve pain and reduce the need for pharmacological analgesics? Evidence Fifteen small studies were reviewed to determine the effectiveness of using finger and hand pressure to stimulate acupoints and relieve pain. The studies demonstrated a reduction in menstrual, labor, low back, headache, and other types of pain in diverse populations. Implications for Nursing Practice “Acupressure can be efficiently conducted by health care professionals as an adjuvant therapy in general practice for pain relief” (Chen & Wang, in press). Physical Agents REFERENCE Physical agents can contribute directly to the patient’s comfort. Examples of physical agents include applications of heat or cold, massage, and e xercise, discussed next. Additional physical interventions such as immobilization or TENS are also available. Chen, Y., & Wang, H. (In press). The effectiveness of acupuncture on relieving pain: A systematic review. Pain Management Nursing. APPLICATION OF HEAT. The application of heat to sore muscles and joints is ef fective for pain relief. Heat w orks to increase circulation, induce muscle relaxation, and decrease inflammation when applied to a painful area. Heat can be applied using dry or moist packs or wraps, or in a bath or whirlpool. Heat is contraindicated in conditions that w ould be worsened by its use, such as in an area of trauma, because of the possibility of increased swelling caused by v asodilation. To prevent burns, heat should not be applied directly to skin or over areas of decreased sensation. NURSING PROCESS FOR THE PATIENT EXPERIENCING PAIN Data Collection Accurate assessment of pain is essential to ef fective treatment. Without appropriate assessment, it is not possible to intervene in a w ay that meets the patient’ s needs. Because of regulatory requirements, most organizations require detailed pain assessments of patients at admission, with an y change 4068_Ch10_147-170 17/11/14 10:01 AM Page 161 Chapter 10 Patient Perspective Terry Versus Joanne I (Terry) have had chronic back pain for 10 years. It is very real, related to multiple herniated discs in my thoracic and lumbar spine, arthritis, and degenerative disc disease. Because I’ve been dealing with it for 10 years, I have adapted—I never look like I am in pain. Sometimes I limp or move around a lot to find a comfortable position, but I don’t have that pained look on my face, and my blood pressure doesn’t go up like some people. I have tried many, many medications over the years and have become quite educated in pain treatments. I have tried antidepressants and antiseizure medications (both are used for neuropathic pain), ice, heat, TENS, relaxation, physical therapy, more physical therapy, exercises, more exercises, massage therapy, steroid injections, and nerve blocks. I had relief once for about a month following some injections, and I kept thinking something was wrong. “Wait, where’s the pain? This doesn’t feel right!” Sometimes I would like a big dose of morphine, but I know that opioids for chronic pain are a one-way street to dependence. I do have a prescription for hydrocodone and acetaminophen (Vicodin) that I take a couple of times a month when I feel desperate. I ration them because I am afraid of them. My friend Joanne also has back pain, which started 20 years ago. When it started, she was writhing in pain—I am positive her blood pressure was sky high! She couldn’t move because of muscle spasms. She was also diagnosed with a herniated disc, but she was able to have surgery to fix it. She said the nerve pain relief was already evident in the recovery room. Of course, surgery causes pain, so opioids are needed for a short while. But once healing started for Joanne, no pain! She still has acute pain from time to time, when she experiences muscle spasms and can’t move very easily for several days. She takes muscle relaxers and has to lay low until the spasms resolve. Sometimes Joanne looks at me and says, “You don’t look like you’re in pain.” At first this made me feel bad, like she was comparing her pain to mine. Then one day, I realized the difference—she experiences acute pain, and I have chronic pain. I’ve adapted. She is way more miserable than I am when she is in pain, but it is short-lived. My pain is not as severe, but after 10 years, it has worn me down. When you are a nurse, please believe your patients when they say they are in pain, even if they don’t look like they are. Maybe they’ve gotten used to it, but that doesn’t mean they enjoy feeling pain. Do whatever you can to help them feel better. Nursing Care of Patients in Pain 161 in condition, and at least quarterly thereafter while in care. Nurses should verbally assess all patients under their care at least once per shift for pain and provide appropriate intervention as needed. The WHAT’S UP? format, introduced in Chapter 1, can help you perform a complete and effective assessment (Table 10.4). The following sections provide some additional key points for assessing pain and putting together more pieces of the pain puzzle. Accept the Patient’s Report of Pain Pain is what the patient says it is, not what the HCP believes it is. When a member of the health care team distrusts the patient’s report of pain, the patient can usually sense this. The patient may compensate by either underreporting pain or, less commonly, anxiously overreporting. Patients may try to hide their pain for fear of being thought of as complainers or drug seekers. Obtain a Pain History Obtain information from the patient about the pain he or she is experiencing. Letting the patient describe the pain in his or her own words helps establish a trust relationship between you and the patient. This is also the time to disco ver the effects the pain is having on the patient’s quality of life. Does the pain prevent the patient from eating, sleeping, or participating in work or family activities? Are there adverse effects such as nausea and vomiting or constipation that need to be addressed? Also assess emotional and spiritual distress and coping abilities. Ask the patient about ho w he or she has coped with pain previously and what treatments ha ve been effective and ineffective in the past. In non verbal or cognitively impaired patients, information may be obtained from family members and the medical record.A painful diagnosis, such as arthritis, typically is a predictor of pain. A thorough history is essential so you can individualize pain interventions to fit the patient’s needs. PAIN ASSESSMENT TOOLS. Various tools are available to as- sist with accurate and complete pain assessment. You should become familiar with the tools used in your clinical practice, setting and use them consistently. It is of utmost importance that all health care personnel caring for a particular patient use the same pain rating scale, whether it is a numerical scale (e.g., 0–10), a visual analog scale (Fig. 10.3), or the FACESR scale (FPS-R) (Fig. 10.4). There should also be consistent scales in place for non verbal/cognitively impaired patients such as the PAINAD (Pain Assessment in Advanced Dementia Scale; Ward, Hurley, & Volicer, 2003; Fig. 10.5). Whatever scale is used, it must be one that has been validated with research. The FACES-R scale was initially developed for use in children and has since been re vised with faces that are more realistic for adults. The PAINAD scale was developed for patients with advanced dementia but is an effective tool for patients with cognitive and communicative barriers. Longer questionnaires are useful in meeting re gulatory requirements for the completion of comprehensi ve pain assessments (Fig. 10.6). These scales often contain examples of verbal pain descriptors—something many patients 4068_Ch10_147-170 17/11/14 10:01 AM Page 162 UNIT TWO 162 Understanding Health and Illness TABLE 10.4 WHAT’S UP? GUIDE FOR PAIN ASSESSMENT Acronym W Key Where is the pain? Pain Assessment Be specific. Use a drawing of the body if needed. H How does the pain feel? Is the pain shooting, burning, dull, sharp, aching? A Aggravating and alleviating factors What makes the pain better? What makes it worse? T Timing When did the pain start? Is it intermittent? Continuous? S Severity How bad is the pain on a scale of 0 to 10? Use a different tool, such as the PAINAD or FACES (see Fig. 10.4 and 10.5) scale, if needed. U Useful other data Are any other symptoms associated with the pain or pain treatment? Itching, nausea, sedation, constipation? How does the pain affect lifestyle (inability to eat, sleep, work, enjoy sex, etc.)? P Patient perception What is the patient’s perception of what caused the pain? Is the patient experiencing suffering? Is the patient satisfied with pain control? No pain 0 Worst pain 1 2 Mild 3 4 5 6 7 8 Moderate 9 10 Severe FIGURE 10.3 Analog pain scale. have difficulty verbalizing. A scale should also be used to monitor the patient’s level of sedation after opioid administration (Fig. 10.7). Any unexpected increase in the patient’s level of sedation should be reported promptly to the RN or HCP. Finally, keeping a pain diary may help patients to document pain ratings, interventions, and responses, which can aid effective intervention. Perform a Complete Physical Assessment A thorough physical assessment is necessary to determine the effect of the pain and pain treatments on the body. It helps identify all of the pain sites and an y medication side effects and helps prioritize the seemingly o verwhelming task of helping the patient achieve acceptable pain relief and good quality of life. As discussed previously, the patient with acute pain may exhibit signs such as grimacing and moaning or elevated pulse and blood pressure. For patients with cognitive impairments, these indicators can be particularly important; however, these signs cannot be relied on to “pro ve” that a patient is in pain. The only reliable source of pain assessment is the patient’s selfreport (“Gerontological Issues”). Even patients with cognitive deficits can provide important information about pain. They can often answer simple yes or no questions regarding comfort and may demonstrate favorable changes in behavior, such as diminished calling out, when pain is effectively controlled. Gerontological Issues Older adults frequently have unmet pain needs. Man y believe that pain is an anticipated part or aging and may be hesitant to take strong medications such as opioids for pain. NSAIDs are often contraindicated for older adults due to medication interactions and GI side effects; however, patients should be evaluated for medications on an individual basis. Patients in long-term care facilities, particularly patients with cogniti ve deficits, should have medications for pain scheduled ATC to ensure re gular administration and effective pain control. Consider incidence of isolation, restlessness, confusion, aggression, and changes in appetite as possible signs of pain. Pulling at dressings, tugging at IV sites, and calling out can also be symptoms of discomfort. Any change in the patient’s usual behavior should be considered a possible sign of discomfort. Remember to take more time when assessing pain in older patients because they may need more time to process what you are asking. Consider using the PAINAD Scale when assessing confused patients. You can anticipate pain and provide relief measures to prevent severe pain. A trial dose of pain medication may help to determine if the patient’s behavior is because of pain. Nagging achiness in hands and feet is often noted as a reason for decreased activity, inability to sleep, and altered functional ability. A hand or foot massage using lotion and gentle massage strokes is often a relaxing comfort measure. Opioid analgesic doses may need to be decreased by 25% to 50% initially because the y tend to work longer and stronger in the older patient. 4068_Ch10_147-170 17/11/14 10:01 AM Page 163 Chapter 10 0 2 4 Nursing Care of Patients in Pain 6 8 163 10 FIGURE 10.4 FACES-R Pain Scale. (With permission from the International Association for the Study of Pain.) Pain Assessment in Advanced Dementia Scale (PAINAD) Behavior 0 1 2 Score Breathing independent of vocalization Normal Occasional labored breathing Short period of hyperventilation Noisy labored breathing Long period of hyperventilation Cheyne-Stokes respirations Negative vocalization None Occasional moan or groan Low level speech with a negative or disapproving quality Repeated troubled calling out Loud moaning or groaning Crying Facial expression Smiling or inexpressive Sad Frightened Frown Facial grimacing Body language Relaxed Tense Distressed pacing Fidgeting Rigid Fists clenched Knees pulled up Pulling or pushing away Striking out Consolability No need to console Distracted or reassured by voice or touch Unable to console, distract, or reassure Total* * Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0–“no pain” to 10–“severe pain”) FIGURE 10.5 PAINAD Scale. (From Warden, Hurley, & Volicer, 2003. The PAINAD was developed and tested by clinicians and researchers at the New England Geriatric Research Education and Clinical Center, a Department of Veterans Affairs center of excellence with divisions at EN Rogers Memorial Veterans Hospital, Bedford, MA, and VA Boston Health System. www.amda.com) Nursing Diagnoses, Planning, and Implementation See the “Nursing Care Plan for the Patient in Pain.” Some additional principles to consider during planning and implementation follow. Set Goals With Patients and Caregivers Establish a pain control goal during the planning phase.Ask the patient to determine an acceptable level of pain if complete freedom from pain is not possible. P atients with cognitive deficits should also have pain goals established that include behavioral indicators. Education is important when helping patients and caregivers set realistic pain control goals. Although a goal of 0 pain is desirable, it may not be possible or safe. On the other hand, a patient who chooses a pain goal of 6 may be unable to get out of bed and do other recovery or daily activities. Patients should also identify acti vity goals. After surgery, goals may include the ability to amb ulate and achieve restful sleep. For patients with chronic pain, the goals may be different. For example, a patient with terminal cancer may want to be able to eat dinner with her family in the evening. You can assist the patient in reaching that goal by teaching her to conserve energy during the day for the activity that is most important to her. Instructing both patients in optimal timing of pain medications will also assist them in reaching their desired activity goals. Giving patients pain management options can provide autonomy and may help pre vent feelings of helplessness and hopelessness. It is the nurse’s responsibility to engage the patient and family in the pain management plan. 4068_Ch10_147-170 17/11/14 10:01 AM Page 164 UNIT TWO 164 Understanding Health and Illness Pain Assessment Chart (For Admission and/or Follow-up) 1. Patient 2. DX Assessment on Admission / Date / Pain No Pain / Date of Pain Onset / 1. Location of Pain (indicate on drawing) 2. Description of Predominant Pain (in patient’s words) 3. Intensity [Scale 0 (no pain) — 10 (most intense)] Right 4. Duration and when occurs 5. Precipitating Factors 6. Alleviating Factors 7. Accompanying Symptoms GI: Nausea CNS: Drowsiness Emesis Constipation Confusion Hallucinations Anger Psychosocial: Mood Anxiety Anorexia Depression Relationships 8. Other Symptoms Sleep Fatigue Activity Other 9. Present Medications Doses and times medicated last 48 hours 10. Breakthrough Pain Signature: FIGURE 10.6 Pain assessment chart. (Modified from the Purdue Frederik Company, Norwalk, CT.) Left Left Right 4068_Ch10_147-170 17/11/14 10:01 AM Page 165 Chapter 10 Nursing Care of Patients in Pain 165 Understand That Pain Affects the Whole Family S Normal Sleep 1 Awake and Alert 2 Occasionally Drowsy 3 Frequently Drowsy 4 Unable to Arouse FIGURE 10.7 Level of sedation scale. It is important to include the whole f amily in the pain management plan. Understanding f amily dynamics helps the nurse in implementing an effective plan. Cultural influences are also important to consider (see Chapter 4 and “Cultural NURSING CARE PLAN for the Patient in Pain Nursing Diagnosis: Pain (acute or chronic) Expected Outcomes: Pain will be at a level that is acceptable to the patient. Patient will be able to participate in activities that are important to him or her. Evaluation of Outcomes: Is pain at a level that is acceptable to the patient? Is the patient able to participate in activities that he or she has identified as important? Intervention Assess pain based on patient report. Use the WHAT’S UP? format. Rationale Patient’s pain is defined as what the patient says it is, when the patient says it is occurring. Evaluation Does the patient verbalize his or her pain? Does the patient use verbal or nonverbal messages that imply trust in nurse’s belief of pain report? Intervention Teach the patient to use a pain rating scale. Use the same scales consistently. Rationale A rating scale is the most reliable method for assessing pain severity. Evaluation Does the patient understand the use of the scale and use it to report pain? Intervention Have the patient or caregiver keep a pain diary, documenting time of pain, interventions, and preand postpain ratings. Rationale A diary can show patterns of pain and pain relief, and help in planning care. Evaluation Does the diary reveal patterns that help with planning? Intervention Determine what is an acceptable pain level for the patient. Consider activities the patient should be able to perform. Rationale Only the patient can decide what pain level is acceptable. Evaluation Is the patient’s pain at an acceptable level? Can they perform necessary activities of daily living (ADLs) with minimal pain? Intervention Assess whether pain is nociceptive, neuropathic, or both. Rationale Nociceptive and neuropathic may present differently and may require different interventions. Evaluation Has nociceptive versus neuropathic pain been identified? Are treatments appropriate? Intervention Assess need for and offer emotional, spiritual, and social support for the experience of pain and suffering. Rationale Pain, as well as disease processes, can be accompanied by feelings of powerlessness, distress, and isolation. Evaluation Does the patient appear emotional, angry, or withdrawn? Does the patient have difficulty making decisions? Does the patient have a support system? Is the patient-nurse relationship therapeutic? Intervention Give analgesics before pain becomes severe. For persistent pain, give analgesics around the clock. Rationale Pain can be more difficult to relieve when it becomes severe. Evaluation Is analgesic schedule effective? Intervention Combine opioid and nonopioid analgesics as ordered. Rationale Balanced analgesia provides optimum pain relief with fewer side effects. Evaluation Is the analgesic combination effective? Intervention Assess for pain relief approximately 1 hr after administration of oral analgesics, or 30 min after IV analgesics. Rationale If pain is not relieved, additional measures will be needed. Evaluation Does patient report acceptable level of relief? Intervention Observe for adverse effects of pain medication. Rationale Many pain medications cause nausea and fatigue. Both tend to subside after a few days. Evaluation Are adverse effects occurring? Can they be managed? Does medication regimen need to be adjusted? Continued 4068_Ch10_147-170 17/11/14 10:01 AM Page 166 166 UNIT TWO Understanding Health and Illness NURSING CARE PLAN for the Patient in Pain—cont’d Intervention If opioids and/or muscle relaxants are being used, assess for respiratory depression and level of sedation at regular intervals. Rationale If patient is opioid-naïve or dose is increased, monitor patient carefully for sedation. Sedation always precedes respiratory depression. Evaluation Is the patient’s respiratory rate greater than 8 per minute or above the parameter ordered by the physician? What is the patient’s level of consciousness? Intervention Institute measures to prevent constipation: 8 to 10 glasses of noncaffeinated fluid daily (unless contraindicated), stimulant laxatives, and exercise as tolerated. Rationale Opioid-induced constipation is a problem of GI motility; stimulant laxatives are most effective. Caffeine can exacerbate constipation. Evaluation Is the patient easily passing soft feces in expected amount every 1–3 days? Intervention Teach patient alternative (nonpharmacological) pain relief interventions, such as relaxation and distraction, to be used with medication. Rationale Nonpharmacological interventions can help the patient feel in control and may help reduce the perception of pain. Evaluation Does the patient use nonpharmacological interventions effectively? Intervention Assess whether patient is taking pain medications appropriately, and if not, assess reasons. Discuss how interventions may be modified. Rationale Pain medications must be taken appropriately to be effective. Evaluation Is the patient able to manage the pain control regimen? Does he or she have concerns about medications? Are adjustments necessary? Considerations”). It is dif ficult for family members to see loved ones in pain or in heavily sedated states. Including them in planning helps them feel that the y can help make the patient more comfortable and recognizes the important role they have in the patient’s care. a plan that w orks for the patient. As the nurse, you play a vital role in ensuring effective communication among team members, always remembering that the patient is at the center of the team. Pain Is Exhausting Patients, and in some instances their family members, must be informed about the medications the y are taking for pain management. This allows them to take an active role in their care. Patients who are informed about the goals of pain management and who are confident that their providers believe them are more likely to report unrelieved pain so that the y can receive prompt and effective treatment. Goals include a satisfactory comfort level with minimal side effects and complications of pain and its treatment, as well as a reduced period of recovery. The patient should be pro vided with information about a drug’s effects, common adverse effects, frequency of the dose and duration of action, and potential drug-drug and drug-food interactions, if indicated. There are many special considerations for medications, such as controlled-release oral agents and transdermal patches; care must be tak en to include these considerations in the education plan for the patient taking these drugs at home. Drug-specif ic instructions are found in drug handbooks or databases. Education must be presented at a level that the patient can understand. Written information should be included when appropriate. Informed patients use their medications more ef fectively and safely. Pain may keep the patient from sleeping well. This cycle of sleeplessness and pain must be interrupted to help the patient. Fatigue is a common problem for the patient with chronic pain and can complicate the treatment process. Although older adults do not require as much sleep as younger adults, patients must get at least 6 to 7 hours of uninterrupted sleep to be relaxed enough to break the c ycle. Controlled-release opioids may help maintain pain relief throughout the night. If controlled-release medications are not used, it may be necessary to wake a patient to administer pain medication so that the pain does not get out of control. The addition of a sedative or sleep aid may be needed to allo w the patient to sleep. Aromatherapy such as la vender, ensuring patient is comfortable, and limiting caffeine intake after 1500 can increase productive sleep. A Team Approach to Pain Management The interdisciplinary pain management team includes the patient and family, the nurse, the physician or HCP , therapists, spiritual advisers, social w orkers, and pharmacists. Communication among team members is essential. It is the important link that allows the team to be effective in creating Patient Education 4068_Ch10_147-170 17/11/14 10:01 AM Page 167 Chapter 10 CRITICAL THINKING Mr. Sebastian Mr. Sebastian is a 75-year-old man who has been diagnosed with lung cancer and is anxious about lea ving the hospital to return home following surgery. The nursing assessment reveals the need for home health care for dressing changes and teaching about the medications he will need at home. While in the hospital, Mr. Sebastian has required 5 mg of IV morphine every 4 hours around the clock. Nursing Care of Patients in Pain 167 Evaluation The final phase of the nursing process is evaluation. Once the plan of care has been implemented, evaluate whether the patient’s goals have been met. What is the patient’s pain rating? Has the patient’s identified goal for an acceptable le vel of pain been met? How were the pain treatments tolerated? Was the patient able to participate in activities that he or she identified as important? The plan should be continuously updated based on the evaluation. Home Health Hints 1. The morphine is available in syringes prefilled with morphine grains 1/6 per mL. How many milliliters should the nurse administer while Mr. Sebastian is in the hospital? 2. What discharge instructions must be given to Mr. Sebastian and his wife before sending him home? 3. How might his pain be managed at home to prevent unnecessary readmissions to the hospital? Emotional or spiritual distress and fear related to dependence on family caregivers may alter the patient’s perception or report of pain. Some patients may feel pain more intensely because of the influence of fear, and others may underreport if they are trying to protect family members. Pill boxes are useful to ease in administration of medications and for nurses to track usage. Massage is commonly used for the treatment of chronic pain, especially musculoskeletal pain. Remember a physician’s order might be necessary for this type of treatment. Discuss this option with the HCP, patient, and caregiver to help determine if this intervention is appropriate for your patient. Suggested answers are at the end of the chapter. NURSING CARE TIP Many medication interventions are available for the treatment of pain. Whenever possible, administer analgesics by the mouth, by the WHO ladder, and by the clock. SUGGESTED ANSWERS TO CRITICAL THINKING Mrs. Smithers and Mr. Brown It is important to accept both patients’ pain reports. Assessment should be based on what the patient says rather than what is observed. Each patient copes with his or her pain in a unique way, and the nurse cannot judge whether one is in more pain than the other. Janet 1. Remember, pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. You must assume that Janet is in pain. She has pancreatitis, which is commonly very painful. She has a history of IV drug abuse and is likely tolerant to the effects of the morphine. She may be experiencing “end-of-dose failure,” when pain medication does not last as long as expected. If her vital signs are within normal limits, it should be safe to treat her pain. 2. Contact the RN or HCP and explain the problem. Making Janet wait another hour in pain is not appropriate. 3. Tylenol works differently from morphine and may offer minimal relief but is not an appropriate order for severe pain. Talk to the RN or supervisor and explain the situation. 4. Listen to Janet and let her know that you understand she is in pain. Keep her updated at all times and assure her that you will continue to advocate for her until she achieves adequate pain relief. Mrs. Zales 1. Mrs. Zales may have been tolerant to opioids because of her need for medication for chronic pain during the past year. For this reason, she needed more medication than a nontolerant patient who does not usually use opioids. Also, the belief that promethazine and other phenothiazines potentiate opioids is a myth. They do cause increased levels of sedation and may limit the Continued 4068_Ch10_147-170 17/11/14 10:01 AM Page 168 168 UNIT TWO Understanding Health and Illness SUGGESTED ANSWERS TO—cont’d amount of opioid that can be given safely. IM injections are not recommended because they are painful, absorption is not predictable, and there is a delay between injection and relief. A more rational approach to Mrs. Zales’s pain management would have been regular pain assessment with ATC treatment until the pain began to subside. 2. If her pain level had been better controlled, she might have been discharged on oral analgesics without the delay. 3. The most important team member here was Mrs. Zales—the patient should be the CENTER of the team! If she had been listened to more carefully and her history considered, she might have been kept more comfortable. Mrs. Shepard 1. Pain medication is most effective when given on a routine schedule around the clock to avoid breakthrough pain. Mrs. Shepard’s epidural infusion should continue to relieve her pain for a time, up to several hours after it is discontinued, depending on the medication used. The oral medication is most effective when given at the time the epidural is stopped so that it is taking effect as the epidural effects wear off. See “Gerontological Issues” for special considerations for the older patient. 2. Pain prevents patients from moving freely. Postoperative complications such as retained pulmonary secretions and ileus can occur when patients are immobile. Effective pain management can help prevent these complications. 3. If she takes a dose every 3 hours, then she will receive eight doses in 24 hours: 500 mg × 8 = 4000 mg or 4 g, which is the maximum safe dose. Recall that older adult patients metabolize and excrete medications more slowly than younger patients. If she will need the hydrocodone/acetaminophen for more than a few days, it would be wise to consult with the physician about giving the opioid and acetaminophen separately. 4. Mrs. Shepard should be instructed about what her role will be when her pain management regimen is altered. Does she have to ask for the pain medication, or will it just be brought to her? Patient and family education are vital to success in management of a patient’s pain. Ms. Jackson Using an equianalgesic conversion, we can determine whether Ms. Jackson is lik ely to have good pain relief based on her requirement with the PCA. Her current pain level of 3 shows that the morphine has been effective. Remember that the pump k eeps a history of what the patient uses, which is the best indicator of what the patient needs. Ms. Jackson has used 15 mg of morphine during the past 6 hours. An equianalgesic dose of Tylenol with codeine No. 3 w ould be almost 200 mg of codeine, but only 30 to 60 mg has been ordered. In addition, if Ms. Jackson tak es enough Tylenol with codeine No. 3 to get 200 mg of codeine, she will receive a dangerous dose of both the codeine and the acetaminophen. The physician needs to be contacted for different analgesic orders. Mr. Sebastian 1. 5 mg 1 grain 1 mL = 0.5 mL 60 mg grains 1/6 2. Home instruction regarding ATC administration of pain medication is indicated, as well as effects and side effects to report. He will also need to implement measures to prevent constipation. 3. MS Contin, a long-acting oral form of morphine, may be an option for Mr. Sebastian, along with an immediate-release preparation for breakthrough pain. Make sure to check an equianalgesic chart to be sure his oral dose is adequate. Also, information about what to do and whom to contact if pain becomes unmanageable is necessary to help prevent readmissions to the hospital. 4068_Ch10_147-170 17/11/14 10:01 AM Page 169 Chapter 10 Nursing Care of Patients in Pain 169 REVIEW QUESTIONS 1. A patient is walking up and down the hall and visiting and laughing with other patients. When the nurse approaches, the patient reports a pain level of 6 on a scale of 0 to 10. Based on McCaffery’s definition of pain, which of the following assumptions by the nurse is most likely correct? 1. The patient is not really in pain but just wants his medication. 2. The patient is having pain at a level of 6 on a scale of 0 to 10. 3. The patient is in minimal pain and should receive an oral analgesic instead of an injection. 4. The patient is in pain but does not need his pain medication yet. 2. A patient with terminal cancer has been requiring 5 mg of IV morphine every 1 to 2 hours to control pain, yet is engrossed in a movie on television and appears to be in no pain. Which of the following explanations of this behavior is most likely correct? 1. Denial of pain is common in patients with cancer. 2. The cancer treatment is working and the pain is improving. 3. The patient is hiding the pain to finish watching the movie undisturbed. 4. Distraction can be an effective treatment for pain when used with appropriate drug treatments. 3. What action should the nurse take when a patient who is in pain develops tolerance to opioid analgesics? 1. Slowly wean the patient from opioids. 2. Request a referral to an addiction specialist for the patient. 3. Talk to the RN or HCP about increasing the dose of analgesic. 4. Offer the patient nonopioid alternatives for pain control. 4. A patient has surgical site pain 24 hours after a total hip replacement. All the following medications are ordered. Which would be the most appropriate choice for the patient at this time? 1. ibuprofen (Motrin) 2. hydromorphone (Dilaudid) 3. acetaminophen (Tylenol) 4. gabapentin (Neurontin) 5. A patient is receiving duloxetine (Cymbalta) for neuropathic pain related to diabetes. For which symptoms of neuropathic pain should the nurse assess? 1. Tingling, shocklike pain 2. Dull aching pain 3. Deep cramping pain 4. Throbbing, aching pain 6. Which of the following methods is the most reliable way to assess the severity of a patient’s pain? 1. Ask the patient to describe the pain. 2. Observe the patient for physical signs of pain such as moaning or grimacing. 3. Ask the patient to rate his or her pain using a valid assessment scale. 4. Ask a family member to rate the patient’s pain. 7. According to the World Health Organization’s analgesic ladder, at what point in a patient’s pain experience is it appropriate to use adjuvant treatments? Select all that apply. 1. In addition to analgesics for early, mild pain 2. As an alternative to analgesics for mild to moderate pain 3. As an alternative to analgesics for severe pain 4. In addition to analgesics for pain that is persistent despite treatment 5. In addition to analgesics for pain that is growing increasingly severe 8. A patient is hospitalized following a motor vehicle accident with multiple orthopedic injuries and reports acute pain at an 8 on a 0 to 10 scale. An order is written for morphine 6 mg IV every 4 hours as needed, as well as a nonopioid oral analgesic every 4 hours as needed. To reduce the risk of adverse effects and maintain an acceptable level of sedation and pain control, which of the following analgesic schedules will be most effective? 1. Offer the opioid every 4 hours. 2. Tell the patient to call when pain becomes severe, and then give the drugs immediately. 3. Give both the IV opioid and the PO nonopioid every 4 hours around the clock. 4. Alternate the IV analgesic with the nonopioid oral analgesic as needed. 9. An 88-year-old patient is admitted with a broken hip after a fall. An order is written for meperidine 50 to 75 mg IM every 4 hours prn (as needed) for pain. Which of the following actions should the nurse take first? 1. Give the meperidine every 4 hours ATC. 2. Offer the meperidine every 4 to 6 hours prn. 3. Administer an NSAID with the meperidine for added pain relief. 4. Discuss the order with the RN or HCP. 4068_Ch10_147-170 17/11/14 10:01 AM Page 170 170 UNIT TWO Understanding Health and Illness 10. A patient is started on gabapentin (Neurontin) 300 mg by mouth three times daily for chronic low back pain related to lumbar disc herniation. Which instruction should the nurse provide? 1. “Take the medication at the first sign of any pain, up to three times daily.” 2. “Take one capsule every 8 hours continuously to keep the pain under control.” 3. “Take the medication only when you need it, to prevent becoming addicted.” 4. “Take one capsule three times a day, then stop it when the pain is under control.” 12. A nurse needs to administer morphine 10 mg IM. It is supplied as grains 1/4 per mL. How many milliliters should the nurse prepare for injection? Answer: _________ mL Answers can be found in Appendix C. 11. A nurse receives an order to administer 1 mL of sterile normal saline solution IM to a patient suspected of opioid abuse. Which response by the nurse is appropriate first? 1. Administer the saline and carefully document the patient’s response in the medical record. 2. Administer the saline but inform the patient exactly what it is and why it was ordered. 3. Refuse to administer the medication and inform the physician that the order is inappropriate. 4. Share concerns about the order with the supervisor and explain why the nurse cannot in good conscience administer the saline. References American Pain Society. (n.d.). Definitions related to the use of opioids for the treatment of pain. Retrieved May 30, 2009, from http://www.ampainsoc.org/advocacy/opioids2.htm American Society of Addiction Medicine. (2011). Public policy statement: Definition of addiction. Retrieved October 26, 2013 from www.asam.org/for-the-public/definition-of-addiction Institute for Safe Medication Practices. (2012). ISMP’s list of high alert medications. Retrieved October 26, 2013 from http://www.ismp.org/tools/highalertmedications.pdf International Association for the Study of Pain. (2011). IASP taxonomy. Retrieved October 26, 2013 from www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/Pain Definitions/default.htm McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store. Warden, V., Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association 4:9–15. For additional resources and information visit davispl.us/medsurg5