1. Medical-Surgical Nursing Critical Thinking in Patient Care CHAPTER Fifth Edition Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Nursing Care of Patients in Pain Nursing Care of Patients in Pain 9 9

2. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Directory NCLEX-RN ® REVIEW Test Questions NCLEX-RN ® REVIEW Test Questions Lecture Note Presentation

3. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Questions

4. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 1 1.During your assessment, a patient tells you he has had lower back pain for 9 months. When planning nursing care, you recognize this type of pain as which of the following? 1.neuropathic pain 2.chronic pain 3.visceral pain 4.somatic pain

5. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 1 Response 1.During your assessment, a patient tells you he has had lower back pain for 9 months. When planning nursing care, you recognize this type of pain as which of the following? 1.neuropathic pain 2.chronic pain 3.visceral pain 4.somatic pain

6. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 1 Rationale Chronic pain is defined as pain that has persisted for 6 or more months. Low back pain is the most common cause of chronic pain.

7. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 2 2.A patient presents to the ED after smashing her finger in the car door. She relates that her pain initially was sharp and so intense she thought she would faint, but now it is dull and throbbing. The nurse appropriately recognizes this as which of the following?

8. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 2 Choices 1.indicative that the injury is less severe than initially perceived 2.the result of interpretation of the pain stimulus by the thalamus 3.an example of the gate theory of pain transmission 4.transmission of pain stimuli via unmyelinated C fibers

9. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 2 Response 1.indicative that the injury is less severe than initially perceived 2.the result of interpretation of the pain stimulus by the thalamus 3.an example of the gate theory of pain transmission 4.transmission of pain stimuli via unmyelinated C fibers

10. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 2 Rationale Initial or “fast” pain is sharp and well-defined as the stimulus is transmitted along myelinated A delta fibers to the thalamus and cerebral cortex. The smaller unmyelinated C fibers transmit the stimulus more slowly, producing a second or “slow” pain, which is less well-localized, dull, and throbbing.

11. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 3 3.You are taking a health history for a patient who has taken an NSAID for several years. Which of the following questions should you ask? Select all that apply.

12. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 3 Choices 1.“Tell me how and when you take this drug.” 2.“Have you ever vomited blood or had very dark stools?” 3.“Do you know that you may become addicted to this drug?” 4.“Have you noticed any problems with your breathing?” 5.“Do you have your blood pressure checked regularly?”

13. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 3 Response 1.“Tell me how and when you take this drug.” 2.“Have you ever vomited blood or had very dark stools?” 3.“Do you know that you may become addicted to this drug?” 4.“Have you noticed any problems with your breathing?” 5.“Do you have your blood pressure checked regularly?”

14. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 3 Rationale NSAIDs are more effective when taken on a scheduled basis rather than PRN. These drugs, when effective (particularly for musculoskeletal pain), can cause gastrointestinal bleeding and hypertension, necessitating regular follow-up.

15. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 4 4.Which of the following would you include when teaching a patient about a transdermal pain medication?

16. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 4 Choices 1.Contact your physician if this medication makes you excessively sleepy. 2.Replace this patch every 24 hours, applying it to clean, dry skin. 3.When reapplying the patch, place it on the anterior thigh. 4.This medication should be effective within 2 to 4 hours; contact your physician if your pain is not at an acceptable level after that.

17. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 4 Response 1.Contact your physician if this medication makes you excessively sleepy. 2.Replace this patch every 24 hours, applying it to clean, dry skin. 3.When reapplying the patch, place it on the anterior thigh. 4.This medication should be effective within 2 to 4 hours; contact your physician if your pain is not at an acceptable level after that.

18. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 4 Rationale Transdermal patches of opioid are slowly absorbed, reaching a therapeutic level 12 to 72 hours after application. The drug can accumulate in the body tissues, leading to a toxic level accompanied by manifestations such as sleepiness or respiratory difficulty.

19. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 5 5.Which of the following statements would be most useful in determining the quality of a patient’s pain? 1.“Tell me where you hurt.” 2.“Rate your pain on a scale of 0–10.” 3.“Describe what your pain feels like.” 4.“Tell me how this pain affects your sleep.”

20. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 5 Response 5.Which of the following statements would be most useful in determining the quality of a patient’s pain? 1.“Tell me where you hurt.” 2.“Rate your pain on a scale of 0–10.” 3.“Describe what your pain feels like.” 4.“Tell me how this pain affects your sleep.”

21. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 5 Rationale The quality of the pain is assessed through descriptive statements such as sharp, burning, stabbing, dull, etc.

22. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 6 6.When assessing a postoperative patient’s pain, you note that he is relaxed, smiling, and visiting with friends. He rates his pain as a 7 on a scale of 0–10. The most appropriate response is to do which of the following?

23. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 6 Choices 1.Reassess the patient’s pain after his friends have left. 2.Document your assessment but take no further action. 3.Administer the prescribed analgesic dose. 4.Note that the patient is developing tolerance to the prescribed opioid analgesic.

24. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 6 Response 1.Reassess the patient’s pain after his friends have left. 2.Document your assessment but take no further action. 3.Administer the prescribed analgesic dose. 4.Note that the patient is developing tolerance to the prescribed opioid analgesic.

25. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 6 Rationale Pain is objective; the patient provides the most accurate information about its intensity.

26. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 7 7.When teaching a patient with chronic malignant pain about using opioid analgesics, you would include which of the following instructions?

27. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 7 Choices 1.“This drug may interfere with urination; contact your physician if that becomes a problem.” 2.“Increase fluid and fiber intake; you may need a stool softener or laxative to prevent constipation.” 3.“This drug may cause itching and rash; take Benadryl (diphenhydramine) as needed.” 4.“There is a risk of addiction with this drug; stop the drug if you find that it no longer provides the degree of pain relief necessary.”

28. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 7 Response 1.“This drug may interfere with urination; contact your physician if that becomes a problem.” 2.“Increase fluid and fiber intake; you may need a stool softener or laxative to prevent constipation.” 3.“This drug may cause itching and rash; take Benadryl (diphenhydramine) as needed.” 4.“There is a risk of addiction with this drug; stop the drug if you find that it no longer provides the degree of pain relief necessary.”

29. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 7 Rationale Constipation is a common side effect of opioids narcotics, especially when used on a regular basis.

30. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 8 8.When assessing pain in a patient who is moderately cognitively impaired due to dementia, the nurse should do which of the following?

31. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 8 Choices 1.Ask the patient to rate his pain using the faces pain scale. 2.Use only behavioral cues such as grimacing, pacing, or agitation. 3.Have the family evaluate the intensity of the patient’s pain. 4.Administer the prescribed analgesic on an around- the-clock basis.

32. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 8 Response 1.Ask the patient to rate his pain using the faces pain scale. 2.Use only behavioral cues such as grimacing, pacing, or agitation. 3.Have the family evaluate the intensity of the patient’s pain. 4.Administer the prescribed analgesic on an around- the-clock basis.

33. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 8 Rationale Research has shown that patients with moderate cognitive impairment can use a pain scale to indicate the intensity of pain. The faces pain scale may be more accurate and effective in the cognitively impaired adult.

34. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 9 9.A patient asks the nurse if she should take glucosamine for her knee pain. The nurse bases her response on the knowledge of which of the following?

35. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 9 Choices 1.There is no evidence that natural products such as glucosamine are effective for treating any type of pain. 2.Chronic pain such as that associated with osteoarthritis is best treated with NSAIDs and acetaminophen. 3.When combined with chondroitin, glucosamine has been effective in relieving moderate to severe knee pain in some patients. 4.Although no studies have shown a benefit from taking glucosamine, other CAM therapies such as acupuncture are effective for treating pain.

36. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 9 Response 1.There is no evidence that natural products such as glucosamine are effective for treating any type of pain. 2.Chronic pain such as that associated with osteoarthritis is best treated with NSAIDs and acetaminophen. 3.When combined with chondroitin, glucosamine has been effective in relieving moderate to severe knee pain in some patients. 4.Although no studies have shown a benefit from taking glucosamine, other CAM therapies such as acupuncture are effective for treating pain.

37. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 9 Rationale The combination of glucosamine and chondroitin has been shown to reduce pain in patients with moderate to severe knee pain.

38. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 10 10.A patient who recently took up running to lose weight asks why she feels better after running when she should be tired and sore. The most accurate response would be which of the following?

39. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 10 Choices 1.Natural narcotic-like substances are released during physical activities like running. 2.Activities such as running activate a natural “gate” in the spinal cord, blocking pain signals. 3.Engaging in activities that actively use large muscle groups changes pain circuits in the brain, reducing the perception of pain. 4.With repeated stimulation through activities such as running, nociceptors in deep tissues become less sensitive to stimuli.

40. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 10 Response 1.Natural narcotic-like substances are released during physical activities like running. 2.Activities such as running activate a natural “gate” in the spinal cord, blocking pain signals. 3.Engaging in activities that actively use large muscle groups changes pain circuits in the brain, reducing the perception of pain. 4.With repeated stimulation through activities such as running, nociceptors in deep tissues become less sensitive to stimuli.

41. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff NCLEX-RN ® REVIEW Test Question 10 Rationale Rigorous physical activity such as running prompts the release of endorphins (natural opioids-like substances). Endorphins bind with opioids receptors in the CNS, inhibiting the transmission of pain signals.

42. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Lecture Note Presentation

43. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Learning Outcome 1 Describe the neurophysiology of pain.

44. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Intro to Neurophysiology of Pain Pain is perceived within the CNS. Connections or synapses occur within the spinal cord and within the brain. Interpretation of the stimulus occurs in the brain, which leads to a response.

45. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Pain Theories Specificity and pattern theories Melzack and Wall’s gate control theory Neuromatrix theory

46. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–1 The spinal cord component of the gate-control theory. Pain transmission by small-diameter fibers is blocked when largediameter fibers carrying touch impulses dominate, closing the gate in the dorsal horn of the spinal cord.

47. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Physiology of Pain Nociceptors are nerve receptors for pain. Pain occurs when tissue containing nociceptors is subjected to noxious stimuli. The intensity and duration of stimuli determine the sensation.

48. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Pain Pathway A noxious stimulus is translated by nociceptors into action potential. Action potential is transmitted through small A-delta (A greek symbol) and even smaller C nerve fibers to the spinal cord. Next, the sensory neuron enters the spinal cord by the dorsal root and terminates in the dorsal horn of the spinal cord.

49. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Pain Pathway Here, it synapses with the spinal (or second-order) neurons that transmit the pain signal to the brain. Spinal neurons transmit impulses via axons that cross over to the spinothalamic tract. The impulses ascend the spinothalamic tracts and pass through the medulla and midbrain to the thalamus.

50. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Pain Pathway The pain signal is distributed from the thalamus via third-order neurons to several areas of the cerebral cortex.

51. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–2 A, Touching the hot lid activates nociceptors in the skin, generating pain impulses that travel via fast Aδ and slower C fibers to the spinal cord. B, Secondary neurons in the dorsal horn pass impulses across the spinal cord to the anterior spinothalamic tract. C, Pain impulses ascend to the thalamus and, from there, to the cerebral cortex and the reticular and limbic systems in the brainstem, which integrate the emotional, cognitive, and autonomic responses to pain.

52. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Pain Modulation No one experiences pain from an identical stimulus in the same way or at the same intensity. Neural and chemical responses explain how pain can be modified.

53. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–3 A, Pain impulse causes presynaptic neuron to release burst of neurotransmitters across synapse. These bind to postsynaptic neuron and propagate impulse. B, Inhibitory neuron releases endorphins, which bind to presynaptic opiate receptors. Neurotransmitter release is inhibited, and pain impulse interrupted.

54. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Learning Outcome 2 Compare and contrast definitions and characteristics of acute, chronic, breakthrough, central, malignant, phantom, and psychogenic pain.

55. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Acute Pain Cutaneous and deep somatic pain Visceral pain Referred pain

56. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–4 Referred pain results of the convergence of sensory nerves from certain areas of the body within the spinal cord. For example, a toothache may be felt in the ear, pain from inflammation of the diaphragm may be felt in the shoulder, and pain from ischemia of the heart muscle (angina) may be felt in the left arm.

57. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Chronic Pain Recurrent acute pain Chronic malignant Chronic nonmalignant pain

58. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Breakthrough Pain Pain which exceeds baseline chronic or persistent pain Described as a sudden flare, exceeds long-acting pain medications The onset and intensity can vary Incident or episodic pain

59. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Central Pain Caused by a lesion or damage in the brain or spinal cord Constant, of moderate to severe intensity Difficult to treat Depends on the area of the CNS affected Described as burning, pressing, lacerating, or aching

60. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Phantom Pain Syndrome that occurs following amputation of a body part Pain experienced in the missing body part

61. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Learning Outcome 3 Discuss factors affecting individualized responses to pain.

62. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff The Individualized Pain Response Shaped by physiologic responses, age, gender, sociocultural influences, and psychological influences Pain threshold Pain tolerance –Amount of pain a person can endure before outwardly responding –Varies significantly among individuals and over time

63. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff The Individualized Pain Response Age –Influences a person’s perception and expression of pain –No evidence that nociception is altered by age –Pain tolerance decreases with aging

64. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff The Individualized Pain Response Gender –Women have lower pain threshold and experience higher intensity of pain Sociocultural influences –Response is influenced by family, community, and culture –Affects pain behavior –Cultural standards

65. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff The Individualized Pain Response Psychological Influences –Intensity of perceived pain is affected by attention, expectation, and suggestion

66. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Learning Outcome 4 Discuss collaborative care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies.

67. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Collaborative Care for Pain Necessary for effective pain relief Acute pain management can be straightforward Chronic pain requires a multidisciplinary approach

68. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Collaborative Care for Pain Medications –Most common approach to pain management –Acute pain, straightforward –Chronic pain, broader range of drug classes –Nursing responsibilities

69. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–5 The WHO analgesic ladder illustrates the process for selection of analgesic medications for pain management. Source: The WHO Analgesic Ladder from Cancer Pain Relief and Palliative Care, Technical Report Series, No. 804, The World Health Organization, Geneva, Switzerland. Reprinted by permission.

70. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–6 The transdermal patch administers medication in predictable doses.

71. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–7 PCA units allow the patient to self-manage acute pain. The units may be portable or mounted on intravenous poles.

72. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene BauldoffSurgery Only used if all other methods have failed, and typically reserved for patients experiencing nerve pain Cordotomy Neuroectomy Sympathectomy Rhizotomy

73. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–8 Surgical procedures may be used to treat severe pain that does not respond to other types of management. They include cordotomy, neurectomy, sympathectomy, and rhizotomy.

74. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Transcutaneous Electrical Nerve Stimulation (TENS) Application of electrical current through the skin to control acute or chronic pain Controls pain in several ways

75. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–9 The TENS unit is used to assist in acute and chronic in pain management. Electrodes deliver low-voltage electrical stimuli through the skin to block transmission of pain stimuli. Source: photo by Gary Ombler / Dorling Kindersley Media Library

76. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Complementary and Adjunctive Therapies (Complementary and Alternative Medicine) Acupuncture Biofeedback Chiropractic Distraction Hypnotherapy and Guided Imagery Massage Therapy Natural Products Relaxation

77. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Learning Outcome 5 Use the nursing process as a framework for providing individualized nursing care for patients experiencing pain.

78. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Nursing Care and Health Promotion Goal –Assist patient to achieve optimal control of the pain Health Promotion

79. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene BauldoffAssessment Varies by acuity of pain and circum- stances Acute pain Chronic pain

80. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene BauldoffAssessment Patient Perceptions –Most reliable indicator of pain –PQRST mnemonic  P: What precipitated the pain?  Q: What is the quality of the pain?  R: What is the region of the pain?  S: What is the severity of the pain?  T: What is the timing of the pain? –McGill Pain Questionnaire –Pain-Rating Scales

81. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–10 The McGill Pain Questionnaire. The descriptors fall into four major groups: sensory (1–10), affective (11– 15), evaluative (16), and miscellaneous (17–20). The rank value for each descriptor is based on its position in the word set; the sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI) is based on a scale of 0 to 5.

82. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Figure 9–11 Examples of commonly used pain scales. Commonly Used Pain Scale from FPS-R. This figure has been reproduced with permission of the International Association for the Study of Pain® (IASP®). The figure may not be reproduced for any other purpose without permission

83. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Physiologic Responses Predictable physiologic changes Over time, these changes might not be visible in patients with chronic pain

84. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Behavioral Responses Pain behaviors –Bracing/guarding the painful part –Crying, moaning, or grimacing –Withdrawing from activity –Breathing with increased effort –Becoming immobile

85. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Behavioral Responses Might not coincide with the patient’s report of pain Not always reliable cues to the pain experience

86. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing: Critical Thinking in Patient Care, Fifth Edition Priscilla LeMone Karen Burke Gerene Bauldoff Behavioral Responses Self-Management of Pain –Useful information for the assessment database –Individualized and patient-specific –Get detailed descriptions of:  Actions taken  When and how the measures were applied  How well the measures worked