pain
Pain is best described as
a. a creation of a person’s imagination.
b. an unpleasant, subjective experience.
c. a maladaptive response to a stimulus.
d. a neurologic event resulting from activation of nociceptors.
b. an unpleasant, subjective experience.
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” (per Lewis text)
Note: Pain can also be related to a psychological phenomenon, and/or is typically associated with noxious stimuli that causes cell damage that lead to the following pain mechanisms: transduction, transmission, perception, & modulation. (fig 8.1 or fig. 9.1)
A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 11 breaths/min. The most appropriate nursing action in this situation is to
a. stop the PCA infusion.
b. obtain an oxygen saturation level.
c. continue to closely monitor the patient.
d. administer naloxone and contact the provider.
c. continue to closely monitor the patient.
When reviewing laboratory results of an older patient with an infection, the nurse would expect to find
a. mild leukocytosis.
b. decreased platelet count.
c. increased hemoglobin and hematocrit levels.
d. decreased erythrocyte sedimentation rate (ESR).
a. mild leukocytosis.
b. no indication from question that the pt has a bleeding issue
c. no indication from question that would be concerning for an elevated Hgb & Hct level
d. if the pt has an infection/inflammation, the ESR would be elevated, but this is a non specific marker
In a severely anemic patient, the nurse would expect to find
a. cyanosis and cardiomegaly.
b. pulmonary edema and fibrosis.
c. dyspnea at rest and tachycardia.
d. ventricular dysrhythmias and wheezing.
c. dyspnea at rest and tachycardia.
Mild anemia (Hgb 10 to 12 g/dL [100 to 120 g/L]) may exist without causing symptoms. If symptoms develop, it is because the patient has an underlying disease or has a compensatory response to heavy exercise. Symptoms include palpitations, dyspnea, and mild fatigue.
In Moderate anemia (Hgb 6 to 10 g/dL [60 to 100 g/L]), there is an increase in cardiopulmonary symptoms. The patient may have them while resting, as well as with activity.
In Severe anemia (Hgb less than 6 g/dL [60 g/L]), the patient has many manifestations involving multiple body systems
(Table 30.3 or table 34.3)
The nurse is aware that a major difference between Hodgkin’s lymphoma and non-Hodgkin’s lymphoma is that
a. Hodgkin’s lymphoma occurs only in young adults.
b. Hodgkin’s lymphoma is considered potentially curable.
c. non-Hodgkin’s lymphoma can manifest in multiple areas.
d. non-Hodgkin’s lymphoma is treated only with radiation therapy.
c. non-Hodgkin’s lymphoma can manifest in multiple areas.
Non-Hodgkin’s lymphomas (NHLs) are a broad group of cancers of primarily B, T, natural killer (NK), histiocytic, and dendritic cells. NHL is the most common hematologic CA.
The method of spread can be unpredictable. Most patients have widespread disease at the time of diagnosis. The primary manifestation is painLESS lymph node enlargement. The lymphadenopathy can wax and wane in indolent (less aggressive) disease.
Because the disease has usually spread, other symptoms are present depending on where the disease is present (e.g., hepatomegaly with liver involvement, neurologic symptoms with CNS disease).
NHL can manifest in nonspecific ways, such as an airway obstruction, hyperuricemia and renal failure from tumor lysis syndrome, pericardial tamponade, and GI symptoms. Patients with high-grade (more aggressive) lymphomas may have lymphadenopathy and B symptoms, such as fever, night sweats, and weight loss.
Hodgkin’s lymphoma, also called Hodgkin’s disease, makes up about 10% of all lymphomas. It is characterized by proliferation of abnormal giant, multinucleated cells, called Reed-Sternberg cells, or it’s variant, Hodgkin cells (mononucleated), which proliferate in the lymph nodes.
The disease likely starts in a single location (it starts in cervical lymph nodes in 60% to 70% of patients) and then spreads along adjacent lymphatics.
However, in recurrent disease, it may spread more diffuse. It eventually infiltrates other organs, especially lungs, spleen, and liver. When the disease begins above the diaphragm, it stays confined to lymph nodes for a variable time. Disease originating below the diaphragm often spreads to extra lymphoid sites, such as the liver.
The onset of symptoms in Hodgkin’s lymphoma is usually gradual. The initial development is most often enlargement of cervical, axillary, or inguinal lymph nodes (Fig. 30.14 or fig. 31.14). A mediastinal node mass is the second most common location. The nodes are movable and NONtender. Enlarged nodes are not painful unless they exert pressure on adjacent nerves.
choice a: HL has a bimodal age-specific incidence, occurring most frequently in persons from 15 to 30 years of age and above 55 years of age.
choice b: depending upon staging/mets and how pt responds to tx; NHL may be curable if detected early enough; HL 5 year survival rate >90%
choice d: Treatment for NHL involves chemotherapy, biotherapy, radiation, and sometimes phototherapy and topical therapy (Table 30.29 or table 34.30). Ironically, more aggressive lymphomas (diffuse large B cell) are generally more responsive to treatment. In contrast, indolent lymphomas (e.g., follicular lymphomas) have a naturally long course but are hard to effectively treat.
A postop 70 yo opioid naive pt is receiving morphine by pca for post op pain. What is the reason for not starting the pca with a basal dose?
a. opioid overdose
b. nausea/itching
c. lack of pain control
d. adverse respiratory outcomes
d. adverse respiratory outcomes
Be wary of opioid naive pts, basal (continuous) dose can cause respiratory depression/arrest.
Patients most at risk for respiratory depression include those who are age 65 or older, have a history of snoring or witnessed apneic episodes, report excessive daytime sleepiness, have underlying heart or lung disease, are obese (body mass index greater than 30 kg/m2), have a history of smoking (more than 20 pack-years), or are receiving other CNS depressants (e.g., sedatives, benzodiazepines, antihistamines).
For postoperative patients, the greatest risk for opioid-related respiratory adverse events is within the first 24 hours after surgery.
A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is
a. probably exaggerating his pain.
b. in need of a referral for surgical treatment of his pain.
c. best treated by receiving a long-acting and a short-acting opioid.
d. best treated by regularly scheduled short-acting opioids plus acetaminophen.
c. best treated by receiving a long-acting and a short-acting opioid.
Opioids normally are prescribed for the treatment of moderate to severe cancer pain.
Drug dosages are adjusted to control pain with the fewest side effects. Analgesic medications (e.g., morphine, fentanyl) should be given on a regular schedule (around the clock) with more doses available as needed for breakthrough pain.
In general, oral administration is preferred. Other routes (e.g., transdermal, transmucosal) are options.
Significant information from the patient’s health history that relates to the hematologic system includes
a. jaundice.
b. bladder surgery.
c. early menopause.
d. multiple pregnancies.
a. jaundice.
Jaundice, a yellowish discoloration of body tissues, results from a change in normal bilirubin metabolism or disruption of the flow of bile into the hepatic or biliary duct systems.
The urine may appear darker due to excess bilirubin being excreted by the kidneys. If conjugated bilirubin cannot pass into the intestines from the liver because of obstruction or inflammation of the bile ducts, the stools will be clay colored.
Hemolytic anemia: increased breakdown of rbc = increased amt of unconjugated bilirubin in blood; liver is unable to process increased amounts
table 43.3 or table 48.3 (types of jaundice)
Which statements describe anemia related to blood loss? (Select all that apply).
a. A major concern is prevention of shock.
b. This anemia is most frequently treated with increased dietary iron intake.
c. In addition to the general symptoms of anemia, this patient also manifests jaundice.
d. A patient who has acute blood loss may have postural hypotension and increased heart rate.
e. Initial clinical symptoms are the most reliable way to evaluate the effect and degree of blood loss.
a. A major concern is prevention of shock.
d. A patient who has acute blood loss may have postural hypotension and increased heart rate.
e. Initial clinical symptoms are the most reliable way to evaluate the effect and degree of blood loss.
With rapid blood loss, hypovolemic shock may occur. Clinical manifestations, such as postural hypotension and increased heart rate, will be more reliable than laboratory values as they reflect the body’s attempt to meet oxygen requirements. As the percentage of blood loss increases, clinical manifestations worsen.
During initial chemotherapy, a patient with leukemia develops hyperkalemia and hyperuricemia which the nurse recognizes as an oncologic emergency. What treatment would the nurse anticipate as the priority?
a. Increase urine output with hydration therapy
b. Establish electrocardiographic (ECG) monitoring
c. Administer a bisphosphonate, such as pamidronate (Aredia)
d. Restrict fluids and administer hypertonic sodium chloride solution
a. Increase urine output with hydration therapy
Hyperkalemia and hyperuricemia are characteristic of tumor lysis syndrome, which is the result of rapid destruction of large numbers of tumor cells.
Signs include hyperuricemia that causes acute kidney injury, hyperkalemia, hyperphosphatemia, and hypocalcemia.
To prevent renal failure and other problems, the primary treatment includes increasing urine production using hydration therapy and decreasing uric acid concentrations using allopurinol (Zyloprim).
Electrocardiogram (ECG) monitoring is important with hyperkalemia, but the priority is to increase urine output.
Administering a bisphosphonate is for hypercalcemia.
Morphine sulfate PCA is ordered for pain.
Basal dose: 2 mg/hr
PCA demand dose: 0.5 mg
PCA lockout interval: 10 minutes
How many mg can the pt receive in 1 hour?
2 mg basal dose + 3 mg demand dose = 5 mg
A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects
a. a belief that will contribute to appropriate pain management.
b. an accurate statement about pain mechanisms and expected goals of pain therapy.
c. a belief that will not have any effect on the type of care provided to people in pain.
d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.
d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.
Nursing care for a patient immediately after a bone marrow biopsy and aspiration includes (select all that apply)
a. giving analgesics as needed.
b. preparing to start a blood transfusion.
c. giving preprocedure and postprocedure antibiotic medications.
d. having the patient lie still for at least 30-60 minutes to keep the sterile pressure dressing intact.
e. monitoring vital signs and assessing the site for excess drainage or bleeding.
a. giving analgesics as needed.
d. having the patient lie still for at least 30-60 minutes to keep the sterile pressure dressing intact.
e. monitoring vital signs and assessing the site for excess drainage or bleeding.
The preferred site for both aspiration and biopsy of bone marrow is the posterior iliac crest.
Before: Explain procedure to patient. Obtain signed consent form. Perform a surgical time-out before procedure. Analgesics may be given to enhance patient comfort and cooperation.
After: Apply pressure dressing. Assess biopsy site for bleeding and apply pressure as needed. Tenderness at the puncture site for a few days may be normal. Assess for infection.
Complications of bone marrow aspiration are minimal. There is a chance of damaging underlying structures. Other complications include infection if the patient is neutropenic. Hemorrhage may occur in the patient with severe thrombocytopenia.
Monitor the patient’s vital signs until stable. Assess the site for excess drainage or bleeding. If bleeding is present, have the patient lie supine for 30 to 60 minutes to keep pressure on the site. If the bed is too soft, have the patient lie on a rolled towel to provide more pressure. Notify the HCP if bleeding continues. You may give analgesics for postprocedure pain. Soreness over the puncture site for 3 to 4 days after the procedure is normal.
The nursing management of a patient in sickle cell crisis includes (select all that apply)
a. monitoring CBC.
b. optimal pain management and O2 therapy.
c. blood transfusions if needed and iron chelation.
d. rest as needed and deep vein thrombosis prophylaxis.
e. administration of IV iron and diet high in iron content.
a. monitoring CBC.
b. optimal pain management and O2 therapy.
c. blood transfusions if needed and iron chelation (tx when body has too much Fe - an agent binds to Fe and it is excreted from body).
d. rest as needed and deep vein thrombosis prophylaxis.
A patient in sickle cell crisis may need hospitalization. O2 therapy treats hypoxia and controls sickling. Assess for any changes in respiratory status and encourage incentive spirometry. Rest can reduce metabolic requirements. DVT prophylaxis (using anticoagulants) should be prescribed. Fluids are given to reduce blood viscosity and maintain renal function. Priapism is managed with pain medication, fluids, and nifedipine (Procardia). If it does not resolve within a few hours, a urologist may be called.
Undertreatment of sickle cell pain is a major problem.
Infection is a frequent complication.
Hydroxyurea (Hydrea) is the only medication that is clinically beneficial. This drug increases the production of hemoglobin F (fetal hemoglobin) and alters the adhesion of sickled RBCs to the endothelium. The increase in Hgb F is accompanied by a reduction in hemolysis, an increase in hemoglobin concentration, and a decrease in sickled cells and painful crises.
When teaching the patient with cancer about chemotherapy, which approach should the nurse take?
a. Avoid telling the patient about side effects of the drugs to prevent anticipatory anxiety.
b. Assure the patient that side effects from chemotherapy are uncomfortable but not life threatening.
c. Explain that antiemetics, antidiarrheals, and analgesics will be given as needed to control side effects.
d. Tell the patient that chemotherapy-related alopecia is usually permanent but can be managed with lifelong use of wigs.
c. Explain that antiemetics, antidiarrheals, and analgesics will be given as needed to control side effects.
Patients should always be taught what to expect during a course of chemotherapy, including side effects and expected outcome.
Side effects of chemotherapy are serious, but it is important that patients be informed about what measures can be taken to help them cope with the side effects of therapy.
Hair loss related to chemotherapy is usually reversible and wigs, scarves, or turbans can be used during and following chemotherapy until the hair grows back.
A pt reports dull pain in the anterior & posterior neck. On exam, the RN notes full ROM of the neck with no throat redness or enlarged head or neck lymph nodes. What will be the RNs next appropriate assessment indicated by these findings?
a. palpate the liver
b. auscultating bowel sounds
c. inspection of ears
d. palpating for presence of hip pain
a. palpating the liver
Referred pain sites of liver
Referred pain must be considered when interpreting the location of pain reported by the person with an injury or a disease involving visceral organs. The location of a stimulus may be distant from the pain location reported by the patient (Fig. 8.3 or fig. 9.3).
For example, pain from liver disease often occurs in the right upper abdominal quadrant. It also can be referred to the anterior and posterior neck region, shoulder area, and posterior flank area.
If we do not consider referred pain when evaluating a pain location report, diagnostic tests and therapy could be misdirected.
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.)
a. Restlessness
b. Grimacing
c. Moaning
d. Clenching
e. Drowsiness
a, b, d
a. Restlessness: (correct) Clients who have uncontrolled pain often become restless and anxious in response to the discomfort.
b. Grimacing: (correct) Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain.
c. Moaning: (incorrect) Moaning, groaning, crying, and screaming are vocalizations, not nonverbal behaviors, that indicate pain.
d. Clenching: (correct) Clenching the teeth and biting the lower lip are common findings in clients who have pain.
e. Drowsiness: (incorrect) Agitation and aggressiveness, not drowsiness, are common indicators of pain.
You are taking care of a male patient who has the following laboratory values from his CBC: WBC 6,500, Hgb 13.4, Hct 40%, Platelets 50,000. What are you most concerned about?
a. The patient is neutropenic.
b. The patient has an infection.
c. There is an increased risk for bleeding.
d. Fall risk precautions are needed due to anemia.
wbc: 5000 - 10,000
rbc: 4.2 - 6.1
hgb (x3 rbc): 12 - 18
hct (x3 hbg): 37 - 52
plts: 150,000 - 400,000
c. There is an increased risk for bleeding.
wbc: 5000 - 10,000
rbc: 4.2 - 6.1
hgb (x3 rbc): 12 - 18
hct (x3 hbg): 37 - 52
plts: 150,000 - 400,000
Priority nursing actions when caring for a hospitalized patient with a new-onset temperature of 102.2°F (39°C) and severe neutropenia include (select all that apply)
a. starting the prescribed antibiotic STAT.
b. drawing peripheral and central line blood cultures.
c. ongoing monitoring of the patient’s vital signs for septic shock.
d. taking a full set of vital signs and notifying the physician immediately.
e. administering transfusions of WBCs treated to decrease immunogenicity.
a. starting the prescribed antibiotic STAT.
b. drawing peripheral and central line blood cultures.
c. ongoing monitoring of the patient’s vital signs for septic shock.
d. taking a full set of vital signs and notifying the physician immediately.
Caring for the Patient With Neutropenia
All members of the health care team have important roles in preventing infection in the patient with neutropenia. Careful hand washing is an important preventive measure. It should be done before, during, and after patient care by everyone caring for the patient.
• Determine the type of isolation precautions that need to be started, if any.
• Assess patient for signs and symptoms of infection.
• Screen visitors for infectious diseases.
• Place the patient on a neutropenic diet to protect them from bacteria found in some foods.
• Obtain cultures of sputum, throat, lesions, wounds, urine, and feces.
• Give antibiotics and hematopoietic growth factors.
• Teach patient and visitors about hand washing.
• Provide teaching about how to avoid infection, including the need for skin care and oral hygiene.
• Teach the patient and caregivers about signs and symptoms of infection and what to do if they occur.
A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate
a. hyperkalemia.
b. hyperuricemia.
c. hypercalcemia.
d. CNS myeloma.
c. hypercalcemia.
Multiple myeloma, or plasma cell myeloma, is a condition in which cancerous plasma cells (plasma cells are a type of lymphocyte that make antibodies) proliferate in the bone marrow and destroy bone.
Multiple myeloma develops slowly and insidiously. The patient often does not have symptoms until the disease is advanced. Skeletal pain is the major manifestation.
Pain in the pelvis, spine, and ribs is particularly common and triggered by movement. Diffuse osteoporosis develops as the myeloma protein destroys bone. Osteolytic lesions are seen in the skull, vertebrae, long bones, and ribs. Vertebral destruction can lead to collapse of vertebrae with ensuing compression of the spinal cord. Loss of bone integrity can lead to the development of pathologic fractures.
Bony degeneration causes calcium loss from bones, eventually causing hypercalcemia.
Hypercalcemia may cause renal, GI, or neurologic problems, such as polyuria, anorexia, confusion, and heart problems.
Amitriptyline is prescribed for a pt with chronic pain from fibromyalgia. When the RN explains that this drug is an antidepressant, the pt states that she isn't depressed. What is the RNs best response?
a. antidepressants will improve the pt attitude and prevent a negative emotional response to the pain.
b. chronic pain almost always leads to depression, and use of this drug will prevent that from happening.
c. some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain.
d. certain antidepressant drugs are metabolized in the liver to substances that numb the ends of nerve fibers, preventing the onset of pain.
c. some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain.
Fibromyalgia (FMS) is a chronic central pain syndrome marked by widespread, nonarticular musculoskeletal pain and fatigue with multiple tender points. It is a common musculoskeletal disorder and a major cause of disability. Women are twice as likely to get FMS. It is the most common cause of musculoskeletal pain in women ages 20 to 55. Symptoms usually appear between ages 30 and 55 years.
Antidep drugs inhibit the reuptake of serotonin and norepi; thereby increasing their ability to inhibit transmission of nerve pain impulses.
Several antidepressants exert their effects through the modulatory systems. For example, tricyclic antidepressants (e.g., amitriptyline) interfere with the reuptake of serotonin and norepinephrine, thereby increasing their availability to inhibit noxious stimuli.
A pt with advanced colorectal CA has continuous, poorly localized abdominal pain, rated 5/10. How does the RN teach the pt to use pain meds?
a. on an around the clock schedule
b. as often as necessary to keep the pain controlled
c. by alternating 2 different types of drugs to prevent tolerance
d. when the pain cannot be controlled with distraction or relaxation
a. on an around the clock schedule
Schedule these pain meds around the clock to prevent pain escalation.
If pain control isn't adequate, the doses can be increased or adjuvant meds can also be added to the tx plan.
Opioids normally are prescribed for the treatment of moderate to severe cancer pain.
Drug dosages are adjusted to control pain with the fewest side effects. Analgesic medications (e.g., morphine, fentanyl) should be given on a regular schedule (around the clock) with more doses available as needed for breakthrough pain.
In general, oral administration is preferred. Other routes (e.g., transdermal, transmucosal) are options.
The nurse is preparing to administer a blood transfusion. Number the actions in order of priority, 1 is the first action and 10 is the last action.
a. ___ Verify the order for the transfusion.
b. ___ Ensure that the patient has a patent 16-to 22-gauge IV.
c. ___ Prime the transfusion tubing and filter with normal saline.
d. ___ Verify that the physician has discussed risks, benefits, and alternatives with the patient.
e. ___ Obtain the blood product from the blood bank.
f. ___ Ask another licensed person (nurse or MD) to assist in verifying the product identification and the patient identification.
g. ___ Document outcomes in the patient record. Document vital signs, names of personnel, and starting and ending times.
h. ___ Adjust the infusion rate and continue to monitor the patient every 30 minutes for up to an hour after the product is infused.
i. ___ Infuse the first 50 mL over 15 minutes, staying with the patient.
j. ___ Obtain the patient’s vital signs before starting the transfusion.
a. 1
b. 3
c. 4
d. 2
e. 6
f. 7
g. 10
h. 9
i. 8
j. 5
A patient with aplastic anemia has impaired oral mucous membranes. This problem can be related to the effects of what deficiencies? (Select all that apply).
a. RBCs
b. Ferritin
c. Platelets
d. Coagulation factor VIII
e. White blood cells (WBCs)
a. RBCs
c. Platelets
e. White blood cells (WBCs)
Aplastic anemia is a disease in which the patient has peripheral blood pancytopenia (decrease of all blood cell types—RBCs, white blood cells [WBCs], platelets) and hypocellular bone marrow.
Aplastic anemia can manifest abruptly (over days) or insidiously over weeks to months. It can vary from mild to very severe. The patient may have symptoms caused by suppression of any or all bone marrow elements.
Aplastic anemia may cause an inflamed, painful tongue. Oxygen is not delivered without RBCs. The thrombocytopenia may contribute to blood-filled bullae in the mouth and gingival bleeding. The leukopenia may lead to stomatitis and oral ulcers and infections. MCV (measures average size of red blood cells) will be normal or slightly increased.
Ferritin and coagulation factors are not affected in aplastic anemia.
Multiple drugs are often used in combinations to treat leukemia and lymphoma because
a. there are fewer toxic and side effects.
b. the chance that one drug will be effective is increased.
c. the drugs are more effective without causing side effects.
d. the drugs work by different mechanisms to maximize killing of cancer cells.
d. the drugs work by different mechanisms to maximize killing of cancer cells.
Combination therapy is the mainstay of treatment for leukemia. The 3 purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity by using multiple drugs with varying toxicities, and (3) interrupt cell growth at multiple points in the cell cycle.