Ache and pain
A 53-year-old woman is evaluated for chronic pain. She describes an 18-month history of aching pressure in her back, neck, and chest that has affected her quality of life. An appropriate evaluation has failed to identify the source of the patient's symptoms; the patient understands that additional testing is unlikely to be helpful. Acetaminophen, duloxetine, and NSAIDs have been minimally effective. She was recently diagnosed with major depressive disorder. Her only medications are ibuprofen and fluoxetine.
On physical examination, vital signs are normal. There is minimal tenderness to palpation in the paraspinal muscles of the lumbar and thoracic spine, posterior neck, and anterior chest wall. The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate management?
A)Lorazepam
B)Multimodal pain management
C)Pregabalin
D)Oxycodone
Multimodal pain management
Chuck c/o 9/10 pain. He received 15 mg of morphine 4 hrs ago with an order for 10-15 mg q 4 hrs for pain. A rapid response was called for Chuck. What would the rapid response mostly likely be for?
Renal Failure
MI
Depressed Respiration
CHF
depressed respiration
NSAIDs carry common potential side effect such as
Anaphylaxis
GI Bleeding
Nausea
Constipation
GI bleeding
Karen is an 84-year-old woman recovering from a double hip replacement. She has an order for 10-15mg morphine q 4 hrs. The nurse gave Karen 12.5 mg 30 minutes ago. Karen has gone into respiratory depression. What is the consequence of giving Karen Narcan?
Karen will come out of her respiratory depression in excruciating pain.
Karen could become afrebile.
Karen could have hallucinations.
Karen will come out her respiratory depression with nausea.
Karen will have excruciating pain
Opioids do what for pain? (multiple answer)
Alter stimuli response and perception
Make a pt forget of the pain
Bind to the MU receptor
CNS depression
release of dopamine in the nucleus accumbens
does not make you forget pain
dopamine release is the cause of addiction.
A 53-year-old woman is evaluated during a follow-up appointment for a multiyear history of chronic back pain in the setting of osteoporotic compression fractures. In addition to nonpharmacologic treatment, including exercise, she has previously undergone vertebroplasty, facet joint injections, medial branch blocks with radiofrequency ablation, and transforaminal epidural glucocorticoid injections. Her pain is not well controlled with gabapentin, topical lidocaine patches, and an oral NSAID, resulting in interference with work and leisure activities. Other medications include zoledronic acid, vitamin D, and calcium.
There are no changes noted on her physical examination from previous visits.
Opioid therapy is being considered.
Which of the following is the most appropriate next step in management?
A)Calcitonin
B) Opioid risk assesment
C)TSH
B)Urine drug screen
opioid risk assesment
Morphine 30 mg oral route is equivalent to:
Codeine 130 mg IV route
Oxycodone 10 mg PO
Fentanyl 0.1 mg IV route
Hydrocodone 20 mg IV route
Fentanyl
Linda is on her 3rd day of recovering from a hip replacement. She has reported that her pain is 5/10 when lying still, but when she has to do her physical therapy it goes to an 8/10. She has been on hydrocodone 1 tab q 4 hours, but her therapy is always cut short due to pain. Therapy comes twice a day. Once mid-morning and once in the late afternoon. What would the nurse do?
Give the pt 2 tabs corresponding to therapy times.
Give the pt morphine before therapy times.
Give the pt fentanyl before therapy times.
Give the pt demerol before therapy times.
Give morphine before therapy
Upon assessment of James, the nurse discovers that James is not easily aroused and is having apnea. What medication could cause this problem?
Morphine
Fentanyl
Hydrocodone
Demerol
Fentanyl
Which pain scale would be the most appropriate for a patient who is unable to communicate their pain or in an unconscious state?
Flacc
Faces
Numerical
Verbal
FLACC (Face, Legs, Activity, Cry, Consolability)
A 59-year-old woman is evaluated for long-standing chronic pain due to rheumatoid arthritis associated with reduced overall functional status. She is in regular follow-up with a rheumatologist and a pain medicine specialist. She recently started immediate-release oxycodone at a daily dose equal to 22.5 morphine milligram equivalents. Her Opioid Risk Tool score was 2, indicating low risk for future opioid abuse. In addition to oxycodone, she takes meloxicam, etanercept, topical diclofenac, duloxetine, prednisone, and acetaminophen.
On physical examination, vital signs are normal. Active synovitis and typical rheumatoid arthritis deformities are seen in the hands, wrists, elbows, and feet.
A urine drug screen before opioid initiation 2 months ago was negative.
The patient requests a refill of her oxycodone prescription today.
Which of the following is the most appropriate risk mitigation step before refilling this patient's opioid prescription?
Change oxycodone to an extended-release, once-daily formulation
Order a urine drug screen
Recommend a naloxone rescue kit
Review the state prescription monitoring database
Review PMD
Nina is 69 years old. She has an order for 8-10 mg of morphine. The nurse understands morphine and the elderly when the nurse states:
Elderly need their dose decreased 35%-50%
Elderly need their dose decreased 20% - 40%.
Elderly need their dose increased by 25%-50%.
None of the above
none of the above
(need to be decreased 25-50%)
Agonist/Antagonists have a potential for:
Increased HR
Hypertension
Withdrawl
Depressed Immune Response
Withdrawl
When to offer opioid overdose prevention education and naloxone kits.
Opioid dosage ≥50 MME/d, concurrent benzodiazepines, substance use disorder
Which anatomical location is least likely to be involved in the perception of pain in animals?
Nociceptors
Cerebral cortex
Ventral horn of the spinal cord
Thalamus
Ventral horn of spinal cord.
A 67-year-old woman is evaluated after admission to the hospital for severely painful and progressive ulcerations on her abdomen and lower extremities due to calciphylaxis. She rates the pain as an 8 on a 10-point scale. Her medical history includes type 2 diabetes mellitus, end-stage kidney disease managed with hemodialysis, and hypertension. Medications are sevelamer, sodium bicarbonate, amlodipine, labetalol, and basal and prandial insulin.
On physical examination, the patient appears to be in acute pain. Vital signs are normal. Multiple areas of violaceous erythema, three with raised black eschars, are seen on the abdomen and thighs.
Which of the following is the most appropriate pain treatment?
Intravenous hydromorphone
Intravenous morphine
Oral oxycodone
Oral tramadol
Transdermal fentanyl patch
hydromorphone
A patient has been receiving 100 mg / day of oral morphine for the past 3 days. What is the appropriate conversion dose of fentanyl patch ?
Fentanyl patch is not recommended unless the patient has received more than 60 mg of oral morphoine for a week or longer.
25mcg/hr
50mcg/hr
75mcg/hr
not recommended
Michael 's PCA pump is being DC'd. He was on a morphine infusion. He has been reporting steady 8/10 pain. The nurse has an order for oxycodone 2 tabs q 4 hrs for Michael. Michael has been sleeping and aroused but not easily. What concern would you have transitioning Michael from morphine to oxycodone?
Michael may have withdrawl from the morphine.
The pump must be DC'd and removed before administering the oxycodone.
Michael may carry extra risk for respiratory depression.
Michael will need to be assessed for apnea.
Michael may carry extra risk for respiratory depression
When titrating an analgesic to manage pain, what is the priority goal?
Administer smallest dose that provides relief with the fewest side effects.
Titrate upward until the patient is pain free.
Titrate downwards to prevent toxicity.
Ensure that the drug is adequate to meet the patient subjective needs.
Administer smallest dose that provides relief with the fewest side effects.
Which patient is at greater risk for respiratory depression while receiving opioids for analgesia?
An elderly chronic pain patient with a hip fracture
A patient with a heroin addiction and back pain
A young female patient with advanced multiple myeloma
A child with an arm fracture and cystic fibrosis
A child with arm fracture an cystic fibrosis
(2 of 3 risk include opiate naive and pulmonary disease)
A 58-year-old man is evaluated for postherpetic neuralgia. Three months ago, he developed herpes zoster involving the left posterior thorax in a T7 distribution. He was treated with antiviral therapy, and the lesions healed; however, he has persistent severe burning pain. He also has severe chronic obstructive pulmonary disease treated with fluticasone furoate-umeclidinium-vilanterol combination inhaler.
Which of the following is the most appropriate treatment?
Duloxetine
Gabapentin
Oxycodone
Prednisone
Duloxetine
A 72-year-old woman is evaluated for oral pain. Five years ago, she underwent treatment for squamous cell carcinoma in the oral cavity; she now shows no evidence of cancer. Her treatment course was complicated by radiation-induced osteonecrosis of the jaw. Medical history also includes hypertension and anxiety. Medications are amlodipine, chlorthalidone, immediate-release morphine (20 mg daily), bupropion, and lorazepam.
Which of the following poses the greatest risk for overdose and death in this patient?
Amlodipine coadministration
Bupropion coadministration
Lorazepam coadministration
Morphine total dose
Short-acting morphine formulation
lorazepam
Worsening pain with opioid dosage escalation
Opioid-induced hyperalgesia
Using the definitions below, choose the most appropriate to define the term "physical dependence".
"A state of adaptation that is manifested by a drug class specific withdrawal symdrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist."
"A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time."
"A primary, chronic, neurobiologic disease, with genetic, psycho-social and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despire harm and craving."
1sst option
Name THREE different nonpharmacological interventions.
• Distraction • Heat/Cold • Massage • Relaxation/ Imagery • Pastoral Consult • Exercise • Immobilization • TENS • Acupuncture • Hydrotherapy • OT/PT consult