Difficult Situations
You have an elderly patient admitted for a hip fracture. They have a history of dementia and are unable to rate their pain. Name at least 3 non-verbal signs of pain that you might see in this patient.
1. Grimacing
2. Rapid blinking
3. Restlessness
4. Labored breathing
5. Decreased mobility (not wanting to move)
Which vital sign (other than pain score) is a mandatory requirement as part of a pain reassessment.
What is respiratory rate?
What anesthetic medication was used in our spine epidurals? Hint: It's the medication that can cause LAST.
Bupivacaine
This is where we can see the information to double check the medication order and the programming on the IV pump.
What is the MAR?
An extra dose of medication, programmed into the pump.
Bolus dose
A recently admitted patient with a history of chronic back pain begins reporting pain disproportionate to their injury, requests specific opioids by name, and resists all non-opioid alternatives, complicating our pain management strategies. What behavior may we suspect in this case based on the above symptoms?
Drug-seeking behavior
You give a dose of IV morphine to a patient and chart a full pain assessment at that time. When should you perform and chart your reassessment?
Within 60 minutes of administration.
What is the most common side effect of an epidural?
Hypotension
An initial dose of medication, programmed into the pump.
Loading dose
What are the 3 most common opioids used for a PCA?
1. Morphine
2. Fentanyl
3. Dilaudid
A total joint patient has been taking 10mg oxyIR q4h per the MD's order. They state that they feel like they need something more often because it wears off too quickly. They also have hydrocodone q4h PRN and IV dilaudid q3h PRN. What is your next course of action?
First, have a conversation with the patient to educate them on safe opioid use. Second, may switch to hydrocodone the next time oxy is available to see if it works better. Utilize the IV dilaudid. Do not alternate oral opioids. Utilize our non-narcotic and non-medication options as well.
At a minimum, when should a pain assessment be completed (2 answers)?
1. With vitals
2. With any pain medication administration
When assessing your patient, you notice that the infusion tubing has come disconnected from the epidural tubing. What immediate action do we take at this point?
Stop the pump and cap the epidural tubing with a non-alcohol cap.
What are two types of monitoring that a patient needs when utilizing a PCA.
1. End tidal carbon dioxide (ETCO2).
2. Continuous pulse oximetry.
When should we verify our settings, clear the pump, and document our totals? (3 answers)
1. At shift change with the oncoming nurse
2. When discontinuing the PCA
3. When transferring the patient to another unit
An elderly patient post-hip replacement appears confused and restless, with elevated pain scores. This nursing intervention addresses both pain and potential delirium.
Implementing delirium precaution interventions. Evaluating for pain misinterpretation and adjusting the environment to reduce sensory overload.
You have a patient on a PCA. At what 3 times should we be performing a pain assessment/reassessment?
1. With vital signs.
2. With titration/ a bolus dose.
3. When weaning.
Following spine surgery, a patient is receiving an epidural infusion. Name at least 2 complications that we want to watch for.
What is:
1. LAST
2. Catheter migration/disconnect
3. Epidural hematoma (N/T below spinal level, diffuse back pain, decrease in motor function, new bowel/bladder dysfunction).
4. Infection at insertion site
5. Post dural puncture headache
Name at least 3 things that we want to assess for with each interaction with a patient on a PCA.
1. RR
2. LOC
3. Pain level
4. Overall safety (lines tangled?, fall precautions in place?, IV button within reach and IV brain plugged in?).
This parameter is intended to prevent the patient from receiving too much medication in too short of a period of time.
Lockout interval
Following total knee replacement, this nursing intervention becomes critical when the patient reports severe pain unrelieved by PCA and oral opioids, refuses physical therapy, and shows signs of anxiety and muscle guarding.
What is initiating a comprehensive pain plan and collaborating with the interdisciplinary team for multimodal pain management?
There are 12 flowsheet rows to chart on when completing a FULL pain assessment. Name at least 6 of them.
1. Assessment type
2. If patient is currently in pain
3. Pain scale type
4. Pain score
5. Pain goal
6. Pain location
7. Pain onset
8. Pain description
9. Pain duration
10. Respiratory character
11. LOC
12. Intervention(s)
Name the 3 early symptoms of LAST that we watch for and what we do if we notice them.
1. Tingling around the mouth, metallic taste, tinnitus
2. Stop the infusion, call a RAT, and have a peer call pharmacy to obtain a LAST kit if not already in our Omnicell
When clearing the pump at the end of your shift, you notice that the number of demand doses is significantly greater than the number of delivered doses. What should your course of action be based on this information?
Assess the patient (what has their pain score/vitals/LOC looked like throughout the shift?).
Page the provider for an increased dose or a different medication.
Have we tried bolus doses or additional orals?
How about any non-narcotic options?
When caring for a post-operative patient using PCA with morphine, these 2 subtle but critical nursing assessments may indicate early opioid-induced respiratory depression—even before oxygen saturation drops.
What is decreasing RR and increasing sedation score (POSS)?