Download Pain Management For The Inpatient: Part I Jassin M. Jouria, MD Dr

Pain Management
For The Inpatient:
Part I
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and medical
author. He graduated from Ross University
School of Medicine and has completed his clinical clerkship training in various teaching
hospitals throughout New York, including King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and
has served as a test prep tutor and instructor for Kaplan. He has developed several medical
courses and curricula for a variety of educational institutions. Dr. Jouria has also served on
multiple levels in the academic field including faculty member and Department Chair. Dr.
Jouria continues to serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine. Recently,
Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
Abstract
Pain is an individualized concept that requires an equally individualized
solution. Every patient feels and responds to pain differently, and it is critical
that pain management strategies for inpatients be tailored to each specific
patient in order to provide adequate pain relief. A variety of analgesics and
alternative treatments are available to assist with pain management, and
nurses need to be familiar with these solutions for their patients’ benefit.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
Every person experiences pain differently. Nurses in the inpatient setting are
required to evaluate pain on an individual basis to determine the type of
medication and other therapies needed.
Course Purpose
To provide nursing professionals with knowledge of pain in the inpatient
setting, varied pain assessment tools and treatments.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 7/14/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Which is an example of traumatic neuropathic pain?
a. Compartment syndrome
b. Diabetic neuropathy
c. Varicella zoster virus
d. Phantom limb pain
2. Which of the following is a true statement regarding pain
assessment?
a. Most patients overemphasize how much pain they are having.
b. Pain should be reassessed 5 minutes after providing pain
management measures.
c. Pain assessment is universally accepted as the “5th vital sign.”
d. The patient’s history, culture, and personality should all be included
as part of the pain assessment.
3. Which of the following is an example of a full agonist opioid?
a. Morphine
b. Buprenex
c. Elavil
d. Nubain
4. All of the following are common medications used with patientcontrolled analgesia except:
a. hydromorphone.
b. morphine.
c. codeine.
d. fentanyl.
5. Mind-body therapies for pain control include:
a. transcutaneous electrical nerve stimulation.
b. massage.
c. distraction.
d. acupressure.
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Introduction
Pain is a personal, subjective experience that can only be described by the
person experiencing it. There is no physical method of measuring the quality
or intensity of pain; rather, the patient who is in pain is the only person who
can say how much something hurts. Pain is “whatever the experiencing
person says it is, existing whenever he or she says it does.”10 Nurses must
rely on the patient’s description of pain, as well as the patient’s report of the
success of pain relief measures. While it is the nurse’s responsibility to
provide pain relief for the inpatient experiencing pain, the patient is the only
one who must endure the situation that is causing pain, and is the one who
relies on the nurse to help manage his or her pain.
Types Of Pain
Pain differs for each person who is experiencing it. A specific type of pain
may only be a small amount of discomfort for one person, while pain in the
same location or from the same type of injury may be quite severe for
another patient. Pain may also be divided into acute and chronic types of
pain. The kind of pain the patient is experiencing affects assessment of the
patient’s condition and impacts pain treatment.
Acute pain occurs for a shorter duration and is classified as occurring for six
months or less. Acute pain may also only last for a few seconds or minutes
before resolving. Acute pain may be severe when the pain begins but often
resolves with time and treatment.4 Acute pain causes a stress response in
the affected person, such as an increased heart rate and rapid breathing, but
this response typically ends when the pain is resolved and the tissue has
healed.5 Examples of situations where a patient may experience acute pain
include surgery, burns, or cuts to the skin.
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Chronic pain differs from acute pain in that it can last for a much longer
period of time, yet it may not be any more tolerable than acute pain
sensations. Chronic pain lasts for longer than six months, and if an injury
has caused the initial pain, the discomfort continues even after the initial
injury or condition has been treated.4 Chronic pain does not elicit a stress
response from the affected person because over time, the patient becomes
more accustomed to the pain. A patient may be admitted for treatment that
causes acute pain, yet already be suffering from chronic pain as well. A
patient may develop a physiologic stress response to the acute pain from
procedures or surgery, however, as the body’s response to chronic pain is
continuous and he or she may have adapted to it. Over time, chronic pain
can be very debilitating, resulting in other complications such as depression,
irritability, and difficulties with sleeping.5 Examples of conditions that may
result in chronic pain include pain from autoimmune disorders such as
arthritis, cancer pain, or low back pain.
Neuropathic Pain
Neuropathic pain occurs when a person experiences pain related to changes
in nerve fibers, usually resulting from a type of injury or disease process.
The person who experiences neuropathic pain may have no obvious injury,
but still has pain because of how his nerves impact the rest of his body.
Neuropathic pain causes damage to the nerve fibers, which continue to send
messages to pain centers throughout the body.1 Neuropathic pain may also
develop if the pain centers of the brain are damaged and do not receive
messages correctly.4
Neuropathic pain may be classified into different categories, depending on
whether co-existing conditions are present as well as how the pain has
developed. Traumatic neuropathic pain occurs when the nerves have been
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injured as a result of some type of traumatic event. The injured nerves
continue to send incorrect pain signals to the brain, whether the injury to
the body healed or not. An example of traumatic neuropathic pain is
phantom limb pain, in which a person who has had an amputated limb
continues to feel pain in the missing extremity.2
Metabolic neuropathic pain occurs when a person experiences sensory pain
as a result of complex medical disorders that affect the metabolic system,
such as malnutrition or diabetes.2 One of the most common conditions
causing metabolic neuropathic pain is diabetic neuropathy. The patient with
diabetes may suffer from nerve damage as a result of uncontrolled blood
glucose levels, resulting in pain, numbness, burning, or tingling in the distal
extremities.
Infectious neuropathic pain develops from an infection in the body that
causes nerve damage and subsequently, chronic pain that may be constant
or intermittent. Examples of infections that can cause neuropathic pain
include post-herpetic neuralgia, caused by varicella zoster virus that causes
chickenpox and shingles; infection with Lyme disease or HIV, and GuillainBarré syndrome, which causes pain, weakness, and paralysis when it
develops after a viral infection.2
Autoimmune pain develops as a result of injury to the nerves from certain
autoimmune disorders that attack the body’s own cells. Chronic
inflammatory demyelinating polyneuropathy occurs when the myelin sheath
over the nerves becomes damaged, resulting in pain in the extremities.
Compressive pain is another type of neuropathic pain that results in physical
damage to the nerves as a result of stretching, pinching, or squeezing of the
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nerve fibers. Examples of this type of pain include carpal tunnel syndrome
and compartment syndrome.2
Toxic causes of neuropathic pain result in damaged nerves due to exposure
of toxic substances. Chemicals such as lead, mercury, arsenic, thallium,
lithium, chemotherapy drugs; antibiotics, such as isoniazid and
metronidazole; and some cardiovascular medications, including captopril and
amiodarone can all cause neuropathic pain with exposure.3
Somatic Pain
Nociceptive pain occurs as a response to stimuli that are perceived by the
body as being painful. This type of pain stimulates the nociceptors in the
body, which are nerves that transmit signals in response to harmful or
noxious stimuli in the environment. Nociceptive pain is categorized as being
somatic pain or visceral pain.10
Somatic pain develops when the nerves send pain messages to the brain
because of cell injury to body areas containing connective tissue. Somatic
pain is pain that occurs in areas such as the bones, joints, muscles, or the
skin. It may be further classified as cutaneous somatic pain and deep
somatic pain.
Cutaneous pain often develops in superficial tissues and is less traumatic to
the body. It may be described as sharp or burning when the patient explains
it. Examples of injuries that can cause cutaneous somatic pain include skin
abrasions or lacerations. Deep somatic pain is often caused by trauma to
deeper tissues in the body, such as the bones or muscles; it may be caused
by trauma and the pain is usually much more intense. Examples of injuries
that can cause deeper somatic pain include broken bones or torn ligaments.4
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Visceral Pain
Visceral pain occurs as pain affecting internal organs and tissues, such as
the heart, gastrointestinal system, or the kidneys.4 A person feels visceral
pain when nociceptive pain receptors in the organs respond to painful
stimuli.10 The pain may develop through part of a disease process, which
results in cramping or tissue spasms, or in ischemia development at the site.
Visceral pain may also occur as a result of injury, or through some type of
medical procedure, during which the organs and tissues are moved,
stretched, or manipulated, resulting in pain.9
Visceral pain may be difficult to localize and the pain may be initiated at one
point in the body but may radiate to another area of the body. When the
pain radiates, it may be difficult to determine the initial location of the pain
and whether an injury has occurred. Visceral pain is sometimes described as
cramping, squeezing, or a feeling of pressure.7 The intensity of the pain may
also vary, from mild and intermittent discomfort, to severe and agonizing
pain. Often, the person experiencing visceral pain may also suffer from a
feeling of doom or dread, wondering if the pain is a sign of something larger
that is life threatening.9 Because visceral pain is internal, it is difficult to see
the cause of the discomfort, which can be disturbing and frightening for the
affected patient.
Assessing Pain
Assessing the patient for pain is important for not only understanding how
much pain he is having and how to treat that pain, but it is also essential for
understanding how to care for the whole person. A patient in pain may also
have other complications and issues that need to be managed as part of his
or her care, such as difficulties with eating, problems with concentration, or
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impaired mobility. The patient taking pain medications may develop
constipation. The location and the source of the pain can significantly impact
a patient’s abilities to perform tasks, such as activities of daily living.5 Pain
assessment is one aspect of assessing the patient’s total needs, including
physical, psychological, and emotional matters that may develop when
receiving care as an inpatient.
Some locations refer to pain assessment as the “5th vital sign,” naming it in
this method to state that assessing and responding to pain should be as
important as assessing blood pressure, heart rate, and other vital signs.
Some experts disagree about pain being the 5th vital sign, instead indicating
that other measures, such as oxygen saturations, should be in this position
instead. Regardless, pain assessment is crucial enough for the patient’s well
being that it should be given the same priority as other assessment tools,
such as assessment of vital signs.10
Pain assessment should occur at regular intervals in order to ensure that
adequate pain management is taking place. Pain should be assessed at
regular times during a nursing shift, such as during vital sign assessment.
Additionally, the patient’s pain should be assessed upon admission to the
facility or the unit, any time a procedure is performed that may produce
pain, whenever the patient reports changes in sensation or an increase in
pain, and 15 to 30 minutes after providing analgesia or adjuvant therapy to
determine its effectiveness.7
Many patients will not voice their pain, despite its presence and severity.
Some people do not want to be labeled as complaining, or they feel that
nurses are too busy to take time out to provide more medication or therapy
for pain. They may believe that pain is a normal part of hospitalization and
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may not feel the need to vocalize it. There are people who feel that
expressing pain is too personal and they do not wish to share that part of
themselves, preferring to remain stoic. Finally, some patients do not notify
their nurses that they are having pain because they fear what the outcome
might be, such as potentially negative side effects of receiving narcotic
medications or possibly needing further tests.10 Because there are so many
reasons why patients may not talk about their pain, it is the nurse’s duty to
assess pain and ask the patient if he or she is experiencing discomfort so
that it can be managed.
How a patient perceives pain is affected by several factors that are particular
for each individual. A patient’s level of pain tolerance, cultural background,
expectations for pain management, and previous experiences with pain all
impact the patient’s responses to a current situation. These factors should
also be recognized as part of the pain assessment process because they
impact pain response.5 Two of the most common causes of unrelieved pain
among patients are inadequate pain assessment measures and failure to act
on patient reports of pain.
Adequate pain assessment involves determining the location, intensity, and
duration of the patient’s pain, relying on the patient’s use of words or
descriptions of discomfort felt. Providing adequate pain control then means
acting on how the patient has expressed pain to the nurse in order to
provide pain relief, as well as evaluating the effectiveness of therapy to
determine its success or whether further measures are necessary.6
Location
The location of the pain is described as where the patient is experiencing it.
This may or may not be the actual site of injury or illness that is causing the
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pain. If the patient is experiencing pain that is radiating, he or she may feel
it at the source of the pain, as well as in the surrounding tissues. When a
patient experiences an injury such as an arm fracture, he or she may feel
pain at the site of the fracture, but may also have pain through the length of
the arm, near the site of the break. Alternatively, referred pain occurs when
the source of the pain is in one part of the body, but the patient feels pain in
a completely different area.10 An example of referred pain may be when a
patient is having a heart attack but is not having chest pain; instead, he or
she only feels pain along the jaw. Referred pain most commonly occurs in
situations where a patient is experiencing visceral pain.
To determine where the patient is feeling pain, the nurse should ask the
patient to point to the place where it hurts, rather than only trying to
describe the area or region. A body diagram may also be useful for some
patients to point to affected areas in the picture and can be particularly
helpful if a patient is experiencing pain in more than one location.10 If the
patient has an injury that is apparent, such as a wound or contusion at a
specific site on the body, it would seem logical that this point is the location
of the patient’s pain. Despite having an obvious injury, the patient needs to
be the person to state where the pain is located. There may be more than
one location of pain, which could indicate another injury, or the patient may
be feeling pain associated with a different condition that is unrelated to the
obvious injury.
Duration
Duration refers to how long the patient has been experiencing the pain. It
may also explain if there are any factors that caused the pain. Knowing if
there are any precipitating factors can give the nurse a better idea of the
overall duration of the pain. A patient may have been participating in certain
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activities that initially caused the pain; for example, he or she might have
been jogging to get some exercise and then developed chest pain. If the
patient jogs every morning, the clinician has a better idea of when the pain
started for the patient.
The patient may also know the specific time of when the pain started or be
able to tell the nurse exactly how long it has occurred. A description of pain
duration also includes whether the pain is constant or intermittent; if
intermittent, the patient should try to describe the intervals, such as the
length of time between episodes of pain. If the patient is currently between
pain intervals, he or she will need to explain how long it has been since a
painful episode occurred.10
Description
The nurse must pay careful attention to the type of words the patient uses
to describe pain. At times, it may be difficult for the patient to come up with
the words or appropriate description to explain the type, intensity, or
location of pain. There are some tools available that the nurse may use to
help the patient come up with the right words to describe the pain felt.
The OLD CARTS mnemonic can be used to help a patient to describe the
location and intensity of his or her pain. The mnemonic is used as:8

Onset: when did the pain start or how long has it been going on?

Localized: where is the pain?

Description: explain how the pain feels: burning, aching, sharp,
stabbing, throbbing

Characteristics: describe the pain’s intensity

Aggravating: is there anything that makes the pain worse?
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
Relief: what factors would improve the pain or provide pain relief?
What treatments have been done for the pain?

Time: how long have you had the pain and has it been constant or
intermittent?

Symptoms: has the pain had an impact on any other of your daily
activities, such as eating, sleeping, or mood?
A simpler method of describing pain intensity would be to ask the patient if
he or she is having pain and if the pain could be described as mild,
moderate, or severe. This pain assessment tool may need to be used in
conjunction with assessment of nonverbal symptoms that indicate pain
severity. In addition to using words to describe the pain, the patient may
also exhibit other non-verbal behaviors that indicate his discomfort.
Activities such as fidgeting or squirming, grimacing, crying, or guarding
painful sites are all indications that the patient may be experiencing pain.
Pain can also cause sleep disturbances, decreased self-esteem, diminished
social interactions, irritability, a lack of interest in eating, and confusion or
impaired thinking.4
In addition to assessing pain severity, location, and duration, part of the
pain assessment process is asking the patient what he or she understands
about the pain felt.10 A patient may be completely aware of why he or she is
having pain and understands the reasons for its existence; for example, a
patient who had surgery and who has pain at the surgical incision site may
completely understand the logic for why he or she is feeling pain in that
location.
Alternatively, some patients may not understand why they are having pain.
They may believe that they are experiencing pain because they did
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something wrong, or, if they have referred pain, they may not understand
why the pain is not located at the source of the injury or illness. Asking a
patient what is known about his or her pain provides an opportunity for
education about how the body processes injuries or illness and may better
explain why some procedures or treatments are necessary.
Numerical Rating Scale
The numerical rating scale is one of the most commonly used methods for
assessing a patient’s pain. Because pain cannot be objectively measured but
instead relies on the patient’s own admission of pain level, this type of scale
can adequately explain the level of intensity the patient is experiencing in a
method that is easy to understand.
The numerical rating scale is appropriate to use for most adult inpatients
who are cognitively aware and who are awake to be able to respond. The
numerical rating scale asks the patient to rate pain on a scale of 0 to 10. A
score of 0 means the patient has no pain, while a score of 10 is the worst
pain imaginable. The patient gives a number somewhere on the scale to
describe his or her current level of pain.7
Some facilities assess a patient’s pain tolerance upon admission to the
facility by explaining the numeric rating scale and asking not only what the
patient’s current level of pain is, but also what number would be an
acceptable level of discomfort. For example, a patient may rate pain felt at a
‘7’ on the numeric rating scale, but may also say that the pain can be
tolerated that would be rated at a ‘2.’ For this patient, a level of pain
described as a ‘2’ may be quite tolerable, while some other patients may
tolerate pain classified as a ‘6’ and others may only be comfortable at a level
of ‘0.’ Understanding the patient’s tolerable level of pain can guide clinicians
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to knowing whether pain management measures are working and whether
the nurse is keeping the patient comfortable.
Assessing Children Using FACES Rating Scale
Other assessment measures are available for some patients who cannot
speak but who are cognitively aware. The Wong-Baker FACES pain rating
scale has a series of faces with different expressions that may explain how
much pain a person is having. At one end of the scale, the equivalent of a ‘0’
on the numeric rating scale, the face is smiling and appears happy,
indicating no pain. Moving down the scale, the expressions of the faces
become progressively sadder or appear to be having more pain. At the
opposite end of the scale in the position of a ‘10’ on the numeric rating
scale, the face is crying and appears to be in significant pain. The patient
who cannot talk can use this type of scale to point to which face most closely
resembles the level of his or her pain. The Wong-Baker FACES scale may
also be used for children ages 3 and older.
Pain may be difficult to assess among patients who are cognitively impaired
and who have difficulty expressing their level of pain on a numerical scale.
During these situations, it is important to assess for visual signs of pain in
the patient and provide pain relief measures if the patient is showing
nonverbal cues that indicate pain, such as fidgeting, grimacing, crying,
moaning, being aggressive or disruptive, rocking, or pacing. Additionally,
physiological changes may also be present, even if the patient is unable to
state that he or she is in pain. Signs include an increased heart rate,
increased respiratory rate, increased blood pressure, dilated pupils, or
sweating.8
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When assessing a very young child or infant who cannot describe his or her
pain, the nurse must use another form of pain assessment technique. There
are several types that have been developed for use in this population, when
giving a numeric score is not possible. Examples include the CRIES scale
(crying, requires oxygen, increased vital signs, expression, sleepless), the
Neonatal Facial Coding System (NFCS) or the Child Facial Coding System
(CFCS), and the FLACC (faces, legs, activity, cry, consolability) score.8
Beyond performing adequate pain assessments, it is important to provide
appropriate treatment based on what the patient says his or her pain level
is. It is not enough just to assess and document the patient’s pain;
treatment through medications and adjuvant therapies, based on the
patient’s reports of pain and provided at levels that are appropriate for
treating the amount of pain present are essential components of nursing
care to provide for pain relief.6
Pharmacotherapy
The concept of pain management means providing treatment for a patient’s
pain in order to eliminate the pain or reduce it to a level that is tolerable.10
In many inpatient situations, this is accomplished through the use of
pharmacotherapy. While the physician is the person to prescribe what
medications to give for pain relief as well as a schedule for when to give
them, the nurse must use clinical judgment to determine whether a type of
pain medication is effective or if it is causing adverse effects. In some cases
when a medication is to be given as needed instead of on a set schedule, the
nurse must use judgment about the appropriate times to give the
medication, as well as when to hold back from giving it, depending on the
patient’s condition.
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Opioids
Opioids are medications given to provide pain relief by binding to certain
receptors in the spinal cord, which then blocks the perception of pain in the
brain. Opiates may be made of natural substances or they may be synthetic.
Opiates are not the same as narcotics, although the two terms may be used
interchangeably. Opioid medications are used specifically for pain control
because of their action, while narcotics may be used for other purposes
beyond pain relief.10
As nurses administer opioid medications for pain relief among patients, they
must understand the fine balance between providing enough to manage pain
while avoiding potential side effects of too much medication. In order to
provide safe care, the nurse must understand the power of opioids and give
enough to control pain while minimizing negative effects, such as sedation,
respiratory depression, or confusion, that may develop with these drugs.
Among hospitalized patients, opioid medications are the most common types
of drugs given to control pain.18
Opioid analgesics are powerful pain relievers that are often used for patients
who are suffering from significant pain. There are three types of opioids:
agonists, agonist-antagonists, and partial agonists. Full agonists work in a
manner similar to endorphins in the body, and increasing amounts of these
drugs continue to increase pain control and sedation levels. Examples of full
agonist opioid drugs include morphine, codeine, and hydromorphone.10
Agonist-antagonist analgesic medications work by blocking some nerve
receptor sites while stimulating other nerve receptor sites. If a patient is
already taking an opioid analgesic, an agonist-antagonist medication may
reduce its effectiveness. However, these drugs can be very effective for use
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without other opioid medications in place. They do have a ceiling effect in
that giving higher or more frequent doses will not necessarily continue to
produce more pain relief. Examples of agonist-antagonist medications
include butorphanol tartrate (Stadol®) and nalbuphine hydrochloride
(Nubain®).10
Partial agonist medications, like agonist-antagonist medications, have a
ceiling effect and so their use is limited. However, these drugs may be used
when other opioid medications are not available or in cases when a patient is
unable to take other kinds of medications for pain relief. Partial agonist
medications work by blocking certain nerve receptor sites while binding to
others. An example of this medication is buprenorphrine (Buprenex®).10
There are several methods of delivery of opioid medications; and, the
selection of which method to administer is based on the patient’s condition
and the ease of taking the medication. The oral route is preferable among
patients who must take opioid medications on a long-term basis. It is the
easiest and cheapest method of administration and can be used among
patients who are conscious, have the ability to swallow, and who do not
have gastrointestinal issues that would preclude its action.20
Some patients who cannot take medication by mouth may receive drugs
through the rectal route. Both morphine and hydromorphone are available
as rectal suppositories. Not all patients tolerate this route, and it is not
usually considered as a first choice for most people. It should also not be
used among patients who have diarrhea or those with breakdown in or
around the anus and rectum. However, rectal administration of medications
can be effective for other patients who have limited alternative routes for
taking medication and the drugs are usually absorbed relatively quickly
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through the intestinal mucosa. Fentanyl is available in the transdermal form;
this method involves placing a patch on the skin and the medication is slowly
absorbed. It can provide analgesia for up to 72 hours but it may take several
hours before effective analgesia levels are achieved.20
Other methods of administration of opioid medications that are more
invasive include subcutaneous, intramuscular, intravenous, and intraspinal.
Subcutaneous administration involves injecting the medication with a needle
into the subcutaneous fat under the surface of the skin. The injection can
only be given in certain locations, such as the abdomen or upper arm, where
the patient is more likely to have fatty tissue present, as compared to other
areas. The intramuscular route also involves injecting medication into the
patient, but the needle must be longer and the injection goes much deeper
into muscular tissue. Common areas used are the deltoid muscle of the
upper arm and the ventrogluteal muscle of the hip. Because this method of
administration can be quite painful for the patient, it is often avoided in
favor of other routes.20
Intravenous (IV) administration involves injecting medication directly into a
patient’s vein. The patient must first have an IV line in place. This route can
be quick and effective and can be used on patients who would otherwise
have difficulty taking medications in other methods, including patients who
are unconscious. The intraspinal method of administration involves injecting
medication into a catheter that has been placed in the epidural space of the
spine. This method may be used for patients who need long-term analgesia
and as an alternative to other routes.20
Patient-controlled analgesia (PCA) is a process that was developed to allow a
patient to have more control over pain by administering his or her own
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doses of medication through a machine. The patient has an intravenous line
for fluids and medication administration and is connected to the PCA
machine. The machine contains a syringe with the prescribed medication in
it, which is set to deliver a specific amount of medication to the patient when
a button is pushed. Some settings offer a basal or continuous dose and the
patient can supplement the pain medicine when the need for more pain relief
occurs. Other situations the PCA is set up to give occasional doses of pain
medicine when the patient needs pain relief.
A PCA machine can reduce the need for the patient to depend on the nurse
for bringing pain medicine. At times, it may be difficult to answer call lights
and to bring medication in a timely manner, before pain becomes out of
control for the patient. With PCA, the patient can push a button to deliver
pain medicine when pain is felt, potentially stopping it before it worsens. The
machine is set to deliver only a certain amount per hour so that the patient
does not receive too much. It will lock out so that even if the patient
continues to push the button, he or she will not receive any more
medication. This safety feature prevents accidental overdosing of opioid
medications. Additionally, patients typically use PCA for themselves, without
someone else pushing the button for them. The safety in this feature is that
if the patient becomes sedated after receiving a bolus of medication, he or
she will not be able to receive more. The most common medications used
with PCA include morphine, fentanyl, and hydromorphone.19
The nurse is typically responsible for setting up the PCA and changing the
medication syringe when it becomes empty. Use of the PCA does not
eliminate the need for continued assessment and patient monitoring. The
nurse must still assess the patient’s level of pain to determine if the PCA is
providing adequate pain relief. If the nurse sets up the PCA, he or she
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should check the settings with another nurse to determine that they are
correct and to avoid accidentally giving the patient too much opioid
medication.
Non-opioids
Non-opioid analgesics are drugs that are typically used for mild to moderate
pain relief. These medications may be provided for patients by prescription
when in the hospital; they may also be bought over the counter. There is a
ceiling as to how much analgesia these medications can provide, so giving
more or repeating doses in an effort to increase comfort may not be
effective or safe.20
Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications such as
ibuprofen or aspirin. These drugs provide mild to moderate pain relief, they
reduce inflammation, and they can help to control high fever. Patients who
take these drugs may be at higher risk of bleeding, as they can have an
anticoagulant effect. Other side effects of NSAID use are gastrointestinal
irritation or bleeding and acute renal failure.20 NSAIDs work by blocking an
enzyme known as cyclooxygenase (COX), which is needed for creating
prostaglandins, the substances in the body that set off pain signals.
Cyclooxygenase may be classified as COX-1 or COX-2, and different
medications inhibit the different types. For example, aspirin and ibuprofen
are COX-1 inhibitors, while celecoxib (Celebrex®) is a COX-2 inhibitor.10
Acetaminophen is another non-opioid analgesic that is effective for reducing
mild to moderate pain and as a fever reducer. Tylenol® is an example of this
type of medication. Acetaminophen does not have anti-inflammatory effects,
but it also does not have the same type of adverse side effects that are
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found with NSAIDs, such as an anticoagulant effect or gastrointestinal
bleeding.20
Adjuvants
Other medications may be combined with analgesics to provide more
effective pain control. Adjuvant medications, also called coanalgesics, are
those that are not designed for analgesia and when used alone, have other
purposes. However, when combined with opioid or non-opioid analgesics,
there can be a greater effect on pain relief.10 The World Health Organization
(WHO) has designed a pain control ladder to guide clinicians toward
choosing and administering medications for pain relief. The WHO
recommends combining medications such as adjuvants and opioid analgesics
to provide more effective relief than when using only one type of analgesic
at a time. Therefore, if possible, the patient can derive better pain relief
when the nurse administers medications in combination.21
Antidepressants may be used in combination with analgesics for better pain
control. Tricyclic antidepressants can affect how the body perceives pain by
interfering with the reuptake of the neurotransmitters serotonin and
norepinephrine in the brain. An example of a tricyclic antidepressant that
may be used as a coanalgesic is amitriptyline (Elavil®).10
Medications normally used as anticonvulsants may also be beneficial as
coanalgesics. Anticonvulsants may work well as adjuvant therapy because
they suppress neuron firing for seizure control, which may also be helpful for
some types of pain, particularly neuropathic pain. Examples of these types
of drugs include gabapentin and carbamazepine.25
Other drugs may also be used as adjuvant therapy in addition to analgesics
because their effects can reduce or eliminate other symptoms that are
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commonly associated with pain. Corticosteroids may be administered with
analgesics to reduce swelling or inflammation that can develop and cause
pain in some conditions. Benzodiazepines, normally prescribed to manage
anxiety, depression, or insomnia, may also be given as part of pain
management. When combined with analgesics, benzodiazepines can help to
reduce muscle spasms and improve release of tension that may accompany
pain.25
Epidural Analgesia
Epidural analgesia involves administering medications for pain control into a
catheter that has been placed in the epidural space in the spinal column. The
epidural space lies between the meninges covering the spinal cord and the
walls of the vertebral canal. The space contains spinal nerves, as well as
blood vessels and adipose tissue. When it is cannulated and medication is
administered, pain control can be achieved because the medication can
quickly impact pain receptors in the nerves of the spinal cord, blocking pain
messages to the brain.
In some situations, a patient receives medication that also causes parts of
the body to become numb, in a process known as epidural anesthesia.
Epidural anesthesia is often provided for patients undergoing surgical
procedures, so that they can stay awake during the procedure but not
encounter pain; for instance, this process is frequently used during cesarean
sections. Providing analgesia through an epidural differs in that medications
are used for pain control but not necessarily to eliminate sensation
entirely.16
A physician or anesthesiologist must place the epidural catheter, but when it
is an indwelling catheter, the nurse is typically responsible for caring for the
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patient while the catheter is in place. The medication may be provided
through a continuous infusion, through a bolus injection, or through a
patient-controlled module.16 Epidural analgesia can be used in many
different kinds of situations to manage pain, such as during or immediately
following surgery, after treatment for traumatic injuries, and to manage
chronic pain, such as among patients who have ongoing cancer-related pain,
back pain, or severe osteoporosis.17
An epidural catheter may be placed at various points along the spinal
column. The tip of the catheter can be positioned to affect specific nerves
along the spinal cord, each of which affects different areas of the body.
There is a risk of placing the catheter in a position that can block certain
nerves that will ultimately result in patient complications; for instance,
placing an epidural catheter too close to nerves that affect motor activity can
result in problems with muscle function or paralysis for the patient.16
Although it is the physician’s job to insert the epidural catheter and ensure
that it is in the correct place, the nurse may either assist the physician with
catheter placement or may care for the patient after the epidural is in
position. During the placement procedure, the nurse is responsible to assist
the physician and monitor the patient; and, if the patient has an adverse
reaction because of nerve stimulation, the nurse must act quickly to respond
and provide care. Additionally, when caring for a patient who has an
indwelling epidural catheter, the nurse must be aware of the potential risks
and complications of this placement as her or she makes decisions for
providing patient care, such as by moving the patient or providing help
during ambulation.
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The most common opioid medications used for pain relief through epidural
analgesia are fentanyl, morphine, and hydromorphone. The type and
amount of analgesia given depend on the patient’s condition and needs for
pain relief. Some analgesics, such as fentanyl, have a rapid onset and
provide pain relief quickly for the patient, but may also wear off quickly.
Alternatively, a medication such as morphine may be given through an
epidural catheter and can take longer to start working, but its effects for
pain relief may last much longer.16
When caring for a patient who has an epidural for pain control, the nurse
must perform regular checks of vital signs, including frequent blood pressure
readings, as hypotension is a potential side effect of using this type of
treatment. The nurse should also ensure that the patient is receiving
adequate pain control. The physician may prescribe other analgesics to be
administered as needed in addition to the medication provided through the
epidural. Other nursing considerations that are part of caring for a patient
with an epidural are to monitor the insertion site to ensure patency. The
epidural catheter is typically covered with a dressing, taped, and secured
very well to the patient’s skin on the back. However, the nurse should check
the site as a regular part of assessment to ensure that it has not become
dislodged or moved in any way. The nurse should also determine if there are
any local reactions at the site, such as redness, swelling, or rash.
Side effects of epidural analgesia are often associated with the catheter’s
effect on specific nerves, or are local reactions to having the catheter in
place in the body. With an epidural, the patient is at higher risk of vital sign
changes such as bradycardia, hypotension, and respiratory depression.
Opioid medications administered through the epidural may cause side effects
such as nausea and vomiting. Patients often complain of widespread itching,
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and a rash may or may not develop. Finally, epidural placement puts the
patient at risk of a postdural headache, which is severe head pain associated
with leakage of fluid around the dura when the space is cannulated during
placement. Often, the pain is relieved when the patient lies down and
worsens when sitting or standing upright. The nurse must be aware of the
potential complications associated with epidural analgesia and work to
manage these effects if they do occur, such as by providing medication to
control undesirable side effects, monitoring vital signs and managing
negative changes, or assisting the physician with correcting complications.17
Nerve Block
A nerve block is a pain control measure that involves injecting medication
into a specific nerve in order to numb a certain part of the body.11 The nerve
block is performed prior to a procedure or treatment to cause the area to
become numb enough that the patient does not feel pain associated with
treatment or for a period of time afterward. Anesthesia providers typically
administer nerve blocks, but nurses are often responsible for caring for the
patients with the blocks to ensure adequate pain relief.
To place a nerve block, the anesthesia provider first locates the main nerve
associated with the injury or affected area. For example, if a patient is
having surgery on his forearm, the anesthesia provider locates the main
nerve affiliated with the area, which is often the brachial plexus nerve.12 To
find the correct location of the nerve, the clinician uses an ultrasound to look
for the right nerve under the skin using an ultrasound machine. When the
correct nerve is identified, the provider can then apply the medication for the
block.
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Using an ultrasound to locate a nerve for a block is becoming increasingly
common practice before surgical procedures or as part of providing
analgesia. Depending on the location of the nerve to block, the anesthesia
provider may need to use different types of ultrasound transducers to locate
the nerve. For example, there are some nerves that run close to the surface
of the body, just under the skin. A provider would need to use a slightly
different ultrasound method to locate these nerves when compared to those
nerves that run very deep into the tissues.12
The nurse may assist the anesthesia provider with placing the nerve block.
The main role of the nurse is to monitor the patient during the procedure,
ensure that certain items such as the ultrasound transducer and needles or
syringes are kept sterile; and assist the provider with certain tasks, such as
opening packages or adjusting the ultrasound machine to improve the
image.12 Alternatively, the correct nerve can also be found through nerve
stimulation. The nerve stimulator contains an electrode and a needle; each
item contains a lead, one of which has a positive charge and one has a
negative charge. The electrode is attached to the patient and the other lead
is attached to the needle. Using the needle, the provider locates the affected
nerve, which responds by twitching. Once the affected muscles respond, the
provider knows he has found the nerve associated with that area and that is
the nerve to block.11,12 The nurse assisting the anesthesia provider may
need to hold the nerve stimulator and adjust the frequency of the machine
while the physician searches for the nerve. Adjusting the machine’s
frequency may cause the nerve to twitch faster or more slowly, allowing the
provider to properly isolate the correct nerve.12
A patient is often monitored while a nerve block is being placed, and may be
connected to a monitor that displays heart rate, respiratory rate, and oxygen
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saturation levels, in addition to regular blood pressure readings. Because
administering the block can be somewhat painful for the patient, he or she
may need analgesia or sedation prior to the procedure.
A nerve block has several distinct advantages for pain control for a patient.
If a patient is undergoing a medical procedure that will be painful, the
anesthesia provider can administer a nerve block to numb the area; the
patient may then remain awake during the procedure, yet feel little to no
pain. Whether the patient remains awake depends on the patient’s condition
and the procedure being performed. In some cases, the patient may need
some sedation, despite having a nerve block in place, in order to remain
calm during the process. A nerve block will help to better control a patient’s
pain after a procedure because the site is numb and often remains so for up
to 24 hours afterward. Additionally, a nerve block reduces or eliminates the
need for general anesthesia because the patient does not need to recover
from feeling drowsy and sedated or having nausea or vomiting often
associated with some anesthetics.15
In many cases a nerve block is placed as a single-shot injection, in which the
anesthesiologist injects the medication into the nerve, which numbs the
affected tissue until the medication wears off. During the next 6 to 24 hours,
the patient may have little to no feeling in the affected area, but this
gradually returns, along with potential pain. There are some cases where a
nerve block provides continuous effects, known as a continuous peripheral
nerve catheter. When this is placed, a catheter that appears similar to a wire
is threaded next to the nerve. The other end of the catheter is connected to
an infuser that controls that rate at which medication is delivered to numb
the nerve.
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The continuous catheter may be kept in place for several days after a
procedure, which allows a patient to have more time to heal from a
procedure before the medication wears off, as would be the case with a
single-shot injection. The continuous catheter may also reduce the amount
of opioids or non-opioid analgesics a patient needs for pain control. It can
also decrease the amount of time it takes for a patient to return to activities
of daily living. Continuous peripheral nerve blocks are not only used for
surgical procedures, but have also been implemented in treating some
patients with cancer pain, complex regional pain syndrome, or phantom limb
pain.14
A peripheral nerve block may not be appropriate as a form of pain relief for
every patient. A patient who has an injury at the site where the block should
be placed should not have a block because placement could cause further
injury at the site. Because nerve blocking involves penetrating the skin,
those who have clotting disorders should also be considered very carefully
for this procedure, as placing the block puts that patient at an increased risk
of bleeding. Those who have peripheral neuropathy should also not have
nerve blocks for pain control, as associated nerves may be damaged and the
patient may already be suffering from peripheral numbness, tingling, or
pain.12
Most nerve blocks are placed as peripheral blocks, in which they are
designed to control pain for one part of the body, such as an extremity. They
are most often used to control pain in procedures affecting the arms,
shoulders, knees, ankles, feet, or hips. There are other types of nerve blocks
that may be used for more central locations, such as abdominal incisions. In
these situations, one or more of the thoracic nerves, such as the intercostal
nerve, may be targeted to provide pain relief. Ultimately, although there are
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other central blocks available, they are a little more rare than peripheral
blocks and the clinician may instead decide to use a different type of pain
control, such as through an epidural when these situations warrant the need
for anesthesia.13
Alternative Therapies
Other methods of pain management may be helpful when used in addition to
or in place of pharmacologic therapy. These methods may impact the body
through physical means or may use cognitive or behavioral therapy to help
the patient to manage pain through psychological measures.
Nonpharmacologic therapies for pain control can help to relieve pain by
making the patient more comfortable and changing the way the body
perceives pain. Some types of nonpharmacologic measures that may be
used for pain control include massage, heat or cold therapy, and
transcutaneous electrical nerve stimulation. Massage involves kneading or
manipulating the muscles and tissues under the skin to promote relaxation
and stress relief. Pain can cause the muscles to contract and tighten, which
can cause further pain and tension for the patient. The massage practitioner
rubs and manipulates the muscles in various parts of the body, most
commonly the back, shoulders, arms, and legs. This results in improved
circulation to the tissues and greater relaxation and tension release.10
Inpatients in the hospital setting may also experience greater amounts of
anxiety and loss of sleep due to the situation causing the hospitalization or
the environment. Massage has been shown to help improve sleep among
these patients and to reduce tension that can contribute to anxiety.22
Improving sleep and anxiety can further supplement pain control measures.
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Heat or cold therapy involves that application of warm or cold packs to
various sites on the body and may be used in areas where a patient is
feeling pain. This process may also include other measures such as warm
baths, heating pads, or ice massage. Application of these measures can help
with pain relief by assisting the body with tissue repair. Heat therapy
increases circulation to the affected site, which can increase range of
motion, improve joint stiffness, and relax the muscles. Alternatively, cold
therapy reduces the amount of blood flow to a site and may reduce swelling
of injured tissues. By decreasing circulation to an affected area, cold therapy
can also reduce inflammation.23
Transcutaneous electrical nerve stimulation (TENS) sends a small electrical
current to impact the nerves associated with pain for the patient. A TENS
unit is an electrical machine that has patches that are placed over the area
where the patient is experiencing pain. The machine sends the electrical
current through the electrode, which stimulates the fibers that regulate the
nociceptive impulses that send pain messages. TENS may also cause an
increase in release of endorphins, which can also help the patient to feel
better.10
In addition to physical activities that can improve pain relief, there are some
mind-body exercises that the patient can learn, which can change how he
responds to pain. These measures do not always relieve pain, but rather
help the patient to manage his body and his response to the pain. Pain can
cause the affected person to experience increased feelings of stress,
depression, or anxiety, which may further compound the feelings of pain.
Using mind-body techniques may help to regulate emotional responses to
pain and diminish these additional factors.24
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Distraction is the process of focusing on some other aspect besides the pain.
When concentrating on something else, a distracted patient may be unaware
of the pain. Distraction can be used with visual methods, such as watching
television or reading a book; auditory measures, such as listening to music,
or physical distraction, such as massage, deep breathing, or moving
rhythmically.10
Other examples of mind-body techniques that can help with pain control
include relaxation, mindfulness, biofeedback, and cognitive-behavioral
therapy. Relaxation techniques help the muscles to relax, reducing tension
and producing an opposite effect of the fight-or-flight response.24 Relaxation
techniques such as progressive muscle relaxation, in which the patient
actively concentrates on tensing and then relaxing certain muscle groups, as
well as laughter as a form of relaxation therapy can improve a patient’s
mood and how he responds to pain. These methods have also been shown to
reduce inflammation and make the brain respond more to endorphins.24
Mindfulness is a form of distraction in that the patient focuses on other
aspects beyond the pain. Mindfulness involves control of thoughts to focus
on awareness of being as well as cultivating an attitude of acceptance. This
practice can also reduce the amount of emotional reaction that often goes
along with pain, helping the patient to focus on life and activity around the
pain.24
Biofeedback involves using thoughts to control certain body functions; for
example, biofeedback might involve using thought processes to slow a
racing heart rate. Biofeedback requires focus of attention toward making a
change in the body. A patient may watch certain measurements of body
functions, such as a blood pressure reading or heart rate monitor, and then
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relax and focus the mind to change these functions. It is a process of
relaxation that can provide pain relief when a patient is in a relaxed state
and learning to control the sympathetic nervous system, thereby reducing
stress and tension that can contribute to pain.24
Summary
Pain continues to be a mechanism that drives people to seek treatment,
undergo procedures, or learn techniques to find ways to manage it. Because
so many hospital inpatients experience pain, understanding ways of
managing it and recognizing signs of its escalation should be a core
component of nursing care. Because pain is a personal, subjective
experience, the person experiencing it should be the one describing it. Pain
is whatever the person with pain describes it to be. Nurses must rely on the
patient’s description of pain, either verbally or through the aid of a pain
assessment tool, as well as the patient’s report of the success of pain relief
measures.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. Which is an example of traumatic neuropathic pain?
a. Compartment syndrome
b. Diabetic neuropathy
c. Varicella zoster virus
d. Phantom limb pain
2. Which of the following is a true statement regarding pain
assessment?
a. Most patients overemphasize how much pain they are having.
b. Pain should be reassessed 5 minutes after providing pain
management measures.
c. Pain assessment is universally accepted as the “5th vital sign.”
d. The patient’s history, culture, and personality should all be included
as part of the pain assessment.
3. A patient is diagnosed with an acute myocardial infarction. He
has not had chest pain at all but instead only feels pain in his
jaw. Which type of pain is this example of?
a. Referred pain
b. Receptive pain
c. Radiating pain
d. Random pain
4. The “O” in the OLD CARTS mnemonic for assessing pain stands
for:
a. obtuse.
b. onset.
c. oxygen.
d. operate.
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5. Which of the following is an example of a full agonist opioid?
a. Morphine
b. Buprenex
c. Elavil
d. Nubain
6. All of the following are common medications used with patientcontrolled analgesia except:
a. hydromorphone.
b. morphine.
c. codeine.
d. fentanyl.
7. Which of the following is a disadvantage of using
acetaminophen for pain control?
a. It has an anti-platelet effect and can cause excessive bleeding
b. It does not have anti-inflammatory properties
c. It has no ceiling effect and requires large doses on a regular basis
d. It can cause stomach irritation and bleeding
8. Which statement is true regarding epidural analgesia?
a. Epidural analgesia involves giving medication to control pain and to
block sensation in certain motor nerves.
b. Epidural analgesia is typically only used for patients undergoing
surgical procedures.
c. The epidural catheter is placed so that its tip lies between the
intravertebral space and the lowest layer of the dermis.
d. The patient who receives epidural analgesia is at risk of
hypotension, bradycardia, and respiratory depression.
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9. Which of the following is an advantage of using a peripheral
nerve block for pain control?
a. The patient will be able to sleep throughout the surgical procedure
b. The affected site may remain numb up to 24 hours after a
procedure
c. The patient will not need any supplemental analgesia with a
successful nerve block
d. The affected site will heal faster with a nerve block than if general
anesthesia were used
10. Mind-body therapies for pain control include:
a. transcutaneous electrical nerve stimulation.
b. massage.
c. distraction.
d. acupressure.
Correct Answers:
1. D
6. C
2. D
7. B
3. A
8. D
4. B
9. B
5. A
10. C
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
Bennett, M. I. (Ed.). (2010). Neuropathic pain (2nd ed.). New York, NY:
Oxford University Press, Inc.
2.
Lema, M. J. (2014). Types of neuropathic pain. Retrieved from
http://www.neuropathy.org/site/News2?id=7775
3.
Shields, Jr. R. W. (2014). Peripheral neuropathy. Retrieved from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement
/neurology/peripheral-neuropathy/
4.
Timby, B. K., Smith, N. E. (2014). Introductory medical-surgical nursing.
(11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins
5.
Wilson, S. F., Giddens, J. F. (2012). Health assessment for nursing
practice (5th ed.). St. Louis, MO: Elsevier Mosby
6.
Pasero, C., McCaffery, M. (2011). Pain assessment and pharmacologic
management. St. Louis, MO: Elsevier Mosby
7.
Davis, A., Thomas, D. (2013). Pain assessment and management in the
adult patient. Retrieved from http://www.ceufast.com/course/painassessment-and-management/
8.
Lee, K. L., Lee, H., Cruz-Oliver, C. M. (Eds.). (2013, Feb.). Pain
assessment in persons with cognitive impairment. Retrieved from
http://emedicine.medscape.com/article/2113960-overview#aw2aab6b2
9.
Shippee-Rice, R. V., Fetzer, S. J., Long, J. V. (2012). Gerioperative
nursing care: Principles and practices in surgical care of the older adult.
New York, NY: Springer Publishing
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10. Kozier, B. J., Erb, G., Berman, A. J., Snyder, S., Buck, M., Yiu, L,
Leeseberg Stamler, L. (2013). Fundamentals of Canadian nursing:
Concepts, process, and practice (3rd ed.). Ontario, Canada: Pearson
Education Canada
11. FOAA Anesthesia Services. (n.d.). Peripheral nerve blocks. Retrieved
from https://www.foaa.net/peripheralnerveblocks.html
12. Moos, D. D. (2011, Sep.) Understanding peripheral nerve blocks. OR
Nurse, 5(5), 24-32. doi: 10.1097/01.ORN.0000403415.90130.ba
13. Kumar, C. M., Bellamy, M. (Eds.). (2007). Gastrointestinal and colorectal
anesthesia. New York, NY: Informa Healthcare USA, Inc.
14. Aguirre, J., Del Moral, A., Cobo, I., Borgeat, A., Blumenthal, S. (2012).
The role of continuous peripheral nerve blocks. Anesthesiology Research
and Practice 2012: 560879. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385590/
15. The University of Arizona. (2008). A patient’s guide to peripheral nerve
blocks. Retrieved from
http://anesth.medicine.arizona.edu/system/files/pdfs/Nerve-BlockBroch.pdf
16. Sawhney, M. (2012). Epidural anesthesia: What nurses need to know.
Nursing, 42(8), 36-41. Retrieved from
http://journals.lww.com/nursing/Fulltext/2012/08000/Epidural_analgesi
a__What_nurses_need_to_know.15.aspx
17. Halm, M. A. (2012, Apr.). Epidural analgesia update. Retrieved from
http://www.netce.com/coursecontent.php?courseid=818
18. Jarzyna, D., et al. (2011, Sep.). American Society for Pain Management
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