During the nurse’s initial interview, Wrenda shares information about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management.
Which information, obtained by the nurse, is most likely to influence Wrenda’s perception of her pain?
Feeding an infant every three hours interrupts sleep and results in fatigue. Fatigue often heightens the perception of pain and impairs coping skills.
The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching or stabbing.
Guarding, or protecting the painful area, is a common behavioral response to pain.
To determine the etiology of Wrenda’s anxiety, what is the priority nursing intervention?
Further assessment by the nurse is needed to determine the cause of the client’s anxiety.
The goal is a broad statement that reflects a positive direction for the client’s problem, in this case, acute pain.
Before implementing any interventions, what action is most important for the nurse to take?
After considering interventions to implement, the nurse should review the plan of care with the client and seek client input.
What instruction should the nurse provide?
Acetominophen (Tylenol) is an effective analgesic and antipyretic, but does not have an antiinflammatory effect.
What information should the nurse include in responding to Wrenda?
Aspirin products seem to be associated with Reye Syndrome in children under the age of eighteen, and should be avoided unless specifically prescribed.
How should the nurse respond?
Heat, whether dry or moist, promotes muscle relaxation and relief of pain caused by stiffness or spasm.
Which instruction is most important for the nurse to provide?
In response to the client’s statement, the nurse should educate the client on safe application of the cold pack. The other information can then be included in the instructions.
The nurse further explains that the cold should only be applied as prescribed, for twenty to thirty minutes at a time. The nurse tells Wrenda to remove the cold pack if her skin appears reddened before the prescribed time period has elapsed.
Cold causes vasoconstriction. After prolonged exposure, reflex vasodilation occurs to restore adequate blood supply to the tissues.
What is the best response by the nurse?
TENS (transcutaneous electrical nerve stimulation) is considered a type of cutaneous stimulation, in which electrodes attached to a battery-operated unit stimulate the skin and underlying tissues near the area of localized pain.
Which instruction should the nurse include?
Conducting gel or conductor pads are applied before attaching the electrodes to the skin to promote safe, effective conduction of the electrical current and reduce the possibility of injury to the client.
What characteristic of scheduled drugs results in the need for these specific protocols?
Scheduled (controlled) medications are those mediations determined to have a high abuse potential, so specific controls are designated to reduce access to these medications.
What action should the nurse implement?
The nurse should first consult with all nurses with access to the medications to determine if a medication was given to a client without proper documentation. This action will frequently resolve the discrepancy. If it does not, the nurse-manager should be consulted for further action to be taken based on the policy of the agency.
While Wrenda is in the emergency department, the healthcare provider prescribes an intramuscular (IM) injection of 60 mg of ketorolac (Toradol), a nonsteroidal antiinflammatory agent. The medication comes in a pre-loaded syringe labeled “30 mg/ml.”
Since Wrenda is fairly thin, which site is the best choice for the injection?
Two mls of medication (the amount needed for this prescription) can safely be injected into the ventrogluteal site of most people, even a thin person such as this client.
The nurse places the palm of the hand over the greater trochanter of the client’s hip. The index finger is pointed toward the anterosuperior iliac spine, and the middle finger toward the iliac crest.
Aspiration for blood reduces the risk of injecting the medication into a capillary. If blood is observed in the syringe, the needle should be withdrawn and a new dose of medication prepared.
To ensure that the exercise is most effective, what action should the nurse implement?
As the client creates an image in her mind, awareness of pain diminishes. Promoting the use of all the senses heightens the client’s awareness of the image, further diminishing the awareness of pain.
What instruction should the nurse provide next?
Once the muscle tension is identified, the client first tenses the muscle fully, then relaxes the muscle completely. In time, the client will be able to relax the tense muscles without first tensing them more fully.Other forms of non-pharmacologic pain-relief interventions include acupressure, distraction, music, biofeedback, and self-hypnosis. All of these measures can assist in pain management and provide the client with a sense of self-control.
When is the best time to teach Wrenda about use of the PCA?
Teaching is best provided before surgery, while the client is awake and alert, and not experiencing acute postoperative pain.
Prior to giving report to the oncoming nurse, the nurse reviews Wrenda’s usage of the PCA pump and determines that she has received four demand doses of morphine each hour for the last four hours.
What is the total dosage of morphine that Wrenda has received in the last four hours?
Wrenda receives a continuous infusion of .5 mg/hour, for a total of 2 mg in 4 hours. Each demand dose is 1 mg. She self-administered 4 doses per hour, for a total of 4 mg/hour for each of four hours, for a total of 16 mg. This is added to the amount in the continuous infusion, for a final total dose of 18 mg of morphine received in the last four hours.
What is the most likely reason for this change?
The most likely explanation for no longer self-administering a demand dose is that the client’s pain has decreased, or is controlled effectively by other measures.
What is the rationale for combining these two ingredients?
A synergistic effect is one in which two medications work together to provide an increased effect. Non-opioids, such as acetaminophen, are often used in combination with opioids so that a lower dose of the opioid can be used, while still providing effective analgesia.
How should the nurse respond?
All opioid analgesics, including both morphine and Vicodin, can be constipating, so the nurse should instruct the client to continue the stool softener until determining the change in bowel patterns that results from the change in the analgesic.
What is the priority nursing intervention?
The nurse must act as a client advocate, protecting the client’s privacy. Discussing the client’s behavior in the hallway violates her right to privacy.
Veracity refers to practicing truthfulness.