NR 226: Patient Care Exam 3 Study Guide -
Topics
Pain Management
1. Pain in older adults, adults, children and infants; nursing process
Pain in older adults – muscle mass decrease, body fat increases, & percentage body water decreases (means increase
concentration of water-soluble drugs (morphin) & amount of distribution for fat-soluble drugs increases (fentanyl)); poor
eating results in low serum albumin levels (protein made by liver) causing drugs that are high protein to increase the risk for
side and/or toxic effect; liver & kidney functions decrease reducing the metabolism & excretion of drugs (means they
experience a greater peak effect & longer duration); skin is thinner w/ loss elasticity making absorption of topical analgesic
rate faster. ; development of pathological conditions that cause pain (reduces mobility, ADL’s, social activities, & activity
tolerance.
Infants – they don’t understand pain and why it happens; they cant express themselves through words; they feel pain
before they are born; they have same sensitivity to pain as older children; their pain is observable; very sensitive to drugs
(absorb faster, response is intense & prolonged)
Children – they don’t remember how the pain happened or associate it w/ experiences
Nursing process for older adults – aggressive assessment, diagnosis,& management; make detailed assessments when they
have more than one source of pain; they have difficulty recalling pain or giving detailed explanations about pain.
Nursing process For infant and children – learn how to assess pain for them; know what to ask; what behaviors to observe;
learn how to prepare them for a painful medical procedure.
2. Classifications of pain by location: Superficial/Cutaneous, Deep/Visceral, Referred, and Radiating
Superficial/cutaneous - pain on the skin; short duration & localized; sharp sensation
Deep/ visceral pain – pain coming from an organ; diffuse pain & radiates in several directions; duration varies but last longe
than superficial; sharp, dull, or unique to organ.
Referred – feeling pain that is distal to the actual site; common in visceral pain because organs have no receptors; sensory
from organ goes into spinal cord in same segment as the area where the pain is felt; pain is felt in area that is not effected;
different characteristics for pain
Radiating – pain that extends from the pain initial area to another part; traveling pain down or along body; intermittent or
constant
3. Pain management; analgesics and nonpharmacological pain relief methods; nursing implications, safety precautions,
medication administration
Analgesics –
Nonopioids - acetaminophen & nonsteroidal anti-inflammatory drugs (NSAIDS); acetaminophen (Tylenol) has no
anti-inflammatory effects, most tolerated & safe, hepatotoxicity is an adverse effect; max 24 hr dose is 4g, used w/
opioids to reduce dose for pain relief; NSAIDs (aspirin & ibuprofen) mild- moderate pain relief for acute intermitten
pain, postoperative pain begins w/ NSAIDs unless contraindicated, does not depress CNS or interfere w/ bowel &
bladder functions, chronic use not recommended for older adults because it causes GI bleed & renal insufficiency, p
w/ asthma or aspirin allergy also allergic to other NSAIDs, since some are OTC discuss w/ pt to tell provider of any
use, safe when taken in short periods
Opioids – narcotic, moderate- severe pain, rare adverse effect in opioid-naïve pt is respiratory depression (only
serious if both rate & depth decrease), adverse effect sedation ALWAYS occurs before respiratory depression, other
adverse effects nausea, vomiting, constipation , itching, urinary retention, myoclonus & altered mental process; side
effects stop after 4-10 days of ATC opiate;
*** Please note that this is meant to serve as an augmentation tool. Students ARE subject to be tested on any
material related to readings, simulations, labs, assignments and activities within the course. ***
, Adjuvants – variety of meds that enhance analgesics or have analgesic properties that were originally unknown; to
treat conditions other than pain but also have analgesic properties.
Nonpharmacological pain relief methods –
relaxation techniques - (mediation, yoga, zen, guided imagery & progressive exercises) teach only when pt is not
distracted by acute discomfort, can use combination for optimal pain relief;
distraction – (singing, praying, listening to music, laughter, playing games) taking the pt’s attention away from the
pain; works best for short intense pain lasting a few minutes
music – treat acute, chronic, stress, anxiety & depression; takes attention away from pain; 20 -30 min; they can use
headphones to increase concentration & not disturb others
cutaneous stimulation – (TENS unit, massage, warm bath, ice bag) stimulates skin to reduce pain perception;
releases endorphins & blocks painful stimuli; remove all noises from the environment, put pt in comfortable
position, & explain therapy; do not use on sensitive skin areas; when using cold & heat application make sure it is
not directly on skin & check temp before putting on skin.
Herbs – (Echinacea, ginseng, ginkgo, biloba & garlic supplements) can interact w/ analgesics so ask pt if they are
taking any
Safety precaution & medication administration – administer ATC instead of PRN to maximize relief & potentially decreasin
drug use. do not use meperidine(Demerol) w/ older adults because it causes seizures. Pt is opioid naïve for first 4-10 days of
ATC then become opioid tolerant. use careful assessment & critical thinking. If inflammation, NSAID is more effective than
opioid. Oral has longer onset & duration than injectable. Controlled or extended release opioid (morphine, oxycodone, &
methadone) are available for 8 to 12 hrs ATC, not PRN. Know potencies of oral or injectable. Know route of admin most
effective for pt. know pt’s situation (treatment, disease/condition, &/or organ functions). Safe and effective range orders go
according to pt’s age, pain intensity. Sedatives, antianxiety & muscle relaxers have no analgesic effect.
4. Administering analgesics; nursing implications, safety concerns, client education, opioid naïve client
know if pt has allergies; any risk using NSAIDs (GI bleed or renal insufficiency) or opioids (obstructive or sleep apnea);
previous dose & route to avoid undertreatment; obtained relief?; nonopioid effective as opioid?. Nonopioid or opioid
combination drugs for mild-moderate pain or severe pain because it treats pain peripherally & centrally; can give both
together except for older adults; fentanyl patches, morphine or hydromorphone are used long-term for severe pain; IV
quicker & relieve within 1 hr and oral takes 2 hrs; avoid IM analgesics especially in older pt; chronic pain give sustained oral
ATC. 4 g max in 24hr for acetaminophen & acetylsaliyic acid; 3200mg for ibuprofen. Adjust doses for kids & older pt’s; large
dose of opioid is ok for opioid tolerant not opioid naïve. Administer as soon as pain occurs & before it increases in severity;
ATC admin is best; give before pain-producing procedures or activities; know average duration of action of drugs & time of
admin so the peck happens when pain is worse; use extended release for chronic pain; to not suddenly stop opiates on
opioid tolerant pt’s
opioid naïve pt – rare adverse effect is respiratory depression; both rate & depth decrease; sedation always occurs before
respiratory depression; closely monitor; if they have it give naloxone (narcan)(0.4mg diluted w/ 9mL saline) IVpush at a rate
of 0.5mL every 2 min until respiratory rate is more than 8 breath/min w/ good depth; giving faster than that rate causes
severe pain & complications; reassess every 15 min for 2 hours because duration is less than opioid & respiratory depression
can come back. If they have PCA do not increase dose or basal and shorten interval time at the same time, this will risk
oversedation & respiratory depression.
5. Physical dependence vs addiction vs tolerance
Physical dependence – withdraw symptoms because the person got use to the drug. It happens when they suddenly stop,
rapidly decreasing dose, decreased blood levels in the blood and/or when given a antagonist.
Addiction – disease w/ genetic, psychosocial & environmental factors causing it to develop. Not being able to control the
use of the drug, overusing, doesn’t care if there is harm they will still use, and craving the drug.
Tolerance – is the level of pain the person is willing to accept
6. Patient controlled analgesics; nursing implications, safety, calculating dosage received, client/family education
is a safe method for pain management; allows pt to self-admin opioid (morphine, hydromorphone & fentanyl) w/ little risk
*** Please note that this is meant to serve as an augmentation tool. Students ARE subject to be tested on any
material related to readings, simulations, labs, assignments and activities within the course. ***
Topics
Pain Management
1. Pain in older adults, adults, children and infants; nursing process
Pain in older adults – muscle mass decrease, body fat increases, & percentage body water decreases (means increase
concentration of water-soluble drugs (morphin) & amount of distribution for fat-soluble drugs increases (fentanyl)); poor
eating results in low serum albumin levels (protein made by liver) causing drugs that are high protein to increase the risk for
side and/or toxic effect; liver & kidney functions decrease reducing the metabolism & excretion of drugs (means they
experience a greater peak effect & longer duration); skin is thinner w/ loss elasticity making absorption of topical analgesic
rate faster. ; development of pathological conditions that cause pain (reduces mobility, ADL’s, social activities, & activity
tolerance.
Infants – they don’t understand pain and why it happens; they cant express themselves through words; they feel pain
before they are born; they have same sensitivity to pain as older children; their pain is observable; very sensitive to drugs
(absorb faster, response is intense & prolonged)
Children – they don’t remember how the pain happened or associate it w/ experiences
Nursing process for older adults – aggressive assessment, diagnosis,& management; make detailed assessments when they
have more than one source of pain; they have difficulty recalling pain or giving detailed explanations about pain.
Nursing process For infant and children – learn how to assess pain for them; know what to ask; what behaviors to observe;
learn how to prepare them for a painful medical procedure.
2. Classifications of pain by location: Superficial/Cutaneous, Deep/Visceral, Referred, and Radiating
Superficial/cutaneous - pain on the skin; short duration & localized; sharp sensation
Deep/ visceral pain – pain coming from an organ; diffuse pain & radiates in several directions; duration varies but last longe
than superficial; sharp, dull, or unique to organ.
Referred – feeling pain that is distal to the actual site; common in visceral pain because organs have no receptors; sensory
from organ goes into spinal cord in same segment as the area where the pain is felt; pain is felt in area that is not effected;
different characteristics for pain
Radiating – pain that extends from the pain initial area to another part; traveling pain down or along body; intermittent or
constant
3. Pain management; analgesics and nonpharmacological pain relief methods; nursing implications, safety precautions,
medication administration
Analgesics –
Nonopioids - acetaminophen & nonsteroidal anti-inflammatory drugs (NSAIDS); acetaminophen (Tylenol) has no
anti-inflammatory effects, most tolerated & safe, hepatotoxicity is an adverse effect; max 24 hr dose is 4g, used w/
opioids to reduce dose for pain relief; NSAIDs (aspirin & ibuprofen) mild- moderate pain relief for acute intermitten
pain, postoperative pain begins w/ NSAIDs unless contraindicated, does not depress CNS or interfere w/ bowel &
bladder functions, chronic use not recommended for older adults because it causes GI bleed & renal insufficiency, p
w/ asthma or aspirin allergy also allergic to other NSAIDs, since some are OTC discuss w/ pt to tell provider of any
use, safe when taken in short periods
Opioids – narcotic, moderate- severe pain, rare adverse effect in opioid-naïve pt is respiratory depression (only
serious if both rate & depth decrease), adverse effect sedation ALWAYS occurs before respiratory depression, other
adverse effects nausea, vomiting, constipation , itching, urinary retention, myoclonus & altered mental process; side
effects stop after 4-10 days of ATC opiate;
*** Please note that this is meant to serve as an augmentation tool. Students ARE subject to be tested on any
material related to readings, simulations, labs, assignments and activities within the course. ***
, Adjuvants – variety of meds that enhance analgesics or have analgesic properties that were originally unknown; to
treat conditions other than pain but also have analgesic properties.
Nonpharmacological pain relief methods –
relaxation techniques - (mediation, yoga, zen, guided imagery & progressive exercises) teach only when pt is not
distracted by acute discomfort, can use combination for optimal pain relief;
distraction – (singing, praying, listening to music, laughter, playing games) taking the pt’s attention away from the
pain; works best for short intense pain lasting a few minutes
music – treat acute, chronic, stress, anxiety & depression; takes attention away from pain; 20 -30 min; they can use
headphones to increase concentration & not disturb others
cutaneous stimulation – (TENS unit, massage, warm bath, ice bag) stimulates skin to reduce pain perception;
releases endorphins & blocks painful stimuli; remove all noises from the environment, put pt in comfortable
position, & explain therapy; do not use on sensitive skin areas; when using cold & heat application make sure it is
not directly on skin & check temp before putting on skin.
Herbs – (Echinacea, ginseng, ginkgo, biloba & garlic supplements) can interact w/ analgesics so ask pt if they are
taking any
Safety precaution & medication administration – administer ATC instead of PRN to maximize relief & potentially decreasin
drug use. do not use meperidine(Demerol) w/ older adults because it causes seizures. Pt is opioid naïve for first 4-10 days of
ATC then become opioid tolerant. use careful assessment & critical thinking. If inflammation, NSAID is more effective than
opioid. Oral has longer onset & duration than injectable. Controlled or extended release opioid (morphine, oxycodone, &
methadone) are available for 8 to 12 hrs ATC, not PRN. Know potencies of oral or injectable. Know route of admin most
effective for pt. know pt’s situation (treatment, disease/condition, &/or organ functions). Safe and effective range orders go
according to pt’s age, pain intensity. Sedatives, antianxiety & muscle relaxers have no analgesic effect.
4. Administering analgesics; nursing implications, safety concerns, client education, opioid naïve client
know if pt has allergies; any risk using NSAIDs (GI bleed or renal insufficiency) or opioids (obstructive or sleep apnea);
previous dose & route to avoid undertreatment; obtained relief?; nonopioid effective as opioid?. Nonopioid or opioid
combination drugs for mild-moderate pain or severe pain because it treats pain peripherally & centrally; can give both
together except for older adults; fentanyl patches, morphine or hydromorphone are used long-term for severe pain; IV
quicker & relieve within 1 hr and oral takes 2 hrs; avoid IM analgesics especially in older pt; chronic pain give sustained oral
ATC. 4 g max in 24hr for acetaminophen & acetylsaliyic acid; 3200mg for ibuprofen. Adjust doses for kids & older pt’s; large
dose of opioid is ok for opioid tolerant not opioid naïve. Administer as soon as pain occurs & before it increases in severity;
ATC admin is best; give before pain-producing procedures or activities; know average duration of action of drugs & time of
admin so the peck happens when pain is worse; use extended release for chronic pain; to not suddenly stop opiates on
opioid tolerant pt’s
opioid naïve pt – rare adverse effect is respiratory depression; both rate & depth decrease; sedation always occurs before
respiratory depression; closely monitor; if they have it give naloxone (narcan)(0.4mg diluted w/ 9mL saline) IVpush at a rate
of 0.5mL every 2 min until respiratory rate is more than 8 breath/min w/ good depth; giving faster than that rate causes
severe pain & complications; reassess every 15 min for 2 hours because duration is less than opioid & respiratory depression
can come back. If they have PCA do not increase dose or basal and shorten interval time at the same time, this will risk
oversedation & respiratory depression.
5. Physical dependence vs addiction vs tolerance
Physical dependence – withdraw symptoms because the person got use to the drug. It happens when they suddenly stop,
rapidly decreasing dose, decreased blood levels in the blood and/or when given a antagonist.
Addiction – disease w/ genetic, psychosocial & environmental factors causing it to develop. Not being able to control the
use of the drug, overusing, doesn’t care if there is harm they will still use, and craving the drug.
Tolerance – is the level of pain the person is willing to accept
6. Patient controlled analgesics; nursing implications, safety, calculating dosage received, client/family education
is a safe method for pain management; allows pt to self-admin opioid (morphine, hydromorphone & fentanyl) w/ little risk
*** Please note that this is meant to serve as an augmentation tool. Students ARE subject to be tested on any
material related to readings, simulations, labs, assignments and activities within the course. ***
