NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
NUR2392 Final Exam Multidimensional Care II MDC 2 Fi
n n n n n n n nn
nal Exam Review (2021-2022)
n n n
AssessmentnandnCarenofnPatientsnwithnPain
Concepts
• Thenprioritynconceptninnthisnchapternisncomfort
• TheninterrelatednconceptsninnthisnchapternarencognitionnsensorynPerception
PainnThenScopenofnthenProblem
• Painnisnanmajorneconomicnproblemnandnanleadingncausenofndisabilitynthatnchangesnthenlivesno
fnmanynpeople,nespeciallynoldernadults.
• Chronicnnon-
cancernpainnsuchnasnosteoarthritis,nrheumatoidnarthritis,nandndiabeticnneuropathynisnt
henmostncommonncausenofnlong-
termndisability,naffectingnmillionsnofnAmericansnandnothersnthroughoutnthenworld.
• Universal,ncomplexnpersonalnexperience
• Isnannimpairmentninncomfort;nmajorneconomicnconcern;nleadingncausenofndisability
• Failurentonmanagenpainnisnanworldwidenhealthnproblem
• Inter-professionalnpainninitiativesnhelpnpatientsnreceivenbestntreatment
DefinitionsnofnPain
• Unpleasantnsensorynandnemotionalnexperiencenassociatednwithnactualnornpotentialntissuen
damage
• Whatevernpersonnexperiencingnitnsaysnitnis;nexistsnwhenevernpersonnsaysnitndoes
• Self-reportnalwaysnmostnreliablenindicationnofnpain
CategorizationnofnPainnbynDuration
• Acutenpain
- Short-lived
- Resultsnfromnsudden,naccidentalntrauma;nsurgery;nischemia;nacuteninflammation
• Chronicn(persistent)npain
- Cannlastnanperson‘snlifetime
- Chronicncancernpain
- Chronicnnon-cancernpain
• Painnisntreatedninadequatelyninnalmostnallnhealthncarensettings.
• Populationsnatnthenhighestnriskninnmedical-
surgicalnnursingnarenoldernadults,npatientsnwithnsubstancenusendisorder,nandnthosenwhosenp
rimarynlanguagendiffersnfromnthatnofnthenhealth
carenprofessional.
• Oldernadultsninnnursingnhomesnarenatnespeciallynhighnrisknbecausenmanynresidentsnarenunablent
onreportntheirnpain.nInnaddition,ntherenoftennisnanlacknofnstaffnmembersnwhonhavenbeenneducate
dntonmanagenpainninnthenolder-adultnpopulation.
AcutenPain
• Actsnasnwarningnsign
• Activationnofnsympatheticnnervousnsystem
• ―Fight-or-flight‖n reactions
- Increasednvitalnsigns
- Sweating
- Dilatednpupils
- Restlessness
- Apprehension
- Distressnofnvaryingndegrees
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
AcutenPainn(Cont.)
• Absencenofnphysiologicnandnbehavioralnresponsesndoesnnotnmeannabsencenofnpain
• Usuallyntemporarynwithnsuddennonset,nandneasilynlocalized
• Sensorynperceptionnofnpainnchangesnasninjurednareanheals
Chronicn(Persistent)nPain
• Lastsnornrecursnfornindefinitenperiodn(morenthann3nmonths)
• Gradualnonset
• Characternandnqualitynoftennchangenoverntime
• Servesnnonbiologicalnpurpose
• Cannresultninnemotional,nfinancial,nandnrelationshipnburdens,nasnwellnasn
depression/hopelessness
ChronicnCancernPain
• Usuallynresultnofntumorngrowth,nnervencompression,ntissueninvasion,nmetastasis
• Cancerntreatmentncannalsoncausenacutenpainn(e.g.,nprocedures,nsurgery,ntoxicitiesnfromnc
hemonandnradiation)
ChronicnNon-CancernPain
• Globalnhealthnissuenfornpeoplen>n65n yearsnold
• Formerlyncallednchronicnnonmalignantnpain
• Neck,nshoulder,nlownback
• Overnhalfnofnveteransnofnrecentnwarsnhaventhisncondition
- Canncausendepression,ndecreasednsensenofnwell-being
CategorizationnofnPainnbynUnderlyingnMechanisms
• Nociceptivenpain
- Somatic
- Visceral
• Neuropathicnpain
PainnTransmission
• Painfulnstimulinoftennoriginateninnextremities
• Ifnpainnisnnotntransmittedntonthenbrain,npersonnfeelsnnonpain
• Twonspecificnfibersntransmitnperipherynpain:
- Andeltanfibers
- Cnfibers
Assessment:nNoticing
• Patient‘snself-reportnisn―goldnstandard‖nfornassessment
• Nurse‘snrole
- Acceptnpatientnself-report
- Servenasnadvocate
- Actnpromptlyntonrelievenpain
- Respectnpatientnvaluesnandnpreferences
PainnAssessmentn(Cont.)
• Location
• Intensity
• Quality
• Onsetnandnduration
• Aggravatingnandnrelievingnfactors
• Effectnofnpainnonnfunctionnandnqualitynofnlife
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
• Comfort-functionnoutcomes
• Otherninformation
PsychosocialnAssessment
• Painnholdsnuniquenmeaningnfornthenpersonnexperiencingnit.
• Remainnobjective;nadvocatenfornpropernpainncontrol
• Referntonresourcesnsuchnasn―10-StepnProgramnfromnPatientntonPerson‖n(asnneeded)
AssessmentnChallenges
• Patientsnwhoncannotnself-reportnpainnarenatnhighernrisknfornunder-treatednpain
- HierarchynofnPainnMeasures
- ChecklistnofnNonverbalnPainnIndicatorsn(CNPI)
- PainnAssessmentninnAdvancednDementianScalen(PAINAD)
DifferentnPainnTypes
• Localizednpainnisnconfinedntonthensitenofnorigin.
• Projectednpainnisndiffusenaroundnthensitenofnoriginnandnisnnotnwellnlocalized.
• Referrednpainnisnfeltninnannareandistantnfromnthensitenofnpainfulnstimuli.
• Radiatingnpainnisnfeltnalongnanspecificnnervenornnerves.
• Intensity:nAsknthenpatientntonratenthenseveritynofnthenpainnusingnanreliablenandnvalidna
ssessmentntool.
• Variousnself-
reportnscalesnhavenbeenndevelopedntonhelpnpatientsncommunicatenpainnintensity.
Teachingnhowntonrespondntonanpainnscale
• TextnbooknTablen4-4
AnalgesicnGroups
• Non-opioidnanalgesics
- Acetaminophen
- NSAIDs
Non-opioidnAnalgesics
• Monitornpatientsntakingnacetaminophennfornhepatotoxicity
• Reducedndailyndosenmaynbenappropriatenfornoldernadultsnonnlong-termntherapy
• MonitornpatientsntakingnNSAIDSnforngastricnsideneffects
• NSAIDSncarrynrisknforncardiovascularnandnrenalnadverseneffectsnthroughnprostaglandinni
nhibition
AnalgesicsnbynClassification:nOpioidnAnalgesics
• Fullnornmunagonists
- Morphine,nfentanyl,nhydromorphone,noxycodone,noxycodone,nhydrocodone
• Mixednagonistsnantagonists
- Butorphanol,nnalbuphine
• Partialnagonists
- Buprenorphine
DrugnFormulationnTerminology
• Shortnacting,nfastnacting,nimmediatenreleasen(IR),nnormalnrelease
- Onsetninnaboutn30nminutes;nshortndurationnofn3nton4nhours
• Modified-release,nextendednreleasen(ER),nsustainednreleasen(SR),ncontrollednreleasen(CR)
- Releasenovernanprolongednperiod
- Neverncrush,nbreak,nornhavenpatientsnchew!
SelectednOpioidnAnalgesics
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
• Morphine
• Fentanyl
- Teachnpatientsntonrefrainnfromnapplyingnheatntonpatches
• Hydromorphone
• Oxycodone
• Hydrocodone
• Methadone
DualnMechanismnAnalgesics
• Tramadoln(Ultram)
• Tapentadoln(Nucynta)
OpioidsntonAvoid
• Meperidine
• Codeine
IntraspinalnAnalgesia
• Analgesicnadministrationnviananneedlenorncatheterninnthenepiduralnornintrathecalnspace
• Placednbynannanesthesianprovider
• Sideneffectsndependnonndrugnadministered
• Complicationsnarenrarenbutncannbenlife-threatening
AdversenEffectsnofnOpioidnAnalgesics
• Constipation
• Nausea
• Vomiting
• Pruritus
• Sedation
• Respiratoryndepressionn(lessncommon,n yetnmostnconcerning)
Adjuvantn (Co-Analgesic)nAnalgesics
• Anticonvulsantsnandnantidepressants
- Gabapentin
- Imipraminen(Tofranil)
- Clomipraminen(Anafranil)
- Doxepin
• Localnanesthetics
- Lidocaine
UsenofnPlacebos
• Anynmedicationnornproceduren(includingnsurgery)nwhichnproducesnanneffectnbecausenofnitsni
ntent
• Usednasncontrolninnresearch
• Anynothernusenhasnethicalnandnlegalnimplications;nviolatesnnurse–
patientnrelationship;ndeprivesnpatientnofnappropriatenassessment
NonpharmacologicnManagement
• Appropriatenfornmild-nandnsomenmoderate-intensitynpain
• Shouldncomplement,nnotnreplace,npharmacologicntherapiesnfornmorenseverenpain
- Physicalnmodalities
- Cognitive-behavioralnstrategies
PhysicalnInterventionsn(Examples)
• Physicalntherapy
(2021/2022)nRasmussen
NUR2392 Final Exam Multidimensional Care II MDC 2 Fi
n n n n n n n nn
nal Exam Review (2021-2022)
n n n
AssessmentnandnCarenofnPatientsnwithnPain
Concepts
• Thenprioritynconceptninnthisnchapternisncomfort
• TheninterrelatednconceptsninnthisnchapternarencognitionnsensorynPerception
PainnThenScopenofnthenProblem
• Painnisnanmajorneconomicnproblemnandnanleadingncausenofndisabilitynthatnchangesnthenlivesno
fnmanynpeople,nespeciallynoldernadults.
• Chronicnnon-
cancernpainnsuchnasnosteoarthritis,nrheumatoidnarthritis,nandndiabeticnneuropathynisnt
henmostncommonncausenofnlong-
termndisability,naffectingnmillionsnofnAmericansnandnothersnthroughoutnthenworld.
• Universal,ncomplexnpersonalnexperience
• Isnannimpairmentninncomfort;nmajorneconomicnconcern;nleadingncausenofndisability
• Failurentonmanagenpainnisnanworldwidenhealthnproblem
• Inter-professionalnpainninitiativesnhelpnpatientsnreceivenbestntreatment
DefinitionsnofnPain
• Unpleasantnsensorynandnemotionalnexperiencenassociatednwithnactualnornpotentialntissuen
damage
• Whatevernpersonnexperiencingnitnsaysnitnis;nexistsnwhenevernpersonnsaysnitndoes
• Self-reportnalwaysnmostnreliablenindicationnofnpain
CategorizationnofnPainnbynDuration
• Acutenpain
- Short-lived
- Resultsnfromnsudden,naccidentalntrauma;nsurgery;nischemia;nacuteninflammation
• Chronicn(persistent)npain
- Cannlastnanperson‘snlifetime
- Chronicncancernpain
- Chronicnnon-cancernpain
• Painnisntreatedninadequatelyninnalmostnallnhealthncarensettings.
• Populationsnatnthenhighestnriskninnmedical-
surgicalnnursingnarenoldernadults,npatientsnwithnsubstancenusendisorder,nandnthosenwhosenp
rimarynlanguagendiffersnfromnthatnofnthenhealth
carenprofessional.
• Oldernadultsninnnursingnhomesnarenatnespeciallynhighnrisknbecausenmanynresidentsnarenunablent
onreportntheirnpain.nInnaddition,ntherenoftennisnanlacknofnstaffnmembersnwhonhavenbeenneducate
dntonmanagenpainninnthenolder-adultnpopulation.
AcutenPain
• Actsnasnwarningnsign
• Activationnofnsympatheticnnervousnsystem
• ―Fight-or-flight‖n reactions
- Increasednvitalnsigns
- Sweating
- Dilatednpupils
- Restlessness
- Apprehension
- Distressnofnvaryingndegrees
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
AcutenPainn(Cont.)
• Absencenofnphysiologicnandnbehavioralnresponsesndoesnnotnmeannabsencenofnpain
• Usuallyntemporarynwithnsuddennonset,nandneasilynlocalized
• Sensorynperceptionnofnpainnchangesnasninjurednareanheals
Chronicn(Persistent)nPain
• Lastsnornrecursnfornindefinitenperiodn(morenthann3nmonths)
• Gradualnonset
• Characternandnqualitynoftennchangenoverntime
• Servesnnonbiologicalnpurpose
• Cannresultninnemotional,nfinancial,nandnrelationshipnburdens,nasnwellnasn
depression/hopelessness
ChronicnCancernPain
• Usuallynresultnofntumorngrowth,nnervencompression,ntissueninvasion,nmetastasis
• Cancerntreatmentncannalsoncausenacutenpainn(e.g.,nprocedures,nsurgery,ntoxicitiesnfromnc
hemonandnradiation)
ChronicnNon-CancernPain
• Globalnhealthnissuenfornpeoplen>n65n yearsnold
• Formerlyncallednchronicnnonmalignantnpain
• Neck,nshoulder,nlownback
• Overnhalfnofnveteransnofnrecentnwarsnhaventhisncondition
- Canncausendepression,ndecreasednsensenofnwell-being
CategorizationnofnPainnbynUnderlyingnMechanisms
• Nociceptivenpain
- Somatic
- Visceral
• Neuropathicnpain
PainnTransmission
• Painfulnstimulinoftennoriginateninnextremities
• Ifnpainnisnnotntransmittedntonthenbrain,npersonnfeelsnnonpain
• Twonspecificnfibersntransmitnperipherynpain:
- Andeltanfibers
- Cnfibers
Assessment:nNoticing
• Patient‘snself-reportnisn―goldnstandard‖nfornassessment
• Nurse‘snrole
- Acceptnpatientnself-report
- Servenasnadvocate
- Actnpromptlyntonrelievenpain
- Respectnpatientnvaluesnandnpreferences
PainnAssessmentn(Cont.)
• Location
• Intensity
• Quality
• Onsetnandnduration
• Aggravatingnandnrelievingnfactors
• Effectnofnpainnonnfunctionnandnqualitynofnlife
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
• Comfort-functionnoutcomes
• Otherninformation
PsychosocialnAssessment
• Painnholdsnuniquenmeaningnfornthenpersonnexperiencingnit.
• Remainnobjective;nadvocatenfornpropernpainncontrol
• Referntonresourcesnsuchnasn―10-StepnProgramnfromnPatientntonPerson‖n(asnneeded)
AssessmentnChallenges
• Patientsnwhoncannotnself-reportnpainnarenatnhighernrisknfornunder-treatednpain
- HierarchynofnPainnMeasures
- ChecklistnofnNonverbalnPainnIndicatorsn(CNPI)
- PainnAssessmentninnAdvancednDementianScalen(PAINAD)
DifferentnPainnTypes
• Localizednpainnisnconfinedntonthensitenofnorigin.
• Projectednpainnisndiffusenaroundnthensitenofnoriginnandnisnnotnwellnlocalized.
• Referrednpainnisnfeltninnannareandistantnfromnthensitenofnpainfulnstimuli.
• Radiatingnpainnisnfeltnalongnanspecificnnervenornnerves.
• Intensity:nAsknthenpatientntonratenthenseveritynofnthenpainnusingnanreliablenandnvalidna
ssessmentntool.
• Variousnself-
reportnscalesnhavenbeenndevelopedntonhelpnpatientsncommunicatenpainnintensity.
Teachingnhowntonrespondntonanpainnscale
• TextnbooknTablen4-4
AnalgesicnGroups
• Non-opioidnanalgesics
- Acetaminophen
- NSAIDs
Non-opioidnAnalgesics
• Monitornpatientsntakingnacetaminophennfornhepatotoxicity
• Reducedndailyndosenmaynbenappropriatenfornoldernadultsnonnlong-termntherapy
• MonitornpatientsntakingnNSAIDSnforngastricnsideneffects
• NSAIDSncarrynrisknforncardiovascularnandnrenalnadverseneffectsnthroughnprostaglandinni
nhibition
AnalgesicsnbynClassification:nOpioidnAnalgesics
• Fullnornmunagonists
- Morphine,nfentanyl,nhydromorphone,noxycodone,noxycodone,nhydrocodone
• Mixednagonistsnantagonists
- Butorphanol,nnalbuphine
• Partialnagonists
- Buprenorphine
DrugnFormulationnTerminology
• Shortnacting,nfastnacting,nimmediatenreleasen(IR),nnormalnrelease
- Onsetninnaboutn30nminutes;nshortndurationnofn3nton4nhours
• Modified-release,nextendednreleasen(ER),nsustainednreleasen(SR),ncontrollednreleasen(CR)
- Releasenovernanprolongednperiod
- Neverncrush,nbreak,nornhavenpatientsnchew!
SelectednOpioidnAnalgesics
, NURn2392n/nNUR2392nFinalnExam:nMultidimensionalnCarenIIn/nMDCn2nFinalnExamnReviewnn
(2021/2022)nRasmussen
• Morphine
• Fentanyl
- Teachnpatientsntonrefrainnfromnapplyingnheatntonpatches
• Hydromorphone
• Oxycodone
• Hydrocodone
• Methadone
DualnMechanismnAnalgesics
• Tramadoln(Ultram)
• Tapentadoln(Nucynta)
OpioidsntonAvoid
• Meperidine
• Codeine
IntraspinalnAnalgesia
• Analgesicnadministrationnviananneedlenorncatheterninnthenepiduralnornintrathecalnspace
• Placednbynannanesthesianprovider
• Sideneffectsndependnonndrugnadministered
• Complicationsnarenrarenbutncannbenlife-threatening
AdversenEffectsnofnOpioidnAnalgesics
• Constipation
• Nausea
• Vomiting
• Pruritus
• Sedation
• Respiratoryndepressionn(lessncommon,n yetnmostnconcerning)
Adjuvantn (Co-Analgesic)nAnalgesics
• Anticonvulsantsnandnantidepressants
- Gabapentin
- Imipraminen(Tofranil)
- Clomipraminen(Anafranil)
- Doxepin
• Localnanesthetics
- Lidocaine
UsenofnPlacebos
• Anynmedicationnornproceduren(includingnsurgery)nwhichnproducesnanneffectnbecausenofnitsni
ntent
• Usednasncontrolninnresearch
• Anynothernusenhasnethicalnandnlegalnimplications;nviolatesnnurse–
patientnrelationship;ndeprivesnpatientnofnappropriatenassessment
NonpharmacologicnManagement
• Appropriatenfornmild-nandnsomenmoderate-intensitynpain
• Shouldncomplement,nnotnreplace,npharmacologicntherapiesnfornmorenseverenpain
- Physicalnmodalities
- Cognitive-behavioralnstrategies
PhysicalnInterventionsn(Examples)
• Physicalntherapy
