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Answer all of the following questions true or false.
Please read the following scenarios and select the best answer to each of the questions below it.
Patient number one is a well-nourished 35-year-old male, 3 days post-exploratory lap. The patient is moaning and diaphoretic. He is afebrile and his vital signs are: BP 180/92, HR 120, RR 24. The patient complains of only minimal relief after 50 mg of Demerol I.M. The patient states that the pain is an 8 on a scale of 1-10, with 10 being the worst pain he has ever experienced. It has been 3 hours since he was last medicated.
Demerol 50-100 mg I.M. every 3-4 hours pm for pain
As his nurse, select the answer below that most closely matches your nursing intervention.
As his nurse, select the most significant assessment that led you to the action above.
Patient number two is a 28-year-old, overweight female who complains of severe low back pain. She rates the pain as a 7 on a scale of 1-10, with 10 being the worst pain she has ever experienced. The patient has difficulty ambulating. She has been irritable and is always on her call light. Her vital signs are: BP 150/76, HR 100, RR 18. Her spinal X rays and MRI were negative. Her skin is warm and moist. She spends most of her time watching TV or talking on the telephone. She was last medicated 3 hours ago with Demerol 50 mg.
Demerol 50-100 mg I.M. every 3-4 hours pm for pain.
As her nurse, select the answer below that most closely matches your nursing intervention.
Which of the following was the most significant piece of assessment data that led you to select the intervention above?
1. The oral route of pain medication administration is less effective than the intramuscular route. (False)
The oral route is actually preferred if the patient can take fluids by mouth. Absorption via the intramuscular route is variable and unpredictable. The intramuscular route does not provide a consistent blood level. When using the oral route, be sure to give a sufficient amount. For example, Demerol 50 mg I.M. is not equal to Demerol 50 mg P.O. For quick therapeutic results, the intravenous route is preferred.1
2. Mental changes in the elderly post-operative client are most often due to the effects of pain medication. (False)
Actually, mental changes in the elderly post-operative patient were found to be related to pain more often than to pain medication.2
3. Pain is an expected finding in the elderly population, due to normal aging changes. (False).
Getting older does not mean that pain is inevitable or normal. Elderly clients are often told to "leam to live with it." However, pain is not a normal aging change and should not be treated as such.3
4. Newborn infants can feel pain. (True)
Infants can and do feel pain. The belief that infants can't feel pain due to a poorly developed central nervous system has led to some terrible practices for children.4-5
5. The use of placebos is a good way to determ ine if a client's pain is physical or psychological. (False)
The use of placebos is unethical, and since pain is not a purely physical sensation, some people may have a positive response to a placebo, some of the time. This does not, however, prove that their pain is not real pain.6 Placebo relief may be due to increased production of endorphins by the body.7
6. Comatose clients are unable to experience pain. (False)
Actually, research suggests that comatose patients do experience pain. In a study by Puntillo, more than half of 24 patients in an intensive care unit, most of whom were unable to communicate due to intubation, reported that they had been in severe pain.8This is important for the nurse to remember. Many times when patients are no longer able to communicate, we tend to forget that their other senses remain intact. A good rule to follow is to medicate comatose patients for the same procedures and injuries you would medicate them for if they were awake.
7. The more experience a person has with pain, the higher their pain threshold will be. (False)
Actually, studies demonstrate that pain frequency and duration does not dull the sensation but instead accentuates it. Patients with chronic pain are the most vulnerable to poor pain management due to this misconception. The body's own pain relief mechanism (the production and release of endorphins) diminishes from prolonged pain. The same stimuli can, over time, produce more pain.9
8. Over 15 percent of all hospitalized patients will become addicted to pain medication. (False)
In one study of 11,882 patients who were given narcotics for pain control, only 4 eventually had a problem with chemical dependency later.10 Would you really under-medicate 11,878 patients because of the 4 who developed a dependency problem, which may or may not have been related to their hospitalization? Using a simple calculation, this study showed only a 0.003 percent incidence of addiction when narcotics were used to control pain. The unfounded belief that we will be contributing to chemical dependency in our clients is probably one of the most common reasons that nurses under-medicate their patients.
9. All pain has a physical cause, such as tissue damage or injury. (False)
All pain does not have a physical cause, at least not one that can be documented with diagnostic tests. The inability to diagnose the cause of pain does not mean that the pain does not exist. Many patients experience chronic non-malignant (benign) pain that has no apparent cause. As a nurse, have you ever experienced low back pain? Has it become a chronic condition? If you had X rays and a barrage of diagnostic tests they would probably all be normal. However, your pain would still exist. Chronic pain is difficult to understand. It affects about 11 percent of the population.11
10. Clients who are sleeping may be assumed to be pain-free. (False)11
Sleeping patients may or may not be having pain. Sleep is often used by people in pain as a coping mechanism.12 Other methods of coping include talking or visiting with friends and diversions such as music or television. One coping mechanism reported by patients is laughter. As nurses, we tend to base our interventions on the patient's response to pain. If patients "act" like they are in pain, we tend to believe them. If they do not act like they are in pain, we do not believe them. In fact, we use pain interventions to treat the patient's expression of pain rather than the pain itself. If that expression is in keeping with our beliefs of how a person in pain should act, we tend to treat this patient as if they indeed have pain. However, when the patient's behavior is not what we believe is appropriate, we are reluctant to use pain management interventions.
11. Opioidpain relic/lasts 4-6 hours in all patients. (False)
Opioid pain relief varies widely depending on route of administration, age and other factors.13Since there is a wide response range for analgesic relief, it is important that the nurse titrate the medication to the patients reported level of pain and side effects. The trick to good pain management is to find out how long the pain medication lasts for your patient.
12. Most people with pain experience acute pain. (False)
Actually, there are at least as many or more people with chronic pain as there are with acute pain. The problem is that chronic pain, especially chronic benign pain, is poorly understood. Much more research is needed in this area.14
13. The most reliable assessment tool for pain is vital signs. (False).
The most reliable assessment tool for pain is the patient's self-report. Remember, pain is a subjective experience. By the time the patient is hypertensive and tachycardic, the pain is "out of control." We would not want to wait this long before providing relief.15
14. Giving Phenergan with narcotics potentiates the analgesic effect of the narcotic. (False)
Phenothiazines, such as Phenergan, have long been thought to potentiate narcotics. This is what I was taught in school, and what I had taught my students. However, recent research indicates that this is not true; in fact, it may actually increase the perception of pain.16
15. Meperidine (Demerol) is the drug of choice for pain lasting more than 48 hours (such as post-op pain). (False)
Demerol was popular for many years. However, morphine is shown to be more useful for pain relief. Demerol is actually short-acting (2-4 hours). It is known to be irritating to tissues when given intramuscular and is only recommended for short-term (less than 48 hours) treatment of pain. It has harmful toxic metabolites and should be used with caution in patients with renal failure.17,18
16. Meperidine (Demerol) 75 mg is equivalent to morphine 10 mg. (True)
These two drugs are equivalent when given via the same route. The guidelines for equivalents come from The American Pain Society and will be discussed later in this text.
17. Chronic pain is worse than acute pain. (True)
Chronic pain is often worse than acute pain for several reasons. First, patients with acute pain know that an end to their discomfort is coming. People with chronic pain feel hopeless and depressed due to the inability to expect relief. Chronic pain depletes the body's endorphins and results in increased pain perception. Over time, chronic pain results in depression, inability to work or perform activities of daily living. The overall effect of chronic pain is a decrease in quality of life. Nurses often underestimate chronic pain and are less likely to report or treat chronic pain.19
18. There is a direct relationship between the amount of tissue damage and the amount of perceived pain. (False)
Contrary to popular belief, there is no correlation between the size of an injury and the amount of perceived pain. A laceration 2 inches long hurts the same as one 4 inches long. Keep this in mind when caring for surgical patients. Remember, it is not the length of the incision that counts.
19. Depression causes chronic pain. (False)
Many people believe that depression leads to chronic pain. Actually, chronic pain causes depression. It destroys quality of life. Practitioners often make the mistake of treating the depression rather than the pain which caused the depression. If I had pain for years, had been told that there was nothing anyone could do about it, and lost my job because of absenteeism, I might be depressed also.20
20. Nurses who have had personal experience with pain perceive higher levels of pain in their patients than nurses -who do not have this experience. (True)
Nurses who have experienced pain themselves tend to rate their patient's pain higher than nurses without this experience. This is logical and demonstrates how our own experiences shape our values and beliefs.21, 22
Next, let's look at the two scenarios. In the first scenario, we had a 35-year-old well-nourished male who had an exploratory lap 3 days ago. He reports pain as an 8 on a scale of 1-10, with 10 being the worst pain he has experienced. He is afebrile, but his blood pressure is elevated and he is tachycardic. When you enter his room, you note that he is moaning and diaphoretic. It has been 3 hours since you last medicated him.
Which answer did you select for the first question?
If you gave him another 50 mg, ask yourself these questions.
If you gave him 75-100 mg, ask yourself these questions.
If you encouraged him to wait, ask yourself these questions.
What assessment data had the most influence on your decision?
In the second scenario we had an overweight, 28-year-old with chronic low back pain. No physical cause was found to account for her pain. Her vital signs are normal. She is often seen watching television and talking on the phone. She is always on her call light and has been extremely irritable. She rates her pain as a 7 on a scale of 1-10, with 10 being the worst pain she has ever experienced. She was last medicated 3 hours ago.
Which answer did you select for the first question?
If you gave another 50 mg, ask yourself the following questions.
If you increased the dose to 75 or 100 mg, ask yourself the following questions.
If you encouraged her to wait, ask yourself the following.
Which piece of assessment data influenced your decision above?
Some other areas to look at, related to these two scenarios, are that your own pain experiences played a part in your decision-making process. Also, your years of nursing experience and previous exposure to pain theory also played a part.
In the second scenario, the overweight female with chronic low back pain is often perceived to be a lazy person who has caused her own problems. “If she would go on a diet and lose weight, her back wouldn't hurt”. While her weight may be a factor in her pain, it may very well have been caused by the depression and immobility that results from chronic low back pain.
It is often difficult to overcome our own bias. The 35-year-old male who is moaning and crying may be seen as a “baby.” In our society this is not perceived as manly behavior.
In general, we are more likely to increase the medication dose and frequency in the post-operative patient, rather than the patient with chronic pain. Nurses tend to be reluctant to medicate patients when a physical cause for the pain is unknown.
For the very astute reader, if you wanted to get the medication order changed from Demerol to morphine for either of these patients, you have a good grasp of the other problems associated with pain management. Many times the drug ordered is not appropriate for the type of pain we are managing.
Now that we have looked at some commonly held myths and stereotypes, we should be more receptive to our patients' reports of pain. At the beginning of this course I asked you to rate yourself on how well you control your clients' pain. If you were to evaluate your past history again, how would you rate yourself?
If you rated yourself lower than previously, you have made the first step toward improving your practice and your patient's quality of life.