Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 15 Pain Management
1. Have you ever felt you should Cut down on your drinking?
2. Have you ever felt Annoyed by others questioning your drinking?
3. Has your drinking ever made you feel Guilty?
4. Do you need a drink first thing in morning for an Eye-opener?
In addition, the following tests may be performed.
•
Blood alcohol levels.
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Screening tests for drug use:
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Blood work.
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Urinalysis.
TREATMENTS
Those treatments for alcohol abuse that include behavior modification seem to be
the most effective. Often, a combination of behavior modification, support group,
and/or medication may be needed.
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ABCs of emergency support—airway, breathing, circulation.
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Inpatient facilities.
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Outpatient settings.
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Counseling.
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Support groups.
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Abstinence.
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Behavior modification.
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Activated charcoal.
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Toxicity medications:
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For opiods:
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naloxone
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nalmefene
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For benzodiazepines:
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flumazenil
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For alcohol:
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acamprosate
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disulfiram
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Medical-Surgical Nursing Demystified
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For acetaminophen:
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acetylcysteine
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For ethylene glycol:
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fomepizole
NURSING DIAGNOSES
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Ineffective denial.
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Hopelessness.
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Altered family processes: alcoholism.
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Ineffective individual coping.
NURSING INTERVENTIONS
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Prevent relapse.
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Instruct the patient:
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Adopt strategies to cope with cravings.
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Use of medication.
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Physical symptoms of withdrawal.
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Benefit of attendance at group sessions.
Drug Addiction
Drug addiction is the chronic overuse and abuse of legal or illegal substances
causing interpersonal, social, and family problems. Addiction occurs when the use
of the substance causes an abnormal physical or psychological dependence in
which the sudden discontinuance will cause severe trauma. This differs from tol-
erance in which the desired effectiveness of the drug diminishes over time. Larger
quantities of the drug must be used to achieve the same effect. Severe addiction
is usually characterized by the inability to carry out work requirements, school
responsibilities, or family obligations and duties.
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CHAPTER 15 Pain Management
WHAT WENT WRONG?
Some patients who take pain medications other than directed or to achieve a sen-
sation different than pain relief are more at risk for addiction. Addiction is a multi-
faceted problem caused by peer pressure, genetic factors, social nonconformity,
stress, depression, and mental anxiety. Those who have a family member with an
addiction or who have themselves had an addiction in the past are at an increased
risk. Societal pressures and environmental pressures can influence the probability
of becoming addicted. Research has determined that long-term drug use results in
changes in brain function, which increases the compulsion to abuse drugs.
PROGNOSIS
People of all ages, young ones in particular, are dying in unprecedented numbers
because of their addictions. Most of the deaths are due to addiction to diverted pre-
scription analgesics, alcohol, and benzodiazepines. Since addiction is such a multi-
faceted problem, treatment prognosis varies greatly. Relapses, unfortunately, are
frequent. Studies have shown that females and older patients respond better to
treatment programs and have fewer relapses. The greatest incidence of drug addic-
tion occurs in males between the ages of 18 and 25. Active participation in a treat-
ment program increases the chances of success.
HALLMARK SIGNS AND SYMPTOMS
•
Tachycardia
•
Dilated pupils
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Restlessness
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Weight loss due to poor appetite
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Hypervigilance
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Euphoria
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Death due to overdose
INTERPRETING TEST RESULTS
•
Urinalysis for initial diagnoses and to monitor compliance; will determine
substance and toxicity.
•
Blood tests will identify the drug used up to 12 hours before testing
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TREATMENTS
•
ABCs of emergency support—airway, breathing, circulation.
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Referral to a specialist in substance abuse.
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Behavioral therapy (counseling, cognitive therapy, and/or psychotherapy).
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Avoidance of situations detrimental to well-being.
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Residential programs.
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Outpatient programs.
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Medications—methadone, naltrexone, and buproprion.
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Antidepressants—paroxetine, fluoxetine, sertraline, amitriptyline, and tra-
zodone.
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Mood stabilizers—olanzapine and risperidone.
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Acupuncture.
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Biofeedback.
NURSING DIAGNOSES
•
Altered family process
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Social isolation
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Risk for loneliness
NURSING INTERVENTIONS
•
Assess for HIV/AIDS, tuberculosis, and hepatitis.
•
Different approaches work for different people.
•
Drug abuse is a result of multiple issues and treatment must address all of
these issues.
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Explain to the patient:
•
Disease process.
•
Long-term treatment is more effective.
•
Benefit of continued counseling.
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Treatment, medications, and side effects.
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CHAPTER 15 Pain Management
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Detoxification.
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Benefit of avoidance of high-risk behaviors.
•
Recovery process is a long-term commitment.
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Strategies for coping.
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Prevention strategies.
Crucial Diagnostic Test
Urine Toxicology Screening
This test detects the presence of drugs in the urine. Urine screening is preferred
to blood screening because urine samples contain the substance for several days
after its use, whereas blood levels diminish after several hours. Hair and nail sam-
ples may also be required for certain tests. The test is done to detect commonly
used drugs, such as alcohol, anabolic steroids, amphetamines, barbiturates, benzo-
diazepines, cannabinoids, cocaine, methamphetamines, opiates, phencyclidine,
propoxyphene.
Before the test—Obtain informed consent if the specimen is needed for medical/
legal purposes. Urine specimen collection must be monitored to ensure the speci-
men has not been altered in any way. Be aware of which prescription medications
the patient is taking as some may alter the test results.
Quiz
1. You are caring for a patient who borrowed pain medication from a friend at
a beauty salon. She seems to be experiencing side effects of the medication.
Your most appropriate response would be:
(a) Stop the medication and call the friend’s practitioner.
(b) Continue the medication if pain relief is adequate.
(c) Instruct the patient as to the proper use of the medication.
(d) Take the medication with milk.
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2. The most appropriate assessment of the efficacy of administered pain med-
ication would be:
(a) The nurses visual assessment.
(b) Changes in blood pressure, pulse, and respiratory rate.
(c) The nurse’s verbal assessment.
(d) The patient’s perception measured on a pain scale.
3. Prior to giving a requested pain medication, you would:
(a) wait longer; the patient did not appear to be uncomfortable.
(b) administer after the family left.
(c) assess the vital signs.
(d) call the doctor.
4. An elderly patient has a two-year history of back pain from arthritis. You
would encourage:
(a) lifestyle modification and NSAIDs.
(b) use of narcotics for pain management.
(c) diagnostic tests.
(d) vigorous physical therapy.
5. It would not be unusual for a patient with chronic pain to be taking:
(a) tricyclic antidepressants.
(b) antibiotics.
(c) antidiabetic medications.
(d) hypertensive medications.
6. A two-day postoperative right-below-the-knee amputation patient complains
of severe right foot pain. Your appropriate nursing response would be to:
(a) refer the patient to psychiatry.
(b) explain to the patient the pain is not real because the foot is not there.
(c) medicate the patient for pain.
(d) encourage guided imagery or another diversion technique.
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7. Your postdischarge instructions for a 65-year-old male with peripheral neu-
ropathy from diabetes would include:
(a) Walk barefoot to increase the stimulation.
(b) Wear socks and shoes.
(c) Check feet weekly for wounds.
(d) Soak feet in hot water daily.
8. On the first postoperative day after a fractured femur, the patient is resting
quietly, watching TV. Your nursing interventions would include:
(a) asking the patient what their pain level is on a scale of 1 to 10.
(b) administering an ordered dose of opioid.
(c) encouraging ambulation.
(d) telling the next shift nurse not to give any pain medication.
9. A mother is concerned about her teenaged son who is depressed and irrita-
ble. His school teachers have called, concerned about his declining grades.
You would ask:
(a) if you can recommend a psychiatrist.
(b) if he has a fever.
(c) about any family history of substance use disorders.
(d) about any allergies.
10. An elderly patient with chronic arthritis asks you for suggestions for pain
relief. You advise
(a) increasing caffeine.
(b) marijuana.
(c) decreasing caffeine.
(d) guided imagery.
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Final Exam
1. A 55-year-old smoker who is normally in good health reports having had a
bad cough for the past three weeks. He does not have crackles, rhonchi, and
discolored, blood-tinged sputum. What would you expect his physician to
rule out?
(a) Asthma.
(b) Pneumonia.
(c) The flu.
(d) Lung cancer.
2. The patient experiences sudden pain in his right calf while sitting at home.
He is diagnosed with deep vein thrombosis (DVT). The first intervention
is to:
(a) apply ice packs to the affected area every 4 to 6 hours.
(b) increase dietary intake of foods rich in vitamin K.
(c) monitor platelet counts daily.
(d) use intermittent warm soaks of the affected area.
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3. While you are talking with the patient she becomes confused and begins
slurring her words. What would you expect the physician to do?
(a) Assess if the patient had an ischemic or hemorrhagic CVS.
(b) Administer TPA since this is within three hours of the CVA.
(c) Tell the patient to go home, get rest, and to call the physician in the
morning if the symptoms continue.
(d) Admit the patient and place her on bed rest.
4. The patient asks when she should take bisphosphonate medications for treat-
ment of osteoporosis. You tell her:
(a) on a full stomach.
(b) just before getting into bed.
(c) first thing in the morning on an empty stomach with a full glass of
water, 30 to 60 minutes before eating, and without lying down.
(d) with an acidic liquid such as orange juice.
5. Mary tells you that she has an undiagnosed case of hypothyroidism. What
symptoms would you expect her to present?
(a) Polydipsia and polyphagia.
(b) Fatigue and cold intolerance.
(c) Weight loss and hyperglycemia.
(d) Tachycardia and diarrhea.
6. You are caring for a patient who has had a transurethral resection of the
prostate for benign prostatic hypertrophy. There is continuous bladder irri-
gation set-up. You would notify the physician if you noted:
(a) any signs of hematuria.
(b) a change from clear red output to thicker, bright red output.
(c) a decrease in the amount of blood in the urine.
(d) the development of uremic pruritis.
7. A patient with a history of asthma is scheduled for an appendectomy. Because
of her asthma, you would include as part of the preoperative teaching the
need to perform postoperatively:
(a) coughing and deep breathing exercises.
(b) leg exercises.
(c) wound dressing changes.
(d) all of these.
8. When assessing the patient, you notice that there is contraction of his facial
muscle after tapping the facial nerve anterior to his ear. This is a sign of:
(a) hyponatremia.
(b) hypokalemia.
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