ANCC Pain Management Nursing 2 — Questions and Answers
Question 1: A patient on a PCA pump is found difficult to arouse with respiratory rate 8/min and pinpoint pupils. Which nursing action is the immediate priority?
- Increase the PCA demand dose since the patient appears to have inadequate pain control
- Stop the PCA, stimulate the patient, provide supplemental oxygen, and prepare naloxone (Correct answer)
- Decrease the lockout interval to give the patient more control
- Notify the pharmacy to adjust PCA settings and reassess in 30 minutes
Correct answer: Stop the PCA, stimulate the patient, provide supplemental oxygen, and prepare naloxone
The patient shows opioid-induced respiratory depression: somnolence, RR below 10, pinpoint pupils. Immediate actions: stop the PCA, stimulate the patient, apply oxygen, prepare naloxone 0.4 mg IV, notify provider stat.
Opioid-induced respiratory depression (OIRD): (1) STOP the PCA; (2) Stimulate patient — sternal rub; if responsive with RR at or above 8, monitor closely and may hold naloxone; (3) Apply O2, maintain airway; (4) Naloxone (Narcan) if RR below 8 or unresponsive: dilute 0.4 mg to 10 mL NS, give 0.1 mg increments every 2 minutes until RR above 10; avoid large bolus doses (cause acute withdrawal, pain crisis, pulmonary edema, arrhythmias); (5) Bag-valve-mask if apneic; (6) Monitor continuously since naloxone half-life of 30-90 minutes is shorter than most opioids; (7) Notify provider stat. PCA safety: ONLY the patient presses the button.
Question 2: A patient with neuropathic pain from diabetic peripheral neuropathy needs medication. Which first-line agent is most evidence-supported?
- Ibuprofen 600 mg every 8 hours
- Duloxetine (Cymbalta) or pregabalin (Lyrica) (Correct answer)
- Oxycodone extended release 10 mg every 12 hours
- Tramadol 50 mg every 6 hours as needed
Correct answer: Duloxetine (Cymbalta) or pregabalin (Lyrica)
First-line treatments for diabetic peripheral neuropathy per ADA, AAN, and NeuPSIG guidelines are duloxetine (SNRI), pregabalin (alpha-2-delta ligand), or gabapentin.
Neuropathic pain pharmacotherapy (NeuPSIG): First-line: SNRIs (duloxetine — FDA-approved for DPN and fibromyalgia; venlafaxine); alpha-2-delta ligands (pregabalin — FDA-approved for DPN, PHN, fibromyalgia; gabapentin); TCAs (amitriptyline, nortriptyline — effective but more side effects). Second-line: tramadol (weak opioid/SNRI), topical lidocaine for localized neuropathy. Third-line: strong opioids (last resort). NSAIDs have minimal efficacy for neuropathic pain. Neuropathic pain involves ectopic firing and central sensitization that traditional prostaglandin-targeting analgesics cannot effectively address.
Question 3: Which mnemonic is most useful for performing a comprehensive pain assessment?
- ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
- OLDCARTS (Onset, Location, Duration, Character, Alleviating/Aggravating factors, Radiation, Timing, Severity) (Correct answer)
- SBAR (Situation, Background, Assessment, Recommendation)
- RACE (Rescue, Alarm, Contain, Extinguish)
Correct answer: OLDCARTS (Onset, Location, Duration, Character, Alleviating/Aggravating factors, Radiation, Timing, Severity)
OLDCARTS is a comprehensive pain assessment mnemonic covering all essential dimensions: Onset, Location, Duration, Character, Alleviating/Aggravating factors, Radiation, Timing, and Severity.
OLDCARTS: O = Onset (when, sudden vs. gradual); L = Location (where exactly); D = Duration (constant vs. intermittent, how long); C = Character (sharp, burning, aching, stabbing, throbbing — neuropathic vs. nociceptive clues); A = Alleviating AND Aggravating factors (position, activity, heat, cold, medications); R = Radiation (does it spread); T = Timing (when, relation to meals, activity, rest); S = Severity (numeric rating 0-10 or descriptive scale). Complete assessment also includes impact on ADLs, sleep, and mood; previous treatments; current medications; and patient goals.
Question 4: A patient takes oxycodone 30 mg orally every 12 hours and is switching to IV morphine. What IV morphine dose per 24 hours is approximately equivalent?
- 30 mg IV morphine per 24 hours
- 20 mg IV morphine per 24 hours (Correct answer)
- 60 mg IV morphine per 24 hours
- 10 mg IV morphine per 24 hours
Correct answer: 20 mg IV morphine per 24 hours
Total daily oral oxycodone = 60 mg. Converting to OME: 60 mg x 1.5 = 90 mg oral morphine/24hr. Converting oral to IV (3:1): 90/3 = 30 mg IV morphine/24hr. After 25-30% dose reduction for incomplete cross-tolerance: approximately 20-22 mg IV morphine/24hr.
Opioid equianalgesic conversion: oral oxycodone 20 mg = oral morphine 30 mg = IV/SC morphine 10 mg (3:1 oral-to-IV morphine ratio). Step 1: total daily oral oxycodone = 30 mg x 2 doses = 60 mg. Step 2: convert to OME: 60 mg x 1.5 = 90 mg oral morphine/24hr. Step 3: convert oral to IV morphine: 90/3 = 30 mg IV morphine/24hr. Step 4: apply 25-30% dose reduction for incomplete cross-tolerance = 21-22.5 mg, rounded to 20 mg. Always use equianalgesic tables as guides not absolute values; titrate based on clinical response.
Question 5: Which validated screening tool is most appropriate for assessing opioid use disorder risk before initiating chronic opioid therapy?
- AUDIT-C (Alcohol Use Disorders Identification Test-Concise)
- ORT (Opioid Risk Tool) or DIRE (Diagnosis, Intractability, Risk, Efficacy) score (Correct answer)
- CAGE questionnaire for alcohol screening
- DAST-10 (Drug Abuse Screening Test)
Correct answer: ORT (Opioid Risk Tool) or DIRE (Diagnosis, Intractability, Risk, Efficacy) score
The ORT and DIRE score are validated instruments specifically designed to predict opioid misuse risk in patients being considered for chronic opioid therapy.
Pre-opioid therapy risk stratification tools: ORT (Opioid Risk Tool) — 5-item self-report: family/personal history of substance abuse, age 16-45, preadolescent sexual abuse history, psychological disease; scores 0-3 (low), 4-7 (moderate), 8 or more (high risk); DIRE — clinician-rated; SOAPP-R — 24-item self-report; PDMP — mandatory in most states before prescribing; urine drug screening at baseline. AUDIT-C and CAGE are for alcohol use disorder; DAST-10 screens for general drug abuse. CDC Clinical Practice Guidelines (2022) recommend universal precautions including risk assessment before chronic opioid therapy.
Question 6: A patient receiving epidural analgesia develops sudden onset lower extremity weakness and urinary retention. Which nursing action is the immediate priority?
- Continue epidural infusion and reassess in 2 hours
- Stop the epidural infusion, notify the provider immediately, and prepare for emergency MRI (Correct answer)
- Reposition the patient and reassess — weakness is expected with epidurals
- Increase epidural infusion rate to improve analgesia
Correct answer: Stop the epidural infusion, notify the provider immediately, and prepare for emergency MRI
New-onset bilateral lower extremity weakness and urinary retention with epidural raises immediate concern for epidural hematoma or abscess — neurosurgical emergencies requiring urgent MRI. Delay can cause permanent paralysis.
Epidural neurological emergencies: Epidural hematoma (rare, 1 in 150,000-220,000); risk factors: anticoagulation, coagulopathy, traumatic placement; onset hours to days; symptoms: back pain, lower extremity weakness or paralysis, urinary/bowel dysfunction; time-sensitive — permanent paralysis if not decompressed within 6-8 hours. Epidural abscess: delayed onset, fever, back pain, progressive neurological deficit; diagnosed by urgent MRI. IMMEDIATE actions: stop epidural infusion; stat notification of anesthesiology/neurosurgery/provider; document neurological assessment; prepare for emergency MRI; prepare for potential OR. NEW motor deficits after epidural are an emergency.
ANCC Pain Management Nursing 2
A patient on a PCA pump is found difficult to arouse with respiratory rate 8/min and pinpoint pupils.
Which nursing action is the immediate priority?