# An adult is recovering from open abdominal surgery with scheduled multimodal analgesia. Which nursing actions are appropriate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368311&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

An adult is recovering from open abdominal surgery with scheduled multimodal analgesia. Which nursing actions are appropriate? Select all that apply.

1

Give oral ibuprofen and IV ketorolac together on a schedule to obtain additive anti-inflammatory effects and further reduce opioid use

2

Use PRN opioid medication as the primary strategy because acetaminophen and NSAIDs do not contribute meaningful relief after abdominal surgery

3

Delay each scheduled analgesic until the client requests it and rates pain at least 8 out of 10 to limit unnecessary medication exposure

4

Add nonpharmacologic measures such as positioning, cold therapy when appropriate, incision splinting, distraction, music, or mindfulness

5

Reassess pain and function with a validated scale after treatment and adjust the plan for response, adverse effects, and the client's goals

6

When not contraindicated, give scheduled acetaminophen and one NSAID, reserving the lowest effective opioid dose for breakthrough pain

## Explanation

Multimodal analgesia combines medications that act through different pathways with nonpharmacologic measures. Scheduled acetaminophen plus one appropriate NSAID can reduce opioid exposure; use the lowest effective opioid dose for breakthrough pain and individualize doses for hepatic, renal, bleeding, and age-related risk (Choice 6). Positioning, incision support, cold therapy when appropriate, distraction, music, and mindfulness can supplement medication (Choice 4). Reassessment of pain, function, adverse effects, and goals guides adjustment (Choice 5). Combining two NSAIDs increases renal, gastrointestinal, and bleeding risk without a useful additive analgesic benefit (Choice 1). Opioid-only treatment and waiting for severe pain undermine a scheduled multimodal plan (Choices 2 and 3).

## In-depth explanation

Multimodal Analgesia (MMA)
Targets multiple pain pathways:
1. Scheduled non-opioid base: acetaminophen + NSAID (when not contraindicated)
2. Regional/local: epidural, peripheral nerve block, local infiltration
3. Neuropathic adjuncts (when indicated): gabapentin/pregabalin
4. Opioid for breakthrough only, lowest effective dose, shortest duration
5. Nonpharmacologic adjuncts: positioning, ice/heat, splinting incision, ambulation, distraction, music, mindfulness, TENS

Reassessment Principles
- Validated pain scale (NRS 0-10, faces, behavioral, FLACC for pediatrics)
- Reassess at peak effect after dose: oral 60 min, IV 15-30 min
- Document effect, side effects (sedation, RR, nausea, constipation), function (cough/breath, ambulation)
- Adjust based on goals — comfort + function, not number alone

Common Pitfalls
- Opioid-only PRN regimen
- Waiting for severe pain before scheduled dose
- Two NSAIDs simultaneously (no additive benefit, additive toxicity)
- Acetaminophen overdose (>3-4 g/day; hepatotoxicity)
- NSAID in renal impairment, active GI bleed, recent CABG

Memory Tip
"Schedule non-opioid base + Block + Adjuncts; Opioid for breakthrough only"

## Clinical scenario

Scenario
Adult post open abdominal surgery on scheduled multimodal analgesia.

Care Bundle
1. Scheduled acetaminophen + NSAID base (when not contraindicated)
2. Opioid for breakthrough only, lowest effective dose
3. Nonpharmacologic adjuncts: incision splinting with cough, ice, positioning, ambulation, distraction, music
4. Reassess with validated scale at peak effect; adjust plan
5. Monitor side effects: sedation, RR, nausea, constipation, renal/GI for NSAID, hepatic for acetaminophen

Avoid
- Opioid-only PRN regimen
- Waiting for 8/10 before scheduled dose
- Two NSAIDs simultaneously
- Acetaminophen >3-4 g/day

## Key concepts

- **Multimodal Analgesia** — Combined use of agents and techniques that target different pain pathways to optimize pain control and minimize opioid use. Components: scheduled acetaminophen, scheduled NSAID (when not contraindicated), regional or local anesthesia (epidural, nerve block, local infiltration), neuropathic adjuncts when indicated (gabapentin/pregabalin), and nonpharmacologic measures. Opioids are reserved for breakthrough pain at the lowest effective dose for the shortest duration. Reduces opioid-related adverse events (respiratory depression, ileus, nausea, constipation, dependence).
- **Opioid-Sparing Strategy** — Practice that reduces total opioid exposure post-operatively by combining non-opioid analgesics, regional anesthesia, and nonpharmacologic adjuncts so that opioids are needed only for breakthrough pain. Goals: better pain control, faster recovery, less constipation/ileus, less respiratory depression, reduced risk of dependence. Especially important in older adults, opioid-naive clients, those with sleep apnea or BMI >30, and post-major surgery in the first 24-48 hours.
- **NSAID Safety in Post-Op Use** — Use only one NSAID at a time — combining NSAIDs (e.g., ibuprofen + ketorolac) does NOT increase analgesia but adds bleeding, GI, and renal toxicity. Cautions/contraindications: active GI bleed or peptic ulcer, severe renal impairment, post-CABG (avoid for at least 10-14 days), late pregnancy, severe heart failure, anticoagulant therapy with elevated bleeding risk. Ketorolac is limited to ≤5 days total parenteral or combined route to limit nephrotoxicity.

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