Definitions of Pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999).Self-report is always the most reliable indication of pain.
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1. Pain: The Fifth Vital Sign
2. Definitions of Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999).
Self-report is always the most reliable indication of pain.
3. Types of Pain Types of pain:
Chronic cancer pain
Chronic non-cancer pain
Sources of pain:
Nociceptive pain types:
4. Pain Transmission
5. Attitudes and Practices Related to Pain Attitudes of health care providers and nurses affect interaction with patients experiencing pain.
Many patients are reluctant to report pain:
Desire to be a “good” patient
Fear of addiction
6. Addiction, Pseudoaddiction, Tolerance, and Physical Dependence Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain
Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time
7. Physical dependence—adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions
8. Collaborative Management History
Physical assessment/clinical manifestations:
Location of pain:
9. Pain Pharmacologic Therapy— Non-Opioid Analgesics Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common
Most are NSAIDs, including aspirin:
Can cause GI disturbances
COX-2 inhibitors for long-term use
10. Non-Opioid Analgesics (Cont’d) Acetaminophen (Tylenol):
Available in liquid form; can be taken on empty stomach
Preferable for patients for whom GI bleeding is likely
Can cause renal or liver toxicity if used long-term
11. Pain Pharmacologic Therapy— Opioid Analgesics Block the release of neurotransmitters in the spinal cord
Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone
12. Side Effects of Opioids Nausea and vomiting
13. WHO Analgesic Ladder World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain)
Level 1 pain (1-3 rating)—Use non-opioids
Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug
Level 3 pain (7-10 rating)—Use strong opioids
14. Pain Management in End of Life Opioid regimen should stay consistent with dose in weeks before last weeks of life
Generally believed that patient still feels pain when unconscious
Does not hasten death unless the dose was not properly and gradually titrated
15. Routes of Opioid Administration Can be administered by every route used
PRN range orders
Patient-controlled analgesia (PCA)
16. PCA Infusion Pump
17. Spinal Analgesia Epidural analgesia
Intrathecal (subarachnoid) analgesia
19. Implantable Devices
20. Adjuvant Analgesics Antiepileptic drugs
Local anesthesia infusion pumps
21. Nonpharmacologic Interventions Used alone or in combination with drug therapy
Physical and occupational therapy
22. Physical Interventions
23. Cognitive/Behavioral Measures Strategies that can be used to relieve pain as adjuncts to drug therapy:
24. Invasive Techniques for Chronic Pain Nerve blocks
Spinal cord stimulation
25. Surgical Procedures for the Alleviation of Pain
26. Community-Based Care Home care management
Health care resources
27. Care of Preoperative Patients
28. Preoperative Period Begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite.
Nurse functions as educator, advocate, and promoter of health and safety.
29. Reason for Surgery Diagnostic
30. Urgency and Degree of Risk of Surgery Urgency:
Degree of Risk:
31. Extent of Surgery Simple
32. Collaborative Management Assessment History and data collection:
Drugs and substance use
Medical history, including cardiac and pulmonary histories
Previous surgical procedures and anesthesia
33. Physical Assessment/Clinical Manifestations Obtain baseline vital signs.
Focus on problem areas identified by the patient’s history and on all body systems affected by the surgical procedure.
Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.
34. System Assessment Cardiovascular system
35. Laboratory Assessment Urinalysis
Blood type and crossmatch
Complete blood count or hemoglobin level and hematocrit
Serum creatinine level
Chest x-ray examination
36. Deficient Knowledge Interventions Preoperative teaching.
Surgeon is responsible for obtaining signed consent before sedation and/or surgery.
The nurse’s role is to clarify facts presented by the physician and dispel myths that the patient or family may have about surgery.
37. Implementing Dietary Restrictions NPO: Patient advised not to ingest anything by mouth for 6 to 8 hours before surgery:
Decreases the risk for aspiration.
Patients should be given written and oral directions to stress adherence.
Surgery can be cancelled if not followed.
38. Administering Regularly Scheduled Medications Medical physician and anesthesia provider should be consulted for instructions about regularly taken prescriptions before surgery.
Drugs for certain conditions often allowed with a sip of water before surgery:
39. Intestinal Preparation Bowel or intestinal preparations performed to prevent injury to the colon and to reduce the number of intestinal bacteria.
Enema or laxative may be ordered by the physician.
40. Skin Preparation A break in the skin increases risk for infection.
Patient may be asked to shower using antiseptic solution.
41. Skin Preparation for Common Surgical Sites
42. Patient and Family Teaching Tubes
44. Prevention of Respiratory Complications Breathing exercises
Coughing and splinting
45. Patient Using Incentive Spirometer
46. Prevention of Cardiovascular Complications Be aware of patients at greater risk for DVT
Pneumatic compression devices
47. External Pneumatic Compression Devices
48. Anxiety Interventions Preoperative teaching
Teaching family members
49. Preoperative Chart Review Ensure all documentation, preoperative procedures, and orders are complete.
Check the surgical consent form and others for completeness.
Document height and weight.
50. Preoperative Chart Review (Cont’d) Ensure results of all laboratory and diagnostic tests are on the chart.
Document and report any abnormal results.
Report special needs and concerns.
51. Preoperative Patient Preparation Patient should remove most clothing and wear a hospital gown.
Valuables should remain with family member or be locked up.
Tape rings in place if they cannot be removed.
Remove all pierced jewelry.
52. Preoperative Patient Preparation (Cont’d) Patient wears an identification band.
Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.
53. Preoperative Drugs Reduce anxiety
Reduce nasal and oral secretions
Reduce vagal-induced bradycardia
Inhibit gastric secretion
Decrease the amount of anesthetic needed for the induction and maintenance of anesthesia
54. Patient Transfer to Surgical Suite
55. Care of Intraoperative Patients
56. Members of the Surgical Team Surgeon and surgical assistant
Anesthesiologist and CRNA
Holding area nurse
57. Operating Room
58. Minimally Invasive and Robotic Surgery
59. Environment of the Operating Room Preparation of the surgical suite and team safety
Health and hygiene of the surgical team
60. Surgical Asepsis
61. Surgical Scrub, Gowning, and Gloving
62. Anesthesia Induced state of partial or total loss of sensation, occurring with or without loss of consciousness
Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve a controlled level of unconsciousness
63. General Anesthesia Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system
Involves a single agent or a combination of agents
64. Four Stages of General Anesthesia Stage 1—analgesia and sedation, relaxation
Stage 2—excitement, delirium
Stage 3—operative anesthesia, surgical anesthesia
Emergence—recovery from anesthesia
65. Administration of General Anesthesia Inhalation
Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents
66. Balanced Anesthesia Combination of IV drugs and inhalation agents used to obtain specific effects
Example: thiopental for induction, nitrous oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation
67. Complications from General Anesthesia Malignant hyperthermia; possible treatment with dantrolene
Complications of specific anesthetic agents
Complications of intubation
68. Local Anesthesia Briefly disrupts sensory nerve impulse transmission from a specific body area or region
Delivered topically and by local infiltration
Patient remains conscious and able to follow instructions
69. Regional Anesthesia Type of local anesthesia that blocks multiple peripheral nerves in a specific body region
70. Nerve Block Sites
71. Spinal and Epidural Anesthesia
72. Complications of Local or Regional Anesthesia Anaphylaxis
Incorrect delivery technique
73. Treatment of Complications Establish open airway.
Notify the surgeon.
Fast-acting barbiturate is usual treatment.
Epinephrine for unexplained bradycardia.
74. Conscious Sedation IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness.
Patient maintains a patent airway and can respond to verbal commands.
Amnesia action is short with rapid return to ADLs.
Etomidate, diazepam, midazolam, meperidine, fentanyl, alfentanil, and morphine sulfate are the most commonly used drugs.
75. Collaborative Management Assessment
Medical record review
Allergies and previous reactions to anesthesia or transfusions
Autologous blood transfusion
Laboratory and diagnostic test results
Medical history and physical examination findings
76. Surgical Positions
77. Risk for Perioperative Positioning Injury Interventions include:
Proper body position
Risk for pressure ulcer formation
Prevention of obstruction of circulation, respiration, and nerve conduction
78. Impaired Skin Integrity and Impaired Tissue Integrity Interventions include:
Plastic adhesive drape
Skin closures, sutures and staples, nonabsorbable sutures
Insertion of drains
Application of dressing
Transfer of patient from the operating room table to a stretcher
79. Common Skin Closures
80. Potential for Hypoventilation Continuous monitoring of:
Blood pressure and heart rate
Continuous presence of an anesthesia provider