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Post-operative Pain Management. Paula Jarzemsky, Kari Hirvela, Cassie Voge UW Madison School of Nursing Spring, 2011. Disclaimer. All names and characters in the following slides are fictional. The protocols, patient education forms, etc. are current as of May, 2011.

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Post-operative Pain Management

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    1. Post-operative Pain Management Paula Jarzemsky, Kari Hirvela, Cassie Voge UW Madison School of Nursing Spring, 2011

    2. Disclaimer All names and characters in the following slides are fictional. The protocols, patient education forms, etc. are current as of May, 2011. Please see reference list near the end of the module for due credit to prior authors’ works which made this module possible. To hear audio clips, be in Slide Show mode and have your volume at an appropriate level.

    3. Informatics: navigate an Electronic Health Record (EHR); use high-quality information sources • Patient-centered care: provide compassionate, coordinated care based on respect for patient preferences, values and needs • Evidenced-based practice: locate a relevant clinical practice guideline; discriminate when to modify EBP based on clinical expertise or patient preferences QSEN CompetenciesIn this module you will learn more about:

    4. The place . . . The University of Wisconsin-Madison (UW) Hospital & Clinics

    5. Shift to Shift Hand Off NoteJen Smith, RN (day shift) gave verbal report to Chris, RN (PM shift) regarding the care of Carmen Gonzales using the standardized SBAR report. Carmen is a 56-year-old female with a history of CAD, CHF, HTN, type 2 diabetes mellitus. She was admitted through the emergency department on Sunday with osteomyelitis and gangrene of her leg and underwent wound debridement today (Monday). She returned to the surgical unit an hour ago.AVSSOxygen: RAPain: stable though 6/10, 2 mg IV morphine with reliefVascular access device sites intactOther tubes/linesDressing CDI (clean, dry, intact) Meet Carmen . . .

    6. Chris, RN. You completed a nurse residency program at UW Hospital and now carry your own patient assignment without direct supervision of a preceptor. Today, you will take care of Carmen after her surgery. Click the icon below to hear the verbal handoff/SBAR (shift-to-shift) report from the AM shift nurse . . . And you are . . .

    7. Check the EHR (Electronic Health Record) See the patient Talk to a colleague All the nurses on your unit are really busy right now, so this is not an option right now. What would you like to talk about anyway? Decision #1 (gather information)After hearing shift report, you decide to: Continue scenario . . .

    8. MAR (Medication Administration Record) Flow Sheets Physician’s Orders Check the EHR . . . After viewing all 3, click here to go back to ‘decision #1’

    9. 1500 VS: Flow Sheets Back to EHR Sedation Score 1

    10. MD Orders Back to EHR

    11. MAR Back EHR

    12. Initial observation of Carmen: Carmen is sitting up in bed, eyes closed and moaning quietly. Dressing clean, dry, and intact over L lower leg. Pulses 2+ bilateral. L foot is warm, with + movement and sensation. When asked about pain, Carmen begins to cry, reporting 8/10 pain at the surgical site. Click audio clip: See the patient . . . Back to ‘decision #1’

    13. You need to make a decision based on this information – with the current order, you cannot administer any more pain medication (Jen Smith, day shift RN last administered 2 mg of IV morphine at 2:30pm). What next?

    14. Click the below icons (in order) to listen to conversation: Chris, RN Dr. Sakei You decide to call for an order change: Chris, RN Dr. Sakei

    15. Decision #2 Now that a range order is available (2-6 mg Morphine IV every 2 hours PRN), you need to decide how much to give within this range. Keep in mind it is 3:30 pm and Carmen received 2 mg of IV morphine at 2:30 pm. 1 mg 6 mg 2 mg 3 mg

    16. Try again. This is less than the desired dose. Back to Q#2 1 mg

    17. Try again. This is less than the desired dose. 2 mg Back to Q#2

    18. Correct! If pain goal is not achieved, try 50% greater than the previous dose Link to Pain Management Reference 3 mg Continue scenario . . .

    19. Try again. This is higher than the desired dose and may cause negative side effects (nausea, sedation, respiratory depression) Click to view an evidence-based protocol: 6 mg Respiratory Depression & Narcan

    20. Decision #3 At 1600, you return to reevaluate Carmen’s pain. She describes her pain as moderately better, but still reports a pain rating of 6/10 . She drifts off to sleep once during the conversation, but is arousable. Respirations are shallow and regular, at a rate of 14/min. She denies any nausea. As you think about your assessment of Carmen ,you decide to: Give more IV morphine, as her pain rating is 6/10. Give no morphineand call Dr. Sakei to alert him of your assessment. Give no morphine, as she describes her pain as ‘moderately better’ and continue to monitor Carmen

    21. Try again. Administering more morphine may bring Carmen’s pain rating below a ‘6’, but she is already experiencing side effects (sedation). Remember to look at the “big picture” and not just the pain rating: Carmen verbalized ‘moderate pain relief’. Give more morphine Back to Q#3

    22. Try again. The MD will likely ask you to continue monitoring the patient – something you would do anyway. Call the MD Back to Q#3

    23. Best choice! Carmen seems groggy, so your best option is to hold off on giving any more morphine for now. Reassessment after giving a pain med is key: Carmen described her pain as “better”, even though she rated it as “6/10”. Monitor, no morphine Continue scenario . . .

    24. Decision #4It is 1645. You respond to Carmen’s call light and she has a pain rating of 8/10. What dose should you give and why: 3 mg: This dose provided best pain relief with manageable side effects. 2 mg: This dose provided minimal side effects. 0 mg: Tell Carmen she needs to wait until 1730 for her next dose. Try again. This dose was ineffective previously. Best choice, nice job! Try again. A pain rating of 8/10 needs intervention.

    25. Decision #5The next morning, Jose (Carmen's husband) comes to visit. Last night, Carmen experienced good pain relief and no side effects (other than yesterday’s transient sedation that you monitored well!). Jose does not like that she is taking IV pain medication. Carmen asks what other options she has. At this time, it is most appropriate for you to explain that: “I can reduce the dosage – let’s try 1 mg the next time you need medication.” “If Carmen feels ready to transition to other pain relief measures, let’s discuss options with the team.” “If there are alternatives to pain medication that have worked for you in the past, let’s talk about them.” “Postop pain is best managed with IV meds. Let’s stay with what works.” Good choice, well-done! There is another good choice . . . Try again. While this is a more collaborative approach, it may not achieve effective analgesia. Good choice, nice job! There is another good choice . . . Try again. This is not the most patient-centered response.

    26. Always assess your patient • Know how to access your facility’s pain algorithm and resources. • Consider cultural perspectives and involve the patient and family as much as possible in clinical decisions. • Understand the importance of integrating EB guidelines (pain algorithm, etc.) into your practice. • Click on the icons for other resources related to this scenario: Cultural Aspects of Pain Management (UWHC) Key Points Click ‘page down’ to view references. Pain Management Reference (UWHC) Pain Algorithm (UWHC)

    27. Gordon, D. & Pellino, T. (2005). Incidence and characteristics of Naloxone use in postoperative pain management. Pain Management Nursing 6 (1), pp. 30-36. • Gordon, D.B., Dahl, J., Phillips, P., Frandsen, J., Cowley, C., Foster, R.L., Fine, P.G., Miaskowski, C., Fishman, S., & Finley, R.S. (2004). The use of “as-needed” range orders for opioid analgesics in the management of acute pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing, 5(2), 53-58. • Pasero, C., Manwarren, R. & McCaffrey, M. (2007). IV opioid range orders for acute pain management. American Journal of Nursing 107 (2), 52-60. • Pasero,C., Portenoy, R.K., & McCaffery, M. (1999). Opioid analgesics. In M. McCaffery & Pasero (Eds.), Pain: clinical manual 2nd ed (pp. 161-299). St. Lous: Mosby. • Cultural Aspects of Pain Fast Fact - and University of Wisconsin Hospital and Clinics (Madison, WI) • Respiratory Depression from Opioids Fast Fact – University of Wisconsin Hospital and Clinics (Madison, WI) • Pain Algorithm – University of Wisconsin Hospital and Clinics (Madison, WI), adapted from Memorial Sloan-Kettering (New York, NY) • Pain Management Reference – University of Wisconsin Hospital and Clinics (Madison, WI) • Sedation Assessment Scale - University of Wisconsin Hospital and Clinics (Madison, WI) • Images of Carmen, EHR, MAR modified and used with permission from Elsevier SLS system. • All other images & audio clips from ClipArt within PowerPoint software application References You have completed the Post-Operative Pain Management Module.

    28. EB Pain Algorithm Back to Key Points

    29. Pain Management Reference (UWHC 2011) Back to Key Points Click here to continue to Question #3

    30. Cultural Aspects of Pain Back to Key Points

    31. Respiratory Depression Back to Q#2