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Pain: The Fifth Vital Sign. 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).
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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.
Types of Pain • Types of pain: • Acute pain • Chronic pain: • Chronic cancer pain • Chronic non-cancer pain • Sources of pain: • Nociceptive pain types: • Somatic pain • Visceral pain • Neuropathic pain
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
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
Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d) • 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
Collaborative Management • History • Physical assessment/clinical manifestations: • Location of pain: • Localized pain • Projected pain • Radiating pain • Referred pain
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
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
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
Side Effects of Opioids • Nausea and vomiting • Constipation • Sedation • Respiratory depression
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
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
Routes of Opioid Administration • Can be administered by every route used • PRN range orders • Patient-controlled analgesia (PCA)
Spinal Analgesia • Epidural analgesia • Intrathecal (subarachnoid) analgesia
Adjuvant Analgesics • Antiepileptic drugs • Tricyclic antidepressants • Antianxiety agents • Local anesthetics • Dextromethorphan, ketamine • Local anesthesia infusion pumps • Topical medications
Nonpharmacologic Interventions • Used alone or in combination with drug therapy • Physical measures • Physical and occupational therapy • Cognitive/behavioral measures
Cognitive/Behavioral Measures • Strategies that can be used to relieve pain as adjuncts to drug therapy: • Distraction • Imagery • Relaxation techniques • Hypnosis • Acupuncture • Glucosamine
Invasive Techniques for Chronic Pain • Nerve blocks • Spinal cord stimulation • Surgical techniques: • Rhizotomy • Cordotomy
Community-Based Care • Home care management • Health teaching • Health care resources
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.
Reason for Surgery • Diagnostic • Curative • Restorative • Palliative • Cosmetic
Urgency and Degree of Risk of Surgery • Urgency: • Elective • Urgent • Emergent • Degree of Risk: • Minor • Major
Extent of Surgery • Simple • Radical • Minimally invasive
Collaborative Management Assessment • History and data collection: • Age • Drugs and substance use • Medical history, including cardiac and pulmonary histories • Previous surgical procedures and anesthesia • Blood donations • Discharge planning
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.
System Assessment • Cardiovascular system • Respiratory system • Renal/urinary system • Neurologic system • Musculoskeletal system • Nutritional status • Psychosocial assessment
Laboratory Assessment • Urinalysis • Blood type and crossmatch • Complete blood count or hemoglobin level and hematocrit • Clotting studies • Electrolyte levels • Serum creatinine level • Pregnancy test • Chest x-ray examination • Electrocardiogram
Deficient Knowledge Interventions • Preoperative teaching. • Informed consent: • 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.
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.
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: • Cardiac disease • Respiratory disease • Seizures • Hypertension
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.
Skin Preparation • A break in the skin increases risk for infection. • Patient may be asked to shower using antiseptic solution.
Patient and Family Teaching • Tubes • Drains • Vascular access
Prevention of Respiratory Complications • Breathing exercises • Incentive spirometry • Coughing and splinting
Prevention of Cardiovascular Complications • Be aware of patients at greater risk for DVT • Antiembolism stockings • Pneumatic compression devices • Leg exercises • Mobility
Anxiety Interventions • Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • Teaching family members
Preoperative Chart Review • Ensure all documentation, preoperative procedures, and orders are complete. • Check the surgical consent form and others for completeness. • Document allergies. • Document height and weight.
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.