Pain: The Fifth Vital Sign and Management Strategies

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: • Acute pain • Chronic pain: • Chronic cancer pain • Chronic non-cancer pain • Sources of pain: • Nociceptive pain types: • Somatic pain • Visceral pain • Neuropathic pain

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. 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

8. Collaborative Management • History • Physical assessment/clinical manifestations: • Location of pain: • Localized pain • Projected pain • Radiating pain • Referred 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 • Constipation • Sedation • Respiratory depression

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 • Tricyclic antidepressants • Antianxiety agents • Local anesthetics • Dextromethorphan, ketamine • Local anesthesia infusion pumps • Topical medications

21. Nonpharmacologic Interventions • Used alone or in combination with drug therapy • Physical measures • Physical and occupational therapy • Cognitive/behavioral measures

22. Physical Interventions

23. Cognitive/Behavioral Measures • Strategies that can be used to relieve pain as adjuncts to drug therapy: • Distraction • Imagery • Relaxation techniques • Hypnosis • Acupuncture • Glucosamine

24. Invasive Techniques for Chronic Pain • Nerve blocks • Spinal cord stimulation • Surgical techniques: • Rhizotomy • Cordotomy

25. Surgical Procedures for the Alleviation of Pain

26. Community-Based Care • Home care management • Health teaching • 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 • Curative • Restorative • Palliative • Cosmetic

30. Urgency and Degree of Risk of Surgery • Urgency: • Elective • Urgent • Emergent • Degree of Risk: • Minor • Major

31. Extent of Surgery • Simple • Radical • Minimally invasive

32. 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

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 • Respiratory system • Renal/urinary system • Neurologic system • Musculoskeletal system • Nutritional status • Psychosocial assessment

35. 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

36. 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.

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: • Cardiac disease • Respiratory disease • Seizures • Hypertension

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 • Drains • Vascular access

44. Prevention of Respiratory Complications • Breathing exercises • Incentive spirometry • Coughing and splinting

45. Patient Using Incentive Spirometer

46. Prevention of Cardiovascular Complications • Be aware of patients at greater risk for DVT • Antiembolism stockings • Pneumatic compression devices • Leg exercises • Mobility

47. External Pneumatic Compression Devices

48. Anxiety Interventions • Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • 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 allergies. • 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.