Pain: The Fifth Vital Sign. Definitions of Pain Pain is an unpleasant sensory and emotional...
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Transcript of Pain: The Fifth Vital Sign. Definitions of Pain Pain is an unpleasant sensory and emotional...
Definitions of PainPain 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 PainTypes of pain:
Acute painChronic pain:
Chronic cancer painChronic non-cancer pain
Sources of pain:Nociceptive pain types:
Somatic painVisceral 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” patientFear 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
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
Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d)
Collaborative ManagementHistoryPhysical assessment/clinical
manifestations:Location of pain:
Localized painProjected painRadiating painReferred pain
Pain Pharmacologic Therapy—Non-Opioid Analgesics Acetylsalicylic acid (aspirin) and
acetaminophen (Tylenol) are most common Most are NSAIDs, including aspirin:
Can cause GI disturbancesCOX-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 AnalgesicsBlock the release of neurotransmitters in
the spinal cordDrugs include codeine, oxycodone,
morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone
WHO Analgesic LadderWorld 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-opioidsLevel 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 usedPRN range ordersPatient-controlled analgesia (PCA)
Adjuvant AnalgesicsAntiepileptic drugsTricyclic antidepressantsAntianxiety agentsLocal anestheticsDextromethorphan, ketamineLocal anesthesia infusion pumpsTopical medications
Nonpharmacologic Interventions Used alone or in combination with drug
therapyPhysical measuresPhysical and occupational therapyCognitive/behavioral measures
Cognitive/Behavioral MeasuresStrategies that can be used to relieve pain
as adjuncts to drug therapy:Distraction ImageryRelaxation techniquesHypnosis AcupunctureGlucosamine
Invasive Techniques for Chronic Pain
Nerve blocksSpinal cord stimulationSurgical techniques:
RhizotomyCordotomy
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.
Collaborative Management Assessment
History and data collection:AgeDrugs and substance useMedical history, including cardiac and
pulmonary historiesPrevious surgical procedures and
anesthesiaBlood donationsDischarge 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 systemRespiratory systemRenal/urinary systemNeurologic systemMusculoskeletal systemNutritional statusPsychosocial assessment
Laboratory AssessmentUrinalysisBlood type and crossmatchComplete blood count or hemoglobin
level and hematocritClotting studiesElectrolyte levelsSerum creatinine levelPregnancy testChest x-ray examinationElectrocardiogram
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 RestrictionsNPO: 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 diseaseRespiratory diseaseSeizuresHypertension
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 PreparationA break in the skin increases risk for
infection.Patient may be asked to shower using
antiseptic solution.
Prevention of Respiratory Complications Breathing exercisesIncentive spirometryCoughing and splinting
Prevention of Cardiovascular ComplicationsBe aware of patients at greater risk for DVTAntiembolism stockingsPneumatic compression devicesLeg exercisesMobility
Anxiety InterventionsPreoperative teachingEncouraging communicationPromoting restUsing distractionTeaching family members
Preoperative Chart ReviewEnsure 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.
Preoperative Patient PreparationPatient 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.
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.
Preoperative DrugsReduce anxietyPromote relaxationReduce nasal and oral secretionsPrevent laryngospasmReduce vagal-induced bradycardiaInhibit gastric secretionDecrease the amount of anesthetic needed
for the induction and maintenance of anesthesia
Members of the Surgical TeamSurgeon and surgical assistantAnesthesia providers:
Anesthesiologist and CRNAHolding area nurseCirculating nurseScrub nurseSurgical technologist Specialty nurses
Environment of the Operating RoomPreparation of the surgical suite and team
safetyLayoutHealth and hygiene of the surgical teamSurgical attireSurgical scrub
AnesthesiaInduced 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
General AnesthesiaReversible 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
Four Stages of General AnesthesiaStage 1—analgesia and sedation,
relaxationStage 2—excitement, deliriumStage 3—operative anesthesia, surgical
anesthesiaStage 4—dangerEmergence—recovery from anesthesia
Administration of General AnesthesiaInhalationIV injectionBalanced anesthesia Adjuncts to general anesthetic agents:
hypnotics, opioid analgesics, neuromuscular blocking agents
Balanced AnesthesiaCombination of IV drugs and inhalation
agents used to obtain specific effectsExample: thiopental for induction, nitrous
oxide for amnesia, morphine for analgesia, and pancuronium for muscle relaxation
Complications from General AnesthesiaMalignant hyperthermia; possible
treatment with dantroleneOverdoseUnrecognized hypoventilationComplications of specific anesthetic agentsComplications of intubation
Local AnesthesiaBriefly disrupts sensory nerve impulse
transmission from a specific body area or region
Delivered topically and by local infiltrationPatient remains conscious and able to
follow instructions
Regional Anesthesia Type of local anesthesia that blocks
multiple peripheral nerves in a specific body regionField blockNerve blockSpinal blockEpidural block
Complications of Local or Regional Anesthesia AnaphylaxisIncorrect delivery techniqueSystemic absorptionOverdose Local complications
Treatment of Complications Establish open airway.Give oxygen.Notify the surgeon.Fast-acting barbiturate is usual treatment.Epinephrine for unexplained bradycardia.
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.
Collaborative ManagementAssessmentMedical record reviewAllergies and previous reactions to
anesthesia or transfusionsAutologous blood transfusionLaboratory and diagnostic test resultsMedical history and physical examination
findings
Risk for Perioperative Positioning InjuryInterventions include:Proper body positionRisk for pressure ulcer formationPrevention of obstruction of circulation,
respiration, and nerve conduction
Impaired Skin Integrity and Impaired Tissue IntegrityInterventions include:Plastic adhesive drapeSkin closures, sutures and staples,
nonabsorbable suturesInsertion of drainsApplication of dressingTransfer of patient from the operating room
table to a stretcher