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). 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

Pain Transmission

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

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 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)

PCA Infusion Pump

Spinal Analgesia Epidural analgesia Intrathecal (subarachnoid) analgesia

Implantable Devices

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

Physical Interventions

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

Surgical Procedures for the Alleviation of Pain

Community-Based Care Home care management Health teaching Health care resources

Care of Preoperative Patients

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.

Skin Preparation for Common Surgical Sites

Patient and Family Teaching Tubes Drains Vascular access

Prevention of Respiratory Complications Breathing exercises Incentive spirometry Coughing and splinting

Patient Using Incentive Spirometer

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

External Pneumatic Compression Devices

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.

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.

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 Drugs Reduce anxiety Promote relaxation Reduce nasal and oral secretions Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion Decrease the amount of anesthetic needed for the induction and maintenance of anesthesia

Patient Transfer to Surgical Suite

Care of Intraoperative Patients

Members of the Surgical Team Surgeon and surgical assistant Anesthesia providers: Anesthesiologist and CRNA Holding area nurse Circulating nurse Scrub nurse Surgical technologist Specialty nurses

Operating Room

Minimally Invasive and Robotic Surgery

Environment of the Operating Room Preparation of the surgical suite and team safety Layout Health and hygiene of the surgical team Surgical attire Surgical scrub

Surgical Asepsis

Surgical Scrub, Gowning, and Gloving

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

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

Four Stages of General Anesthesia Stage 1—analgesia and sedation, relaxation Stage 2—excitement, delirium Stage 3—operative anesthesia, surgical anesthesia Stage 4—danger Emergence—recovery from anesthesia

Administration of General Anesthesia Inhalation IV injection Balanced anesthesia Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents

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

Complications from General Anesthesia Malignant hyperthermia; possible treatment with dantrolene Overdose Unrecognized hypoventilation Complications of specific anesthetic agents Complications of intubation

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

Regional Anesthesia Type of local anesthesia that blocks multiple peripheral nerves in a specific body region Field block Nerve block Spinal block Epidural block

Nerve Block Sites

Spinal and Epidural Anesthesia

Complications of Local or Regional Anesthesia Anaphylaxis Incorrect delivery technique Systemic absorption Overdose 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 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

Surgical Positions

Risk for Perioperative Positioning Injury Interventions include: Proper body position Risk for pressure ulcer formation Prevention of obstruction of circulation, respiration, and nerve conduction

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

Common Skin Closures

Potential for Hypoventilation Continuous monitoring of: Breathing Circulation Cardiac rhythms Blood pressure and heart rate Continuous presence of an anesthesia provider