Nursing Care of Clients in Acute Pain

1. Nursing Care of Clients in Acute Pain Larry Santiago, MSN, RN

2. The Fifth Vital Sign • Acute pain - Pain lasting from seconds to 6 months

3. The Fifth Vital Sign 2 • Chronic (malignant)pain - Lasts for 6 months or longer

4. The Fifth Vital Sign 3 • Cancer-related pain

5. Pathophysiology of Pain • Pain transmission - Among the nerve mechanisms and structures involved in the transmission of pain perceptions to and from the area of the brain that interprets pain are nociceptors

6. Pathophysiology of Pain 2 • Nociceptors • Free nerve endings in the skin that respond only to intense, potentially damaging stimuli • Part of complex multidirectional pathways

7. Pathophysiology of Pain 3 • Peripheral Nervous System - Nociception: the transmission of pain

9. Nursing Assessment of Pain Pain assessment is high subjective • Report of pain is a social transaction • Review the patient’s description of pain • Review the patient’s response to pain relief strategies

10. Characteristics of Pain • Intensity • Timing • Location • Quality • Personal meaning • Aggravating and alleviating factors • Pain behaviors

11. Pain Assessment • Visual Analogue Scales

12. Pain Assessment 2 • Faces Pain Scale

14. Nurse’s Role in Pain Management • Identify Goals • Elimination of pain may be unrealistic • Factors to determine goal: severity of pain, anticipated harmful effects of pain, anticipated duration of pain

15. Nurse’s Role in Pain Management 2 Establish Trust • Positive nurse-patient relationship and teaching are key • Teaching

16. Nurse’s Role in Pain Management 3 • Providing Care

17. Nurse’s Role in Pain Management 4 - Managing Anxiety

18. Pain Management Strategies • Premedication assessment • Ask the patient about allergies • Obtain medication history

19. Pain Management Strategies 2 • Individualized dosage • Based on the patient requirements rather than on standard

20. Patient-controlled analgesia (PCA) • Indications • Allows patients to control the administration of their own medication • The pump has predetermined safety limits

21. PCA 2 • Desired patient outcomes • To achieve better pain relief • Require less pain medication than those who are treated PRN • Can maintain a near-constant level of medication

22. PCA 3 • Patient education • Teach about operation of the pump • Side effects of the medication • Strategies to manage side effects

23. PCA 4 • Nursing implications • Warn family not to push PCA button • Be very careful when programming pump, can accidently overdose or underdose patient

24. Epidural Analgesia • Indications • Childbirth • Post-operative pain

25. Epidural 2 • Desired Patient Outcomes • Provide effective pain relief • Able to suppress the stress response

26. Epidural 3 • Patient education • Can provide pain relief for days after surgery • Often times a combination of narcotics and anesthetics are used • A PCA to give additional boluses may be implemented

27. Epidural 4 • Nursing implications -assess pain, motor, and sensory function -check LOC and sedation -assess epidural site for hematoma or displaced catheter -assess for CSF leakage

28. Acute pain management for the geriatric patient • Conditions that cause pain in older persons: • Exacerbations of degenerative joint disease • Flare-ups of chronic conditions like gout or rheumatoid arthritis • Trauma from falls

29. Acute pain management for the geriatric patient 2 • Conduct a baseline patient assessment • First priority for acute pain is relief through analgesics • Watch for greater possibilities of adverse effects • PCA may not be an option if patient has cognitive impairment

30. Perioperative Concepts and Nursing Management Larry Santiago, MSN, RN

31. Preoperative Phase • Begins with decision to proceed with surgical intervention • Baseline evaluation • Preparatory education

32. Intraoperative Phase • Begins when patient is transferred to operating room table • Provide for patient safety • Maintain aseptic environment • Provide surgeon with supplies and instruments • Documentation

33. Postoperative Phase • Admission to PACU • Maintain airway • Monitor vital signs • Assess effects of anesthesia • Assess for complications of surgery • Provide comfort and pain relief • Ends with follow-up evaluation in clinical setting or home

34. Preparation for Surgery • Informed Consent • Assessment of health factors that affect patients preoperatively

35. Definition • Informed consent – prior to granting a consent, the client must be fully informed regarding treatment, tests, surgery, etc., and must understand both the intended outcome and the potentially harmful results

36. Physician’s Responsibility • The clinician who will carry out the procedure has the responsibility of explaining to the patient its risks, benefits, and possible alternatives

37. Nurse’s Responsibility • If the patient has not adequately grasped the implications of the procedure, the nurse must either: • Give the patient the appropriate information in terms he can understand • Communicate with the appropriate person who can provide the information

38. Witness signature • When a nurse has signed the witness section of the consent form, she believes the client is informed about the upcoming treatment including: • Anticipated risks and benefits • Answers to questions • Statements that consent may be withdrawn at any time

39. Ethical dilemma • What if the med-surg nurse finds that the patient does not fully understand what he has consented for? • What are the responsibilities of the nurse at this point?

40. Deference to Physicians • In the early days of the profession, nurses were taught to obey doctors without question: • “Above all, let her remember to do what she is told to do and no more…implicit, unquestioning obedience is one of the first lessons a probationer must learn” • From Nursing Ethics: For Hospital and Private Use, by Isabel Hampton Robb (1901)

41. Code of Ethics • Quote from 3rd provision of ANA’s 2001 Code of Ethics for Nurses with Interpretive Statements • “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

42. Informed Consent and Autonomy • Each person must be considered the authority on his or her own best interests. • Nurses must recognize that adults of sound mind have the right to determine what may be done to their bodies

43. Informed Consent and Advocacy • Nurses are obligated to be their patient’s advocates. • 2001 Code of Ethics for Nurses – nurses must be alert to and take appropriate action regarding instances of incompetent, illegal, or impairedpractice by any member of the health care team

44. Incompetance vs. Refusal • If a patient is unable to accomplish simple mental tasks, he may be unable to make more complex judgments • The patient’s wishes must be respected, even though the consequences of refusal may be death

45. Case Studies • 1) The patient signed a consent for Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy, but she told the nurse later that she did not wish to have her ovaries removed.

46. Case Studies • 2) The patient consented for a right breast biopsy with possible modified radical mastectomy. However, she told the nurse that she thought, depending on the results, the mastectomy would be scheduled at a later date.

47. Special Considerations • Ambulatory Sugery Patient • Quickly assess and anticipate patient’s needs

48. Special Considerations 2 • Elderly • Hazards of surgery are proportional to the number and severity of co-existing health problems

49. Special Considerations 3 • Obese • Disabilities • Emergency Surgery

50. Preoperative Teaching • Deep-breathing, coughing and incentive spirometry - Teach patient how to promote optimal lung expansion