Surgical Pain (Discussion)

do NSAIDS or acetaminophen have more adverse effects with the GI system?

NSAIDS.

chronic pain treatments (6 examples)

NSAIDs, cognitive restructurings, coping enhancement, injection of anesthetics into cramping muscles, antidepressants, transcutaneous electrical nerve stimulation (TENS),

define hyperalgesia

abnormally heightened sensitivity to pain

What is the reccomended approach for the trx. of pain in all age groups called?

multimodal analgesia or multimodal pain management

What is significant to remember about veterans and pain?

that as a result of their services they may be in higher levels of pain than other populations, so advocating for multimodal pain mngment would help them better cope with pain

Even though pain is subjective, the patients self-report is the _____

undisputed standard for assessing the existence & intensity of pain

When should you reassess pain? (orala vs parenteral meds)

(peak effect of medication) 15-30 mins after parentarel & 1-2 hrs after oral meds given.

what are physical modalities (non pharm pain mngmt)

-Proper body alignment; -application of heat and/or cold; massage; transcutaneous electrical nerve stimulation (TENS); acupuncture; physical therapy; and aqua therapy

Why is multimodal pain management so great?

-allows for different meds to help at reducing pain; which lowers the dose used for each med, lowering the RISK for adverse side effects

Define acute pain how long does it last?

-comes about abruptly & results from tissue damage -pain that lasts less than 6 months

What would you include in (questions to ask) in a comprehensive pain assessment?

-location -intensity -number on a scale -periodicity -quality -what number they would like to be at ona scale of 1-10./ whats tolerable for them

define chronic pain how long does it last?

-pain that is persistent beyond the usual course/time of healing -lasts > 6months

Case Study #3 Mrs. Bell is a 65-year-old admitted to your unit after a laparoscopic cholecystectomy. She is admitted from the Post Anesthesia Care Unit (PACU). On initial assessment Mrs. Bell is complaining of pain 8 out of 10 for which she receives Morphine IV. Order: · Lidocaine patch 5%-700mg QD · Hydrocodone/acetaminophen 5/325mg BID PRN · Morphine 2mg IV push every 2 hours for pain >8 · Hydrocodone 5/325 PO every 4 hours for pain >5 · Acetaminophen 650mg PO every 4 hours for pain >2 Two hours later Mrs. Bell's pain rating is 9 and she is requesting pain medication. Priority assessment? 1. What assessment will you do prior to administering medication? 2. Why is it necessary to assess pain each time it occurs before an analgesic is administered? 3. What medication will you administer? What are the nursing implications prior to giving this medication? An hour after administering the medication Mrs. Bell's pain rating is a 4. She is due for her Lidocaine patch and Hydrocodone/acetaminophen 5/325mg. 4. Will you administer these two medications? Why or Why not? After going for a nice walk Mrs. Bell states, she is feeling pretty good but requests Tylenol before she goes to bed. 5. Will you administer this medication? What other information do you need to gather? 6. What care do we provide with administration of a Lidocaine patch?

-priority assessment: respiratory assessment (ALL THESE MEDS YOU HAVE TO DO A RR ASSESSMENT) 1. --vital signs -pain assessment: frequency, quality, number, what makes worse/ better. -respiratory assessment -check LOC 2. to make sure that the pain management is effective. 3. -pain level is at a 9: so they will give morphine. -reassess pain, vital signs, -if going thru an IV (morphine) give very very slowly. Because its going straight into the blood stream. 4. -what's lidocaine doing? Local anesthetic. (can be for acute/chronic) -morphine: is for accute pain not chronic. 5. -check times & dosages before administering meds & see if shes close to max dose! "pretty good" for her could be a 3/10. Since she was walking around, when she gets back to bed her pain may go back up. 6. Make sure area is clean. -DTI -skin intergrity -Lidocaine patches: usually your putting it over the SAME spot. Bc its for a specific site. Back pain in lower back? It will always be placed there.

Describe nursing actions when deciding to give pharmacological intervention for pain (5)

1. Comprehensive Pain assessment 2. Try/educate on all non-pharmacological interventions first 3. Re-assess for degree of pain relief & presence of any S/E. (AT PEAK EFFECT TIME OF MED). 4. Obtain additional prescription PRN 5.Prevent & treat adverse effects

Give 10 examples of non-pharmacological interventions

1. Cutanous Simulation 2. TENS Unit 3. Distraction 4. Humor 5. Guided imagery 6. Therapy dogs 7. massage 8. Diaphragmic Breathing 9. Immobilization 10. Cognitive-behvioral interventions / coping-mechaninsms

Case Study #1: Mr. Jones is a 64 year old man who was involved in an automobile accident. He suffered a tibia-fibula fracture in the right leg. He underwent an ORIF last evening. He was admitted to a medical surgical unit. Mr. Jones is currently receiving a Hydromorphone (Dilaudid) PCA for pain control. He is alert and orientated x3. 1. Whats the primary nursing assessment? 2) Why is it important to monitor Mr. Jones vital signs frequently while on a PCA? What information will this show the nurse? 3) Describe the purpose for using a PCA on a surgical client? What information can a PCA pump tell us about Mr. Jones pain management? 4) What nursing interventions/education should be included in the client's plan of care regarding their PCA? 5) The surgeon has also started Mr. Jones on Docusate 100mg PO BID and Gabapentin 300mg PO BID. While completing your morning medication pass, Mr. Jones asks you why these medications were ordered. What will you tell your client? 6) Identify some non-pharmacological interventions you could implement for Mr. Jones.

1. PNV (priority assessment) 2. PCA (patient controlled analgesic) has an opiod in his pump. Opiods can cause respiratory depression, so assessing RR, apical pulse, etc. 3. Purpose of PCA: Analgesics are effective for acute pain, and can be used to effectively keep his pain level at a somewhat tolerable level (pain controlled consistently). PCA's can be... -bolus (can be pushed when needed) -steady/constant flow 4. Teach about maximum pumps, the "lockout" feature. Locks you out if you've had too many pushes in 10 minutes. -When the best time to admin a pump may be (before painful PT, or before getting out of bed). -Pt. is the only one that can manage the pump. -Assess mental status b/c they have to be able to press the button and understand what they are doing. Maybe someone has arthritis? They cant push that button. Make sure they are able. 5) Docusate is ta stool softrner o reduce the risk of constipation caused by the anesthesia & opiods. Gabapentin is to decrease muscle spasms that may occur post-op, nerve pain is different, opiodwouldnt treat the burning nerve pain. Any factors that increase the risk of constipation of this client? YES. Immbolity Teaching for these drugs?? Gabapentin= drowsy. 6) Distraction, TV, talking, music, TENS unit, relaxation techniques, humor, animal assisted therapy. -bilateral massage -Heat & ice. Elevated position -diet: high fiber, lots of fluids, to help with inflammation.

Give the rationale for each of these nursing actions: (write these out) 1. Comprehensive Pain assessment 2. Try/educate on all non-pharmacological interventions first 3. Re-assess for degree of pain relief & presence of any S/E. (AT PEAK EFFECT TIME OF MED). 4. Obtain additional prescription PRN 5.Prevent & treat adverse effects

Rationale: 1. Baseline pain assessment: Foundation of pain treatment Plan. 2. Non pharm: can supplement pharmacological interventions. 3. Reassess: allows for evaluation of effectiveness & safety. 4. Additional dose/meds: to maximize pain control 5. Through education & promptly treating any pt. Discomfort.

acute pain treatment +examples

Short-term therapy with nonopioid and opioid medications for mild-moderate acute pain (Non-opiods=acetaminophen & NSAIDS)

what are biologically based therapies (non pharm pain mngmt)

Taking herbs, vitamins, and proteins; aromatherapy; diet modifications

is morphine used for acute or chronic pain?

accute

define pain

an unpleasant experience that is emotional or sensory; and is uniquely experienced and described by an individual

what is an adverse effect of acetominophen?

hepatic/liver damage. if high doses are given; the liver should be monitored.

oxycodone & hydrocodone are examples of ___ drugs.

opioids

Case Study #2 Mrs. Smith is a 36 year old women who tripped and fell down a flight of stairs. Mrs. Smith has multiple rib fractures on her right side. Although, she did not break her hip, Mrs. Smith complains of pain rating it an 8/10 in her right hip. She was admitted to a medical surgical floor for further observation. She has no past medical history and takes no medications at home. After accepting care of Mrs. Smith you review her medication orders. Her PRN medication orders are: - Morphine 2mg IV push every 2 hours for pain >8 - Hydrocodone 5/325 PO every 4 hours for pain >5 - Acetaminophen 650mg PO every 4 hours for pain >2 whats your primary nursing assessment? what would you want to monitor medication wise? 1) Describe the rationale for the multiple PRN pain medication orders 2) When entering Mrs. Smith's room, she complains of a pain of 9/10 in her right hip and asked for something for pain. How will you choose what medication to medicate the client with? What information should you look at prior to administering? 3) Discuss the importance of pain reassessment The following day you return to work and once again are assigned to Mrs. Smith's care. During morning rounds, the physician states he would like to send Mrs. Smith home later that evening. After looking in Mrs. Smith's EHR, you note she has only taken the PRN Morphine during the night shift. 4) Discuss a plan of care for transitioning Mrs. Smith to be ready for discharge in regards to her pain management.

primary assessment: respiratory (rib frx. & opiods) & musculoskeletal (bc hip) make sure meds are not over max doses (4,000 mg is max for acetominophen) 1) -all of these used together would help manage pain working together. Multimodal pain management is more effective than the drugs by themselves. It will give you a desried synergistic effect. And her pain is. A8/10, which will require more medicine to decrease the score. 2) Morphine: RR, HR -ask the patient wat they want to decide! which helped your pain better? 3)See what's working what's not. See if you met your outcomes like if her pain was at a 8/10 youd want it to be lower than that with the next pain assessment. -move toward patients goal. Whats their acceptable pain level? 3 ? 5? Whats tolerable for them. Anticipate pain going up after certain activities. 4) -what is their insurance status? Can they afford the meds? -do they have any concerns taking opiods at home.

define nociceptive pain

the pain produced from activation of nociceptors

What are the 4 stages of pain?

transduction, transmission, perception, modulation (change perception of pain)