Pain Management

o Autogenic therapy, a mental-health therapy based on the concept that natural forces in the brain

are able to remove disturbing influences. It involves biofeedback exercises.

o Biofeedback, a process monitoring certain functions of the body, as blood pressure, muscle

tension, and brain wave activity. The patient can see or hear this information and is taught to alter these functions through relaxation. Biofeedback may be used to treat many conditions, as high blood pressure, insomnia, and migraine headache.

o Meditation, a state of consciousness in which the individual tries to stop awareness of the

surroundings so the mind can focus on a single thing, as a sound, key word, or image. It leads to a state of rest and relief from stress. A wide variety of meditation therapies are used to clear the mind of stressful outside disturbances.

o Guided imagery, (in psychiatry) the forming of mental concepts, figures, ideas; any product of

the imagination. In mentally ill persons these images are often bizarre and delusional.

o Hypnosis, a passive, trancelike state that resembles normal sleep during which perception

and memory are changed, resulting in increased responsiveness to suggestion. The condition is usually caused by the monotonous repetition of words and gestures while the subject is completely relaxed. Susceptibility to hypnosis varies from person to person. Hypnosis is used in some forms of psychotherapy and psychoanalysis to gain access to the subconscious, in behavior changing programs to help a person stop overeating or smoking or to end other unwanted behavior, or in medicine to reduce pain and aid relaxation.

o Acupressure a therapy of putting pressure on set points of the body. It is used to relieve

pain, make anesthesia, or control a body function.

o Operant conditioning, also called instrumental conditioning. A way of learning used in treatment to

change the way a patient thinks or does things (behavior therapy). The patient is rewarded for the right response and punished for the wrong response.

o Progressive relaxation, a way to combat tension and worry by tensing and relaxing groups of muscles in sequence.

o The Use of Pain Medications

This is the most common approach to pain management. The drugs may include 1) non narcotic analgesics, 2) Non steroidal Anti-

inflamatory drugs (NSAIDs) 3) Narcotics, 4) Anti-depressants, 5) Local Annesthetic Agents

Common Pain Medications Classification

1. Non steroidal Anti-inflammatory drugs (NSAIDs) 2. Narcotics, (Morphine S04)3. non narcotic analgesics (ex. Tylenol)4. Anti-depressants, 5. Local Anesthetic Agents

Terms to remember

Addiction- The compulsive use of the substance despite negative consequences, such as health

threats or legal problems

Drug abuse The use of any chemical substance for other than a medical purpose

Physical Drug dependence A biologic need for a substance. If the substance is not supplied, physical withdrawal

symptoms occur

Psychologic drug dependence A psychologic need for a substance. If the substance is not supplied, Psychologic

withdrawal symptoms occur

Drug tolerance The Process by which the body requires a progressively greater amount of a drutg to

achieve same results

Equianalgesic Having the same pain killing effect when administered to the same individual. Drug

doses are equianalgesic if they have the same as morphine sulphate 10mg administered intramuscularly

Pseudoaddiction Behavior involving drug seeking, a result of receiving inadequate pain relief

Surgery

o It involves the treatment process modality that requires an incision or deep body penetration of sharp objects or electricity.

o It is a Stressful process

Common Terms to remember

o Ambulatory Surgery (same day Surgery) It doest require an overnight stay in the hospital

o Introperative Phase Period of time when the patient is transferred to the operating room

table when admitted to the post anesthesia unit

o Informed consent Making autonomous decisions, based on the nature of condition, the

treatment options and the risks involved

o Perioperative period- Period of time that constitutes the surgical experience this includes the preoperative, intraoperative and post operative

phases

o Post operative phase It is the period of time that begins from the admission of the patient

from the Post Anesthesia care unit and ends in a follow-up evaluation in the home or in a clinical setting

o Pre- admission testing Diagnostic testing done before admitting the patient to the hospital

o Pre operative phase The period of time from the decision for surgical intervention made

by the patient until the time he or she is brought to the operating room

Surgical classification Base on Urgency

Emergency The patient requires immediate Attention The condition may be life threatening Must be done without delay Examples; severe bleeding, fractured skull, gun shot or stab wounds, burns

Urgent

The patient requires prompt attention The surgery must be done within 24-30 hours Examples are kidney stones and gall bladder obstruction

Required Surgery

The patient needs to have surgery Planned within weeks or months Examples are thyroid disorders and cataracts

Elective

The patient should be operated on The failure to have this surgery is not catastrophic Examples are repair of scar or vaginal repairs

Optional

The decision rests on the patient It is a personal preference Cosmetic surgery is an example

The Inform Consent

Voluntary and Informed written consent from the patient is necessary before surgery can be performed

It protects the patient from unsactiontioned surgery Protects the health care team from claims of an unauthorized operation In informed consent

o The patient who signs the consent must be mentally capableo If unconscious or incapable the consent must be obtained from a responsible

family member or a legal guardiano The nurse may ask the patient to sign the form and may witness that the form

has been signed but it is however the responsibility of the physician to provide appropriate information.

When is Informed consent necessary?

1. If the procedure is invasive such as a surgical incision, performing biopsy, cystoscopy or paracentesis

2. If anesthesia is used3. A non surgical procedure is performed in which there is a slight risk to the patient such

as performing arteriography4. If radiation is involved in the procedure

Criteria for a valid consent

1. Consent Must be Voluntary given2. Must not be signed by an incompetent subject

o Incompetent subjects are individuals who are not autonomous and can not give or withhold consent

o Exam[les are patients who are mentally ill or under coma

3. The Patient must be informed in writing and it should contain the followingo Explanation of the procedure and its riskso Description of benefits and alternativeso An offer to answers about the procedureo Informing the patient that he or she may withdraw the consento A statement informing the patient if the protocol differs from the customary

procedure

4. The subject must be able to comprehendo The information must be delivered in a language understood by the patiento Questions regarding the procedure must be answered in order to eliminate

doubts

Phases in Surgery

Preoperative Phase

The period of time from the decision for surgical intervention made by the patient until the time he or she is brought to the operating room

Pre-admission testing ( the following things are being done)

1. Initial preoperative assessment is initiated2. Health teachings appropriate to the patients needs3. Family interview4. Completion of the preoperative testing is verified5. The patient’s needs for post operative transportation and care are being assessed

Preoperative Checklist

1. Patient’s Identification Number2. Checking whether the following consents were signed

o For an operative procedureo For blood transfusiono For disposal of limbso For sterilization

3. Checking whether the history and physical examinations were completed4. Checking if consultations were done5. Checking if laboratory results were charted6. Blood s creening, typing and cross matching7. Checking if the person has already voided; voiding time is noted8. Checking if the following things are removed

a. Jewelriesb. Nail polishesc. Dentures and hair pinsd. Prosthesise. Eyeglasses

9. Checking valuables are safely kept10. ECG and X-ray reports11. Checking if preoperative medications were given

Intra-operative phase

Period of time when the patient is transferred to the operating room table when admitted to the post anesthesia unit

The Surgical team

1. Surgeon- A physician with a specialization in a specific surgical procedure

2. OR Directors

o Anesthesiologist- a physician trained to administer anesthesia and to monitor the patients condition during surgery

o Anesthetist- a health care professional trained to administer anesthesia and to monitor the patients condition during surgery

3. Intra-operative nurses

o They are responsible for the safety and well being of the patiento They are also responsible for the coordination of the operating room personnelo Concerned about the patients emotional stateo Monitors the factors that might cause possible injury top the patient like

positioning, equipment malfunction and environmental hazards protects the dignity and interest of the patient while anesthetized

4. Circulating Nurse

o Manages the operating room by monitoring the activities of the surgical teamo Responsible for verifying the informed consento Controls asepsis, temperature, humidity safe functioning of the equipment in the

operating roomo Responsible for the availability of the supplies

5. Scrub Nurse

o The one scrubbing for surgeryo The one setting up the sterile tableso Preparing sutures, ligatures and special equipmento Assist the surgeon during the procedure by anticipating the required instruments,

sponges drains and other equipmento Keeps track of the time the patient is under anesthesia and the time wound is

openo Counts all the needles sponges, instruments before the incision is being closedo Labels specimen and sent them immediately to the laboratory

Caring for the Patients under Anesthesia

Anesthesiao A state of narcosis (A state of deep stupor or unconsciousness produced by a drug.),

analgesia, relaxation and reflex losso The lack of normal sensation, especially awareness of pain. It is brought on by an

anesthetic drug or by hypnosis.

Types of Anesthesia

1. General Anesthesia

o The total lack of sensation and consciousness as brought on by anesthetic agents. They are usually breathed in or injected into a vein. The kind of anesthesia used and the dose and route by which it is given depend on the reason for anesthesia

o Examples are volatile liquids, halothane( flourthane) and enflurance (Ethrane), and gasses Nitrous Oxide

Stages of General Anesthesia

Stage I (Onset/ Induction) Extends from the administration of Anesthesia to the time of

the loss of consciousness

Stage II ( Excitement/ Delirium) Extends from the time of loss of consciousness to the time of

the loss or lid of reflexes The patient may be shouting or struggling at this time

Stage III (Surgical) Extends from lid reflex to loss of most reflexes The surgical procedure is started

Stage IV (Medullary/ Stage of Danger) Characterized by respiratory depression or Cardiac Arrest This is due to an overdose of anesthesia Resuscitation must be done

2. Regional anesthesiao anesthesia of a part of the body by giving a numbing medication to block a

group of sensory nerve fibers

Spinal anesthesia

A type of extensive conduction nerve block that occurs by introducing a local anesthetic into the subarachnoid space at the lumbar level (between L$ and L5)

It produces anesthesia in the lower extremity, perineum and the lower abdomen

For lumbar puncture the patient lies on her side in a knee chest position

Complications and Discomforts of Patients having Spinal Anesthetic

1. Hypotension2. Nausea and vomiting3. Head aches4. Respiratory paralysis5. Neurologic complications (paraplegia, sever muscle weakness of the legs)

3. Conduction Block Anesthesia

Epidural anesthesia

o The process of numbing the pelvic, stomach, genital, or other area. A local anesthetic is injected into the epidural space (space surrounding the dura matter) of the spinal column. Epidural anesthesia is commonly used during labor and childbirth.

o It differs with the spinal anesthesia by the injection site It does not come in contact with the spinal cord) and the amount of anesthetic used that has usually higher doses

Other Examples of Nerve blocks

Brachial Plexus block- arm Paravertebral anesthesia- for the chest abdominal wall and extremities Transsacral (caudal)- for the perineum and lower abdomen

Examples of Anesthetic Agents used

Procaine (Novocaine) Tretracaine (Pontocaine) Lydocaine (Xylocaine)

4. Local infiltration Anesthesia/ Local anesthesia

o Involves injection of a solution containing local anesthetic agent into the tissues at the planned incision site

o The direct administration of a local anesthetic agent to cause the loss of feeling in a small area of the body.

o Brief surgical or dental procedures are the most common reasons for using local anesthesia.

o The anesthetic may be applied to the surface of the skin or membrane or injected through or under the skin.

o Principal drawbacks to using local anesthesia are allergic reactions to certain anesthetics and occasional difficulty in deadening the local nerves. The advantage is that a conscious patient can cooperate and does not require breathing support.

o To avoid general anesthesia, some major surgical procedures are occasionally performed using local anesthesia. The tissues are anesthetized layer by layer, as the surgeon approaches the deeper structures of the body.

o Regional anesthesia has largely replaced this procedure. In all cases, the recommended dosage of any anesthetic agent is the smallest possible to achieve the desired loss of pain, because side effects are directly related to the total amount of drug given. Each anesthetic agent carries a recommended maximum allowable dose that is not safely exceeded.

The advantages Simple, economical and non explosive The equipment is minimal Post operative recovery is shortened Undesirable effects of other types of anesthetics are avoided Ideal for superficial surgical procedures

Examples are……1. Mepivacaine (Carbocaine)2. Bupivacaine (Marcaine)

Guidelines on Surgical Asepsis

In General

1. There is sterile to sterile contact only2. A doubtful article is considered unsterile3. Whatever sterile for a particular patient is sterile for that patient only

For the Health Care personnel

1. The scrubbed personnel must remain in the surgical area. If he or she leaves the room the status of sterility will be breached. The personnel must scrub again if he or she wishes to return in the surgical area.

After the scrubbing the parts of the body that is considered sterile are ….a. Waist to shoulderb. Fore arms and gloves

Always remember this:

‘ Gloved hand must be kept in front between the shoulders and the waistline ”

2. The circulating Nurse or any unscrubbed personnel must remain at a safe distance to avoid contamination of any sterile area

Draping

Covering the area around a part to be operated upon or examined. The area to be operated are the ones only exposed Surgical drapes are composed of sterilized cloth.

1. During the draping of a patient the sterile drape is above the surface to be covered

2. Only the top of the patient that is draped is considered sterile3. Drapes hanging over the edges are considered not sterile4. Sterile drapes are kept in position by clips or adherent material; drapes are

not moved during the surgical procedure5. A tear on drapes allows access to an unsterile surface underneath thus it

must be replaced.

Delivery of supplies

1. Packages are wrapped in a way that they ca be opened easily without risk of contaminating its contents

2. Sterile supplies including solutions, are delivered to a sterile field or handled to a “scrubbed person” in such a way that the sterility of the object remains intact

3. Edge of wrappers covering sterile supplies or outer lips of bottles or flasks containing sterile solutions are not considered sterile

4. The unsterile arm of the “circulating nurse” must not extend over a sterile area5. sterile articles are to be dropped on a sterile field, a reasonable distance from the edge

of the sterile area

Giving of solutions

1. Sterile solutions are poured from a point high enough to prevent accidental touching of the sterile receiving cup or basin but not high enough to cause prevent splashing.

2. When the sterile area becomes wet it is considered contaminated

Patient Positioning

General considerations

1. The patient must be comfortable as possible2. The operative area must be adequately exposed3. The vascular supply must not be obstructed by an awkward position or undue pressure4. There must be no interference on the patients respiration5. Nerves must be well protected from undue pressure to prevent injuries, which may

lead to paralysis

Common Surgical Positions

1. Dorsal recumbent- for hernia repair, mastectomy and bowel resection2. Trendelenburg- for lower abdomen and pelvic surgeries3. Lithotomy- for vaginal repairs, D and C, rectal surgery, abdomino perineal resection4. Prone- for spinal Surgery and spinal cord related surgeries5. Lateral- for kidney, chest, and hip surgeries

Nursing Interventions

1. Explain the purpose of the position2. Avoid undue exposure3. Strap the person to prevent falls4. Maintain adequate respiratory and circulatory functions5. Maintain good body alignment

The Post Operative Phase

It is the period of time that begins from the admission of the patient from the Post Anesthesia care unit and ends in a follow-up evaluation in the home or in a clinical settingGoals:

Maintain adequate system Restore homeostasis Alleviate pain and discomfort Prevent post operative complications Ensure adequate discharge planning and teaching

Nursing during the Post-op Phase

1. Transport of client from OR to RRo Avoid over exposureo Rough handling

o Hurried movement or rapid change of position2. Nursing assessment and intervention

o Assessment 1. Appraise air exchange status and note the skin color2. Verify the identity, operative procedure done and surgeon3. Assess the neurologic status ( LOC)4. Determine vital signs and skin status

o Examine operative site and check the dressingso Perform safety checks

1. Position for good body alignment2. Side rails in place3. Restraints for IVF and blood transfusion

o Check if the patient requires briefing on problems encountered in the OR

Interventionso Ensure maintenance of patent airway and adequate respiratory function

1. Place the patient in lateral position with neck extended2. Keep the airway in place until the patient is fully awake3. Suction secretions as necessary4. Encourage deep breathing exercises5. Administer Oxygen as ordered

o Assess status of Circulation1. Monitor vital signs and report the abnormalities2. Observe signs and symptoms of shock and hemorrhage3. Promote comfort and maintain safety4. Continuous and constant surveillance of the client until he or she is

completely out of anesthesia5. Recognize the stress factors that may affect the clients respiratory rate

and minimize these factors

It is the period of time that begins from the admission of the patient from the Post Anesthesia care unit and ends in a follow-up evaluation in the home or in a clinical setting

Parameters for discharge from the Recovery Room

1. Activity The Patient is able to follow instructions Can perform deep breathing and coughing

2. Respiration The respiration is easy There is noiseless breathing

3. Circulation The Blood pressure is with in the parameters of the baseline data

4. Consciousness responsive

5. Color The skin and the mucous membrane color is pinkish

Nursing care for Patient at the Recovery Room

Baseline Assessment

1. Check the respiratory status2. Check the Cardio-vascular status ( assess the vital signs, note the color and

temperature of the skin)3. Assess the level of Consciousness4. Check the tubes ( Drainage, NGT, and T tube)5. Check the position

On-going assessment goals and interventions

1. Goals Restore homeostasis and prevent complication Maintain Cardio-vascular and Tissue Perfusion Maintain adequate respiratory function Maintain adequate Nutrition and Elimination Maintain adequate fluid and electrolyte balance Maintain adequate renal function Promote adequate rest, comfort and safety Promote adequate wound healing Promote and maintain activity and mobility Provide adequate Psychological support

Common Causes of Obstruction

1. Mucous collection in the throat2. Aspirated Mucous or vomitus3. Loss of swallowing reflex4. Loss of control of the jaw muscle or tongue5. Laryngiospasm due to intubation6. Bronchospasm

Causes of Hypoventilation1. Pain2. Chronic Lung Disease3. Obesity4. Medications

Signs and Symptoms of Hypoventilation and Respiratory Obstruction

1. Restlessness2. An attempt to sit up on bed3. Fast and thready pulse (the earliest sign)4. Air hunger5. Apprehension, confusion and nausea6. Cyanosis7. Stridor, snoring and wheezing

Care for Patients on the Surgical Unit

Monitoring the Respiratory Status and Promoting optimal Functioning1. Encourage the client to cough or to do deep breathing, If contraindicated instruct

do it only every 1-2 hours.2. Instruct the client to split incision while coughing3. Assist the client to turn on bed every 2 hours4. Encourage early ambulation5. Encourage the use of incentive spirometer every 2 hours. It promotes sustained ,

maximal inspiration that inflates the alveoli6. Assess respiratory status and auscultate every 4 hours

Monitoring cardio vascular status and avoid post operative complications1. Encourage leg exercises every 2 hours while in bed2. Encourage early ambulation3. Apply anti embolism stockings as ordered4. Assess the vital signs and the temperature of the skin every 4 hours

Promoting Optimum Nutrition1. Maintain IV infusion as ordered2. Assess for the return of Peristalsis3. Add progressively to diet as ordered and note for tolerance

Monitoring and promoting the return of Urinary function1. Monitor the I &O2. Assess the clients ability to void3. Report to the surgeon if the client has not voided within 8 hours4. Check g\for bladder distension5. Use measures to promote urination

Promoting bowel elimination1. Encourage early ambulation2. provide adequate food and fluid intake when tolerated3. Keep stool records and note difficulties with bowel elimination

Administering of Post-op analgesics a ordered; provide additional comfort measures

Provide wound care1. Check frequently if the dressings are clean, dry and intact2. Observe aseptic technique when changing dressings3. Encourage diets high in protein and vitamin C4. Report any signs of infection ( redness, drainage, odor and fever)

Providing Psychological support to clients and significant others Provide appropriate discharge teaching

o Dietary restrictionso Medication regimeno Activity limitationso Wound care

o Possible complications

Post Operative Complications

1. Respiratory System- Atelectasis Pneumonis

2. Cardio-vascular Deep vein throbosis Shock

3. Genito Urinary System Urinary tract Infection Urinary retension

4. Gastro-intestinal Paralytic ileus

5. Wound complications Dehiscence- opening of wound edges Evisceration- protrusion of loops through n incisiomn

The Nursing Process Application

Assessment

Physiological o Health and illness levelo Level of consciousness

Psychosocial statuso expressions of concerno anxiety level, verbal communicative problems o coping mechanisms

Physical statuso operative siteo skin condition

Diagnoses Anxiety Risk for Injury related to anesthesia and surgery Risk for infection