Pain: The Fifth Vital Sign

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

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” 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

Side Effects of OpioidsNausea and vomitingConstipationSedationRespiratory depression

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)

PCA Infusion Pump

Spinal AnalgesiaEpidural analgesia Intrathecal (subarachnoid) analgesia

Implantable Devices

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

Physical Interventions

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

Surgical Procedures for the Alleviation of Pain

Community-Based CareHome care managementHealth teachingHealth 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

DiagnosticCurativeRestorativePalliativeCosmetic

Urgency and Degree of Risk of Surgery

Urgency:ElectiveUrgentEmergent

Degree of Risk:MinorMajor

Extent of Surgery

SimpleRadicalMinimally invasive

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.

Skin Preparation for Common Surgical Sites

Patient and Family TeachingTubesDrainsVascular access

Prevention of Respiratory Complications Breathing exercisesIncentive spirometryCoughing and splinting

Patient Using Incentive Spirometer

Prevention of Cardiovascular ComplicationsBe aware of patients at greater risk for DVTAntiembolism stockingsPneumatic compression devicesLeg exercisesMobility

External Pneumatic Compression Devices

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

Patient Transfer to Surgical Suite

Care of Intraoperative Patients

Members of the Surgical TeamSurgeon and surgical assistantAnesthesia providers:

Anesthesiologist and CRNAHolding area nurseCirculating nurseScrub nurseSurgical technologist Specialty nurses

Operating Room

Minimally Invasive and Robotic Surgery

Environment of the Operating RoomPreparation of the surgical suite and team

safetyLayoutHealth and hygiene of the surgical teamSurgical attireSurgical scrub

Surgical Asepsis

Surgical Scrub, Gowning, and Gloving

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

Nerve Block Sites

Spinal and Epidural Anesthesia

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

Surgical Positions

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

Common Skin Closures

Potential for HypoventilationContinuous monitoring of:

BreathingCirculationCardiac rhythmsBlood pressure and heart rate

Continuous presence of an anesthesia provider