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
Addiction, Pseudoaddiction, Tolerance, and
Physical Dependence (Cont’d)
 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
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
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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
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Antiepileptic drugs
Tricyclic antidepressants
Antianxiety agents
Local anesthetics
Dextromethorphan, ketamine
Local anesthesia infusion pumps
Topical medications
Nonpharmacologic Interventions
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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:
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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
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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:
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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
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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
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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:
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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
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Be aware of patients at greater risk for DVT
Antiembolism stockings
Pneumatic compression devices
Leg exercises
Mobility
External Pneumatic Compression
Devices
Anxiety Interventions
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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
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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
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Holding area nurse
Circulating nurse
Scrub nurse
Surgical technologist
Specialty nurses
Operating Room
Minimally Invasive and Robotic Surgery
Environment of the Operating Room
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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
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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
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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
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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
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Field block
Nerve block
Spinal block
Epidural block
Nerve Block Sites
Spinal and Epidural Anesthesia
Complications of Local or Regional
Anesthesia
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Anaphylaxis
Incorrect delivery technique
Systemic absorption
Overdose
Local complications
Treatment of Complications
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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
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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:
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Breathing
Circulation
Cardiac rhythms
Blood pressure and heart rate
 Continuous presence of an anesthesia provider