Lemessa Jira pain managment in surgical patient ppt

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PRINCIPLE OF PAIN MANAGEMENT IN SURGICAL PATIENT

By:- Lemessa J ira

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PRESENTATION OUT LINESession Objectives Introduction To Pain pathophysiology of painCategories of pain Pain AssessmentManagement in surgical painPossible Nursing care plan for surgical

patient

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SummeryReferences Acknowledgement

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SESSION OBJECTIVES Describe about pain and nociceptive pain process

with there managementDescribe about types of pain describe pre,intera and postoperative pain by

pharmacological and non pharmacologicalDescribe and proceed assessment of pain with

different tools.Describe which drug is used for which types of

pain and tissue damage in surgical patient describe possible Nursing care plan for surgical

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Pain and physical discomfort is common in the surgical patient as a result of injury, invasive procedures, or preexisting illnesses.

(Orlando Regional Medical Center 2005)

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pp .by Atsede Unrelieved pain may contribute to patient discomfort, anxiety, exhaustion, disorientation, agitation, tachycardia, increased myocardial oxygen consumption, pulmonary dysfunction, impairs immune function, which slows healing and increase susceptibility to infections and dermal ulcers.

Orlando Regional Medical Center 2005

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Effective pain controlto improving patient comfortdecrease the incidence of many

complications in the postoperative patient.

Orlando Regional Medical Center 2005

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pp .by Atsede CATEGORIES OF PAINPostoperative pain can be divided into acute pain and chronic pain:Acute pain is experienced immediately after surgery (up to 7 days);Pain which lasts more than 3 months after the injury is considered to be chronic.

Hanna Misiołek1 etal, 2014 and Orlando center2005

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pp .by Atsede Classified by inferred pathophysiology: 1.Nociceptive pain 2.neuro pain 3.mixed type

Minsteri of health in Rwanda September 2012

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pp .by Atsede 1.Nociceptive pain: Nociception is the activity in peripheral pain pathways that transmits or processes the information about noxious events associated with tissue damage.


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Nociceptive pain can be: somatic or visceral pain• Somatic pain: Pain originating from bone, muscle, connective tissue etc. This type of pain can be described as aching, sharp, stabbing, throbbing and is well localized.


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• Visceral pain: Pain originating from organs such as pancreas, liver, GI tract etc. This type of pain is described as cramping, dull, colicky, squeezing, often poorly localized, and may be referred to other areas.


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pp .by Atsede 2. Neuropathic pain: It is caused by an injury or dysfunction of the peripheral or central nervous system. It is often described as: burning, shooting, stabbing, numbness or tingling. It has the following types:


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pp .by Atsede A•Central neuropathic pain :Example: Post stroke pain, Spinal cord injury, multiple sclerosis and syringomyelia.


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pp .by Atsede B• Peripheral → Focal: Examples: Trigeminal neuralgia, Carpal tunnel syndrome, failed back surgery syndrome with nerve root fibrosis, post -herpetic neuralgia.

Minsteri of health in Rwanda September 2012 15

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pp .by Atsede Multifocal: Exemples: Vasculitis, diabetes mellitus and brachial or lumbar plexus Symmetrical : Examples: Diabetes mellitus, ethanol abuse, toxins (e.g.: vincristine) and amyloidosis.


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pp .by Atsede C• Other sensations of neuropathic pain→ Dysesthesia (bugs crawling on the skin, pins and needles)→ Allodynia (pain to a non painful stimulus)→Hyperalgesia (increased pain sensation to a normally painful stimulus).


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3.Mixed This involves both Nociceptive and Neuropathic types of pain.


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ASSESSMENT OF PAINA variety of tools and assessment scales

have been advocated to document the degree of pain. The most reliable and valid indicator of pain has been shown to be the patient’s self-report.

Assessment of the patient experiencing pain is the cornerstone to optimal pain management.

REGINA FINK, RN, PHD, AOCN ,July 2000 19

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Using the WILDA approach ensures that the 5 key components to a pain assessment are incorporated into the process.

REGINA FINK, RN, PHD, AOCN ,July 2000

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pp .by Atsede 5 .component of WILDA approach pain assessment word • What does your pain feel like?• Because various pain types are described using different words Intensity express what pain feels like. The

ability to quantify the intensity of pain is essential when caring for persons with acute and chronic pain.


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Facial expressions Verbal rating scale Numerical rating scale Visual analogue scale (VAS):

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universal adoption of a Classified using a standard 0(no pain) to 10 (worst possible pain) scale.VAS and NRS(common scale)

1.Mild pain- rating of 1-3, 2.Moderate pain- rating of 4-6, 3.Severe pain- reaching 7-10 and is associated with worst outcome.

/ MOH/P/PAK/257.12 (HB), in October 2013 and REGINA FINK, RN, PHD, AOCN ,July 2000/

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pp .by Atsede 3.LocationMost patients have 2 or more sites of pain. Thus, it is important to ask patients, “Where is your pain?” or “Do you have pain more than one area?” .


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pp .by Atsede 4.Duration Patients need to be asked, “Is your pain always there, or does it come and go?” or “Do you have both chronic and breakthrough pain?”.

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pp .by Atsede 5.Aggravating/alleviating factorsAsking the patient to describe the factors that aggravate or alleviate the pain will help plan interventions.


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pp .by Atsede MANAGEMENT OF SURGICAL PAIN1.Pharmacological 2.non Pharmacological

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pp .by Atsede 1.Pharmacological Pain is prevented and/or treated using various pharmaceutical agents. These medications can be divided into four general categories:1.Non opioid analgesics (aspirin, acetaminophen, naproxen, NSAIDS and cyclooxygenase inhibitor/cox 2 inhibitor2. Opioid analgesics weak opioid Codeine and Tramadol Orlando Regional Medical Center,2005

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Strong opioid(morphine, Diamorphine ,Pethidine, Piritramide ,hydromorphone, fentanyl, oxycodone, hydrocodone).

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pp .by Atsede 3. Local anesthetics (lidocaine, bupivacaine) 4.Analgesic adjuvant drug that has a primary indication other than pain (tricyclic antidepressants,antihistamines,benzodiazepines,steroids,phenothiazines,anticonvulsants,clonidine)

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pp .by Atsede Produced in consultation with the European Society of Regional

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WHO analgesic ladder- Step 1• Non opioid ±adjuvant : ASA, Paracetamol, NSAIDs/COX-2s±adjuvant- Step 2• Opioid for mild to moderate pain± nonopioid ± adjuvant:Codeine, Tramadol, oxycodone, ± NSAIDs/COX– 2s, ± adjuvants. . Minsteri of health in Rwanda September 2012

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pp .by Atsede - Step 3• Opioid for moderate to severe pain, ± non opioid,±Adjuvant: Oxycodone, Morphine, Hydromorphine,Fentanyl, methadone, ± NSAIDs/COX – 2s, ± adjuvants- Step 4:• Nerve block, epidurals, PCA pump, neurolytic nerve blocks,. . Minsteri of health in Rwanda September 2012

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Monitering a patient with analgesics 1.To provide effective analgesia for patients 2.To detect serious and potentially dangerous side effects and complications of analgesic techniques monitor? Respiratory Rate ,Sedation Score , Pain Score , Blood Pressure , Pulse Rate .

MOH/P/PAK/257.12 (HB), in October 2013

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pp .by Atsede Sedation Score 0= Awake and alert 1= Mild (occasionally drowsy) 2= Moderate (frequently drowsy but easy to arouse) 3= Severe (difficult to arouse) S= Sleeping .


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Determines when to give the next dose of analgesic drug in techniques that use intermittent bolus doses High Pain Score (≥4) inform doctor Low Pain Score (<4) maintain present

dose.


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pp .by Atsede The doctor or anaesthesiologist on call should be informed if 1. Sedation score > 2, respiratory rate < 8 2. Sedation score > 3, does not matter what

respiratory rate is 3. Pain score is >4 in 2 observations 4. Vomiting is persistent despite anti-emetics 5. Hypotension (systolic < 90 mmHg) .


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pp .by Atsede pain relief in adults according to the extent of surgical trauma surgical procedures . 1. slight tissue damage procedures of small extent and post-operative. pain intensity < 4 points according to NRS or vas. postoperative pain persists for 3 days.

Hanna Misiołek1 etal, 2014

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A. pharmacotherapy before surgery (preventive analgesia) non 0p0iedmetamizole (1–2.5 g), intravenous or oral, paracetamol (1.0–2.0 g), intravenous or oral , ketoprofen (50–100 mg), intravenous or oral, ibuprofen (200–400 mg), oral, diclofenac (50–100 mg), oral, other NSAIDs (oral) .


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pp .by Atsede Local Analgesia Before surgery, the anticipated incision line should be injected with 10–20 mL lidocaine 1%, 5−10 mL bupivacaine 0.25−0.125%, 5−10 mL ropivacaine 0.2%, to induce the effect of pre-emptive analgesia; after completion of the surgery, depending on its type, re-injection of the wound.


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B.Pharmacotherapy After Surgery: (non opioids)metamizole (1 g–2.5 g, max. 5 g day-1), intravenous or oral every 6–12 hours and/or paracetamol 1.0 g, intravenous or oral, every 6 h (max. 4 g doba-1) combined with a non-selective NSAID in a continuous infusion or orally or a selective COX-2 inhibitor, oral .


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pp .by Atsede Later (post-operative day 1) oral analgesics can be used in fractionated doses: metamizole 500 mg, and/or, paracetamol (0.5–1 g) combined (or otherwise) with a non-selective or selective NSAID, ketoprofen (50 mg) p.o., every 6−8 h or, dexketoprofen (25 mg) p.o., every 6−8 h or,


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diclofenac (50 mg) p. o., every 8 h or,ibuprofen (400 mg) p.o., every 8 h or, naproxen (250–500 mg) p.o., every 8 h or, nimesulide (100 mg) p. o., every 12−24 h or, meloxicam (7.5 mg–15 mg) p.o., every 24 h.



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pp .by Atsede 2. surgical procedures associated with moderate tissue damage and NSR or VAS post-operative pain intensity levels > 4 and post-operative pain persists for 3 days


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pp .by Atsede A.Pharmacotherapy Before Surgery clonidine tablets 75−150 μg, 1 h before

surgery or as a slow intravenous infusion, 150 μg directly before the induction of anaesthesia,

dexmedetomidine 200 μg, a slow intravenous infusion directly before induction of anaesthesia and/or,

gabapentin, oral, 600 mg 4 h before surgery or pregabalin, oral, 50−75 mg 1 h before surgery and/or,

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pp .by Atsede lidocaine 1.5 mg kg-1, a slow intravenous infusion before the induction of general anesthesia and/or, ketamine 50 mg i.v. bolus before induction of general anesthesia.

B .Intraoperative:

Lidocaine 1.5−3 mg kg-1 h-1

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pp .by Atsede C.Pharmacotherapy After Surgery: metamizole (1–2.5 g, max. 5 g day-1) every 6–12 h, intravenous, and/or, paracetamol 0.5–1.0 g, intravenous, every 6 h combined (or otherwise) with ketoprofen (50 –100 mg) in an intravenous infusion every 12 h or dexketoprofen (50 mg) in an intravenous infusion every 8 h, and/or, lidocaine 0.5−1 mg kg-1 h-1.

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pp .by Atsede Additionally, in the case of pain, on demand — small doses of i.v. opioids using nurse-controlled analgesia (NCA; lockout interval 10 min): opioidstramadol (10–20 mg) or, nalbuphine (10 mg) or, morphine (1–2 mg ) or, oxycodone (1−2 mg).

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pp .by Atsede Beginning on post-operative day 2, oral

analgesics can be administered (unless contraindicated) in the following fractionated doses:

NON-OPIOIDS: metamizole 500 mg (max. 5 g day-1),

and/or, paracetamol 500 mg (max. 4 g day-1), with (or without) NSAID:

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pp .by Atsede diclofenac 50 mg (max. 200 mg day-1),

or, ketoprofen 50 mg (max. 200 mg day-1)

or, dexketoprofen 50 mg (max. 75 mg day-

1), or, naproxen 250−500 mg (max. 1250 mg

day-1), or, nimesulide, 100 mg (max. 200 mg day-1)

and/or, meloxicam 15 mg (max. 15 mg day-1).

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pp .by Atsede OPIOIDS: tramadol 5−20 drops every 6–8 h ( max. 400 mg day-1) or, oxycodone 10−20 mg, controlled-release tablets (max. 10−20 mg every 12 h) or, buprenorphine 0.2−0.4 mg every 6−8 h (max. 2.4 mg day-1).

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pp .by Atsede Local Analgesia: Before surgery (for pre-emptive analgesia), the anticipated incision line can be injected with: lidocaine 1%, 10–20 mL (when an intravenous infusion is used, the total lidocaine dose should be verified) or, bupivacaine 0.25–0.125%, 5–10 mL or, ropivacaine 0.2%, 5−10 mL.

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pp .by Atsede 3.Surgical Procedures Associated With Substantial Or Extensive Tissue Damage NRS or VAS anticipated post-operative pain intensity levels > 6 and duration of post-operative pain longer than 5 days

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pp .by Atsede A.Pharmacotherapy Before Surgery (Preventive Analgesia) non opioidmetamizole (1–2.5 g), intravenous or

oral, paracetamol (1.0−2.0 g), intravenous or

oral, ketoprofen (50–100 mg), intravenous or

oral, ibuprofen (200−400 mg), oral, diclofenac (50−100 mg), oral other

NSAIDs, oral.

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pp .by Atsede Additionally, the following drugs, selectively or combined: adjuvant analgesicclonidine tablets 75−150 μg 1 h before surgery or as a slow intravenous infusion 150 μg directly before the induction of anaesthesia or, dexmedetomidine 200 μg, a slow intravenous infusion directly before the induction of general anaesthesia, gabapentin, oral 600 mg 4 h before surgery or,

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pp .by Atsede pregabalin, oral 50−75 mg h-1 before surgery, lidocaine 1.5 mg kg-1 body weight, a slow intravenous infusion before the induction of general anaesthesia, ketamine 50 mg, intravenous bolus before the induction

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pp .by Atsede B.Intraoperative Lidocaine 1.5–3 mg kg-1 h-1.

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pp .by Atsede C.Pharmacotherapy After Surgery: metamizole (1 –2.5 g, max. 5 g day-1), intravenous, every 6–12 h; and/or, paracetamol 0.5–1.0 g, intravenous, every 6 h combined (or otherwise) with ketoprofen (50–100 mg), an intravenous infusion every 12 h or, dexketoprofen (25 mg), an intravenous infusion every 8 h.

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lidocaine, an intravenous infusion 0.5-1 mg kg-1 h-1, a continuous infusion of an opioid (e.g., morphine, oxycodone, fentanyl, sufentanil, nalbuphine)

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morphine, a single intravenous bolus 2.5−10 mg; the dose can be repeated after 4–6 h or a continuous infusion 0.8−2.5 mg h-1 or lockout interval 5−15 min, oxycodone, a single intravenous bolus, 1–10 mg for 1–2 min; the dose can be repeated after 4 h or a continuous infusion, 2 mg h-1, lockout interval 5−10 min,

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pp .by Atsede fentanyl, single bolus 50−200 μg; a dose of 50 μg can be repeated after 20−40 min or a continuous infusion, 0.05−0.08 μg kg-1 min-1 lockout interval 5−10 min, During the next post-operative days, the

analgesic management provided should be modified based on the level of pain intensity determined using the chosen scale.

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pp .by Atsede Local Analgesia In the majority of cases in this group of procedures, regional analgesia is a continuation of surgical anaesthesia. Continuous epidural analgesia, together with PCEA using LAs and opioids, is currently recommended only for select procedures .


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Caution! Metoclopramide and ondansetron should not used in patients who are receiving tramadol. In the case of nausea and vomiting in patients who have been administered tramadol, small doses of levomepromazine can be given as an antiemetic (12.5−50 mg, intravenous

SEVERITY OF PAIN MILD PAIN

MODERATE PAIN

SEVERE PAIN

Type of Surgery Myringotomy Submucous resection Excision of nasal or aural polyps Biopsy of oral lesions Excision of tongue tie Dilatation and Curettage Hysteroscopy 0ther minor gynaecological surgery Excision of breast lump Removal of other lumps and bumps Orchidopexy Circumcision Lymph node biopsy Toenail surgery Cataract surgery

Reduction of nasal fracture Tonsillectomy Adenoidectomy Removal of dental bone plates and wires Surgical removal of wisdom tooth Cone biopsy of cervix Termination of pregnancy Laparoscopic tubal ligation Marsupialisation Cystoscopy Herniotomy Ligation of Varicose veins Ligation of Hydrocoele Vasectomy Excision of thyroid nodule Bunion surgery Dupuytren‟s contracture surgery Carpel tunnel surgery Excision of ganglion Excision of chalazion

Wisdom teeth extraction Wide excision of breast lump with axillary clearance Open hernia repair Laparoscopic hernia repair Laparoscopic cholecystectomy Haemorrhoidectomy Varicose vein surgery Anal fissure dilatation or excision Arthroscopic surgery Removal of orthopaedic implants

Preop analgesia Oral NSAIDs/Cox-2inhabitor + Paracetamol

Oral NSAIDs/cox-2 inhibitor + Paracetamol

Oral NSAIDs/Cox-2 inhibitor + Paracetamol

Intraop analgesia Wound infiltration with LA +/- IV fentanyl*

Wound infiltration with LA and/or Peripheral Nerve/plexus block or Single shot spinal +/- IV fentanyl*

Wound infiltration with LA and/or Peripheral Nerve/plexus block or Single shot spinal +/- IV fentanyl*

Postop analgesia In Recovery Room

Oral NSAIDs/Cox-2 inhibitor + Paracetamol (if not given preop)

Oral NSAIDs/Cox-2 inhibitor (if not given preop) Oral or IV Tramadol Oral Oxynorm IV fentanyl (titrated to effect)

Oral NSAIDs/Cox-2 inhibitor (if not given preop) Oral or IV Tramadol Oral Oxynorm IV fentanyl (titrated to effect)

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pp .by Atsede 2.Non-pharmacological approaches Techniques proven to be useful in acute pain management: 1. Psychological approaches: Music- reduction in postoperative pain

and opioid consumption. Pre-operative information- effective in

reducing procedure-related pain. Srinivas pyati and tong j.gan CNS 2007

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pp .by Atsede Distraction- effective in procedure-related

pain in children Cognitive methods-training in coping

methods or behavioural instruction prior to surgery, reduces pain and analgesic use.

Hypnosis and relaxation-inconsistent evidence of benefit in the management of acute

Srinivas pyati and tong j.gan CNS 2007

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2. Complementary therapies and other techniques: including massage, acupuncture, Tens(transcutaneous electrical nerve stimulation), hot and cold packs.

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pp .by Atsede POSSIBLE NURSING CARE PLAN FOR SURGICAL PATIENT

Nursing Diagnosis Expected Outcome Nursing Intervention1. Knowledge defcitrelated to unfamiliarityof procedureenvironment

1. Patients will verbalizeunderstanding ofprocedure andnecessarypreparation

B. Perform pre-op/post-op educationC. Assess barries/readiness to learn and response to teachingD. Use age/developmentally specific statements when instructing patientsE. Reassure the patient, encourage feedback and questionsF. Review discharge instructions and follow up with written copy for patient

2. Anxiety/fear related to procedure

2. Anxiety will be managed or relieved

A. Assess patient’s level of anxietyB. Acknowledge patient’s anxietyC. Reassure patient/family, encourage verbalization and questions

3. Percentage of surgicalInfection

3. Patient is infection free A. Patients will receive ordered antibiotics prior to procedure

Preoperatively by Rockland & Bergen Surgery Center,

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INTRA OPERATIVELY

1. Anxiety related tosurgery/procedure andpossible finding

1. Patient verbalizesand/or demonstratesdecreased anxiety level

A. Assess patient’s knowledge of operative routine• Instruct of operative routine• Provide clear, concise explanationB. Remain with patient as much as possibleC. Offer emotional support• Discuss concerns and possibilities

2. Potential for injuryto musculoskeletaland/or neurologicalsystems related tomovement.transfer, position, orlength of procedure

2. No injuries, falls,redness, bruises, or skinabrasions evident onarrival to PACU

A. Assess skin condition pre-op and document any unusual markingsB. Keep side rails up on stretcher during transportationC. Lift or roll patient with extra help when transferring from stretcher to tableD. Check for and relieve all potential pressure areas, ie., elbows, coccyx, popliteal• Pad bony prominences• Smooth out sheets under patientE. Document placement of safety strap above knees unless otherwise indicated

Diagnosis Expected Outcome

Nursing Intervention

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3. Potential loss ofprivacy and dignityrelated to physicalexposure or disclosureof confidentialinformation

3. Reasonable privacy/dignity maintainedthroughout procedure.Confidentialitymaintained

A. Keep doors closedB. Limit traffic of personnelC. Avoid unnecessary exposure by limiting skin exposure only to area needed for peopD. Make chart available only to authorized personnel

4. Potential impairmentof skin integrity r/t• Prep solutions pooling• Improper placement ofelectro-surgicalgrounding pad

4. No unusual loss to skinintegrity demonstratedby absence of redness,bruises, abrasions,blisters and/or burns

A. Assess for allergies to skin prep.• Obtain appropriate solution• Place towel along skin edges of surgical site to absorb excess solution andremove when prep. completeB. Check grounding pad site

5. Potential for infection• Contamination of woundor steril fileld• Peripheral lines

5. No contamination ofsterile fileld, wound.invasive lines or tubes

A. Supervise skin prep. for correct procedure• Ensure personnel are clad properly• Maintain an aseptic environmentB. Record insertion site and ensure integrity of IV sites with dressing or properpositioning of arm

intraoperative

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1. Potential for alterationin comfort

1. Patient will verbalizepain tolerable or relieved

A Assess pain levelB. Acknowledge patient’s perception of painC. Position for comfortD. Administer medications as ordered by physicians

2. Potential for postoperativecomplications

2. Patient will meet dischargecriteria (Phase I & II)

A. See policy “Nursing Care in the PACU-Phase I":" Transfer of patients from Phase I to Phase II”; “Nursing Care in the PACU-Phase II”B. Written discharge order from physician noted on chartC. See policy “The Center Discharge Criteria”

postoperative

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SUMMERY Pain is must be asses for all patients who are

preoperatively ,interaoperatively ,postoperatively. Asses the patient based on WILDA approach and 4

pain intensity scale. For all surgical patient who are on analgesic

assessed for B/P ,R/R, sedative score,pain intensity by VAS and NRS.

Give an analgesics drug depend on pain scale,severity,duration ,tissue damage

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pp .by Atsede REFERENCE

1. Orlando Regional Medical Center,Revised 4/08/03 and 6/21/05 pain management in surgical patient.2. Minsteri of health in Rwanda September 2012,pain management guide line.3. REGINA FINK, RN, PHD, AOCN ,July 2000Pain assessment: the cornerstone to optimal pain management .4. Produced in consultation with the European Society of Regional Anesthesia and Pain Therapy, Postoperative Pain Management –Good Clinical Practice.

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5. Hanna Misiołek1 etal, 2014, guidelines for post-operative pain management. 6 .MOH/P/PAK/257.12 (HB), in October 2013 ,pain management handbook.7. Srinivas pyati and tong j.gan CNS 2007,preoperative pain management8.Barbara kuhan timbyed,9th July 2013 Fundamental Nursing Skills and Concepts on pain management.9. Rockland & Bergen Surgery Center, 2013,nursing care plan in surgical

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Pain can kill you!!!

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Thank you!!!

Health & Medicine

Lemessa Jira pain managment in surgical patient ppt