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Managing Pain in The Surgical Patient PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Managing Pain in the Surgical Patient" by LUCILLE LUTZ, RN, MSN, APRNBC.

This medical PowerPoint presentation is about managing pain in surgical patients which is crucial for their recovery and overall well-being. There are several approaches to pain management in surgical patients, including pharmacological and non-pharmacological interventions.

Pharmacological interventions typically involve the use of analgesics such as opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Opioids are often used for moderate to severe pain and can be administered orally, intravenously, or via patient-controlled analgesia (PCA) pumps. NSAIDs are often used for mild to moderate pain and can be administered orally or intravenously. Local anesthetics can be administered via injection or topical application and can provide pain relief to a specific area of the body.

Non-pharmacological interventions can also be effective in managing pain in surgical patients. These may include the use of relaxation techniques such as deep breathing, visualization, and meditation. Physical therapy and rehabilitation can also be effective in managing pain and improving mobility.

It is important to develop a comprehensive pain management plan that takes into account the individual needs and preferences of each patient. This may involve a combination of pharmacological and non-pharmacological interventions tailored to the specific surgical procedure and the patients medical history.

It is also important to monitor patients for side effects and complications related to pain management, such as respiratory depression and gastrointestinal disturbances. Effective pain management can improve patient outcomes and reduce the risk of complications during the recovery process.

Tags : managing pain in surgical patients, opioids, non-steroidal anti-inflammatory drugs, local anesthetics, relaxation techniques

Published on : Jun 23, 2023 | Views : 811 | Downloads : 0

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Slide 1-

Managing Pain in the Surgical Patient LUCILLE LUTZ, RN, MSN, APRNBC CLINICAL NURSE SPECIALIST PAIN MANAGEMENT
Slide 2-

Objectives Discuss preop pain assessment Discuss intraop pain management Discuss postop pain management
Slide 3-

Background Acute Pain Immediate Serves as a warning Easier to treat (generally) Has an end (generally)
Slide 4-

Background Chronic Pain Lasts longer than 3-6 months Serves no purpose Cannot identify a cause Can lead to pain behaviors Very difficult to treat
Slide 5-

Pain Conduction Injury triggers release of bio-chemicals Inflammation takes place Stimulation of nerve fibers Bio-chemicals causes pain impulses to begin
Slide 6-

Pain Perception Impulse is sent to the brain via ascending tracts in spinal cord Neurotransmitters released by C fibers (substance P) Message to the brain (Thalamus) Sends message down descending pathway= pain response
Slide 7-

Why Pain Control Persistent acute postoperative pain: Decreases the body’s physiologic reserves May exacerbate co-morbid conditions (e.g.) increase risk of MI in patients with CAD Contributes to pulmonary complications.
Slide 8-

Impairs rehabilitation and functional outcome May lead to development of chronic pain syndromes and long-term disability. Increases hospital stay and the cost of patient care Decreases patient satisfaction.
Slide 9-

Metabolic Stress Response Surgical insult results in post op pain Increased circulating catecholamines Resulting in tachycardia and hypertension Leading to increased cardiac work Resulting in increased myocardial oxygen consumption
Slide 10-

Cardiovascular ↑ HR, ↑ BP, ↑ SVR, altered regional blood flow, ↑CMO2, ↑ DVT Respiratory: – ↓ VL (atelectasis), ↓ cough (sputum retention) – hypoxemia and infection
Slide 11-

Gastrointestinal: – ↓ gastric and bowel motility, nausea, vomiting • Genitourinary: urinary retention • Neuroendocrine: ↑ catabolic hormones – ↑ blood glucose, Na + H20 retention
Slide 12-

Musculoskeletal: Muscle spasm, immobility (↑ DVT) Psychological: fear, anxiety, insomnia • Chronic pain
Slide 13-

Pre Op Assessment Indication for surgical procedure Allergies and intolerances to medications, anesthesia, or other agents Known medical problems Surgical history Trauma (major) Current medications (incl.OTC herbal & dietary supplements,and illicit drugs) Gayatri,P (2005). Post-op pain services. Indian J. Anaesth. 49 (1) : 17-19
Slide 14-

Discuss History of Acute or Chronic Pain Identify history of pain control methods What has worked How long on pain meds Do they work True allergies, ask what happens
Slide 15-

Differentiate between tolerance and physical dependence Discuss pain management problems (ie) anxiolytic therapy with pain meds Identify if there is a need to wean from any pain medications prior to surgery Do not stop suddenly
Slide 16-

Consider Patients with: Multiple back operations Abdominal pain patients (ie) Crohn’s disease Recurrent cancer Chronic joint pain, (ie) RA or DJD
Slide 17-

If with a history of chronic opioid use for pain management may require higher doses for pain control This will include using PCA and/or meds for break through pain May not get adequate relief with “standard” doses of “standard” post op pain orders
Slide 18-

Do a directed pain history Type of pain Location, description, duration, exacerbation and relieving factors Directed pain examination Discussion of post-op pain control plan
Slide 19-

Evaluate each patient individually Do not assume that aging is the same in all patients Evaluate for side effects of narcotics Need complete list of meds to check for interactions What about the Elderly
Slide 20-

Dispel myths Concerns about opioids Concerns about addiction Fear of tolerance Age related expectation of pain
Slide 21-

Pre Op Teaching Educate patient/family/staff Pain plan How & when to evaluate Use of alternative methods of pain control Patient and/or Family education on use of PCA
Slide 22-

Explain blocks !!!!!! Provide pre-anesthetic evaluation, brochures, and videotapes to educate patients about therapeutic options (music and/or guided imagery, other)
Slide 23-

Preoperative Preparation of the Patient Instruct on bedside postoperative evaluation Include instruction in behavioral modalities to control anxiety Distraction, deep breathing, visualization (etc)
Slide 24-

Preoperative Preparation of the Patient Instruct on pain ranking tools prior to surgery Use age appropriate tools, why, when and how to be used. Instruct S.O., parents if needed. May want to use personalized tool (i.e.Randall)
Slide 25-

Generally there is decreased cardiac and pulmonary reserve with increased age Opioids may produce confusion or cause some delirium postoperatively in some patients An elderly patient taking six medications is likely to have adverse reactions 14 times more than a younger person taking the same number of medications.
Slide 26-

Consider additive respiratory depressant effect of both opiates and anxiolytics Most elderly patients metabolize drugs at a slower rate and may require less-frequent dosing or a reduction in dosage Certain medications should be avoided in elderly patients, based on their adverse effects (Beers list)
Slide 27-

Sedative effects with an increased risk of falls Constipation related to opiates & NSAIDS May have reduced gastrointestinal motility Stool softener with stimulant Start pain meds at a lower dose and increase to pain relief if opioid naive
Slide 28-

Special Populations Pediatrics Use pain scales specific to age FLACC (pre-op instruction) Observe frequently Medication dose wt specific Guided Imagery Distraction Music/video
Slide 29-

Special Populations Pediatrics Allergies Sensitivities Comfort frequently If non verbal anticipate painful procedures result in pain Be an advocate
Slide 30-

Special Populations Special needs: Identify what works for this patient Ask the family or caregiver Comfort frequently If non verbal anticipate painful procedures result in pain Again be an advocate
Slide 31-

Cultural Considerations Be aware of specific needs and beliefs Respect the patient/family tradition Internalize (how would I feel if) Do not pre judge Explain need for pain control
Slide 32-

Intra Op Consideration Therapy selected should reflect the individual needs of the patient. Ability to recognize and treat adverse effects during surgery Special caution during continuous infusion modalities Drug accumulation may contribute to adverse events
Slide 33-

Patients who are pretreated with pain meds, anxiolytics or NSAIDS prior to surgery Have a greater decrease in postoperative pain Decrease in postoperative anxiety Olorunto,W & Galandiuk, S. 2006. Managing the Spectrum of Surgical Pain: Acute Management of the Chronic Pain Patient. American College of Surgeons
Slide 34-

Surgeries to upper abdominal and thoracic areas associated with severe pain can lead to: Restrictive lung defect Depressed diaphragmatic activity Gayatri,P (2005). Post-op pain services. Indian J. Anaesth. 49 (1) : 17-19
Slide 35-

Study: Early and aggressive use of pain medications after surgery results in shorter hospital stays, fewer chronic pain problems later, and use less pain medication overall than people who avoid pain medication. Taylor, M. (2001).Managing postoperative pain. Hosp Med; 62: 560-563.
Slide 36-

Intra Op Consideration Patient Advocate Continue to assess for anxiety/pain Provide comfort Positioning Guided imagery Music
Slide 37-

Adequately treating Post-surgical Pain Increased Comfort =quicker healing Increased activity= increased strength Decreased complication= improved post-op period
Slide 38-

The risk of addiction to pain medication is low for patients using such medications for post-surgical pain Addictive personality leads to addiction Dependency is another issue
Slide 39-

Effective Pain Control Listen to the patient Believe the patient’s pain ranking Support the patient/family Answer questions Provide information Instruct re: need for pain control
Slide 40-

Acute nociceptive pain from incision. • Musculoskeletal pain from abnormal body positioning and immobility during and after surgery • Neuropathic pain from excessive stretching or direct trauma to peripheral nerves Sources of postoperative pain
Slide 41-

Post Operative Pain Control Decreases risk of Myocardial ischemia Tachycardia and dysrhythmia Impaired wound healing Atelectasis Thromboembolic events Peripheral vasoconstriction
Slide 42-

Post Operative Pain Near the surgical site. Acute exacerbation of pain may be added to the basal pain Increases with activities such as coughing, turning, dressing changes Generally self limiting Progressive improvement over a relatively short period
Slide 43-

With Special Populations Geriatric Be aware of renal/hepatic function Sensitivities/allergies Be pro-active with medication Opioids Combination meds Be aware of drugs to be avoided in the elderly
Slide 44-

ASSESS & RE-ASSESS Before and after pain medications Put it in the patient’s own words Assess for non verbal cues Be aware of special needs of the cognitively impaired patient Use appropriate pain scale Document, Document, Document,
Slide 45-

ASSESSMENT TOOLS VAS PAIN FACES PAINAD FLACC
Slide 46-

Post Op of Special Populations Geriatric If with Cognitive Impairment PAINAD scale Observe & re-assess frequently Guard/observe for delirium superimposed on dementia Know drug side effects Know method of elimination
Slide 47-

Medication Use Review information gathered during pre op assessment If something has not worked in the past don’t use it. Explain what you are doing and what you are giving When in doubt, follow the WHO guidelines
Slide 48-

World Health Organization (WHO) 3- Step Ladder approach to pain management Step 1- Mild Pain (1-3/10) Nonopioid Add adjuvant analgesic agent (i.e.) Ice, heat
Slide 49-

WHO cont’d Step 2 Mild to moderate pain (4-7/10) This step builds on step 1 Treat with opioid combination drug (hydrocodone/acetaminophen) Watch ceiling effect of adjuvant drug Peds are dosed by weight Watch special needs patients/elderly
Slide 50-

WHO cont’d Step 3- Severe pain (8-10/10) Use opioids Add adjuvant (i.e.)anti-anxiety,anti-emetics, muscle relaxants Start with short acting opioids to determine pain relief, breakthrough needs and frequency. Switch to long acting use equianalgesic dosing chart for conversion
Slide 51-

POINTS TO REMEMBER The pain intensity determines the step at which to begin. Opioids are the only group of analgesics with no ceiling on dose with careful titration. Most opioid side effects resolve within a few days. Exception>>>>Constipation-- need to write for this immediately
Slide 52-

Commonly used first line opioids Codeine Morphine Hydromorphone Oxycodone
Slide 53-

Share the following characteristics Half-life of immediate release preparations is 2 to 4 hours Duration of analgesic effect between 4 to 5 hours when given at effective doses. Sustained release formulations have duration of analgesic effect of 8 to 12 hours
Slide 54-

Equianalgesic doses need to be calculated when switching from one drug to another when changing routes of administration or both. An equianalgesic table should be used as a guide in dose calculation Due to incomplete cross-tolerance clinicians should consider reducing the dose by 20 to 25% when ordering.
Slide 55-

Morphine Onset: 15 to 60 minutes Peak Effect: 30 minutes to 1 hr Half Life: 1.5 to 2 hr IV: 0.05 to 0.1 mg/kg 5 minutes prior to procedure; max: 15 mg/dose
Slide 56-

Morphine Sedation, somnolence, respiratory distress or depression, pruritis Reversal: Naloxone: 5 to 10 mcg/kg/dose; Single dose should not exceed max recommended adult dose of 0.2 mg
Slide 57-

Fentanyl Fentanyl is 80 to 100 times more potent than morphine. Studies report less constipation and somnolence in patients using transdermal fentanyl compared to those using SR morphine.
Slide 58-

Fentanyl Fentanyl’s high lipophilic properties provide a sufficient sublingual bioavailability of 90%, thus making it a suitable opioid for use sublingually. Conditions that may effect absorption, bl levels & clinical effects if the drug Morbid obesity Ascites opioid-naïve patients
Slide 59-

Fentanyl Onset: 1 to 5 minutes Peak Effect: (no data available) Half Life: 1.5 to 6 hr IV: 0.5 to 3 mcg/kg/dose; may repeat after 30 to 60 minutes; max: 50 mcg/dose Use lower doses (0.5 to 1 mcg/kg/dose) when used in combination with other agents, such as midazolam
Slide 60-

Fentanyl Respiratory distress or depression, apnea, seizures, shock, chest wall rigidity (most likely to occur with rapid infusion or high doses) Reversal: Naloxone: 5 to 10 mcg/kg/dose; Single dose should not exceed max recommended adult dose of 0.2 mg
Slide 61-

Sufentanil 5 to 10 times more potent than fentanyl. Injectable sufentanil (like fentanyl) is readily absorbed through the mucous membranes Early onset of action of about 5 to 10 minutes, when used sublingually
Slide 62-

Sufentanil Good for incident pain control. Peak analgesic effect of 15 to 30 minutes Duration of the analgesic effect is 30 to 40 minutes. Use for incident pain control, dosing 10 to 15 minutes prior to the painful event.
Slide 63-

Methadone Long half life of methadone prevent it being a first-line opioid. When converting to methadone dose reduction of 75 to 90% should be considered Initiation for pain management is 5mg bid or tid depending on age
Slide 64-

Dilaudid 10mg IV morphine is equivalent to 1.3-2mg Hydromorphone IV Dilaudid has a half life of 2.5 hours, duration of effect varies Administering 1 mg or more of IV Dilaudid every 1 - 2 hours leads to a build up of the drug (stacking) and can increase adverse effects like respiratory depression. Know elimination
Slide 65-

Stacking from delayed peak effect Occurs when additional doses are given prior to peak effect leads to multiple doses, resulting in over dosage. Caution: Administration of a benzodiazepine with narcotic analgesics increases the risk of respiratory depression. (ie: Xanax, Lorazepam, Versed, Valium)
Slide 66-

Onset: 1 to 5 minutes (short acting) Peak Effect: 3 to 5 minutes (IV) Half Life: 1.5 to 12 hr Oral: 0.2 to 1 mg/kg; 30 to 45 minutes before procedure; max: 20 mg IV: 0.05 mg/kg 3 minutes before procedure (may repeat dose X 2); max: 2 mg/dose Midazolam: CNS Depressant
Slide 67-

Respiratory distress, depression, apnea, PVC's, amnesia, blurred vision, or hyperexcitibility Reversal: Flumazenil:(Romazacon) 0.2 mg/dose q 1 minute; max cumulative = 1 mg Midazolam: CNS Depressant
Slide 68-

POINTS TO REMEMBER Dosing intervals are determined by the duration of action as well as the half-life of the drug Know the route of elimination Adjust dose and frequency for special populations. Be aware of prior surgeries involving bowel, stomach, liver, kidneys
Slide 69-

Opioid-induced Neurotoxicity (OIN) Hyperalgesia (heightened sensitivity to the existing pain) Allodynia (a normally non-noxious stimuli resulting in a painful sensation), Agitation/delirium with hallucinations and possibly seizures. Due to the accumulation of toxic metabolites and impaired renal
Slide 70-

Post Op Documentation Document response to medication Pain relief Increased agitation Be pro-active if patient unable to verbalize Painful procedures result in pain (Treat as you would a family member)
Slide 71-

GOAL Promote optimal pain management Reduce anxiety Support the patient Improve post op outcomes Promote patient satisfaction
Slide 72-

QUESTIONS????
Slide 73-

THANK YOU