PAIN
Constant or intermittent pain that
Pain
 Unpleasant sensory and emotional
associated with actual or potential tissue
damage
 Most common reason for seeking
healthcare
 AMERICAN PAIN SOCIETY: pain as the 5th
vital sign
 NSG RESPONSIBILITY
o Collaborate with other health care
professionals while administering
pain relief intervention
o Evaluating their effectiveness
o Being pt’s advocate, teaching to
manage pain
o Pain relief mngt
 Mc Caffrey: whatever the person says it is,
existing whenever the experiencing person
says it does
 Pain is highly SUBJECTIVE
Multidimensional nature of pain
1. Physiological- pain affects the physiologic
processes including the nervous system
2. Affective- psychological aspect of pain such
as its ability to arouse fear and anxiety
3. Cognitive- correlates to the person’s
understanding of pain and his coping
strategy
4. Behavior- correlates to the person’s reaction
to pain such as facial grimace and moaning
5. Socio-cultural factors- such as culture and
ethnicity influences on pain perception and
expression
Classification of pain
1. Nociceptive pain
a. Pain that is associated with
somatic(sensory) to visceral tissue
injury
2. Neuropathic pain
a. Pain that is associated or has a
direct effect within the central
nervous system
3. Acute pain
a. Of recent onset and commonly
associated with a specific injury
b. If no lasting damage occurs and no
systemic disease exists, acute pain
usually decreases as healing occurs
c. Lasting from seconds to less than 6
months
4. Chronic pain
a.
persists beyond the expected
healing time and is seldom attributed
to specific cause of injury
b. Chronic pain is pain that lasts for 6
months or larger than the expected
healing time
c. After 6 months, most pain
experiences are accompanied by
problems related to the pain itself.
Causes of pain
1. Noxious Stimuli
a. Causes are from physical
environment
b. Examples are mechanical, thermal,
pressure
2. Ischemia
a. Anaerobic glycolysis leads to the
production of lactic acid
b. Lactic acid irritates nerves which
when uncontrolled, results to tissue
death
3. muscle spasm
a. involuntary contractions and rigidity
of the muscle produces lactic acid
4. psychogenic
a. “it’s all in the mind”
b. Emotional and affective factors
affect client’s perception of pain
Types of Pain
A. According to duration
a. Acute pain
b. Chronic pain
c. Cancer-related pain
i. Pain in px with cancer can be
directly associated with the
cancer (e.g. surgery,
radiation) or not associated
with cancer (e.g. trauma)
ii. Pain associated with cancer
is a direct result of tumor
involvement also known as
breakthrough pain
B. According to Location
a. Referred pain
i. Ex. Chest pain radiating to
the left arm, to jaw suggests
angina or MI
b. Phantom Pain
i. Normally, a neurosignature
output with a constant stream
of input and varying patterns
produces the feeling of the
 whole body with constant
changing quantities.
ii. In the absence of modulating
inputs, from the missing limb,
the active neuromatrix
produces a neurosignature
pattern that is perceived as
pain
C. According to etiology
a. Central
i. Associated with neuro and is
direct with the brain
ii. Neuropathic in nature
b. Peripheral
D. According to pain characteristics
a. Pricking
i. Characterized by a sharp or
“needle stick like” pain
b. Burning
c. Aching
i. Characterized by vague pain,
growing pain
Theories of Pain
1. Gate control theory
a. The gating
mechanism is influenced by nerve
impulses that descend from the brain.
This theory proposes a specialized
system of large diameter fibers that
activate selective cognitive process via
the modulating properties of the spinal
gate. Cognitive process stimulates
endorphin production in the descending
control system. Activation of the
descending control system results in less
noxious or painful info being transmitted to
consciousness.
Stimulation of the skin – production of nerve
impulses- transmission by 3 systems in spinal cord
1. Substantia gelatinosy in dorsal horn; 2. Dorsal
column fibers; 3. Central transmission cells –
GATING MECHANISM STIMULATED
 Large – diameter fiber stimulation – gate
closed – X pain
 Small – diameter fiber stimulation – gate
opened - + pain
2. Sensory or Specificity
theory
a. In every pair
of stimulus, there is a specific receptor for
that
3. Intensity theory
a. The intensity
or the amount of painful stimulus is equal
to the intensity of pain perceived
4. Affect theory
a. Reception of
pain is influenced by psychological effects
of past painful experiences
5. Pattern theory
a. There is a
specific pattern of transmission in every
pain stimulus
Factors influencing pain response
 Past experience
o Often, the more experience a person
has had with pain, the more
frightened he/she is about
subsequent pain full events
o Px may be less able to tolerate pain
o If pain is relieved promptly and
adequately, the person may be less
fearful of future pain and better able
to tolerate it.
 Anxiety and depression
o Anxiety that is relevant to pain may
increase. The patient’s perception of
pain
o Anxiety that is unrelated to the pain
may distract the patient and may
actually decrease the perception of
pain
o Depression is associated with
chronic pain and unrelieved cancer
pain resulting to major life changes
such as unemployment
 Culture
o Factors that help explain differences
in a cultural group include age,
gender, education level and income
o The degree to which px will identify
with culture influences the degree to
which they will adopt new health
behaviors
 Age
o If pain perception is diminished in
elderly people, it is most likely
secondary to disease process rather
than aging
o Because elderly people have a
slower metabolism and a greater
ratio of body fat to muscle mass than
young people do, small doses of
analgesic agents may be sufficient
to relieve pain and these doses may
be effective longer
 o Confusion is often a result of  4-8 moderate
untreated and unrelieved pain. In  7-10 – severe
some cases, post operative  Influenced by pain threshold
confusion clears once the pain is and pain tolerance
relieved  Pain threshold – smallest
 Gender stimulus for which a person
o Women have consistently reported reports pain
pain intensity, pain, unpleasantness,  < 12°C , >47° C
frustration and fear compared to  Pain tolerance maximum
men amount of pain a person can
o Women report significantly greater tolerate
pain intensity than men o Timing
o The pharmacokinetics and  Onset; during/relationship
pharmacodynamics of opioids differ between time and intensity
in men and women and have been and duration; include
attributed to hepatic metabolism rhythmic pattern
where the microsomal enzyme  Sudden pain that rapidly
activity differs reaches maximum intensity
 Genetics is indicative of tissue rupture
o Genetic factors play a role in the  Pain from ischemia gradually
varied responses to NSAIDS and increases and becomes
opioids seen in patients intense over longer time
o African Americans had higher levels o Location
of clinical pain, greater pain related  Best determined by having
disability and less pain tolerance the px point to the area of the
compared to Caucasians body involved
o Drug metabolism involves o Quality
genetically controlled enzyme  Ask the px to describe pain in
activity for absorption, distribution, his own words and which
inactivation and excretion words are suggested by the
o Poor metabolizers do not nurse correlates to it
demethylate codeine to morphine; o Personal meaning
therefore; they do not experience its
 Understands how the px is
analgesic effects.
affected and assists in
 Placebo effects planning treatment
o Occurs when a person responds to o Aggravating and alleviating factors
the medication or other treatment  Ask the px what makes the
because of an expectation that the pain worse and what makes
treatment will work rather than it better
because it actually does so.
 Ask specifically bout the
o The placebo effect results from
relationship of/between
natural production of endorphins in activity and pain
the descending control system o Pain behaviors
o Its true physiologic response can be
 Non verbal and behavioral
reversed by naloxone, an opioid
expressions of pain; e.g.
antagonist
grimace, crying, rubbing,
guarding, immobilizing,
NURSING ASSESSMENT OF PAIN
grunting, groaning, sighing,
Characteristics of pain
 V/s changes
 Pain assessment begins by careful px
Clinical Manifestations of pain
observation, noting over all posture and
 non physiological
presence or absence of overt pain
o restlessness
behaviors
o Intensity o facial expression
o moaning and other sound
 0-3 – mild
 o irritability • Found in female
o weakness; feeling of fatigue reproductive tract,
 physiological brain/brainstem
o increased sweating (DIAPHORESIS)  Endorphins and Encephalin
o anorexia o Chemicals that reduce or inhibit the
o nausea transmission or perception of pain
o vomiting o Morphine like neurotransmitters that
o increased or decreased BP are endogenous or produced by the
o increased or decreased RR and PR body
o pallor o Have heavy concentrations in the
CNS (Descending control system)
Pathophysiology of pain o Inhibit pain impulses by stimulating
definition of terms the inhibitory interneuronal fibers
 Nociceptors which in turn reduce the
o Receptors that are preferentially transmission of noxious impulses via
sensitive to a noxious stimulus the ascending system
o AKA pain receptors o Descending control system – inhibits
o Free nerve endings in the skin that interneuronal fibers
o Ascending control system –
respond only to intense, potentially
damaging stimuli (mechanical, transmission of noxious
thermal or chemical) stimulus/impulses
o Joints, skeletal muscle, fascia,  Tolerance
tendons and cornea have o Results when a patient who has
nociceptors with potential to transmit been taking opioids becomes less
stimuli to produce pain sensitive to their analgesic
 Algogenic properties
o Pain causing substances that affect o Increased dose of medication is
the sensitivity of nociceptors needed to maintain the same level of
o They are released in to the pain relief
extracellular tissue as a result of  Dependence
tissue damage o Results when a person taking opioid
o Histamine experiences a withdrawal syndrome
o Bradykinin when opioids are discontinued
abruptly
o Acetylcholine
o Serotonin  Addiction
o Behavioral pattern of substance
o Substance P
abuse characterized by a
 Prostaglandins compulsion to take the drug to
o Chemical substances that affect the experience its psychic effect
sensitivity of the pain receptors by  Antagonist
enhancing the pain provoking effect o Substance that block or reverses the
of bradykinin
effect of the drug by occupying /
o Cause vasodilatation and increased
producing the effect
vascular permeability resulting in
 Agonist
redness, warmth and swelling
o Behavior/substance that when
o TYPES
combined with the receptor
 COX 1 produces the drug effect/ desired
• Highly abundant in all effect
tissue body
specifically in the Types of fibers involved in the transmission
endothelial wall/cells,  A delta fibers
platelets, GIT and o Small, myelinated fibers that
GUT
transmit nociception rapidly
 COX2 o Produces initial fast pain; sharp,
pricking and superficial pain
  C fibers that exerts inhibitory
o Larger, unmyelinated or facilitatory effect on
o Produces second pain; with dull, the transmission of
aching, burning qualities pain
o Lasts longer than initial fast pain • Its signals occur at
the peripheral level,
PAIN MECHANISMS spinal cord, brainstem
 Nociception and cerebral cortex
o Physiological process by which • Descending
information about tissue damage is modulatory fibers
communicated to CNS releases chemicals
o FOUR PROCESSES OF such as serotonin,
NOCICEPTION norepinephrine,
 Transduction GABA and
endogenous opioids
• Conversion of a
that inhibit pain
mechanical, thermal
transmission(endorph
or chemical stimulus
ins and encephalin)
into a neuronal action
potential
• Occurs at the level of  Perception
peripheral nerves in • Pain is recognized,
particular with free defined and
nerve endings or responded to by the
nociceptors individual
• Chemicals involved experiencing pain
are: H+ ions, subs P, • Involves several
ATP, serotonin, structures of the brain
histamine, • Somatosensory
bradykinins and system id responsible
prostaglandins that for localization and
are stressed from characteristic of pain
mast cells. • Limbic system is
 Transmission responsible for
• Mov’t of pain emotional and
impulses from the site behavioral responses
of transduction to the to pain
brain • Reticular activity
• 3 signals involved in system is responsible
transmission for warning an
o Transmission individual to attend
along the pain stimulus
peripheral
nerve fibers to Factors that influence pain tolerance
this spinal  increase tolerance
cord o alcohol
o Dorsal horn o drugs
processing o hypnosis
o Transmission o warmth
to the o rubbing
thalamus and o distraction
cerebral o strong beliefs
cortex  decrease tolerance
 Modulation o fatigue
• Activation of o anger
descending pathways o boredom
 o anxiety
o persistent pain
o depression
 BARRIERS TO EFFECTIVE PAIN
MANAGEMENT
o Psychological factors
o Tolerance
o Physical dependence
o Addiction
Nursing Care process on pain management
I. Assessment
a. PQRST
i. Accurate assessment will
lead to an accurate
formulation of a nsg dx and
therefore an appropriate nsg
intervention will be applied
b. Functional impairment
i. Pertinent observations
include:
1. Px’s withdrawal from
communication
2. grimacing/facial
expression
3. verbalization of
discomfort
4. moaning/crying
5. guarding painful area
6. poor eye contact
7. restlessness/irritability
8. verbalization of
feeling scared
9. VS= increased &
blood sugar
increased
10. diaphoresis
ii. nurses must be aware of
their own biases when
managing pain as it may
affect pain assessment due
to lack of objectivity
c. Pain goal
i. Goals should be shared and
validated with the px. Their
goals may include
decrease in the intensity,
duration or frequency of pain
and a decrease in the
negative effects of the pain
ii. Factors in determining a
goal: severity of pain as
judged by the patient,
anticipated harmful effects of
pain, anticipated duration of
pain
iii. Goals may be the best
achieved by the combination
of pharmacologic and non
pharmacologic methods
iv. As the px progresses through
the stages of recovery,
increase px use of self
management pain relief mngt
may be a goal
d. Red flags
i. Ex: weight loss or pain that
worsens at night and does
not resolve may be indicators
of malignancy
ii. Neurologic symptoms that
accompany pain maybe
indicative of spinal cord injury
II. Pain diagnosis
a. Anxiety
b. Ineffective coping
c. Fatigue
d. Fear
e. Hopelessness
f. Impaired physical mobility
g. Imbalanced nutrition: less than body
req’ts
h. Acute/chronic pain
i. Powerlessness
j. Ineffective performance
k. Self care deficit
l. Low self esteem
m. Risk for low self esteem
n. Sexual dysfunction
o. Disturbed sleeping pattern
p. Impaired social distraction
q. Spiritual distress
III. Pain management
a. Pharmacologic
i. Accomplished in
collaboration with other
health care team members,
px and family
ii. Requires close monitoring
and communication with
other health care team.
Several preparations are
a necessary before
administration of medication
for pain
iii. ASSESS:
1. drug allergies
2. med HX and HX of
present condition
3. pain status
4. any current meds
5. system review
Strategies for using analgesic agents
 balance anesthesia
o client is receiving 2 forms or more of
pain meds. Analgesics to obtain
synergistic effect and relieve pain
o no overdose because it is properly
calculated
o using 2 or 3 types of agents
simultaneously can maximize pain
relief while minimizing the potentially
toxic effects of any one agent
 Pro renata (PRN)/ “As needed”
o Nurse waits for the Pt to complain
before administering analgesia
leaving pt sedated/ in severe pain
much of the time
o By the time the pt complains of pain,
the serum opioid concentration is
below the therapeutic level. The
lower the serum opioid level, the
more difficult it is to achieve the
therapeutic level with the next dose
o The only way to ensure significant
amounts/periods of analgesia is to
give doses large enough to produce
periodic sedation
o PRN orders for opioids analgesics
 Specificity is required(drug
name, dose, route) when
prescribing meds or a
maximal allowance
difference between the high
and low dose no more than
four times the lowest dose
 Preventive approach
o Round the clock pain meds
o Most effective strategy because a
therapeutic serum level of meds is
maintained
o Analgesic agents are administered
at set intervals and that meds can
act before the pain becomes severe
and before the serum opioid level
decreases to a sub therapeutic level
o Small doses of meds are needed,
helping prevent tolerance
analgesic agents and decreasing the
severity of side effects
 Individualized dosage
o Dosage and interval between doses
should be based on the pt req’ts
rather than on an inflexible standard
or routine. People metabolize and
absorb meds at different rates and
experience different levels of pain
o Effects of opioid analgesic meds,
especially when the first dose is
given or when the dose is changed
or given more frequently. The time,
date and pt’s pain rating, analgesic
agent, other pain relief measures,
side effects and pain activity are
recorded
o If the pain as not decreased in 30
mins. And pt is reasonably alert and
has a satisfactory respiratory status
and BP and RR and PR, some
change in analgesia is indicated
 Patient controlled analgesia
o Allows pt to control the
administration of their own meds
within predetermined safety limits
o Permits the pt to self administer
continuous infusions of meds safely
and to administer extra meds with
episodes of increased pain or painful
activities
NON OPIOIDS
 NSAIDS
o Non steroidal anti inflammatory
drugs
o Anti inflammatory, analgesic,
antipyretic
o Inhibits prostaglandin synthesis and
enzyme COX
o Have analgesic celling and their
analgesic properties
o Do not produce
tolerance/dependence
 Aspirin
o Analgesic and anti rheumatic effect;
ASA (acetyl salicylate acid)
o Inhibit prostaglandin synthesis which
are important mediators of
inflammation, blocks COX1 and
COX2
o Side effects: GI upset, platelet
dysfunction, bleeding
 Acetaminophen
to o Analgesic, anti pyretic
o No anti platelet and anti
inflammatory
o Metabolized in the liver
OPIOIDS
 goals: relieve pain and improve quality of
life
 can be administered via oral, IV, subQ,
intraspinal, intranasal, rectal, transdermal
 COMMON SIDE EFFECTS
o Respiratory depression and sedation
 Most serious adverse effect
when opioid is administered
via IV, sub Q and epidural
routes
 Risks: age due to
concomitant use of other
opioids and epidural catheter
placement on thoracic area
and increased
intraabdominal/intrathoracic
pressure
 Patterns may develop
tolerance quickly so that they
are no longer sedated by the
initial dose. Increase the time
between doses or reducing
dose temporarily prevents
deep sedation from occurring
o Nausea and Vomiting
 occur some hour after initial
injection
 May be triggered by a
position change and may be
prevented by having the pt
change position slowly
 Adequate hydration and
administration of anti emetic
agents may decrease
incidence of nausea
o Constipation
 Can occur after surgery and
in pt receiving large doses of
opioids to treat cancer
related pain
 Mild laxatives and increase
intake of fluid and fiber may
be effective in managing mild
constipation. Unless
contraindicated, mild laxative
and stool softener should be
administered on regular
schedule
 Inadequate pain relief
 Pruritus (itching)
 Urinary retention
 Morphine
o A standard comparison for all other
opioids and analgesics
o Acts as an agonist at specific opioid
receptors in the CNS to produce
analgesia, euphoria and sedation
o MAJOR RISKS
 Respiratory depression
 Apnea
 Circulatory depression
 Respiratory arrest
 Shock
 Cardiac arrest
o If RR is less than 12 bpm, withhold
morphine and administer naloxone,
its antagonist
o Assess for:
 Vomiting
 Nausea
 Blurring of vision
 Anorexia
 Diarrhea
 Meperidine (Demerol)
o Agonist at specific opioid receptors
at CNS to produce analgesia,
euphoria and sedation
o Shorter acting than morphine
o Meperidine is transformed
biologically to normeperidine, a toxic
metabolic causing CNS excitability
o High risk for seizures
 Adjuvant analgesics
o Drugs that are developed for other
purposes which serves as co-
antigenic that produces synergistic
effect
Administration techniques
 scheduling
 titration/calculation based on body weight
 equioanalgesic dose
 administering routes
 naloxone (NARCAN)
o used to reverse the respiratory
sedation accompanying acute
overdose of opioid side effect
Surgical intervention
 neuroablative technique
o performed for severe uncontrolled
pain
o it will destroy the nerve, interrupting
pain transmission
o TYPES OF NEUROABLATIVE
TECHNIQUE
 Neurectomy
• Removal of the nerve
 Rhizotomy
• Cutting into or
removal of nerve in
 the dorsal horn/spinal
routes
 Cordectomy
• incision of
anterolateral spinal
cord
NON PHARMACOLOGIC PAIN MANAGEMENT
 relaxation techniques
o mental or physical freedom from
tension or stress
o yoga, meditation, Zen, guided
imagery, progressive relaxation
techniques
 biofeedback
o behavioral therapy that informs
clients about physiologic responses
and the ways to control these
responses
 cutaneous stimulation
o stimulation of the skin to relieve pain
by utilizing the gate control theory
through substansia and gelatinosa
o massage, cold and heat application
 transcutaneous electrical nerve stimulation
o uses wild electrical current passed
thru external electrodes attached to
the skin over or near site of pain
 herbals
o use of medicinal herbal preparations
o not sufficiently studied to be
recommended for pain relief
 distraction techniques
o shifts focus away from pain
sensation
o music therapy, watching TV, talking
with family
 acupuncture and acupressure
o mechanism of relieving pain is not
understood and remains
controversial
 good nurse pt relationship
 comfort measures
ROLES OF NURSE IN MANAGING PAIN
 assessing and communicating pain
 ensuring the initiation and coordinating
adequate pain relief measures
 evaluating the effectiveness of the said
interventions
 advocating people with pain
EVALUATION
 nursing measures
 try different approach if the first one is
effective
 pharmacologic and non pharmacologic
management combined
SURGERY
PHASE 1: Pre operative nursing
Objectives: clients will be able to:
 allay fear by being mentally prepared
 have physical condition assessed and be
physically prepared
 enumerate physical changes that will occur
post operatively
 practice post operative exercise that will
help in fast recovery
 calculate the length of recovery from
surgery
ASSESSMENT:
 assess the client’s diagnosis and planned
surgery
 assess the client’s surgical history
 assess for complicating factors
 assess for any allergies
 assess for usage of dentures
 determine when NPO status was initiated.
Oftentimes, NPO post midnight before
surgery for at least 8 hrs is indicated
 assess client’s level of understanding
 make sure that signed consent is
accomplished and signed
DIAGNOSIS:
 knowledge deficit r/t surgery and post
operative course
 anxiety
 fear
PLANNING AND EXPECTED OUTCOMES
 pt will experience decreased anxiety
subsequent to appropriate instructions
 pt will not experience adverse reactions
caused by inadequate physical preparation
 pt will not experience any loss of
belongingness or possessions during
surgery or recovery period
 pt will not experience any disruption or
delay of the surgery caused by poor pre
operative care or planning
EQUIPMENTS NEEDED:
 sphygmomanometer
 stethoscope
  penlight/flashlight
 pre operative checklist
 containers for dentures, glasses
 appropriate storage for valuables and
clothes
 information packets regarding surgery
 surgical consent forms indicating risks
 IVF, needles and equipment as needed
 Pre operative meds
 Transfer cart
CLIENT EDUCATION NEEDED
 Ascertain what information has been given
by the physician or qualified practitioner
 If the pt has further questions, answer as
appropriate
 Remind pt that there are no dumb questions
 Explain the need for removal of rings,
dentures, prosthesis, contact lenses or
glasses
 Explain the reason for not eating prior to
surgery such as to prevent regurgitation of
food
 Inform pt what to expect pre operatively and
post operatively. Long waits in the operating
room can be frightening if not anticipated
especially if pts do not know what to expect
 Transfer the pt directly to another staff
member. Do not move the pt to operating
room waiting area and leave unattended.
IMPLEMENTATION:
 Wash hands
 Verify admission orders regarding type of
operation, risks (recent changes in VS) and
pt preparation
 Verify the client by checking name tag and
asking name
 Check whether the pt has any questions
regarding the surgery, if able to understand
the procedure and explains accordingly
 Complete the pre operative checklist
 Perform neurological assessment, check
orientation, eye coordination, hand grips,
knee bends, plantar flexion and dorsal
flexion of the feet (to check for the
distribution of nerves)
 Perform vascular assessment including
checks of pulse, BP, apical pulse, rhythm,
peripheral pulse and temperature. Check
and compare with previous findings. Pt over
50 years old may require baseline data of
ECG
 Auscultate the lungs bilaterally front and
back. If there are presence of bronchi,
coughs, upper respiratory infections,
increased temp/fever, notify physician
 Assess the GI system such as the last meal,
food allergies, bowel sounds, last bowel
movement, time of last fluids, etc.
 Assess the genitals or urinary system such
as LMP, lat void, state of pregnancy,
estrogen replacement therapy, etc.
 Assess the skin and muscle tone for any
skin breakdown, redness, bruises or
impaired skin integrity
 Ascertain any allergies or adverse reactions
during previous surgeries or with the use of
anesthesia
 Obtain medical history to include time and
date of the last dose of meds
 Ascertain any history of drugs or alcohol
use and when they were last used
 Check wt
 Check if family is available and who is
present
 Ascertain if client has signed the surgical
consent. Determine if the client has a living
will or a designated resuscitation status
 Remove all valuables with exception of
wedding rings if requested. If requested,
tape rings in place. Check and record
whether valuables are placed in a locked
area or given to a family member
 Check if eye glasses or dentures are
removed
 Administer IV according to orders
 Administer meds according to orders
 Ascertain if pre operative checklist is
accomplished
 Transport pt to appropriate area
 Inform family members where surgical
waiting area is located and establish a way
to contact them when surgery is completed
EVALUATION
 check if plans/goals and objectives are met
or not met
DOCUMENT:
 pre operative checklist are filled out
 report abnormal/usual findings
 conducted pre operative teaching
 disposition of valuables
 medicine administration record
 note for pre operative meds and IV insertion
site

DEFINITION OF TERMS
 Medical care de_____/ informed consent
o Needed/required in all surgical or
diagnostic studies
o Obtained by physician in a verbal
discussion and written process
o Includes name of pt, procedure to be
done, MSRS, benefits, surgeon,
alternative forms discussed
o Identifies the nature of the ailment,
proposed treatment and risks
o Complications and expected benefits
of the treatment
o Made consent should be signed by
age of at least 18 y.o
o Must be witnessed by nurse or
appropriate persons
o Valid until the procedure has been
done or there are changes with
treatment
 Living will
o Specify treatment wishes in writing
o Permit individuals to give
instructions concerning the use of
withdrawal of artificial life situations
in end of life situations
Health history and evaluation should focus on:
 Cardio-pulmonary status
o Anesthetic agents depress cardiac
and respiratory function
o Increased risk for hypoventilation
 Medication history
o Allergies
o Anticoagulant use = risk for
hemorrhage
o Antidepressants
o Corticosteroids = reduces body’s
ability to withstand stress
o Insulin = DM hx may alter glucose
metabolism and impair circulation
o Antibiotics = potentiates action of
anesthesia; resp and neuro
depression
 Mobility limitations
 Nutritional status
o Has direct effect on normal tissue
repair and infection resistance
 Oral and dental status
 Laboratory and diagnostic results
o Hemoglobin
o WBC
o Prothrombin time
o Electrolytes
o Blood typing
Pre operative meds
 prescribe to facilitate:
o administration of any anesthetic
o respiratory tract secretions and
changes in heart rate
o relaxes pt and reduces anxiety
 Anti-cholinergics
o Atrophic sulfate
o Reduces respiratory tract secretions
and prevents severe reflex slowing
of the heart during anesthesia
 Narcotics analgesics
o Demerol
o Reduces pain and anxiety
 Histamine receptor antagonist
o PHENERGAN
 Prophylactic antibiotics
o Administered just before or during
surgery, ideally before skin incision
is made
PHASE 2: Intra operative phase
Objectives:
 be protected from trauma and injury
 be able to verbalize understanding of the
procedure and the reason for it
 not experience infection secondary to poor
site preparation
 not experience disruption to any existing
appliances, catheters or instruments
 assessed for sensitivity to scrub solution,
skin integrity, knowledge and level of
mobility at surgical site
DIAGNOSIS:
 Risk for infection
 Risk for impaired skin integrity
 Knowledge deficit r/t surgical preparation
 Risk for perioperative positioning injury
PLANNING/EXPECTED OUTCOME
 surgery will be prepared without injury or
trauma to pt
 pt will be able to understand the procedure
and reason for it
 will not experience any allergic reaction or
skin sensitivity secondary to surgical
preparation
 pt will not experience any infection
secondary to poor skin site preparation
  will not experience any injury secondary to  Scrub nurse
peri operative nursing o Sterile Person
o Preparation of the sterile field
GOALS  Drape sterile table
 relief of anxiety  Set up basic instruments
o establish rapport perioperatively (dissecting scalpel, scissors,
o listen to verbalizations and provide clamps, needle holders,
pertinent answers to questions tissue forceps or pick ups)
o offering comfort measures o Enhance the use of basic
 correct procedure performed on the right instruments to facilitate the
patient procedure (suction tips, tubing
o check pt’s name tag, consent, irrigators, electrosurgical devices)
procedures and surgeon o Hands instruments to the surgeon
 maintain fluid balance o Watch the need/field and anticipated
o check availability of prescribed fluids the needs of surgeon and assistant
and blood o Notify circulator if additional supplies
o maintains I and O record throughout are needed
the procedure o Keep instruments as clean as
o assess blood loss on sponges, pads possible
and suction o Place ligature in the surgeon’s hand
o check incision at the end of and hand suture in the assistant
procedure o Save and care for all tissue
 prevent retention of foreign bodies specimens according to policy and
o circulating nurse counts with the procedures
scrub nurse all instruments, o Alert the circulator that closure is
sponges, pads and needles before about to start so that 3rd count of
the procedure and as surgeon instruments should be done,
begins to close the skin as an end intraabdominal or cavity pouching
 prevent infection materials be removed
o circulating nurse monitors every o Have sterile dressing ready
personnel while opening sterile o Do after care of the soiled drapes
supplies and instrument in the appropriate
 prevent injury receptacle
o pt should be positioned carefully to  Circulator
maintain body alignment o Unsterile/clean person
 respect the pt’s privacy o Assist the scrub nurse by
o no unnecessary exposures anticipating/providing and opening
o chart should be available to sterile supplies needed
concerned medical team only o Test all equipment before bringing
the patient to the room
EQUIPMENTS: o Assist in gowning the team
 gloves clean and sterile o Count sponges, sharps and
 sterile gauze instruments with the scrub person to
 warm water establish baseline table contents,
 antibacterial cleansing agents and record on a tally sheet
o Attend to the pt while the scrub
 sterile cotton swabs
nurse continues to prepare the
 sterile cotton sponges
instrument table
 transfer forceps in antiseptic solution
o Check wristband and verify name
 solution for surgical site cleaning 70%
and number
alcohol
o Describe understanding of the
 solution basins
surgical procedure
COORDINATED ROLES OF THE SCRUB
PERSON AND CIRCULATOR
 o Validate the area by having the point
to the spot and double check again
the scheduled procedure
 Verify any allergies
 Transfer the pt safely to the
operating bed
 Remains on the pt’s side
during the induction of
anesthesia
 Reposition pt accordingly
o Be alert to anticipate the needs of
the entire team
o Know the condition of the pt at all
times
o Prepare and label the specimens for
laboratory
o Complete count records with the
scrub nurse
o Transfer pt from OR to PACU
CLIENT EDUCATION
 explain the reason for the surgical
preparation and any shaving of the area. If
the area to be prepared/ shaved is
cosmetically important, reinforce the need to
do a thorough preparation of the site
 assess the pt that surgery may not include
total area prep
 explain the need for proper positioning
during surgery so the surgeon can easily
access the site
IMPLEMENTATION
 review the pt for surgery to be performed
and determine area to be prepped
 perform surgical hand washing to reduce
transmission of microbes
 assess the pt’s LOC and mobility to
determine pt’s ability to cooperate
 explain the procedures to the pt to provide
comfort and support
 be sure that hairpins, jewelry, nail polish are
removed
 arrange for adequate light in the area
 use warm water. Hold the skin and the razor
at a 45 angle. Shave the area carefully by
stroking in the direction of hair growth.
Rinse the razor
 dry the skin with sterile towels
 clean any hidden area
 rinse the area with sterile water. Wait for the
skin/site to be pat dry
Positioning pt for surgery
 pt should be comfortable
 operative area must be adequately exposed
 circulation must not be obstructed in any
body part
 nerves should be protected from undue
pressures. Shoulder braces must be patted
to protect nerve injury
 provide for pt’s privacy by proper draping
Stages of Anesthesia
 Stage 1: Relaxation Phase
o Induction to the beginning of less
consciousness
o Pt is aware that he is unable to
move his extremities, voluntarily
 Stage 2: Excitement Phase
o Excitement characterized by
struggling, shouting, talking,
laughing or even crying
o Loss of eyelid reflex, pupils are
dilated but when exposed to light will
contract
o PR is rapid and RR is irregular
 Stage 3: Surgical anesthesia
o Pt is unconscious, muscles are
relaxed and most reflexes are
absent
o With proper _________, this stage is
maintained for hours
 Stage 4: ________________________
o Be on observation of the
anesthesiologist will gradually move
the pt from the stage to the other
MALIGNANT HYPERTHERMIA
 extreme condition of core temperature, rare
condition due to general anesthesia
 CAUSES:
o Rare reaction to anesthetic inhalator
and muscle relaxants
o Deadly condition most prone in
younger individuals with inherited
muscle disorders
o Excessive intracellular accumulation
of calcium with resulting
hypermetabolism and increased
muscle contractions
Congenital muscle deficits young age
unknown
Increased production of Ca in muscles
Increased contraction/hypermetabolism of Ca in
muscles
 o Anesthesize the surgical site
Increased metabolism
PHASE 3: Post operative Phase
Increased heat production  begins in the PACU

CNS damage ASSESSMENT:

Goal: gather baseline data
VS Cyanosis Heart failure  assess pt’s sedation level, mental status
and level of consciousness
Prevalence rate: 1:15000 children  assess pt’s cardiovascular status by taking
1:10000 adult VS to assess for bleeding or hemorrhage
o every 5 mins. For the 1st 30 mins.
MANIFESTATION Q10/q15 for the next hr and q30 for
 Muscle rigidity the succeeding hrs until stable
 High fever  Assess for pt’s respiratory status
 Cyanosis, heart failure, CNS damage (conscious=full expansion of lungs)
 Assess for complications
TREATMENT  Assess for pt’s level of pain
 hypothermic measures  Assess surgical site and surgical appliances
o cooling blanket to assess for drainage and signs of bleeding
o iced saline lavage of stomach,  Assess for pt’s fluid status via IV bottles
bladder, rectum  Assess pt’s neurovascular status of the
 O2 therapy client’s extremities (for spinal anesthesia,
 D5 dextrose check for ability to move extremities)
 Antidysrhythmia
 Na HCO3 for severe acidosis DIAGNOSIS
 risk for infection
COMMON ANESTHETIC EFFECTS  risk for altered body temp
 Deep sedation  altered tissue perfusion, cardio pulmonary
o Pt is asleep but easily arousable (present with fluid administration if GA is
o Protective reflexes are minimally given)
diminished  risk for fluid volume deficit
 General Anesthesia  risk for aspiration
o Complete less of consciousness  impaired tissue integrity/injury
o Reversible state that provides  risk for perioperative positioning injury
analgesics, muscle relaxation and  sensory/perceptual alteration secondary to
sedation anesthesia
o Produced by IV inhaled anesthesia  pain
 Regional Anesthesia  fear
o Produced of anesthesia in a specific
body part PLANNING/EXPECTED OUTCOME
o Achieved by injecting local  The pt pain control will be adequate
anesthesia to appropriate nerve  Airway will be patent
 Spinal anesthesia  VS will be stable for at least 1 hr
o Anesthesia is injected into lumbar
 Will be alert and oriented when stable
______________ space
 Respiratory status including oxygen
o Blocks conduction in spinal nerve
saturation, respiratory rate and tidal volume
roots and dorsal ganglia will be adequate
o Paralysis and analgesia occur below
 In pt who is receiving regional anesthesia,
level of injections
motor and sensory function will be at
 Epidural anesthesia adequate level
o Injecting anesthesia into epidural
 Surgical site will be intact with a dry or
space by way of lumbar puncture
appropriately reinforced dressing present
 Peripheral Nerve blocks
 when pt is discharged from the recovery  Inform the pt that he is out of the operating
area room and is in the recovery room
 IV access will be intact and patent without  If bedside: ECG monitoring is available,
signs and symptoms of infection/infiltration attach the leads to the body and run the
when pt is discharged from recovery area baseline ECG strip
 Output will be within normal limits  Attach the oxymeter to the pt and monitor
 Temp will be within normal limits (malignant the pt’s O2 saturation
hyperthermia)  Check IV site using gloves. Check IV
solutions flow rate and that IV line is taped
CLIENT’S EDUCATION NEEDED as necessary
 Inform client of purpose of various  Check surgical dressing and site if visible.
equipment to ease fear of the unknown Assess dressing for amount and type of
 Inform pt about the required position drainage. Reinforce dressings as needed.
changes Change dressing, only with the physician’s
 Inform pt to let nurse know when pain and approval
shivering is noted  Complete a total head to toe examination
 Explain reason for deep breathing, turning o Airway
and coughing are encouraged right away  Patency
despite the cx recent surgery  Presence of breath sounds
 Reinforce perioperative teaching regarding that is equal on both sides,
post operative expectations and exercises especially if pt is intubated
 Explain reason for frequent VS and  Note the presence of
neuromuscular checks. Note that the rhonchi, rales or wheezes
frequent checks do not indicate anything is while assessing breath
“wrong”. sounds
 Regular checks are part of routine to o Respiratory
prevent problems  Note the presence of any
 Instruct the pt tell you if he is in pain, supplementary O2 and type
nauseated or uncomfortable of O2 delivery system
 Encourage pt to ask questions regarding  Assess the pt’s blood o2
surgical procedures or post operative saturation as well as the
routines or any surgical changes that might type, depth, and efficiency of
have taken place pt’s respirations
o Cardiovascular
EQUIPMENTS NEEDED  Check apical pulse, radial
 stethoscope and peripheral pulses
 sphygmomanometer especially those that are
 oximeter distal
 blankets  Color and temp of the
extremities and capillary refill
 cardiac monitoring equipment
 Check the pt’s cardiac rate,
 sterile dressing as needed
rhythm, BP and signs of
 pt’s chart with postoperative orders bleeding
 incentive spirometer (may be optional) o Temperature
 supplemental o2, if needed  Check the pt’s temp. note
 sequential stocking and/or antiembolic any complaints of coldness
stockings (as ordered) or shivering
 thermometer o Neurological
 LOC, orientation, level of
IMPLEMENTATION cooperation, equality of
 Wash hands and apply gloves pupils, verbal response,
 Check VS upon the client’s arrival in the unit equality of movements and
 Identify pt via armband and verify the pt’s feeling in the extremities
identity with chart o Gastrointestinal
  Evaluate for the presence of
n/v. if NGT is present,
auscultate the placement of
the tube. If the NGT is
hooked to the suction, note if
the suction is intermittent or
continuous and whether it is
functioning properly
 Assess gastric secretions for
color and amount. Record
the amount of gastric output
(for bleeding and pat as
initiated)
 Replace fluids as indicated. If
client is vomiting, NGT
placement may be necessary
o Genitourinary
 Evaluate the amount and
color of pt’s urine output
 If indicated, check for the
presence of blood, evaluate
pH, specific gravity, presence
of glucose, ketones and
sediments
 Assess that the catheter is
flowing properly
o Pain
 Assess the pt’s level of pain
on a 1 to 10 pain scale and
treat as appropriate.
 If PCA system is employed,
as the pt recovers from
sedation, instruct the pt on
the use of PCA
 Assess for other means of
controlling pain such as
repositioning, sometimes anti
inflammatory agents
o Fluid balance
 Evaluate the pt’s fluid status
 Check i/o
 Check for peripheral edema
or jugular vein distention.
Note and report any
extremes
o Vital signs
 Reevaluate VS as needed or
at least Q15
 Encourage pt to do deep
breathing, coughing and use
the incentive spirometer
 Check and implement post
operative orders
 Inform the pt’s family/SO that
the pt is in the recovery room
 Turn the pt every hour,
maintaining proper alignment
 Upon discharge on PACU, a
full report of the post
anesthesia process and
intraoperative cause of
events shall be given to the
nurse assuming care of the
pt
 Remove jewelries and wash
hands
DOCUMENTATION
 VS
 Neurologic checks, LOC,
 O2 saturation
 Condition of surgical site
 I/O record (IV and oral intake, urine output,
drainage)
 Medicine administration record (date, time,
route, dosage)
 Nurse’s notes
 Time received
 Unusual findings
PERI OPERATIVE CARE FOR OLDER ADULTS
Nurses should consider:
 post operative risks due to psychological,
cognitive and psychosocial changes
 integument – diminished skin integrity due
to loss of subQ fat, decreased oil production
and hydration
 Respiratory – decreased efficiency cough
reflex and expansion of lung fields
 Sensory/perceptual – decline vision and
hearing
 Cardiovascular – less efficient, decreased
adaptation to stress
 GIT – decrease motility
 GUT – decrease in efficiency for kidney,
loss of bladder control
 Cognitive/psychosocial – decreased
reaction time, decreased sedation, prone to
delirium, increased altered mental status
POST ANESTHESIA RECOVERY
 Dismissal criteria
o Total score of 10+ stable signs
o Doctor’s order is required for
discharge with lower score
 Activity – able to move
voluntarily or on command
 Respiratory – able to cough
freely and deep breath
  Circulatory – BP + -20 mm of
pre-anesthesia level
 Consciousness – fully awake
 Color – normal

Transferring the PT from the PACU: Criteria to

determine readiness:
 uncompromised cardiopulmonary status
 stable vital signs
 adequate UO (at least 30 ml)
 orientation to time, place, person and
events
 satisfactory response to commands
 movement of extremities after regional
anesthesia
 control of pain
 control/absence of vomiting

POST OPERATIVE CARE

 begins as soon as the surgical procedure is
concluded or the pt is transferred to PACU
 Duration and type of observation and care
verify:
o Pt’s condition (alert/conscious vs
unresponsive)
o Need for physiologic support
(ventilation/dependent vs awake and
extubated)
o Complexity of surgical procedure
o Type of anesthetic agent
administered (general vs local)
o Need for pain therapy (intermittent
analgesic vs continuous epidural)
o Physiologic status (stable vs.
unstable)

PREVENT:
 hypotension or SHOCK :o
 hypertension and dysrhythmias
 Hgc
 N/V (plasil/metoclopromide)