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Pain is highly SUBJECTIVE Multidimensional nature of pain 1. Physiologicalpain affects the physiologic processes including the nervous system 2. Affectivepsychological aspect of pain such as its ability to arouse fear and anxiety 3. Cognitivecorrelates to the person's understanding of pain and his coping strategy 5. Socio-cultural factorssuch as culture and ethnicity influences on pain perception and expression.
Pain is highly SUBJECTIVE Multidimensional nature of pain 1. Physiologicalpain affects the physiologic processes including the nervous system 2. Affectivepsychological aspect of pain such as its ability to arouse fear and anxiety 3. Cognitivecorrelates to the person's understanding of pain and his coping strategy 5. Socio-cultural factorssuch as culture and ethnicity influences on pain perception and expression.
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Pain is highly SUBJECTIVE Multidimensional nature of pain 1. Physiologicalpain affects the physiologic processes including the nervous system 2. Affectivepsychological aspect of pain such as its ability to arouse fear and anxiety 3. Cognitivecorrelates to the person's understanding of pain and his coping strategy 5. Socio-cultural factorssuch as culture and ethnicity influences on pain perception and expression.
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Attribution Non-Commercial (BY-NC)
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Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
persists beyond the expected Pain healing time and is seldom attributed Unpleasant sensory and emotional to specific cause of injury associated with actual or potential tissue b. Chronic pain is pain that lasts for 6 damage months or larger than the expected Most common reason for seeking healing time healthcare c. After 6 months, most pain AMERICAN PAIN SOCIETY: pain as the 5th experiences are accompanied by vital sign problems related to the pain itself. NSG RESPONSIBILITY o Collaborate with other health care Causes of pain 1. Noxious Stimuli professionals while administering a. Causes are from physical pain relief intervention environment o Evaluating their effectiveness b. Examples are mechanical, thermal, o Being pt’s advocate, teaching to pressure manage pain 2. Ischemia o Pain relief mngt a. Anaerobic glycolysis leads to the Mc Caffrey: whatever the person says it is, production of lactic acid existing whenever the experiencing person b. Lactic acid irritates nerves which says it does when uncontrolled, results to tissue Pain is highly SUBJECTIVE death 3. muscle spasm Multidimensional nature of pain a. involuntary contractions and rigidity of the muscle produces lactic acid 1. Physiological- pain affects the physiologic 4. psychogenic processes including the nervous system a. “it’s all in the mind” 2. Affective- psychological aspect of pain such b. Emotional and affective factors as its ability to arouse fear and anxiety affect client’s perception of pain 3. Cognitive- correlates to the person’s understanding of pain and his coping Types of Pain strategy A. According to duration 4. Behavior- correlates to the person’s reaction a. Acute pain to pain such as facial grimace and moaning b. Chronic pain 5. Socio-cultural factors- such as culture and c. Cancer-related pain ethnicity influences on pain perception and i. Pain in px with cancer can be expression directly associated with the cancer (e.g. surgery, Classification of pain radiation) or not associated 1. Nociceptive pain with cancer (e.g. trauma) a. Pain that is associated with ii. Pain associated with cancer somatic(sensory) to visceral tissue is a direct result of tumor injury involvement also known as 2. Neuropathic pain breakthrough pain a. Pain that is associated or has a B. According to Location direct effect within the central a. Referred pain nervous system i. Ex. Chest pain radiating to 3. Acute pain the left arm, to jaw suggests a. Of recent onset and commonly angina or MI associated with a specific injury b. Phantom Pain b. If no lasting damage occurs and no i. Normally, a neurosignature systemic disease exists, acute pain output with a constant stream usually decreases as healing occurs of input and varying patterns c. Lasting from seconds to less than 6 produces the feeling of the months 4. Chronic pain whole body with constant a. The intensity changing quantities. or the amount of painful stimulus is equal ii. In the absence of modulating to the intensity of pain perceived inputs, from the missing limb, 4. Affect theory the active neuromatrix a. Reception of produces a neurosignature pain is influenced by psychological effects pattern that is perceived as of past painful experiences pain 5. Pattern theory C. According to etiology a. There is a a. Central specific pattern of transmission in every i. Associated with neuro and is pain stimulus direct with the brain ii. Neuropathic in nature Factors influencing pain response b. Peripheral Past experience D. According to pain characteristics o Often, the more experience a person a. Pricking has had with pain, the more i. Characterized by a sharp or frightened he/she is about “needle stick like” pain subsequent pain full events b. Burning o Px may be less able to tolerate pain c. Aching o If pain is relieved promptly and i. Characterized by vague pain, adequately, the person may be less growing pain fearful of future pain and better able to tolerate it. Theories of Pain Anxiety and depression 1. Gate control theory o Anxiety that is relevant to pain may a. The gating increase. The patient’s perception of mechanism is influenced by nerve pain impulses that descend from the brain. o Anxiety that is unrelated to the pain This theory proposes a specialized may distract the patient and may system of large diameter fibers that actually decrease the perception of activate selective cognitive process via pain the modulating properties of the spinal o Depression is associated with gate. Cognitive process stimulates chronic pain and unrelieved cancer endorphin production in the descending pain resulting to major life changes control system. Activation of the such as unemployment descending control system results in less Culture noxious or painful info being transmitted to o Factors that help explain differences consciousness. in a cultural group include age, Stimulation of the skin – production of nerve gender, education level and income impulses- transmission by 3 systems in spinal cord o The degree to which px will identify 1. Substantia gelatinosy in dorsal horn; 2. Dorsal with culture influences the degree to column fibers; 3. Central transmission cells – which they will adopt new health GATING MECHANISM STIMULATED behaviors Large – diameter fiber stimulation – gate Age closed – X pain o If pain perception is diminished in Small – diameter fiber stimulation – gate elderly people, it is most likely opened - + pain secondary to disease process rather than aging 2. Sensory or Specificity o Because elderly people have a theory slower metabolism and a greater a. In every pair ratio of body fat to muscle mass than of stimulus, there is a specific receptor for young people do, small doses of that analgesic agents may be sufficient 3. Intensity theory 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 iii. Goals may be the best o persistent pain achieved by the combination o depression of pharmacologic and non BARRIERS TO EFFECTIVE PAIN pharmacologic methods MANAGEMENT iv. As the px progresses through o Psychological factors the stages of recovery, o Tolerance increase px use of self management pain relief mngt o Physical dependence may be a goal o Addiction d. Red flags i. Ex: weight loss or pain that Nursing Care process on pain management worsens at night and does I. Assessment not resolve may be indicators a. PQRST of malignancy i. Accurate assessment will ii. Neurologic symptoms that lead to an accurate accompany pain maybe formulation of a nsg dx and indicative of spinal cord injury therefore an appropriate nsg II. Pain diagnosis intervention will be applied a. Anxiety b. Functional impairment b. Ineffective coping i. Pertinent observations c. Fatigue include: d. Fear 1. Px’s withdrawal from e. Hopelessness communication f. Impaired physical mobility 2. grimacing/facial g. Imbalanced nutrition: less than body expression req’ts 3. verbalization of h. Acute/chronic pain discomfort i. Powerlessness 4. moaning/crying j. Ineffective performance 5. guarding painful area k. Self care deficit 6. poor eye contact l. Low self esteem 7. restlessness/irritability m. Risk for low self esteem 8. verbalization of n. Sexual dysfunction feeling scared o. Disturbed sleeping pattern 9. VS= increased & p. Impaired social distraction blood sugar q. Spiritual distress increased III. Pain management 10. diaphoresis a. Pharmacologic ii. nurses must be aware of i. Accomplished in their own biases when collaboration with other managing pain as it may health care team members, affect pain assessment due px and family to lack of objectivity ii. Requires close monitoring c. Pain goal and communication with i. Goals should be shared and other health care team. validated with the px. Their Several preparations are goals may include a necessary before decrease in the intensity, administration of medication duration or frequency of pain for pain and a decrease in the iii. ASSESS: negative effects of the pain 1. drug allergies ii. Factors in determining a 2. med HX and HX of goal: severity of pain as present condition judged by the patient, 3. pain status anticipated harmful effects of 4. any current meds pain, anticipated duration of 5. system review pain Strategies for using analgesic agents o Effects of opioid analgesic meds, balance anesthesia especially when the first dose is o client is receiving 2 forms or more of given or when the dose is changed pain meds. Analgesics to obtain or given more frequently. The time, synergistic effect and relieve pain date and pt’s pain rating, analgesic o no overdose because it is properly agent, other pain relief measures, calculated side effects and pain activity are o using 2 or 3 types of agents recorded simultaneously can maximize pain o If the pain as not decreased in 30 relief while minimizing the potentially mins. And pt is reasonably alert and toxic effects of any one agent has a satisfactory respiratory status Pro renata (PRN)/ “As needed” and BP and RR and PR, some o Nurse waits for the Pt to complain change in analgesia is indicated before administering analgesia Patient controlled analgesia leaving pt sedated/ in severe pain o Allows pt to control the much of the time administration of their own meds o By the time the pt complains of pain, within predetermined safety limits the serum opioid concentration is o Permits the pt to self administer below the therapeutic level. The continuous infusions of meds safely lower the serum opioid level, the and to administer extra meds with more difficult it is to achieve the episodes of increased pain or painful therapeutic level with the next dose activities o The only way to ensure significant amounts/periods of analgesia is to NON OPIOIDS give doses large enough to produce NSAIDS periodic sedation o Non steroidal anti inflammatory o PRN orders for opioids analgesics drugs Specificity is required(drug o Anti inflammatory, analgesic, name, dose, route) when antipyretic prescribing meds or a o Inhibits prostaglandin synthesis and maximal allowance enzyme COX difference between the high o Have analgesic celling and their and low dose no more than analgesic properties four times the lowest dose o Do not produce Preventive approach tolerance/dependence o Round the clock pain meds Aspirin o Most effective strategy because a o Analgesic and anti rheumatic effect; therapeutic serum level of meds is ASA (acetyl salicylate acid) maintained o Inhibit prostaglandin synthesis which o Analgesic agents are administered are important mediators of at set intervals and that meds can inflammation, blocks COX1 and act before the pain becomes severe COX2 and before the serum opioid level o Side effects: GI upset, platelet decreases to a sub therapeutic level dysfunction, bleeding o Small doses of meds are needed, Acetaminophen helping prevent tolerance to o Analgesic, anti pyretic analgesic agents and decreasing the o No anti platelet and anti severity of side effects inflammatory Individualized dosage o Metabolized in the liver o Dosage and interval between doses should be based on the pt req’ts OPIOIDS rather than on an inflexible standard goals: relieve pain and improve quality of or routine. People metabolize and life absorb meds at different rates and can be administered via oral, IV, subQ, experience different levels of pain intraspinal, intranasal, rectal, transdermal COMMON SIDE EFFECTS Respiratory depression o Respiratory depression and sedation Apnea Most serious adverse effect Circulatory depression when opioid is administered Respiratory arrest via IV, sub Q and epidural Shock routes Cardiac arrest Risks: age due to o If RR is less than 12 bpm, withhold concomitant use of other morphine and administer naloxone, opioids and epidural catheter its antagonist placement on thoracic area o Assess for: and increased Vomiting intraabdominal/intrathoracic Nausea pressure Blurring of vision Patterns may develop Anorexia tolerance quickly so that they are no longer sedated by the Diarrhea initial dose. Increase the time Meperidine (Demerol) between doses or reducing o Agonist at specific opioid receptors dose temporarily prevents at CNS to produce analgesia, deep sedation from occurring euphoria and sedation o Nausea and Vomiting o Shorter acting than morphine occur some hour after initial o Meperidine is transformed injection biologically to normeperidine, a toxic May be triggered by a metabolic causing CNS excitability position change and may be o High risk for seizures prevented by having the pt Adjuvant analgesics change position slowly o Drugs that are developed for other Adequate hydration and purposes which serves as co- administration of anti emetic antigenic that produces synergistic agents may decrease effect incidence of nausea o Constipation Administration techniques Can occur after surgery and scheduling in pt receiving large doses of titration/calculation based on body weight opioids to treat cancer equioanalgesic dose related pain administering routes Mild laxatives and increase naloxone (NARCAN) intake of fluid and fiber may o used to reverse the respiratory be effective in managing mild sedation accompanying acute constipation. Unless overdose of opioid side effect contraindicated, mild laxative and stool softener should be Surgical intervention administered on regular neuroablative technique schedule o performed for severe uncontrolled Inadequate pain relief pain Pruritus (itching) o it will destroy the nerve, interrupting Urinary retention pain transmission o TYPES OF NEUROABLATIVE Morphine TECHNIQUE o A standard comparison for all other Neurectomy opioids and analgesics • Removal of the nerve o Acts as an agonist at specific opioid Rhizotomy receptors in the CNS to produce • Cutting into or analgesia, euphoria and sedation removal of nerve in o MAJOR RISKS the dorsal horn/spinal try different approach if the first one is routes effective Cordectomy pharmacologic and non pharmacologic • incision of management combined anterolateral spinal cord SURGERY
NON PHARMACOLOGIC PAIN MANAGEMENT PHASE 1: Pre operative nursing
relaxation techniques Objectives: clients will be able to: o mental or physical freedom from allay fear by being mentally prepared tension or stress have physical condition assessed and be o yoga, meditation, Zen, guided physically prepared imagery, progressive relaxation enumerate physical changes that will occur techniques post operatively biofeedback practice post operative exercise that will o behavioral therapy that informs help in fast recovery clients about physiologic responses calculate the length of recovery from and the ways to control these surgery responses cutaneous stimulation ASSESSMENT: o stimulation of the skin to relieve pain assess the client’s diagnosis and planned by utilizing the gate control theory surgery through substansia and gelatinosa assess the client’s surgical history o massage, cold and heat application assess for complicating factors transcutaneous electrical nerve stimulation assess for any allergies o uses wild electrical current passed assess for usage of dentures thru external electrodes attached to determine when NPO status was initiated. the skin over or near site of pain Oftentimes, NPO post midnight before herbals surgery for at least 8 hrs is indicated o use of medicinal herbal preparations assess client’s level of understanding o not sufficiently studied to be make sure that signed consent is recommended for pain relief accomplished and signed distraction techniques o shifts focus away from pain DIAGNOSIS: sensation knowledge deficit r/t surgery and post o music therapy, watching TV, talking operative course with family anxiety acupuncture and acupressure fear o mechanism of relieving pain is not understood and remains PLANNING AND EXPECTED OUTCOMES controversial pt will experience decreased anxiety good nurse pt relationship subsequent to appropriate instructions comfort measures pt will not experience adverse reactions caused by inadequate physical preparation ROLES OF NURSE IN MANAGING PAIN pt will not experience any loss of assessing and communicating pain belongingness or possessions during ensuring the initiation and coordinating surgery or recovery period adequate pain relief measures pt will not experience any disruption or evaluating the effectiveness of the said delay of the surgery caused by poor pre interventions operative care or planning advocating people with pain EQUIPMENTS NEEDED: EVALUATION sphygmomanometer nursing measures stethoscope penlight/flashlight Auscultate the lungs bilaterally front and pre operative checklist back. If there are presence of bronchi, containers for dentures, glasses coughs, upper respiratory infections, appropriate storage for valuables and increased temp/fever, notify physician clothes Assess the GI system such as the last meal, food allergies, bowel sounds, last bowel information packets regarding surgery movement, time of last fluids, etc. surgical consent forms indicating risks Assess the genitals or urinary system such IVF, needles and equipment as needed as LMP, lat void, state of pregnancy, Pre operative meds estrogen replacement therapy, etc. Transfer cart Assess the skin and muscle tone for any skin breakdown, redness, bruises or CLIENT EDUCATION NEEDED impaired skin integrity Ascertain what information has been given Ascertain any allergies or adverse reactions by the physician or qualified practitioner during previous surgeries or with the use of If the pt has further questions, answer as anesthesia appropriate Obtain medical history to include time and Remind pt that there are no dumb questions date of the last dose of meds Explain the need for removal of rings, Ascertain any history of drugs or alcohol dentures, prosthesis, contact lenses or use and when they were last used glasses Check wt Explain the reason for not eating prior to Check if family is available and who is surgery such as to prevent regurgitation of present food Ascertain if client has signed the surgical Inform pt what to expect pre operatively and consent. Determine if the client has a living post operatively. Long waits in the operating will or a designated resuscitation status room can be frightening if not anticipated Remove all valuables with exception of especially if pts do not know what to expect wedding rings if requested. If requested, Transfer the pt directly to another staff tape rings in place. Check and record member. Do not move the pt to operating whether valuables are placed in a locked room waiting area and leave unattended. area or given to a family member Check if eye glasses or dentures are removed IMPLEMENTATION: Administer IV according to orders Wash hands Administer meds according to orders Verify admission orders regarding type of Ascertain if pre operative checklist is operation, risks (recent changes in VS) and accomplished pt preparation Transport pt to appropriate area Verify the client by checking name tag and Inform family members where surgical asking name waiting area is located and establish a way Check whether the pt has any questions to contact them when surgery is completed regarding the surgery, if able to understand the procedure and explains accordingly EVALUATION Complete the pre operative checklist check if plans/goals and objectives are met Perform neurological assessment, check or not met orientation, eye coordination, hand grips, knee bends, plantar flexion and dorsal DOCUMENT: flexion of the feet (to check for the pre operative checklist are filled out distribution of nerves) report abnormal/usual findings Perform vascular assessment including conducted pre operative teaching checks of pulse, BP, apical pulse, rhythm, disposition of valuables peripheral pulse and temperature. Check medicine administration record and compare with previous findings. Pt over note for pre operative meds and IV insertion 50 years old may require baseline data of site ECG o Electrolytes DEFINITION OF TERMS o Blood typing Medical care de_____/ informed consent o Needed/required in all surgical or Pre operative meds diagnostic studies prescribe to facilitate: o Obtained by physician in a verbal o administration of any anesthetic discussion and written process o respiratory tract secretions and o Includes name of pt, procedure to be changes in heart rate done, MSRS, benefits, surgeon, o relaxes pt and reduces anxiety alternative forms discussed Anti-cholinergics o Identifies the nature of the ailment, o Atrophic sulfate proposed treatment and risks o Reduces respiratory tract secretions o Complications and expected benefits and prevents severe reflex slowing of the treatment of the heart during anesthesia o Made consent should be signed by Narcotics analgesics age of at least 18 y.o o Demerol o Must be witnessed by nurse or o Reduces pain and anxiety appropriate persons Histamine receptor antagonist o Valid until the procedure has been o PHENERGAN done or there are changes with Prophylactic antibiotics treatment o Administered just before or during Living will surgery, ideally before skin incision o Specify treatment wishes in writing is made o Permit individuals to give instructions concerning the use of PHASE 2: Intra operative phase withdrawal of artificial life situations Objectives: in end of life situations be protected from trauma and injury be able to verbalize understanding of the Health history and evaluation should focus on: procedure and the reason for it Cardio-pulmonary status not experience infection secondary to poor o Anesthetic agents depress cardiac site preparation and respiratory function not experience disruption to any existing o Increased risk for hypoventilation appliances, catheters or instruments Medication history assessed for sensitivity to scrub solution, o Allergies skin integrity, knowledge and level of o Anticoagulant use = risk for mobility at surgical site hemorrhage o Antidepressants DIAGNOSIS: o Corticosteroids = reduces body’s Risk for infection ability to withstand stress Risk for impaired skin integrity o Insulin = DM hx may alter glucose Knowledge deficit r/t surgical preparation metabolism and impair circulation Risk for perioperative positioning injury o Antibiotics = potentiates action of anesthesia; resp and neuro PLANNING/EXPECTED OUTCOME depression surgery will be prepared without injury or Mobility limitations trauma to pt Nutritional status pt will be able to understand the procedure o Has direct effect on normal tissue and reason for it repair and infection resistance will not experience any allergic reaction or Oral and dental status skin sensitivity secondary to surgical Laboratory and diagnostic results preparation o Hemoglobin pt will not experience any infection o WBC secondary to poor skin site preparation o Prothrombin time 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 pt should be comfortable to the spot and double check again operative area must be adequately exposed the scheduled procedure circulation must not be obstructed in any Verify any allergies body part Transfer the pt safely to the nerves should be protected from undue operating bed pressures. Shoulder braces must be patted Remains on the pt’s side to protect nerve injury during the induction of provide for pt’s privacy by proper draping anesthesia Reposition pt accordingly Stages of Anesthesia o Be alert to anticipate the needs of Stage 1: Relaxation Phase the entire team o Induction to the beginning of less o Know the condition of the pt at all consciousness times o Pt is aware that he is unable to o Prepare and label the specimens for move his extremities, voluntarily laboratory Stage 2: Excitement Phase o Complete count records with the o Excitement characterized by scrub nurse struggling, shouting, talking, o Transfer pt from OR to PACU laughing or even crying o Loss of eyelid reflex, pupils are CLIENT EDUCATION dilated but when exposed to light will explain the reason for the surgical contract preparation and any shaving of the area. If o PR is rapid and RR is irregular the area to be prepared/ shaved is Stage 3: Surgical anesthesia cosmetically important, reinforce the need to o Pt is unconscious, muscles are do a thorough preparation of the site relaxed and most reflexes are assess the pt that surgery may not include absent total area prep o With proper _________, this stage is explain the need for proper positioning maintained for hours during surgery so the surgeon can easily Stage 4: ________________________ access the site o Be on observation of the anesthesiologist will gradually move IMPLEMENTATION the pt from the stage to the other review the pt for surgery to be performed and determine area to be prepped MALIGNANT HYPERTHERMIA perform surgical hand washing to reduce extreme condition of core temperature, rare transmission of microbes condition due to general anesthesia assess the pt’s LOC and mobility to CAUSES: determine pt’s ability to cooperate o Rare reaction to anesthetic inhalator explain the procedures to the pt to provide and muscle relaxants comfort and support o Deadly condition most prone in be sure that hairpins, jewelry, nail polish are younger individuals with inherited removed muscle disorders arrange for adequate light in the area o Excessive intracellular accumulation use warm water. Hold the skin and the razor of calcium with resulting at a 45 angle. Shave the area carefully by hypermetabolism and increased stroking in the direction of hair growth. muscle contractions Rinse the razor dry the skin with sterile towels Congenital muscle deficits young age clean any hidden area unknown rinse the area with sterile water. Wait for the skin/site to be pat dry Increased production of Ca in muscles
Positioning pt for surgery 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 Turn the pt every hour, n/v. if NGT is present, maintaining proper alignment auscultate the placement of Upon discharge on PACU, a the tube. If the NGT is full report of the post hooked to the suction, note if anesthesia process and the suction is intermittent or intraoperative cause of continuous and whether it is events shall be given to the functioning properly nurse assuming care of the Assess gastric secretions for pt color and amount. Record Remove jewelries and wash the amount of gastric output hands (for bleeding and pat as initiated) DOCUMENTATION Replace fluids as indicated. If VS client is vomiting, NGT Neurologic checks, LOC, placement may be necessary O2 saturation o Genitourinary Condition of surgical site Evaluate the amount and I/O record (IV and oral intake, urine output, color of pt’s urine output drainage) If indicated, check for the Medicine administration record (date, time, presence of blood, evaluate route, dosage) pH, specific gravity, presence Nurse’s notes of glucose, ketones and Time received sediments Unusual findings Assess that the catheter is flowing properly PERI OPERATIVE CARE FOR OLDER ADULTS o Pain Nurses should consider: Assess the pt’s level of pain post operative risks due to psychological, on a 1 to 10 pain scale and cognitive and psychosocial changes treat as appropriate. integument – diminished skin integrity due If PCA system is employed, to loss of subQ fat, decreased oil production as the pt recovers from and hydration sedation, instruct the pt on Respiratory – decreased efficiency cough the use of PCA reflex and expansion of lung fields Assess for other means of Sensory/perceptual – decline vision and controlling pain such as hearing repositioning, sometimes anti Cardiovascular – less efficient, decreased inflammatory agents adaptation to stress o Fluid balance GIT – decrease motility Evaluate the pt’s fluid status GUT – decrease in efficiency for kidney, Check i/o loss of bladder control Check for peripheral edema Cognitive/psychosocial – decreased or jugular vein distention. reaction time, decreased sedation, prone to Note and report any delirium, increased altered mental status extremes o Vital signs POST ANESTHESIA RECOVERY Reevaluate VS as needed or Dismissal criteria at least Q15 o Total score of 10+ stable signs Encourage pt to do deep o Doctor’s order is required for breathing, coughing and use discharge with lower score the incentive spirometer Activity – able to move Check and implement post voluntarily or on command operative orders Respiratory – able to cough Inform the pt’s family/SO that freely and deep breath the pt is in the recovery room 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)