PAIN AND SURGERY Pain a feeling of distress, suffering or agony caused by the stimulation of specialized nerve endings a blend

nd of physiological and psychological experience of events occurring within the patient's body which is always unpleasant and associated with the impression of damage to the tissues

PAIN First symptom of injury; Indicator of a disease process The fifth vital sign

SOURCES OF PAIN STIMULI NOCICEPTORS receptors that transmit pain sensation. NOCICEPTION physiologic processes related to pain perception.

PHYSIOLOGY OF PAIN FOUR PHASES OF NOCICEPTION 1. TRANSDUCTION Noxious stimuli (tissue injury) trigger the release of biochemical mediators (e.g., prostaglandins, bradykinin, serotonin, histamine, stubstance P) that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excite nociceptors. Pain medication can work at this phase: by blocking production of prostaglandins (e.g., ibuprofen) or by decreasing the movement of ions across the cell membrane (e.g., local anesthetic) 2. TRANSMISSION Neuronal action potential must be transmitted to & through the CNS before pain is perceived. Involves 3 segments before pain impulse is transmitted: 1st Segment pain impulse travels from the peripheral nerve fiber to the spinal cord 2nd Segment pain transmission from the spinal cord ascending to the brain via spinothalamic tracts to the brainstem and thalamus. 3rd Segment transmission of signals between the thalamus to the somatic sensory cortex.

2 Types of Nociceptor fibers cause this transmission to the dorsal horn of the spinal cord: a. C fibers large & myelinated; carry pain impulse at a rapid rate; throbbing, dull, aching pain. b. A-Delta fibers small & unmyelinated; carry pain sensation at a slower rate; sharp, localized pain Pain control can take place during this process: Opioid (narcotics) block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level. Pain Threshold the point at which a stimulus is perceived as pain. Pain Tolerance amount of pain a person is willing to endure; only the person determines tolerance level. 3. PERCEPTION When the client becomes conscious of pain. Pain perception occurs in the cortical structures, which allows for different cognitive-behavioral strategies to be applied to reduce the sensory & afferent components of pain. e.g., nonpharmacologic interventions such as distraction, guided imagery, & music can help direct the clients attention away from the pain. 4. MODULATION Described as descending system Occurs when neurons in the brain stem send signals back down to the dorsal horn of the spinal cord. These descending fibers release substances such as endogenous opioids, serotonin, norepinephrine, which can inhibit the ascending noxious impulses in the dorsal horn.

PHYSIOLOGICAL THEORIES OF PAIN TRANSMISSION 1. SPECIFICITY THEORY There are specific nerve receptors for particular stimuli. e.g., Nociceptors noxious stimuli (always interpreted as PAIN) Thermoreceptors heat/cold Mechanoreceptors pressure, pulling or tearing sensation Chemoreceptors chemicals

2. PATTERN THEORY States that pain is produced by intense stimulation on nonspecific fiber receptors, so any stimulus could be perceived as painful if the stimulation is intense enough. 3. GATE CONTROL THEORY States that there is a gate in the spinal cord (substantia gelatinosa) When the gate is open, pain stimulus is transmitted thus pain is perceived. When the gate is closed, pain is blocked thus no pain is perceived. The gate is controlled by the balance impulse input from the small and large peripheral nerve fibers TYPES OF PAIN ACCORDING TO DURATION 1. ACUTE PAIN Temporary, immediate onset Last for less than 6 months Eventually subside after treatment or sometimes without treatment e.g., headache, postop pain, labor pain, toothache 2. CHRONIC PAIN Continuous, may begin gradually, persist or recur for an indefinite period of time, more difficult to manage effectively (last 6 months or longer) PAIN ASSESSMENT TOOLS Onset Location Duration Characteristics Aggravating factors Radiation Treatment 2. FACES RATING SCALE ACCORDING TO SOURCE/ORIGIN 1. CUTANEOUS PAIN Includes superficial somatic structures located in the skin & the subcutaneous tissues direct pain since the pain accurately localizes the point of disturbance e.g., finger cut, knot hair pulled out while combing, 1st degree burn 3. 10 POINT PAIN INTENSITY SCALE

3 TYPES of Chronic Pain: a. Chronic Nonmalignant Pain e.g., low back pain, Rheumatoid A. b. Chronic Intermittent Pain e.g., migraine headache c. Chronic Malignant Pain e.g., cancer

2. DEEP SOMATIC PAIN Includes bones, nerves, muscles & other tissues supporting these structures Poorly localized; frequently radiates from primary site. e.g., ankle sprain, jamming a knee 3. VISCERAL PAIN Includes all body organs located in a body cavity Diffuse, poorly localized, vague, dull pain e.g., obstructed bowel, cardiovascular disease

4. ACCORDING TO INTENSTIY 1. MILD One that is bearable usually tolerated by the client 2. SEVERE One which is intense & usually could not be tolerated by the client 5. ACCORDING TO LOCATION 1. RADIATING PAIN Perceived at the source of the pain & extends to nearby tissue Cardiac pain chest, left shoulder, down the arm 2. REFERRED PAIN Felt in an area distant from the site of the stimulus MI left arm, shoulder, or jaw pain Cholecystitis back pain & angle of scapula 2. INTRACTABLE PAIN Pain that is highly resistant to relief Advanced Malignancy

3. NEUROPATHIC PAIN Result of current or past damage to the peripheral or CNS & may not have a stimulus, such as tissue or nerve damage. Nerve injury that serves the hand would be perceived a pain-hand even though the injury may be at the spinal cord level. 4. PHANTOM PAIN Painful sensation perceived in a body part that is missing

FACTORS AFFECTING PAIN PERCEPTION AND RESPONSE 1. ETHNIC & CULTURAL VALUES Filipinos are known to be sufferers who consider pain as sacrifice for sins committed. Voicing pain appropriate Italians inappropriate Germans (stoicism) Mexicans/arabs moaning/crying use to alleviate pain rather than need for intervention 2. DEVELOPMENTAL STAGES Infants - sensitivity Toddlers cry & anger - threat to security & punishment School-age not cry or express much pain so that parents will not get angry Adolescent not report pain weakness Adults not report pain indicates poor diagnosis, weakness, failure

3. ENVIRONMENT & SUPPORT PEOPLE Hospital environment can be associated with pain; Places that are noisy & have glaring lights can compound pain sensation 4. POST PAIN EXPERIENCES A person who has witnessed a family member who experienced severe pain may have difficulty enduring the same experience once it arises 5. MEANING OF PAIN A woman giving birth may tolerate pain infavor of a desired baby An athlete who undergone knee surgery to prolong his career may tolerate pain better than one who was shot by an enemy 6. ANXIETY & STRESS A person who suffers fatigue may not have a good coping with pain MISCONCEPTION & MYTHS OF PAIN Myth: Addiction occurs with prolonged use of Morphine and Morphine derivatives FACT: THE INCIDENCE OF ADDICTION IS LESS THAN 0.1% Myth: The nurse or the physician is the best judge of a client's pain. FACT: ONLY THE CLIENT CAN JUDGE THE LEVEL & DISTRESS OF THE PAIN, THAT'S WHY CLIENTS SHOULD BE INCLUDED IN PAIN MANAGEMENT. Myth: Pain is a result not a cause. FACT: UNRELIEVED PAIN CAN CAUSE OTHER PROBLEMS SUCH AS ANGER, ANXIETY, IMMOBILITY, RESPIRATORY PROBLEMS, & DELAY IN HEALING. Myth: It is better to wait until a client has pain before giving medication. FACT: IT IS BETTER TO ROUTINELY ADMINISTER ANALGESIA TO MAINTAIN LOW LEVEL OF PAIN THAN TO CATCH-UP ONCE PAIN ARISES. Myth: Real pain has an identifiable cause. FACT: THERE ARE ALWAYS CAUSES OF PAIN BUT SOME MAY BE VERY OBSCURE. Myth: The same physical stimulus produces the same pain intensity, duration and distress in the same people. FACT: INTENSITY, DURATION, AND DISTRESS VARY WITH EACH INDIVIDUAL

Myth: Some clients lie about the existence or severity of their pain. FACT: VERY FEW PEOPLE LIE ABOUT THEIR PAIN Myth: Very young or very old people do no have as much pain. FACT: ALL CLIENTS WITH INTACT NEUROLOGIC SYSTEM EXPERIENCE PAIN. AGE IS NO A DETERMINANT OF PAIN EXPERIENCE. Myth: Pain is a part of aging. FACT: PAIN DOES NOT ACCOMPANY AGING UNLESS A DISEASE, OR AN AILMENT IS PRESENT Myth: If a person is asleep they are not in pain. FACT: PAIN CAN CAUSE EXHAUSTION WHICH CAN LEAD TO CLIENTS IN PAIN TO SLEEP, BUT THEY ARE IN PAIN. SOME CLIENTS USE SLEEP AS AN ESCAPE FROM PAIN. Myth: If the pain is relieved by non-pharmaceutical pain relief techniques, the pain was not real anyway. FACT: NON-PHARMACEUTICAL METHODS CAN BE EFFECTIVE IN RELIEVING PAIN.

ASSESSMENT Ask the client about the pain and to describe it in terms of degree, quality, area, and frequency Observable indicators of pain include: moaning; crying; irritability; restlessness; grimacing or frowning; inability to sleep, rigid posture; increased blood pressure, heart rates, or respirations; nausea; and diaphoresis Ask the client to use a number-based pain scale (a picture-based scale may be used in children) to rate the degree of pain

PAIN MANAGEMENT Refers to the techniques used to prevent, reduce, relieve pain.

A. NON-PHARMACOLOGIC PAIN MANAGEMENT 1. PHYSICAL INTERVENTION Includes providing comfort, altering physiologic responses & reducing fears associated with pain-related immobility or activity restriction. CUTANEOUS STIMULATION Redirects the clients attention to the tactile stimuli away from the pain stimuli; It releases endorphins; it stimulates large diameter A-beta sensory nerve fibers. MASSAGE back rub to reduce pain; stimulate clients skin by lightly kneading, pulling or pressing with fingers, palms or knuckles.

o ACCUPRESSURE

Application of pressure to areas or points used in acupuncture known as Meridians

o CONTRALATERAL STIMULATION Stimulating the skin opposite to the painful area.

o HEAT & COLD APPLICATION The application of heat and cold or the alternate application can soothe pain resulting from muscle strain Heat applications may include warm-water compresses, warm blankets, Aquathermia pads, and tub and whirlpool baths; may require a physicians order

B. IMMOBILIZATION Restricting movement of body part may help manage episodes of acute pain e.g., Splint holds joints or fractured bones that maybe painful once moved

C. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) (portable, battery operated device) is a method of applying low voltage electrical stimulation directly over identified pain areas. C/I in clients with pacemakers, arrhythmias or in areas of skin breakdown. D. ACUPUNCTURE very thin metal needles are skillfully inserted into the body @ designated locations & @ various depths & angles Meridians accupuncture points distributed patterns disease interrupts energy flow in the body and insertion of needles at specific points will re establish healthy energy flow. 2. MIND-BODY INTERVENTION (Cognitive-Behavioral) A. DISTRACTION Directs away the attention of the client from the painful sensation or the negative emotional arousal associated with pain TYPES OF DISTRACTION: 1. Visual Distraction read or watch tv 2. Auditory Distraction humor, listen to music

MUSIC Physiologic mechanism has not been established in the use of music to relieve pain but possible theories include distraction, release of endogenous opioids, & dissociation HUMOR Believed to help increased the production of endogenous opioids endorphines, which are natural pain killers. 3.Tactile Distraction massage, slow rhythmic breathing 4. Intellectual Distraction card games, crossword puzzle B. RELAXATION TECHNIQUES Gradually tighten then deeply relax various muscle groups proceeding systematically from one area to the next Reduce muscle tension & anxiety C. IMAGERY Help client visualize a pleasant experience Help distract themselves from their pain which may increase pain tolerance; produce relaxation response; diminished the source of pain (e.g.tension headache) D. MEDITATION Client sits comfortably & quietly with focused attention away from pain E.g., flow of the breath; picture image of great spiritual being or peaceful place E. BIOFEEDBACK F. HYPNOSIS Hypnotic state; suggest to alter character of pain or ones attitude toward it G. THERAPEUTIC TOUCH use hands to rearrange energy field to normal H. MAGNETS Believed that the pull of magnet increased blood flow to the region of pain, opening the NaCl channels in the cell.

PHARMACOLOGIC PAIN MANAGEMENT 1. OPIOID ANALGESICS (NARCOTIC) -Derived from natural opium alkaloids & their synthetic derivatives -Suppress pain impulses but can suppress respiration and coughing by acting on the respiratory and cough center in the medulla of the brain stem -Can produce euphoria and sedation -Can cause physical dependence PHYSICAL DEPENDENCE means that a person experiences physical discomfort, known as withdrawal syndrome, when a drug that client has taken routinely for some time is abruptly discontinued. to avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. Dosage or frequency of adm. is lowered over 1 week or longer. NARCOTIC ANALGESICS MEPERIDINE HYDROCHLORIDE (Demerol) Can cause respiratory depression, tachycardia, constipation, urine retention, hypotention, and dizziness Used for acute pain and as a preoperative medication Contraindicated in head injuries and in the presence of increased intracranial pressure, respiratory disorders, hypotentions, shock and severe hepatic or renal didsease, Should not be taken with alcohol or sedative hypnotics; may increase CNS depression To administer intravenously, dilute in at least 5 ml of sterile water or NSS for injection, then administer dose over 4 to 5 minutes CODEIN SULFATE Also used in low doses as a cough suppressant Can cause constipation Monitor intake and output and assess client for urine retention Instruct client to avoid activities that require alertness Have a narcotic antagonist available (e.g., Naloxone (Narcan), oxygen, and resuscitation equipment available NARCOTIC ANTAGONISTS Use to treat respiratory depression from narcotic overdose - Naloxone (Narcan) Interventions Monitor BP, pulse, & RR q 5 mins. initially, tapering to q 15 minutes, & then q 30 mins. until the clients condition is stable Attach a cardiac monitor to the client & observe cardiac rhythm Ascultate breath sounds Have resuscitation equipment available

Do not leave client unattended Monitor client closely for several hours; when the effects of the antagonist wears off, the client may again display signs of narcotic overdose

3 Primary Types of Opioids: 1. FULL AGONISTS pure opiod drugs producing maximum pain inhibition, an agonists effect. No ceiling on the level of analgesia Dose can be steadily increased to relieve pain No maximum daily dose limit Demerol, Morphine, Codeine 2. MIXED AGONISTS-ANTAGONIST can act like opioids & relieve pain (agonist effect) when given to client who has not taken any pure opioids. block or inactivate other opioid analgesics when given to client who has been taking pure opioids (antagonist effect) have ceiling dose & not recommended for use w/ terminally ill clients. Nubain, Stadol 3. PARTIAL AGONISTS have ceiling effect in contrast to a full agonist. Buprenorphine (Buprenex) Pentazocine (Talwin)

2. NON-OPIOID ANALGESICS ACETAMINOPHEN (TYLENOL) Inhibits prostaglandin synthesis Used to decreased pain and fever Contraindications Hepatic or renal disease, alcoholism, and hypersensitivity Side Effects Major concern is hepatotoxicity

NSAIDs and ACETYLSALICILIC ACID (Aspirin) NSAIDs are aspirin and aspirin-like medications that inhibit the synthesis of prostaglandins Act as analgesics to relieve pain, as antipyretics to reduce body temperature, and as anticoagulants to inhibit platelet aggregation

Used to relieve inflammation and pain and to treat rheumatoid arthritis, bursitis, tendonitis, osteoarthritis, and acute gout

3. ADJUVANT ANALGESICS Is a medication that was developed for other than analgesia but has been found to reduce chronic pain & sometimes acute pain, in addition to its primary action. Muscle Relaxant muscle spasm Anticonvulsants nerve injury Corticosteroids reduce inflammation & edema *** Concept on Surgery SURGERY as a science and an art surgery is the branch of medicine that comprises perioperative patient care encompassing such activities as pre-operative preparation, intra-operative judgement, and post-operative care of patients. CATEGORIES & PURPOSES OF SURGERY ACCORDING TO PURPOSE 1. Diagnostic 2. Exploratory 3. Curative Performed to resolve a health problem by repairing or removing the cause Classification: Ablative Includes removal of an organ; e.g., appendECTOMY (suffix) Estimation of the extent of disease or confirmation of a diagnosis exploratory laparotomy, pelvic laparotomy Performed to determine the origin & cause of a disorder or the cell type for cancer breast biopsy

a. Constructive Involves the repair of congenitally damaged organ e.g., cheiloPLASTY, orchidoPEXY b. Reconstructive Involves repair of damaged organ e.g., Total joint replacement 4. Palliative Performed to relieve symptoms of a disease process, but does not cure Nerve root resection, Colostomy 5. Cosmetic Performed primarily to alter or enhance personal appearance Rhinoplasty, Blepharoplasty ACCORDING TO URGENCY 1. Emergent 2. Urgent 3. Required 4. Elective 5. Optional

condition is life-threatening that requires surgery at once e.g., gunshot or stab wound, severe bleeding performed as soon as client is stable & infection is under control; life threatening if treatment is delayed more than 24-48H e.g., appendectomy, intestinal obstruction Client should have surgery; planned for a few weeks or months e.g., Prostatic hyperplasia w/o obstruction, Cataracts, Simple Hernia Client will not be harmed if surgery is not performed but will benefit if it is performed e.g., Revision of Scars, Vaginal Repair Personal preference usually for aesthetic purposes e.g., Cosmetic surgery

ACCORDING TO DEGREE OF RISK 1. Minor Procedure of less risk; generally not prolonged; leads to few complications 2. Major Procedure of greater risk; usually longer & more extensive; great risk of complications ACCORDING TO EXTENT OF SURGERY 1. Simple 2. Radical Extensive surgery beyond the area obviously involved e.g., Radical Mastectomy, Radical Hysterectomy Only the most overtly affected areas involved in the surgery e.g., Simple or Partial Mastectomy

SURGICAL SETTING 1. INPATIENT Refers to client who is admitted to a hospital Admitted on the day of surgery (Same-day Admission SDA) 2. OUTPATIENT & AMBULATORY Refers to a client who goes to the surgical area the day of the surgery & returns home on the same day (Same-day Surgery SDS) PERIOPERATIVE NURSING Assist clients and their significant others through the surgical episode, to help promote positive outcomes, and to help clients achieve their optimal level of function and wellness after surgery. Emphasis on safety & client education Use Knowledge, judgement & skills PREOPERATIVE PERIOD Begins when the client is scheduled for surgery & ends at the time of transfer to surgical suite PREOPERATIVE PERIOD

Focuses on clients readiness client education & any intervention: 1. Reduce anxiety 2. Reduce complication 3. Promote cooperation Needed before surgery to: 1. Validate & clarify information client received from surgeon or members of health team 2. Identify problems that warrant further assessment &/or intervention before surgery PREOPERATIVE ASSESSMENT A. MEDICAL/HEALTH HISTORY Purpose of reviewing medical history is to determine operative risk. COLLECT THE FOLLOWING DATA:

1. AGE Older risk of complication; immune system functioning; delays wound healing; frequency of chronic illness; alter operative response/risk

2. DRUGS & SUBSTANCE USE Tobacco - risk of pulmonary complications (changes in lungs & cavity) Alcohol & illicit subs. alter response to anesthesia & pain meds. withdrawal before surgery may lead to delirium tremens o PRESCRIPTION & OVER THE COUNTER affect how client reacts to operative experience o Potential effects for reaction or serious adverse effect with some herbs & specific drugs. 3. MEDICAL HISTORY o Chronic illness increased surgical risk

4. CARDIAC HISTORY o Complications from anesthesia occur often o Impair ability to withstand hemodynamic changes & alter response to anesthesia o Risk for MI during surgery higher with pre-existing cardiac problem 5. PULMONARY HISTORY o Smoker/Chronic Respiratory Problem - chest rigidity & loss of lung elasticity reduce anesthesia excretion. o Smoking - blood level of Carboxyhemoglobin which decreases O2 delivery to organs acts on cilia of pulmonary mucous membrane which lead to retain secretion & predisposes clients to pneumonia & atelectasis (reduce gas exchange & causes intolerance of anesthesia) Chronic lung problems (asthma, emhysema, chronic bronchitis) reduce lung elasticity reduce gas exchange reduce tissue oxygenation 6. ANESTHESIA o Affect readiness for surgery those w/ complication - fear & concerns of scheduled surgery

8. DISCHARGE PLANNING o Assess clients home, environment, self-care capabilities, support system, & anticipate post-op needs before surgery o Older clients & dependent adult need transport referrals o Home care nurse/health center nurse need to monitor recovery & provide instruction