Module 1 Peri-Operative Nursing Care

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Pain: A subjective response to both physical and psychologic stressors. Referred to as the fifth vital sign.
Influenced by physiologic, psychologic, cognitive, sociocultural, and spiritual factors
"Whatever the person experiencing it says it is and existing whenever the person says it does?
Has a personal meaning
All pain is real
Protective Mechanism
Gate Control Theory of Pain 1: 1960's-Interaction of two systems which determines pain and its perception.
1.Spinal Cord:
Substantia gelatinosa: regulates impulses entering or leaving the spinal cord
"Gate" encountered by impulses" either large diameter touch fibers or small diameter pain fibers
When pain outnumbers touch fibers the "gate" is openedand pain impulses travel unimpeded to brain
Gate Control Theory of Pain 2: 2.Brainstem: Inhibitory system
Opiates, psychologic factors, and pain itself all stimulate receptors in the medulla which stimulate nerve fibers i the spinal cor to block pain transmission
New research shows a more complex theory.
New Pain Theory (Stimulus Based): Stimuli:
Pain occurs when biologic, mechanical, thermal, electrical or chemical factors stimulate nociceptors (nerve receptors for pain located throughout the body except the brain)
Nociceptors stimulated: when there is direct damage to the cell there is a local release of biochemicals secondary to celll injury
Pain-Biochemical Release: Bradykinin: most prevalent
Prostaglandins
Histamines
Hydrogen and Potassium Ions
Endorphins: Chemical Inhibitory mechanism for pain
Types of Pain: Acute
1.Somatic
2.Visceral
3.Referred
Chronic
1.Recurrent Acute Pain
2.Ongoing time limited pain
3.Chronic nonmalignant pain
Chronic intractable nonmalignant pain syndrome
Neuralgias
Reflex sympathetic Dystrophies
Hyperesthesias
Myofascial
Cancer
Chronic Postoperative pain
3.Central Pain
4.Phantom pain
5.Psychogenic pain
Acute Pains: sudden onset, temporary, localized often, accompanied by N/V
Less than 6mo in duration
Identified cause of tissue injury-trauma, surgery or inflammation
Initiates the fight or flight mechanism
Characteristic responses inc.: tachycardia, rapid and shallow respirations, increased blood pressure, dilated pupils, sweating and pallor.
Somatic Pain: Type of Acute Pain
Arises from nerve receptors in the skin or close to the surface of the body
Either sharp and well localized or dull and diffuse
(often accompanied by nausea and vomiting)
Visceral Pain: A type of acute pain
Arises from body organs.
Dull and poorly localized (low number of nociceptors)
Viscera are sensative to stretching, inflammation, ischemia, but relatively sensative to cutting and temp extremes.
(Associated with nausea,vomiting, hypotension, and restlessness. It often radiates or is referred)
Referred Pain: A type of Acute Pain
Percieved in an area distant from the site of stimuli-usually with visceral pain
Dermatomes: Body areas defined by spinal nerve routes
(Referred pain-Pain in a spinal nerve may be felt over the skin in any body area innervated by sensory neurons that share that same spinal nerve route.
Chronic Pain: Pain lasting longer than 6 months
Not always associated with an identifiable cause
Often Unresponsive to medical tx
Dull/Aching and diffuse
More complex and poorly understood than accute pain
Recurrant Acute pain: Well defined episodes of pain interspersed with pain-free episodes
ex. migraine headaches and sickle cell crisis
Ongoing time-limited Pain: Pain within an identified time period
Ex. Cancer pain-ends with the control of the disease and death and burn pain, which ends with rehab or death
Chronic nonmalignantant Pain: Non Life-threatening pain that persists beyond the expected time for healing
Ex. Chronic lower back pain
Chronic Intractable nonmalignant Pain Syndrome: Similar to simple chronic nonmalignant pain, characterized by the persons inability to cope well with the pain and sometimes by physical, social, and/or psychologic disability resulting from pain
Neuralgias: Painful conditions that result form damage to a peripheral nerve caused by infection or disease
Reflex Sympathetic Dystrophies: Continuous, severe, burning pain. Follows peripheral nerve damage and present as symptoms of pain, vasospasm, muscle wasting, and vasomotor changes
Hyperesthesias: Condition of oversensitivity to tactile and painful stimuli. Hyperesthesias result in diffuse pain that is increases by fatigue and emotional liability
Myofascial Pain Syndrome: Condition marked by injury to or disease of muscle and facial tissue. Pain results from muscle spasm, stiffness, and collection of lactic acid in the muscle.
Ex. fibromyalgia
Chronic Pain Due to Cancer: tumors that press on nerves or other structures, stretching of viscera, obstruction of ducts, or metastasis to bones. Malignant tumors may stimulate pain or the production of biochemicals that cause pain
Chronic Postoperative Pain: rare but may folloew incisions in the chest wall, radical mastectomy, radical neck dissection, and surgical amputation
Central Pain: caused by vascular lesion, tumor, trauma, or inflammation in the brainff
Phantom Pain: pain in amputated body part..itching, tingling, or pressure, twisted or cramped limb
Psychogenic Pain: emotional needs prompt the pain sensation
Pain in the absence of any diagnosed cause or event
Factors Affecting Responses to Pain: Perception and reation to pain
Age, sociocultural influences, emotional state, past experiences with pain, source and meaning of pain and knowledge base
Pain tolerance
Pain tolerance: the amount of pain a person can endure before outwardly responding to it.
Dec by: pain, fatigue, anger, anxiety and sleep deprivation
Inc by: Meds, alcohol, hypnosis, warmth, distraction, and spiritual practices
NSAIDS: Non Steroidal Anti Inflamatory Drugs
Act on peripheral nerve endings and minimize pain by interfering with prostaglandin synthesis
ex. aspirin, ibuprofin, celecoxib (Celebrex).
NSAIDS have inti-inflammatory, analgesic and antipyretic actions. The tx of choice for mild to moderate pain
Addiction: The compulsive use of a substance despite negative consequences, such as health threats or legal problems.
Drug Abuse: use of any chemical substance for other than a mefdical purpose
Physical Drug Dependence: A Biologic need for a substance. If te substance is not supplied, physical withdrawal symptoms occur.
Psychologic Drug Dependence: A psychologic need for a substance. If te substance is not supplied, psychologic withdrawal symptoms occur.
Drug Tolerance: the body requires a progressively greater amt of a drug to achieve the same results
Equianalgesic: having the same pain killing effect when administered to the same individual. Drug doses are equianalgesic if they have the same effect as morphine sulfate 10mg admin IM.
Pseudoaddiction: Behavior involving drug seeding;a result of receiving inadequate pain relief
Narcotics (Opiods): moderate to severe pain relief.
Ex. morphine, codeine, and fentanyl (Durgesic, Actiq)
Narcotic analgesics produce analgesia by binding to opioid receptors within and outside the CNS.
Study table 4-3 pg 62
If used correctly ....little to no risk of addiction exists.
Antidepressants for Pain Relief: tricyclic and related act on the production and retention of serotonin in the CNS, inhibiting the pain sensation.
Promote normal sleeping patterns, further alleviating the suffering of the client in pain.
Local Anesthetics: benzocaine, zylocaine
Block the initiation and transmission of nerve impulses in a local area, thus blocking pain
ATC / PRN: Around the Clock (ATC)
As Necessary (PRN)
Preventative Pain Measures: Give analgesics before pain occurs
The client may spend less time in pain
Frequent analgesic administration may allow smaller doses
Smaller doses = fewer side effects
The clients frear and anxiety about the return of pain will decrease
The client will probably be meore physically active and avoid the difficulties caused by immobility
Intraspinal Analgesia: May be either intrathecal (into the subarachnoid space) or epidural (into the epidural space)
There is a direct effect on the opiate receptors in the dorsal horn of the spinal cord; the narcotics are also absorbed systematically and affect the brain. Provides complete pain relief
Cordotomy: An incision into the anterolateral tracts of the spinal cord to interrupt the transmission of pain. Because it is difficult to isolate the nerves responsible for upper body pain, this surgery is most often performed for pain in the abdominal region and legs, including severe pain from terminal cancer.
Neurectomy: Removal of a nerve
Sympathectomy: The sympathetic nerves play an important role in producing and transmitting the sensation of pain. Destruction by injection or incision of the ganglia of the sympathetic nerves, usually in the lumbar region of the cervicodorsal region at the base of the neck
Rhizotomy: Surgical severing of the dorsal spinal roots or by injecting a chemical such as alcoholor phenol into the subarachnoid space or by using radio frequency currents to selectively destroy pain fibers.
Ex. To relieve the pain of cancer of the head, neck, or lungs.

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