nursynurse

[nursynurse]

Pain in the butt!

Surgical Pain

Many patients will come to you in pain, or you will start a shift and they will be in pain. Pain can be a frustrating stimuli not only for the patient but for the you when you're interventions are unsuccessful. Lets have the lowdown on Pain

Acute vs Chronic

Acute pain is protective pain. It usually comes on suddenly and my result from injury, surgery, a medical disorder, or diagnostic procedure. It is caused by damage to the tissues. Chronic pain is any pain that lasts longer than 6 months but it is not a warning pain. It can be related to ongoing inflammatory disorders, muscle strains, etc. In chronic pain the body gets used to the stimuli and doesn't respond the same physiologically as acute pain (therefore there are usually no changes in vital signs (vs) or facial expressions). 

PQRST Assessment

Precipitating Factors: What makes this pain better/worse?

Quality: What does it feel like? Describe the pain.

Radiation:  Is the pain in one place? Or does it move around? 

Site and Severity: Where is it and on a scale of 1-10 how bad is it?

Timing & Treatment: When did it start, how often does it occur? What are the patterns? Is it constant or waves? Have you taken anything for it and did that help?

Note* Although you likely know that the pain is related to surgery, there are always potentials for complications. I had one guy who had and ALIF surgery and then ended up getting appendicitis! Talk about trying to differentiate pain!

Pain Scales

Personally I find this a tough one. I can't even begin to count how many patients I've had NOT understand the 1-10 scale, and if they do, they often dont know when to ask for pain relief. It can be pretty frustrating to say the least. 

Okay. The 1-10 scale. Pretty simple, “Whats your pain based on 1-10, 10 being the worse pain imaginable and 0 being none at all?” If they are post op, some amount of pain is to be expected. I tell my patients that likely zero is an unreal expectation and we’re happy with anything under 4. However, if you've had surgery, toughing out the pain and trying to be a hero will only get you into trouble. Surgical pain does NOT go away! Here’s my superpower trick too keeping pain well controlled. I tell my patients that they should expect some level of pain, IF their pain starts to head up to 4 or 5 to give me a call for some analgesia. First this gives me time to get it (and on a surgical ward that can sometimes be up to 20 minutes on a crazy day) and by the time they gets it on board it'll take another 20-30 mins to kick in. Secondly, if you're asking for pain relief at 4-5 we can bring that pain back down to 2-3, if we’re waiting until we’re 8/10 pain, were only really going to be bringing that pain back down to a 6-7, and then we’re chasing the pain rather than staying on top of it. This explanation usually works like a charm. Dont forget to come back and and reassess the pain after 40-60 minutes to see if your intervention was effective. 

Now.... if I get a patient that rates his pain at 8/10 on a constant basis and is sitting there smiling or better yet sleeping through his pain, then I have to question wether or not he understand the scale, or wether there is something else going on. If the 1-10 isn't working i’ll go with the mild, moderate, severe question. Same idea as the 1-10. Sometimes this works better in the geriatric population. 

Then theres the little ones. If you're not familiar with kids then google the Wong Baker scale. Its the one where the happy face goes into the really sad crying face. Depending on your age group, this is a useful tool. Sometimes you just have to make a judgment call. Often we have wee little kiddies that can't talk yet. Crying is a good indication or not eating can signal pain too. Sometimes they just get a little fussy too. Other times they will tell you straight up that its an owie and won't let you touch the site. 

Pharmacological Intervention

After surgery, we love to give Tylenol (Panadol) out like candy. This works well for mild pain, personally it doesn't ever touch my headaches. But it works for a lot of people so I roll with it. Depending on the surgery NSAIDS are usually avoided due to their causing an increase risk of bleeding. We use them with gyne patients and it seems to work well. Ketorolac  is another NSAID that I am a huge fan of, however, depending on what country you work in might not be readily available.  These are basically your non opioids. For any pain thats not being managed with the above, you move to your narcotic selection. There are probably too many too mention but they are things like morphine, fentanyl, pethidine, oxycodone, hydromorphone, tramadol etc. All I can say is start low and go slow! You will never be faulted for under dosing your patient if you dont know what they can handle!! If these aren't really cutting it either, get the doctor to review or consider stacking a long acting medication like oxycontin, palexia SR, or Targin. Again these will all vary depending what country you're in. I did my training in Canada, and now work in Australia, so name brands will vary as will what you use. 

The only exception to this rule is the dreaded WIND pain! Wind pain will knock a grown ass man OVER! Im not even exaggerating, that shit is worse than surgical patients AND patients will rarely believe you. Unfortunately wind is common after surgery especially laparoscopic surgery because they pump the cavity full of it to get better views. The only thing to get rid of it is to MOBILIZE! You can use heat packs and simethecone (Degas), they can be slightly effective but the only fool proof hack is to walk, walk, walk. Thats it. Wind pain can also cause shoulder tip pain. This is when the gas rises and gets trapped in your shoulders (I've never had it but I've seen it numerous times and it doesn't look pleasant!). Opioids will NOT touch this pain and thats a good sign that its probably gas. 

Lastly, you want to keep your patients pain at bay so that they can mobilize. Mobilizing prevents muscle wastage, blood clots (pulmonary embolisms and deep vein thrombosis), pneumonia, bed sores, and wind. Keep reassessing their pain through out your shift, especially those that like to be heroes (usually though they're only silly enough to do it once and then never again). Sometimes you got to get a little tough too, get them out moving, suggests that pain relief might be a good idea, explain that they will not become addicted after one dose, whatever it takes to get your patient feeling well and confident. 

I hope that was helpful! If you have any questions let me know :) If you want anymore topics, leave a request. Im a surgical nurse with a lot of experience with post op patients and I love to teach :)

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