Nursing Care
What is Pain? - ANS whatever the patient says it is and excists whenever the patient says it
does
Nociceptive Pain - ANS -pain along an intact nerve
-warning sign for tissue damage
Neuropathic Pain - ANS damaged or malfunctioning nerves
Pain Assessment in Non-verbal patients - ANS assume pain is present if there is reason to
suspect pain
WILDA - ANS -words to describe pain
-intensity
-location
-duration
-aggravating or alleviating factors
Comfort Goal for Pain - ANS 4 or less
Mild Pain - ANS (1-4) may or may not see any physical signs or symptoms
Moderate Pain - ANS (5-6) start to see symptoms such:
-tachycardia
-rapid/shallow respiration
-increased BP
-dilated pupils
-diaphoresis
-pallor
-anxiety
Severe Pain - ANS (7-10) s/s include:
-increased HR & BP
-rapid/irregular breathing
-nausea/vomiting
-weakness
-pallor
-diaphoresis
-restless
*IMMEDIATE INTERVENTION
3 Classes of Analgesics - ANS - non opioid
-opioid
adjuvent
Side Effects of Opioids - ANS -constipation
-sedation
-respiratory depression
-nausea/vomiting
-pruritus
urinary retention
Nursing Interventions for Constipation - ANS -administer stool softeners/laxatives
*increase activity
*increase fluid intake
, *water & walking*
Nursing Interventions for Respiratory Depression - ANS -watch RR
-watch O2 sat
-color of skin
-LOC
-administer oxygen
-administer narcan (respiratory rate <10)
Interventions for Pruritus - ANS -cold packs
-lotion
-antihistamines
Interventions for Vomiting - ANS -anti emetics
-change analgesic
Interventions for Urinary Retention - ANS -monitor I&O
-monitor for bladder distention
-foley
Evaluation must be done at Drug Peaks - ANS Oral: 60 min after administration
SQ/IM: 30 min after administration
IV: 15 min after administration
How Long do Anti Depressants Take to Work? - ANS 2-4 weeks
Cymbalta (anti depressant) - ANS diabetic neuropathy and migraines
Lyrica & Neurotin (anticonvulsants) - ANS treat neuropathic pain
What does the order 2/10/30/4 mean? - ANS 2mg every 10min or 30mg q4h
PCA Nursing Interventions - ANS -assess pain, respirations, and sedation every 1hr until VS
stable then every 2hrs x 24, then every 4hrs
-if dose changed must reassess
Who is allowed to push the PCA pump? - ANS only the patient unless you have doctors orders
and documented education, then family members may press it
basil vs bolus PCA - ANS basil: continuous rate
bolus: have to press the button
Epidural - ANS *NO ANTICOAGULANTS*
-bleeding can cause damage to nerves and cause paralysis
-must have an order from anesthesiologist and neuro checks q2h
S/S to watch for w/ epidural - ANS -numbness and tingling
-urinary retention
-hypotension
SBAR - ANS -situation
-background
-assessment
-recomendation
Preoperative Nursing - ANS begins when the client makes the decision to have surgery and
ends when the client is transferred to the operating table.
Nursing Responsibility for Informed Consent - ANS -witness the client sign the document
-client was alert and aware
General Anesthesia - ANS -puts to sleep with no pain or feeling
What is Pain? - ANS whatever the patient says it is and excists whenever the patient says it
does
Nociceptive Pain - ANS -pain along an intact nerve
-warning sign for tissue damage
Neuropathic Pain - ANS damaged or malfunctioning nerves
Pain Assessment in Non-verbal patients - ANS assume pain is present if there is reason to
suspect pain
WILDA - ANS -words to describe pain
-intensity
-location
-duration
-aggravating or alleviating factors
Comfort Goal for Pain - ANS 4 or less
Mild Pain - ANS (1-4) may or may not see any physical signs or symptoms
Moderate Pain - ANS (5-6) start to see symptoms such:
-tachycardia
-rapid/shallow respiration
-increased BP
-dilated pupils
-diaphoresis
-pallor
-anxiety
Severe Pain - ANS (7-10) s/s include:
-increased HR & BP
-rapid/irregular breathing
-nausea/vomiting
-weakness
-pallor
-diaphoresis
-restless
*IMMEDIATE INTERVENTION
3 Classes of Analgesics - ANS - non opioid
-opioid
adjuvent
Side Effects of Opioids - ANS -constipation
-sedation
-respiratory depression
-nausea/vomiting
-pruritus
urinary retention
Nursing Interventions for Constipation - ANS -administer stool softeners/laxatives
*increase activity
*increase fluid intake
, *water & walking*
Nursing Interventions for Respiratory Depression - ANS -watch RR
-watch O2 sat
-color of skin
-LOC
-administer oxygen
-administer narcan (respiratory rate <10)
Interventions for Pruritus - ANS -cold packs
-lotion
-antihistamines
Interventions for Vomiting - ANS -anti emetics
-change analgesic
Interventions for Urinary Retention - ANS -monitor I&O
-monitor for bladder distention
-foley
Evaluation must be done at Drug Peaks - ANS Oral: 60 min after administration
SQ/IM: 30 min after administration
IV: 15 min after administration
How Long do Anti Depressants Take to Work? - ANS 2-4 weeks
Cymbalta (anti depressant) - ANS diabetic neuropathy and migraines
Lyrica & Neurotin (anticonvulsants) - ANS treat neuropathic pain
What does the order 2/10/30/4 mean? - ANS 2mg every 10min or 30mg q4h
PCA Nursing Interventions - ANS -assess pain, respirations, and sedation every 1hr until VS
stable then every 2hrs x 24, then every 4hrs
-if dose changed must reassess
Who is allowed to push the PCA pump? - ANS only the patient unless you have doctors orders
and documented education, then family members may press it
basil vs bolus PCA - ANS basil: continuous rate
bolus: have to press the button
Epidural - ANS *NO ANTICOAGULANTS*
-bleeding can cause damage to nerves and cause paralysis
-must have an order from anesthesiologist and neuro checks q2h
S/S to watch for w/ epidural - ANS -numbness and tingling
-urinary retention
-hypotension
SBAR - ANS -situation
-background
-assessment
-recomendation
Preoperative Nursing - ANS begins when the client makes the decision to have surgery and
ends when the client is transferred to the operating table.
Nursing Responsibility for Informed Consent - ANS -witness the client sign the document
-client was alert and aware
General Anesthesia - ANS -puts to sleep with no pain or feeling
