PAIN
❖ Definition: unpleasant sensory and emotional experience associated with actual or potential tissue damage
❖ Types of Pain:
➢ Acute Pain
■ Short lived
■ Results from SUDDEN, accidental trauma, surgery, ischemia, acute inflammation
■ Serves as warning sign
■ Activation of sympathetic nervous system: fight/flight
■ Sensory perception of pain (begins to feel better) as injury heals
➢ Chronic Pain
■ Lasts or recurs for indefinite period (more than 3 months)
■ Gradual onset
■ Character and quality often change over time (burning, throbbing, sharp pain)
■ Serves no biological purpose
● NON-Cancer Pain: common sites: neck, shoulder, lower back
● Cancer Pain: usually result of tumor growth, nerve compression, tissue invasion,
metastasis, cancer tx
➢ Nociceptive Pain
■ Pain from a normal process that results in noxious stimuli being perceived as painful
■ 2 Types:
● Somatic: arises from SKIN & MUSCULOSKELETAL structures
◆ Superficial or deep somatic pain
● Visceral: arises from ORGANS (dull, non-specific location pain)
➢ Neuropathic Pain
■ Pain from damage to neurons of either the peripheral or central nervous system
● "communication system sends the wrong messages to the brain about pain"
■ **Described as burning, tingling, shooting, pins & needles pain
❖ Assessment
➢ Pain is what the patient says, important for nurse to serve as advocate, respect patient value, and act
promptly to relieve pain
➢ COLDSPA
➢ Comfort function outcomes (patient goal for pain relief/function ability)
➢ Nonverbal assessment (facial expressions, vocalizations/screaming, body movements/restless,
mental status changes, change in activity and interaction levels
❖ Interventions:
➢ Drug Therapy
■ Non-opioid Analgesics
● Acetaminophen, NSAIDS
◆ Monitor pts taking acetaminophen for hepatotoxicity
◆ Reduced daily dose may be appropriate for older adults on long-term
therapy
◆ Monitor pts taking NSAIDS for gastric side effects (bleeding, gastritis)
◆ NSAIDS carry risk for cardiovascular disease and renal disease
■ Opioid Analgesics
● Full or Mu Agonists
◆ Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone
◆ 1st choice for moderate to severe pain, no ceiling (able to increase dose
without limitations until pain relief achieved)
● Mixed Agonists Antagonists
◆ Butorphanol, nalbuphine (Ex. stadol, nubain)
◆ Can trigger severe pain and opioid withdrawal symptoms in someone
that have been taking regular daily doses of a mu agonist opioid for
several days {S/S rhinitis, abdominal pain, cramping, nausea, agitation,
restlessness}
● Partial Agonists
◆ Buprenorphine, transdermal patch (Butrans, Suboxone)
◆ Sustained release agents
● ANTIDOTE:
◆ Narcan: reversal agent to counteract an opioid overdose
➢ Nonpharmacologic Management
■ Appropriate for mild and some moderate pain intensity
■ Should complement, not replace, pharm therapies for more severe pain
● Physical modalities
● Cognitive-behavioral strategies
,PREOPERATIVE PERIOD
❖ Definition: Begin when the patient is scheduled for surgery; Ends at time transfer to surgical suite
➢ NURSE functions as: Educator, Advocate, Promoter of health and safety
❖ Types of Surgeries:
➢ Diagnostic: determines origin and cause of disorder (biopsy)
➢ Curative: resolves health problems by repairing or removing cause (ex. gallbladder removal)
➢ Restorative: improves patient functional ability (ex. shoulder surgery)
➢ Palliative: relieves symptoms of disease process, but does not cure (ex. tumor removal to provide
comfort)
➢ Cosmetic: alters/enhances personal appearance
❖ Assessment:
➢ Physical
■ Obtain baseline V/S
■ Focus on PROBLEM areas identified in history
■ Report any abnormal assessment findings to surgeon/anesthesiology personnel
➢ System Assessment
■ Cardiovascular:
● CAD or MI within 6 months before surgery
● HTN
● Angina
● Dysrhythmias
■ Respiratory:
● Chronic respiratory problems
● Smoking increases carboxyhemoglobin blood level, decrease oxygen delivery
■ Renal/Urinary:
● Kidney impairment inhibits drugs/anesthetic excretion
■ Neurologic
● Determine baseline
● Assess LOC, ability to follow commands, orientation
■ Musculoskeletal
■ Psychosocial
● How patient feels about surgery
● Support system
➢ Labs/Testing
■ Urinalysis
■ Blood type
■ CBC or H&H levels: increase WBC may indicate infection decrease levels blood cells may
indicate anemia *may postpone surgery
■ Clotting studies: PT, INR, aPTT
■ Electrolyte levels
■ Serum creatinine levels
■ Pregnancy test
■ Chest x ray
■ EKG
❖ Patient Teaching
➢ Teach (deep breathing, coughing, incentive spirometer, splinting, exercising) and education the
patient by clarifying details presented by the surgeon/provider
➢ Educate pt about any possible tubes or devices that may be attached to them after surgery
➢ Educate and demonstrate the various techniques to prevent respiratory complications or
cardiovascular complications
❖ Drug Therapy
➢ Anxiolytics: reduce anxiety
➢ Hypnotic/sedative: promote relaxation
➢ Anticholinergics: reduce nasal and oral secretions
➢ H2 Histamine Blockers: inhibit gastric secretion
➢ Opioids: decrease amount of anesthetic needed for induction and maintenance
➢ Prevent laryngospasm
➢ Reduce vagal induced bradycardia
INFORMED CONSENT
❖ To witness the client's signature on the informed consent form and to ensure that informed consent has been
appropriately obtained
❖ Nurse is able to clarify facts and dispel facts about surgery, if further detailed information needed nurse
advocates and contacts surgeon to further educate pt
,POSTOPERATIVE PERIOD
❖ Definition: begins with the completion of surgery and transfer to PACU, ambulatory care unit, or ICU
❖ Assessment
➢ Respiratory
■ Patent airway, adequate gas exchange
■ Note artificial airway when applicable
■ Rate pattern depth of breathing
■ Breath sounds
■ Accessory muscle use (intercostal movements)
■ Snoring and stridor
■ Respiratory depression or hypoxemia
➢ Cardiovascular
■ V/S
■ Heart sounds
■ Cardiac monitoring
■ Peripheral vascular assessment
■ Monitor VTE
➢ Fluid/Electrolyte & Acid/Base
■ I&O
■ Hydration status (moist/dry, color)
■ IV fluids
■ Wound drainage
■ NG tube drainage
➢ Gastrointestinal
■ Post Op N/V **common
■ Peristalsis may be delayed up to 24 hours
■ Monitor bowel sounds
■ Reduce N/V: ondansetron, Dramamine, scopolamine patch)
❖ Lab Values
➢ Hemoglobin (Hgb):
■ Female 12-16 g/dL
■ Male 14-18 g/dL
➢ Hematocrit (Hct)
■ Female 37%-47%
■ Male 42%-52%
➢ PaCO2: 35-45 mmHg
➢ HCO3: 21-28 mEq/L
❖ Complications:
➢ Hypoxemia
■ ***Highest incidence occurs on 2nd postoperative day
■ Interventions:
● -Airway maintenance (position for open airway)
● -Monitor (Spo2)
● -Semi-Fowler's position
● -Oxygen therapy, breathing exercises
● -Mobilization as soon as possible
➢ Dehiscence- first breech of skin incision
➢ Evisceration: bowel escapes from breached opening
■ Interventions:
● Stay with patient, notify surgeon immediately
● Patient remain still, bend knees
● Apply sterile wet dressing to abdomen
➢ Wound infection
■ Nursing assessment of surgical area is critical
● Dressings—First change usually done by surgeon
● Drains—Provide exit route for air, blood, bile; help prevent deep infections,
abscess formation during healing
■ Interventions
● Drug therapy, irrigation to treat wound infection, antibiotic prophylactically
● Debridement
● Surgical management required for wound opening
Chronic Obstructive Pulmonary Disorder (COPD)
❖ Emphysema
➢ Definition: Loss of lung elasticity and hyperinflation of lung
, ■ O2 exchange does not occur due to structural changes
➢Symptoms: dyspnea, decreased gas exchange, increased RR, Barrel chest, flatten diaphragm
■ “PINK PUFFER”
➢ Assessment:
■ -Cough: occurs late
■ -Sputum: scanty, small amount
■ -Weight: thin/wasted/cachexia (working too hard to breathe)
■ -Dyspnea: SOB
■ -Skin: pink, normal ABGs
■ **BARREL CHEST
■ -Edema: LATE resulting from Cor Pulmonae
❖ Chronic Bronchitis
➢ Definition: inflammation of bronchi and bronchioles from exposure to irritants causing mucous
glands to increase in number and size
■ “BLUE BLOATER”
➢ Etiology: impaired airflow due to mucus
➢ Assessment
■ -Cough: chronic, considerable
■ -Sputum: Copious/A LOT and purulent
■ -Weight: stocky build
■ -Dyspnea: mild(PaCO2 retention increased)
■ -Skin: CYANOTIC (PaO2 REDUCED)
■ -Edema: dependent edema common and r/t R-HF
❖ COPD Complications
➢ Hypoxia leads to respiratory failure
➢ Acidosis: pH too low
➢ Prone to respiratory infection (pneumococcal vaccine q3-5yrs, annual flu vaccine)
➢ Dysrhythmias lead to cardiac failure
➢ *Extreme caution when administering opioids/sedative: RESP DEPRESSION
❖ O2 Consideration
➢ COPD = CO2 Retainer
■ Oxygen induced hypoventilation
■ Reduced O2 is the stimulus to breathe
● Healthy people breathe drive-> HIGH CO2 to breathe off and get more O2
● COPD breathe drive O2 if levels too high body won’t try to breathe off excess CO2
❖ Drug Therapy for COPD
➢ ***Bronchodilators administered first then other inhalants***
➢ Beta adrenergic agents
➢ Cholinergic antagonists
➢ Xanthines
➢ Corticosteroids
➢ Cromones
➢ Mucolytics
■ Systemic: thin secretions, promotes exprectoration
● Guaifenesin (Mucinex, Robitussin)
■ Aerosol: thin secretions and breaks own mucus to promote expectoration
● Acetylcysteine
● Side effects: N/V
CATARACTS
❖ Definition: lens opacity that distorts images and causes gradual loss of visual acuity over time
❖ Types:
➢ Nuclear cataracts
➢ Cortical cataracts
➢ Posterior capsular cataracts
➢ Congenital cataracts
➢ Secondary cataracts are caused by disease or medications
■ Diseases that are linked with the development of cataracts include glaucoma and diabetes.
➢ Age related: 70 or >
❖ Treatment
➢ Surgical tx: phacoemulsification (Probe inserted into capsule, lens broken up by high-frequency
sound waves and then suction out and replaced with an intraocular lens [IOL] implant
■ *Teaching Post-Op: Wear glasses outdoors, do not rush/scratch eyes after surgery
➢ Eyedrops: antibiotic and anti-inflammatory
■ Expect mild discomfort, itching, and sensitivity to light
❖ Definition: unpleasant sensory and emotional experience associated with actual or potential tissue damage
❖ Types of Pain:
➢ Acute Pain
■ Short lived
■ Results from SUDDEN, accidental trauma, surgery, ischemia, acute inflammation
■ Serves as warning sign
■ Activation of sympathetic nervous system: fight/flight
■ Sensory perception of pain (begins to feel better) as injury heals
➢ Chronic Pain
■ Lasts or recurs for indefinite period (more than 3 months)
■ Gradual onset
■ Character and quality often change over time (burning, throbbing, sharp pain)
■ Serves no biological purpose
● NON-Cancer Pain: common sites: neck, shoulder, lower back
● Cancer Pain: usually result of tumor growth, nerve compression, tissue invasion,
metastasis, cancer tx
➢ Nociceptive Pain
■ Pain from a normal process that results in noxious stimuli being perceived as painful
■ 2 Types:
● Somatic: arises from SKIN & MUSCULOSKELETAL structures
◆ Superficial or deep somatic pain
● Visceral: arises from ORGANS (dull, non-specific location pain)
➢ Neuropathic Pain
■ Pain from damage to neurons of either the peripheral or central nervous system
● "communication system sends the wrong messages to the brain about pain"
■ **Described as burning, tingling, shooting, pins & needles pain
❖ Assessment
➢ Pain is what the patient says, important for nurse to serve as advocate, respect patient value, and act
promptly to relieve pain
➢ COLDSPA
➢ Comfort function outcomes (patient goal for pain relief/function ability)
➢ Nonverbal assessment (facial expressions, vocalizations/screaming, body movements/restless,
mental status changes, change in activity and interaction levels
❖ Interventions:
➢ Drug Therapy
■ Non-opioid Analgesics
● Acetaminophen, NSAIDS
◆ Monitor pts taking acetaminophen for hepatotoxicity
◆ Reduced daily dose may be appropriate for older adults on long-term
therapy
◆ Monitor pts taking NSAIDS for gastric side effects (bleeding, gastritis)
◆ NSAIDS carry risk for cardiovascular disease and renal disease
■ Opioid Analgesics
● Full or Mu Agonists
◆ Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone
◆ 1st choice for moderate to severe pain, no ceiling (able to increase dose
without limitations until pain relief achieved)
● Mixed Agonists Antagonists
◆ Butorphanol, nalbuphine (Ex. stadol, nubain)
◆ Can trigger severe pain and opioid withdrawal symptoms in someone
that have been taking regular daily doses of a mu agonist opioid for
several days {S/S rhinitis, abdominal pain, cramping, nausea, agitation,
restlessness}
● Partial Agonists
◆ Buprenorphine, transdermal patch (Butrans, Suboxone)
◆ Sustained release agents
● ANTIDOTE:
◆ Narcan: reversal agent to counteract an opioid overdose
➢ Nonpharmacologic Management
■ Appropriate for mild and some moderate pain intensity
■ Should complement, not replace, pharm therapies for more severe pain
● Physical modalities
● Cognitive-behavioral strategies
,PREOPERATIVE PERIOD
❖ Definition: Begin when the patient is scheduled for surgery; Ends at time transfer to surgical suite
➢ NURSE functions as: Educator, Advocate, Promoter of health and safety
❖ Types of Surgeries:
➢ Diagnostic: determines origin and cause of disorder (biopsy)
➢ Curative: resolves health problems by repairing or removing cause (ex. gallbladder removal)
➢ Restorative: improves patient functional ability (ex. shoulder surgery)
➢ Palliative: relieves symptoms of disease process, but does not cure (ex. tumor removal to provide
comfort)
➢ Cosmetic: alters/enhances personal appearance
❖ Assessment:
➢ Physical
■ Obtain baseline V/S
■ Focus on PROBLEM areas identified in history
■ Report any abnormal assessment findings to surgeon/anesthesiology personnel
➢ System Assessment
■ Cardiovascular:
● CAD or MI within 6 months before surgery
● HTN
● Angina
● Dysrhythmias
■ Respiratory:
● Chronic respiratory problems
● Smoking increases carboxyhemoglobin blood level, decrease oxygen delivery
■ Renal/Urinary:
● Kidney impairment inhibits drugs/anesthetic excretion
■ Neurologic
● Determine baseline
● Assess LOC, ability to follow commands, orientation
■ Musculoskeletal
■ Psychosocial
● How patient feels about surgery
● Support system
➢ Labs/Testing
■ Urinalysis
■ Blood type
■ CBC or H&H levels: increase WBC may indicate infection decrease levels blood cells may
indicate anemia *may postpone surgery
■ Clotting studies: PT, INR, aPTT
■ Electrolyte levels
■ Serum creatinine levels
■ Pregnancy test
■ Chest x ray
■ EKG
❖ Patient Teaching
➢ Teach (deep breathing, coughing, incentive spirometer, splinting, exercising) and education the
patient by clarifying details presented by the surgeon/provider
➢ Educate pt about any possible tubes or devices that may be attached to them after surgery
➢ Educate and demonstrate the various techniques to prevent respiratory complications or
cardiovascular complications
❖ Drug Therapy
➢ Anxiolytics: reduce anxiety
➢ Hypnotic/sedative: promote relaxation
➢ Anticholinergics: reduce nasal and oral secretions
➢ H2 Histamine Blockers: inhibit gastric secretion
➢ Opioids: decrease amount of anesthetic needed for induction and maintenance
➢ Prevent laryngospasm
➢ Reduce vagal induced bradycardia
INFORMED CONSENT
❖ To witness the client's signature on the informed consent form and to ensure that informed consent has been
appropriately obtained
❖ Nurse is able to clarify facts and dispel facts about surgery, if further detailed information needed nurse
advocates and contacts surgeon to further educate pt
,POSTOPERATIVE PERIOD
❖ Definition: begins with the completion of surgery and transfer to PACU, ambulatory care unit, or ICU
❖ Assessment
➢ Respiratory
■ Patent airway, adequate gas exchange
■ Note artificial airway when applicable
■ Rate pattern depth of breathing
■ Breath sounds
■ Accessory muscle use (intercostal movements)
■ Snoring and stridor
■ Respiratory depression or hypoxemia
➢ Cardiovascular
■ V/S
■ Heart sounds
■ Cardiac monitoring
■ Peripheral vascular assessment
■ Monitor VTE
➢ Fluid/Electrolyte & Acid/Base
■ I&O
■ Hydration status (moist/dry, color)
■ IV fluids
■ Wound drainage
■ NG tube drainage
➢ Gastrointestinal
■ Post Op N/V **common
■ Peristalsis may be delayed up to 24 hours
■ Monitor bowel sounds
■ Reduce N/V: ondansetron, Dramamine, scopolamine patch)
❖ Lab Values
➢ Hemoglobin (Hgb):
■ Female 12-16 g/dL
■ Male 14-18 g/dL
➢ Hematocrit (Hct)
■ Female 37%-47%
■ Male 42%-52%
➢ PaCO2: 35-45 mmHg
➢ HCO3: 21-28 mEq/L
❖ Complications:
➢ Hypoxemia
■ ***Highest incidence occurs on 2nd postoperative day
■ Interventions:
● -Airway maintenance (position for open airway)
● -Monitor (Spo2)
● -Semi-Fowler's position
● -Oxygen therapy, breathing exercises
● -Mobilization as soon as possible
➢ Dehiscence- first breech of skin incision
➢ Evisceration: bowel escapes from breached opening
■ Interventions:
● Stay with patient, notify surgeon immediately
● Patient remain still, bend knees
● Apply sterile wet dressing to abdomen
➢ Wound infection
■ Nursing assessment of surgical area is critical
● Dressings—First change usually done by surgeon
● Drains—Provide exit route for air, blood, bile; help prevent deep infections,
abscess formation during healing
■ Interventions
● Drug therapy, irrigation to treat wound infection, antibiotic prophylactically
● Debridement
● Surgical management required for wound opening
Chronic Obstructive Pulmonary Disorder (COPD)
❖ Emphysema
➢ Definition: Loss of lung elasticity and hyperinflation of lung
, ■ O2 exchange does not occur due to structural changes
➢Symptoms: dyspnea, decreased gas exchange, increased RR, Barrel chest, flatten diaphragm
■ “PINK PUFFER”
➢ Assessment:
■ -Cough: occurs late
■ -Sputum: scanty, small amount
■ -Weight: thin/wasted/cachexia (working too hard to breathe)
■ -Dyspnea: SOB
■ -Skin: pink, normal ABGs
■ **BARREL CHEST
■ -Edema: LATE resulting from Cor Pulmonae
❖ Chronic Bronchitis
➢ Definition: inflammation of bronchi and bronchioles from exposure to irritants causing mucous
glands to increase in number and size
■ “BLUE BLOATER”
➢ Etiology: impaired airflow due to mucus
➢ Assessment
■ -Cough: chronic, considerable
■ -Sputum: Copious/A LOT and purulent
■ -Weight: stocky build
■ -Dyspnea: mild(PaCO2 retention increased)
■ -Skin: CYANOTIC (PaO2 REDUCED)
■ -Edema: dependent edema common and r/t R-HF
❖ COPD Complications
➢ Hypoxia leads to respiratory failure
➢ Acidosis: pH too low
➢ Prone to respiratory infection (pneumococcal vaccine q3-5yrs, annual flu vaccine)
➢ Dysrhythmias lead to cardiac failure
➢ *Extreme caution when administering opioids/sedative: RESP DEPRESSION
❖ O2 Consideration
➢ COPD = CO2 Retainer
■ Oxygen induced hypoventilation
■ Reduced O2 is the stimulus to breathe
● Healthy people breathe drive-> HIGH CO2 to breathe off and get more O2
● COPD breathe drive O2 if levels too high body won’t try to breathe off excess CO2
❖ Drug Therapy for COPD
➢ ***Bronchodilators administered first then other inhalants***
➢ Beta adrenergic agents
➢ Cholinergic antagonists
➢ Xanthines
➢ Corticosteroids
➢ Cromones
➢ Mucolytics
■ Systemic: thin secretions, promotes exprectoration
● Guaifenesin (Mucinex, Robitussin)
■ Aerosol: thin secretions and breaks own mucus to promote expectoration
● Acetylcysteine
● Side effects: N/V
CATARACTS
❖ Definition: lens opacity that distorts images and causes gradual loss of visual acuity over time
❖ Types:
➢ Nuclear cataracts
➢ Cortical cataracts
➢ Posterior capsular cataracts
➢ Congenital cataracts
➢ Secondary cataracts are caused by disease or medications
■ Diseases that are linked with the development of cataracts include glaucoma and diabetes.
➢ Age related: 70 or >
❖ Treatment
➢ Surgical tx: phacoemulsification (Probe inserted into capsule, lens broken up by high-frequency
sound waves and then suction out and replaced with an intraocular lens [IOL] implant
■ *Teaching Post-Op: Wear glasses outdoors, do not rush/scratch eyes after surgery
➢ Eyedrops: antibiotic and anti-inflammatory
■ Expect mild discomfort, itching, and sensitivity to light
