Pain

Management

Pain Management

Definition of Pain
o Pain is what the patient says it is.
Categorizing pain
o Acute pain
Acute pain is usually of recent onset and commonly associated with
a specific injury.
Acute pain indicates that damage or injury has occurred.
o Chronic pain
Chronic pain is constant or intermittent pain that persists beyond
the expected healing time and that can seldom be attributed to a
specific cause or injury.
Subcategorized as being of cancer or noncancer origin and can be
time limited or persist throughout the course of a persons life.
Patients can experience acute pain along with chronic pain.
o Phantom pain
Occurs when the body experiences a loss, such as an amputation,
and still feels pain in the missing part.
Phantom pain is caused by the abnormal reorganization of the
nervous system.
Types of pain
o Nociceptive pain
o Neuropathic pain
o Transduction refers to the processes by which noxious stimuli, such as a
surgical incision or burn, activate primary afferent neurons called
nociceptors.
o Transmission, perception, and modulation
Cultural/Ethnic/Gender/Age conisderations
o Older people may respond differently to pain than younger people.
Because elderly people have a slower metabolism and a greater ratio of
body fat to muscle mass compared with younger people, small doses of
analgesic agents may be sufficient to relieve pain, and these doses may
be effective longer. Monitor for drug toxicity. The elderly may require
lower doses of medication and are easily confused with new medications.
o Drug interactions are more likely to occur in older adults because of the
higher incidence of chronic illness and the increased use of prescription
and OTC medications.
o Pain assessment for patients who cannot speak English you can use a
chart with English on one side and his native language on the other.
Assessment of Pain
o Two patients may have the same type of injury or surgery, and rate their
pain differently because endorphin levels may vary between patients,
affecting the perception of pain.
o Some patients may need education about pain scales and rating pain, if
they are physically exhibiting signs of pain but rating their pain extremely
low.

o Depression is associated with chronic pain and can be exacerbated by

the effects of chronic fatigue.
o Chronic pain may affect the patient's quality of life by interfering with
work, interpersonal relationships, or sleep.
o Pain is whatever the patient says it is, you should never assume the
patient is not really in pain unless there is strong evidence to support this
claim.
o The nurses assessment of pain is a priority.
o Regardless of how patients cope with chronic pain, pain that lasts for an
extended period can result in depression, anger, or emotional withdrawal.
o Nurses should understand the effects of chronic pain on patients and
families and should be knowledgeable about pain-relief strategies and
appropriate resources to assist effectively with pain management.
Management of Acute and Chronic Pain
o Medication should be taken when pain levels are low so the pain is easier
to reduce.
o Before administering medications such as narcotics for the first time, the
nurse should assess for any previous allergic reactions.
o A patient who receives opioids by any route must be assessed frequently
for changes in respiratory status.
o Combination medication regimens may be to achieve pain control than
with one medication alone.
o Over time, the patient with cancer pain is likely to become more tolerant
of the dosage. Their drug dosages may keep getting larger to continue
relieving pain.
o Cancer pain can be acute or chronic and it typically requires
comparatively high doses of pain medications.
o In some situations, especially with long-term severe intractable pain,
usual pharmacologic and nonpharmacologic methods of pain relief are
ineffective. In those situations, neurologic and neurosurgical approaches
to pain management may be considered.
o PCA pump teaching:
o Patients requiring opioids for chronic pain, especially cancer patients,
need increasing doses to relieve pain. The requirement for higher drug
doses results in a greater drug tolerance, which is a physical dependency
as opposed to addiction, which is a psychological dependency. The dose
range is usually higher with cancer patients.
o Preventive pain measures:
Check for allergies
Use a pain scale to assess the patient's pain
Offer the pain as prescribed until the patient is discharged
o Much cancer pain is due to tumor involvement, and needs to be treated
in a way that brings the patient relief.
o NSAIDs produce pain relief primarily by blocking the formation of
prostaglandins in the periphery; this is a central component of the
pathophysiology of transduction.

o Severe opioid-induced sedation necessitates the administration of

naloxone (Narcan), an opioid antagonist.
o Tolerance to opioids is common and becomes a problem primarily in
terms of maintaining adequate pain control.
o For patients who have persistent, severe pain that fails to respond to
other treatments or who obtain pain relief only with the risk of serious
side effects, medication administered by a long-term intrathecal or
epidural catheter may be effective.
o The nursing care of patients who undergo procedures for the relief of
chronic pain depends on the type of procedure performed, its
effectiveness in relieving the pain, the patients comorbidities, and the
changes in neurologic function that accompany the procedure.
o Patients who have been taking analgesic agents may mistakenly assume
that clinicians suggest a nonpharmacolgical method to reduce the use or
dose of analgesic agents. They are used to reduce pain.
o If pain management interventions do not relieve pain, the nurse needs to
be the patient advocate and collaborate with the physician.
o Placebos are never used in the treatment of pain.
o Gabapentin is used for neuropathic pain.

Perioperative
Care

Preoperative Stage

Categories of Surgery Based on Urgency

o Emergent patient requires immediate attention; disorder may be life
threatening; without delay.
Severe bleeding
Bladder or intestinal obstruction
Fractured skull
Gunshot or stab wounds
Extensive burns
o Urgent patient requires prompt attention; within 42-30 hours.
Acute gallbladder infection
Kidney or ureteral stones
o Required patient needs to have surgery; plan within a few weeks or
months.
Prostatic hyperplasia without bladder obstruction
Thyroid disorders
Cataracts
o Elective patient should have surgery; Failure to have surgery not
catastrophic.
Repair of scars
Simple hernia
Vaginal repair
o Optional Decision rests with patient; personal preference.
Cosmetic surgery
Assessment
o Alcohol withdrawal syndrome may be anticipated between 48 and 96
hours after alcohol withdrawal and is associated with a significant
mortality rate when it occurs postoperatively.
o Any nutritional deficiency, such as malnutrition, should be corrected
before surgery to provide adequate protein for tissue repair. The
electrolyte levels should be evaluated and corrected to prevent
metabolic abnormalities in the operative and postoperative phase.
o The reduction of smoking will enhance pulmonary function; in the
preoperative period, patients who smoke should be urged to stop 4 to
8 weeks before surgery.
o The only opportunity for preoperative assessment may take place at
the same time as resuscitation in the ED.
Education
o Deep breathing and coughing:
The patient assumes a sitting position to enhance lung
expansion. The nurse then demonstrates how to take a deep,
slow breath and how to exhale slowly. After practicing deep
breathing several times, the patient is instructed to breathe
deeply, exhale through the mouth, take a short breath, and
cough from deep in the lungs.

o Teaching is most effective when provided before surgery. Preoperative

teaching is initiated as soon as possible, beginning in the physician's
office, clinic, or at the time of preadmission testing when diagnostic
tests are performed.
o Exercise of the extremities includes extension and flexion of the knee
and hip joints (similar to bicycle riding while lying on the side) unless
contraindicated by type of surgical procedure (e.g., hip replacement).
When the patient does leg exercises postoperatively, circulation is
increased, which helps to prevent blood clots from forming.
o One goal of preoperative nursing care is to teach the patient how to
promote optimal lung expansion and consequent blood oxygenation
after anesthesia.
o The major purpose of withholding food and fluid before surgery is to
prevent aspiration.
Informed consent
o The surgeon must inform the patient of the benefits, alternatives,
possible risks, complications, disfigurement, disability, and removal of
body parts as well as what to expect in the early and late
postoperative periods.
o The nurse clarifies the information provided, and, if the patient
requests additional information, the nurse notifies the physician.
o When asked, if the patient is able to tell the nurse what will occur
during the procedure and the associated risks. This indicates the
patient has a sufficient understanding of the procedure to provide
informed consent.
o An emancipated minor (married or independently earning his or her
own living) may sign his or her own consent form.
o Criteria for legally valid informed consent:
Must be freely given, no coercion
Must be obtained by a physician
Must be witnessed by a professional staff member
o In an emergency, it may be necessary for the surgeon to operate as a
lifesaving measure without the patient's informed consent. However,
every effort must be made to contact the patient's family. In such a
situation, contact can be made by electronic means.
o
Preoperative Medications and Pain Management:
o It is imperative to know a preoperative patient's current medication
regimen, including OTC medications and supplements.
o A patient on hospice will undergo a surgical procedure only for
palliative care to reduce pain, but it is not curative.
o If a preanesthetic medication is administered, the patient is kept in
bed with the side rails raised because the medication can cause
lightheadedness or drowsiness. If a patient needs to void following
administration of a sedative, the nurse should offer the patient a
urinal. The patient should not get out of bed because of the potential
for lightheadedness.

o Because of the potential effects of herbal medications on coagulation

and potential lethal interactions with other medications, the nurse
must ask surgical patients specifically about the use of these agents,
document their use, and inform the surgical team and
anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is
recommended that the use of herbal products be discontinued at least
2 weeks before surgery. Patients with uncontrolled thyroid disorders
are at risk for thyrotoxicosis and respiratory failure. The administration
of Synthroid is imperative in the preoperative period.
o Before most abdominal surgeries, especially bowel resection, a
cleansing enema is given. The administration of a cleansing enema
will allow for satisfactory visualization of the surgical site and to
prevent trauma to the intestine or contamination of the peritoneum by
feces.
o The use of guided imagery will enhance pain relief and assist in
reduction of anxiety. It may be combined with analgesics.
o When the preoperative medication is given, the bed should be placed
in low position with the side rails raised. The patient should not get up
without assistance.
o Postoperatively, medications are administered to relieve pain and
maintain comfort without increasing the risk of inadequate air
exchange.
Nursing interventions
o In the holding area, the nurse reviews charts, identifies patients,
verifies surgical site and marks site per institutional policy, establishes
IV lines, administers medications, if prescribed, and takes measures to
ensure each patient's comfort.
o During the intraoperative phase, the nurse is responsible for
physiologic monitoring.
o The PACU nurse is responsible for informing the floor nurse of the
patient's intraoperative factors (e.g., insertion of drains or catheters,
administration of blood or medications during surgery, or occurrence
of unexpected events), preoperative level of consciousness, presence
of family and/or significant others, and identification of the patient by
name.
o The nurse must verify that preoperative teaching was performed
before the patient is taken to the holding area.
o The completed chart (with the preoperative checklist and verification
form) accompanies the patient to the OR with the surgical consent
form attached, along with all laboratory reports and nurses' records.
Any unusual last-minute observations that may have a bearing on
anesthesia or surgery are noted prominently at the front of the chart.
Special Considerations:
o Gerontological
The underlying principle that guides the preoperative
assessment, surgical care, and postoperative care is that elderly
patients have less physiologic reserve (the ability of an organ to

return to normal after a disturbance in its equilibrium) than do

younger patients.
Older patients report higher levels of preoperative anxiety;
therefore, the nurse should be prepared to spend additional
time, increase the amount of therapeutic touch utilized, and
encourage family members to be present to decrease anxiety.
The lessened physiological reserve of older adults results in an
increased risk for infection postoperatively.
o Immune
Patients who are immunosuppressed are more susceptible to
infection when having surgery.
o Diabetes
Diabetic patient is at risk for hypoglycemia, hyperglycemia,
acidosis, and glycosuria as postoperative complications.
The patient with diabetes who is undergoing surgery is at risk for
hypoglycemia and hyperglycemia. Close glycemic monitoring is
necessary. Dextrose infusion and prolonged NPO status are
contraindicated.
o Bariatric patients:
Like age, obesity increases the risk and severity of complications
associated with surgery. During surgery, fatty tissues are
especially susceptible to infection. In addition, obesity increases
technical and mechanical problems related to surgery.
Therefore, dehiscence (wound separation) and wound infections
are more common.
The postoperative phase begins with the admission of the patient to the
PACU and ends with a follow-up evaluation in the clinical setting or home.
SCIP identifies performance measures aimed at preventing surgical
complications, including venous thromboembolism (VTE) and surgical site
infections (SSI).

Intraoperative Care

Patient
o Inadvertent hypothermia may occur as a result of a low temperature in
the OR, infusion of cold fluids, inhalation of cold gases, open body
wounds or cavities, decreased muscle activity, advanced age, or the
pharmaceutical agents used.
Factors that affect the elderly surgical patient in the intraoperative
period include the following:
Impaired ability to increase metabolic rate
Impaired thermoregulatory mechanisms increase
susceptibility to hypothermia
The elderly patient cannot adjust rapidly to physical or emotional
stress.
Warmed IV fluids can prevent the development of hypothermia.
The Circulating Nurses:
o Main responsibilities of the circulating nurse include verifying consent;
coordinating the team; and ensuring cleanliness, proper temperature and
humidity, lighting, safe function of equipment, and the availability of
supplies and materials.
o The circulating nurse monitors aseptic practices to avoid breaks in
technique while coordinating the movement of related personnel as well
as implementing fire safety precautions.
o The circulating nurse also monitors the patient and documents specific
activities throughout the operation to ensure the patient's safety and
well-being.
o Few patients undergoing an elective procedure require blood transfusion,
but those undergoing high-risk procedures may require an intraoperative
transfusion. The circulating nurse anticipates this need, checks that blood
has been cross-matched and held in reserve, and is prepared to
administer blood.
The Scrub Role:
The Surgeon:
The Registered Nurse First Assistant:
The Anesthesiologist or Anesthetist:
o The anesthetist should be informed of any allergies.
Due to the increased number of patients with latex allergies, it is
essential to identify this allergy early on so precautions can be
taken in the OR.
o When the patient arrives in the OR, the anesthesiologist or anesthetist
reassesses the patient's physical condition immediately prior to initiating
anesthesia.
o The anesthetic is administered, and the patient's airway is maintained
through an intranasal intubation, oral intubation, or a laryngeal mask
airway. The tube also helps protect aspiration of stomach contents.
Surgical Asepsis:

o Masks are worn at all times in the restricted zone of the OR.
o Basic guidelines for maintaining sterile technique include that sterile
surfaces or articles may touch other sterile surfaces only.
o Whenever a sterile barrier is breached, the area must be considered
contaminated.
o At least a 1-foot distance from the sterile field must be maintained to
prevent inadvertent contamination.
Types of Anesthesia and Sedation:
o General Anesthesia
Patients under general anesthesia are not arousable, not even to
painful stimuli.
They require assistance in maintaining an airway.
Patients at greatest risk for anesthesia awareness are
Cardiac
Obstetric
Major trauma patients
There are four stages of general anesthesia
Stage I: beginning anesthesia
o Drowsy, feeling of detachment; Although still conscious
may sense an inability to move extremities easily;
Noises are exaggerated.
o Avoid unnecessary movement or motion.
Stage II: excitement
o Struggling, shouting, talking, singing, laughing, crying
o The anesthesiologist or anesthetist must always be
assisted to restrain the patient or the apply cricoid
pressure in the case of vomiting to prevent aspiration.
Stage III: surgical anesthesia
o Patient is unconscious and lies quietly on table.
Stage IV: medullary depression
o This stage is reached if too much anesthesia has been
administered.
o Cyanosis develops and, without prompt intervention,
death follows rapidly.
o Anesthetic agent discontinued rapidly.
o Respiratory and circulatory support provided
immediately to prevent death.
During smooth administration of an anesthetic agent, there is no
sharp division between stages I, II, and III, and there is no stage IV.
Anesthetic agents used in general anesthesia are inhaled or
administered IV.
Inhaled anesthetic agents include volatile liquid agents and
gases.
o Volatile liquid agents produce anesthesia when their
vapors are inhaled.

All are administered in combination with oxygen

and usually nitrous oxide as well.
o Gas anesthetic agents are administered by inhalation
and are always combined with oxygen.
o When anesthetic administration is discontinued, the
vapor or gas is eliminated through the lungs.
General anesthesia can also be produced by the IV
administration of various substances, such as barbituates,
benzodiazepines, nonbarbituates hypnotics, dissociative
agents, and opioid agents.
o May be administered to induce or maintain anesthesia.
o Although often used in combination with inhalation
anesthetic agents, they may be used alone.
o Advantages of IV administration:
Onset is pleasant
Duration action is brief
Patient awakens with little nausea or vomiting
(very useful in eye surgeries)
Require little equipment
Easy administration
o Used for short procedures not long
o It is not indicated for children who have small veins or
those who require intubation because of their
susceptibility to respiratory obstruction.
o May be used in combination with muscle relaxant.
o Regional Anesthesia
In regional anesthesia, an anesthetic agent is injected around
nerves so that the region supplied by these nerves is anesthetized.
The patient receiving regional anesthesia is awake and aware of his
or her surroundings unless medications are given to produce mild
sedation or to relieve anxiety.
A quiet environment should be maintained.
The diagnosis should not be stated aloud if the patient is not to
know at this time.
Epidural anesthesia:
Achieved by injecting a local anesthetic agent into the
epidural space that surrounds the dura mater of the spinal
cord.
An advantage of epidural anesthesia is the absence of
headache that can result from spinal anesthesia .
A disadvantage is the greater technical challenge of
introducing the anesthetic agent into the epidural space
rather than the subarachnoid space.
Spinal anesthesia:
An extensive conduction nerve block that is produced when a
local anesthetic agent is introduced into the subarachnoid
space at the lumbar level, usually between L4 and L5.

It produces anesthesia of the lower extremities, perineum,

and lower abdomen.
For the lumbar puncture procedure, the patient usually lies on
the side in a knee-chest position.
Sterile technique is used as a spinal puncture is made and
the medication is injected through the needle.
After injection, patient is placed on back.
A few minutes after induction of a spinal anesthetic agent,
anesthesia and paralysis affect the toes and perineum and
then gradually the legs and the abdomen.
Nausea, vomiting, and pain may occur during surgery when
spinal anesthesia is used.
o Adequate hydration and the IV administration of
appropriate medications may prevent such reactions.
Headache may be an aftereffect of spinal anesthesia.
o Maintain a quiet environment
o Keep the patient lying flat
o Keep the patient well hydrated.
o Moderate Sedation
Previously referred to as conscious sedation, is a form of anesthesia
that involves the IV administration of sedatives or analgesic
medications to reduce patient anxiety and control pain during
diagnostic or therapeutic procedures.
The goal is to depress a patients LOC to a moderate level to enable
surgical, diagnostic, or therapeutic procedures to be performed
while the patients comfort during and cooperation with the
procedure.
Patient is able to maintain a patent airway, retain protective airway
reflexes, and respond to verbal and physical stimuli.
The patient receiving moderate sedation is NEVER left alone and is
closely monitored by a physician or nurse who is knowledgeable
and skilled in detecting dysrhythmias, administering oxygen, and
performing resuscitation.
The continual assessment of the patients vital signs, LOC, and
and respiratory function is an essential component.
Moderate sedation can be administered by an anesthesiologist
anesthetist, or other specially trained and credentialed physician or
nurse.
Monitored anesthesia care:
Is moderate sedation administered by an anesthesiologist or
anesthetist who must be prepared and qualified to convert to
general anesthesia if necessary.
o Local Anesthesia
The injection of a solution containing the anesthetic agent into the
tissues at the planned incision site.

Often is combined with a local regional block by injecting around

the nerves immediately supplying the area.
Advantages of local anesthesia:
Simple, economical, and nonexplosive
Equipment needed is minimal
Postoperative recovery is brief
Undesirable effects of general anesthesia are avoided.
It is ideal for short and minor surgical procedures.
Often administered in combination with epinephrine.
Potential Intraoperative Complications:
o Malignant hyperthermia is an inherited muscle disorder chemically
induced by anesthetic agents. Identifying patients at risk is imperative
because the mortality rate is 50%.
The initial symptoms of malignant hyperthermia are related to
cardiovascular and musculoskeletal activity. Tachycardia (heart rate
greater than 150 beats per minute) is often the earliest sign.
Oliguria, hypotension, and increased temperature are later signs of
malignant hyperthermia.
o Loss of pain sense, reflexes, and ability to communicate subjects the
intraoperative patient to possible injury.
Positioning:
o The lithotomy position is used for nearly all perineal, rectal, and vaginal
surgical procedures.
o The Sims or lateral position is used for renal surgery.
o The Trendelenburg position usually is used for surgery on the lower
abdomen and pelvis.
Trendelenburg position has the highest risk for positioning injury.
o The usual position for surgery, called the dorsal recumbent position, is
flat on the back,
Random:
o It is important to review the patient's record for the following: correct
informed surgical consent, with patient's signature; completed records for
health history and physical examination; results of diagnostic studies;
and allergies (including latex).
o Tissue adhesives can cause an anaphylactic reaction, always check
patient allergies before using these.
o As the intraoperative nurse, you should be aware of maintaining your
patients privacy.
o Some major nursing diagnoses may include the following:
Anxiety related to surgical or environmental concerns
Risk of latex allergy response due to possible exposure to latex in
the OR environment
Risk for perioperative positioning injury related to positioning in the
OR
Risk for injury related to anesthesia and surgical procedure

Disturbed sensory perception related to general anesthesia or

sedation
If the patient aspirates vomit, an asthma-like attack with severe bronchial
spasms and wheezing is triggered. Pneumonitis and pulmonary edema
can subsequently develop, leading to extreme hypoxia.
The National Patient Safety Goals all pertain to the perioperative areas,
but the one with the most direct relevance to the OR is the reduction of
the risk of surgical fires.
The aging cardiovascular system increases the risk for hypervolemia
related to surgery.
To help with coping encourage the patient to use their cultural or religious
beliefs in their care.
If the patient is anxious, explain any information the patient may ask you
about.

o
o
o
o
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Postoperative

In the postoperative period, the most important assessment is airway patency.

If the patient complains of nausea or begins to vomit, turn the patient
completely to one side, this allows collected fluid to escape from the side of the
mouth.
If a patient has ambulatory surgery, instructions usually advise limited activity
for 24 to 48 hours. However, complete bed rest is usually contraindicated. They
should not drive a vehicle, so someone needs to be there to pick them up. They
should eat only as tolerated.
Older adults are at an increased risk for orthostatic hypotension secondary to
age related changes in vascular tone. The patient should sit up and then stand
for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension.
Atelectasis occurs when the postoperative patient fails to move, cough, and
breathe deeply. With good nursing care, this is an avoidable complication, but
reduced mobility greatly increases the risk.
Redness, warmth, and tenderness in the incision area should lead the nurse to
suspect a postoperative infection.
When having dressings changed, the patient needs to be informed that the
dressing change is a simple procedure with little discomfort; privacy will be
provided; and the patient is free to look at the incision or even assist in the
dressing change itself. If the patient decides to look at the incision, assurance is
given that the incision will shrink as it heals and that the redness will likely
fade. Dressing changes should not be painful, but giving pain medication prior
to the procedure is always a good preventive measure.
If the patient has an indwelling urinary catheter, hourly outputs are monitored
and rates of less than 30 mL/hr are reported.
Patients who have surgery that limits mobility are at an increased risk for
pulmonary embolism secondary to deep vein thrombosis. The use of an
external pneumatic compression stocking significantly reduces the risk by
increasing venous return to the heart and limiting blood stasis.
Hypovolemic shock, the patient has hypotension and tachycardia. The patients
skin is cold, moist, and pale. The nurse should notify the patient's physician
and anticipate orders for fluid and/or blood product replacement.
Hypertension is common in the immediate postoperative period secondary to
sympathetic nervous system stimulation from pain, hypoxia, or bladder
distention.
An increase in blood pressure and restlessness are symptoms of pain.
Healing:
o First intention wounds are wounds made aseptically with a minimum of
tissue destruction.
o Second intention is when the wound is left open and the wound is filled
with granular tissue.
o Third-intention healing or secondary suture is used for deep wounds that
either had not been sutured early or that had the suture break down and
are resutured later.

Postoperative confusion is common in the older adult patient, but it could also
indicate blood loss and the potential for hypovolemic shock; it is a critical
symptom for the nurse to identify.
The patient with a hemorrhage presents with hypotension; rapid, thready pulse;
disorientation; restlessness; oliguria; and cold, pale skin.
The PACU provides care for the patient while he or she recovers from the
effects of anesthesia. The patient must be oriented, have stable vital signs, and
show no evidence of hemorrhage or other complications when they leave the
PACU.
When a nurse finds a patient who is not breathing, the priority intervention is to
open the airway and treat a possible hypopharyngeal obstruction. To treat the
possible airway obstruction, the nurse tilts the head back and then pushes
forward on the angle of the lower jaw or performs the jaw thrust method to
open the airway.
Optimal nutritional status is important for wound healing; the patient should
eat plenty of fruits and vegetables and not reduce protein intake.
Dehiscence:
o The nurse should first place saline-soaked sterile dressings on the open
wound to prevent tissue drying and possible infection.
o Then the nurse should call the physician and take the patient's vital
signs.
o The dehiscence needs to be surgically closed, so the nurse should never
try to close it.
The primary cardiovascular complications seen in the PACU include
hypotension and shock, hemorrhage, hypertension, and dysrhythmias.
If you suspect a hemorrhage, you should quickly try to determine the cause of
hemorrhage.
If you have an elderly patient in the PACU, Special attention is given to keeping
the patient warm because elderly patients are more susceptible to
hypothermia.
A patient remains in the PACU until fully recovered from the anesthetic agent.
Indicators of recovery include stable blood pressure, adequate respiratory
function, and adequate oxygen saturation level compared with baseline.
Before discharging the patient, the nurse provides written instructions,
prescriptions and the nurse's or surgeon's telephone number.
Patients admitted to the clinical unit for postoperative care have multiple needs
and stay for a short period of time.
In the initial hours after admission to the clinical unit, adequate ventilation,
hemodynamic stability, incisional pain, surgical site integrity, nausea and
vomiting, neurologic status, and spontaneous voiding are primary concerns.
Flash pulmonary edema occurs when protein and fluid accumulate in the
alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and
symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry
readings; frothy, pink sputum; and crackles on auscultation.

If the patient is very anxious, but his mental status, level of consciousness,
speech, and orientation are intact and at baseline, then next you should assess
his oxygen levels.
Hypostatic pulmonary congestion, caused by a weakened cardiovascular
system that permits stagnation of secretions at lung bases, may develop; this
condition occurs most frequently in elderly patients who are not mobilized
effectively. The symptoms are often vague, with perhaps a slight elevation of
temperature, pulse, and respiratory rate, as well as a cough. Physical
examination reveals dullness and crackles at the base of the lungs. If the
condition progresses, then the outcome may be fatal.
To clear secretions and prevent pneumonia, the nurse encourages the patient
to turn frequently, take deep breaths, cough, and use the incentive spirometer
at least every 2 hours. These pulmonary exercises should begin as soon as the
patient arrives on the clinical unit and continue until the patient is discharged.
The two requirements for PCA are an understanding of the need to self-dose
and the physical ability to self-dose.
Dehiscence can be caused by vomiting. Vomiting can produce tension on
wounds, particularly of the torso.
Spots of drainage on a dressing are outlined with a pen, and the date and time
of the outline are recorded on the dressing so that increased drainage can be
easily seen.
While changing the dressing, the nurse has an opportunity to teach the patient
how to care for the incision and change the dressings at home. The nurse
observes for indicators of the patient's readiness to learn, such as looking at
the incision, expressing interest, or assisting in the dressing change.
Dehydration is a contributory factor to the formation of deep vein thrombi.
Wound infection may not be evident until at least postoperative day 5.
Postoperative delirium, characterized by confusion, perceptual and cognitive
deficits, altered attention levels, disturbed sleep patterns, and impaired
psychomotor skills, is a significant problem for older adults.

Fluid and Electrolytes

A specific gravity will detect if the patient has a fluid volume deficit or fluid
volume excess.
To gauge a patient's magnesium status, the nurse should check deep tendon
reflexes. If the reflex is absent, this may indicate high serum magnesium.
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular
space but not into the intracellular space, can cause hypovolemia.
Burns typically cause acidosis.
The most common cause of acute respiratory alkalosis is hyperventilation.
Extreme anxiety can lead to hyperventilation.
Acute respiratory acidosis occurs in emergency situations, such as pulmonary
edema, and is exhibited by hypoventilation and decreased PaCO2.
Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates
the wall of the vein. Infiltration is characterized by edema around the insertion
site, leakage of IV fluid from the insertion site, discomfort and coolness in the
area of infiltration, and a significant decrease in the flow rate.
Inelastic skin is a normal change of aging.
IV placement:
o Ideally, both arms and hands are carefully inspected before choosing a
specific venipuncture site that does not interfere with mobility.
o Instruct the patient to hold his arm in a dependent position to increase
blood flow.
o Never leave a tourniquet in place longer than 2 minutes.
Tetany is the most characteristic manifestation of hypocalcemia. Sensations of
tingling may occur in the tips of the fingers, around the mouth, and, less
commonly, in the feet.
The kidneys regulate the bicarbonate level in the ECF; they can regenerate
bicarbonate ions as well as reabsorb them from the renal tubular cells. In
respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete
hydrogen ions and conserve bicarbonate ions to help restore balance. The
lungs regulate and reabsorb carbonic acid to change and maintain pH.
The most common cause of metabolic alkalosis is vomiting or gastric
suctioning. These can deplete potassium and cause hypokalemia.
If a patient is not excreting enough urine, the health care provider needs to
determine whether the depressed renal function is the result of reduced renal
blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute
tubular necrosis that results in necrosis or cellular death from prolonged FVD. A
typical example of a fluid challenge involves administering 100 to 200 mL of
normal saline solution over 15 minutes. The response by a patient with FVD but
with normal renal function is increased urine output and an increase in blood
pressure.
When an elderly client wants to stop drinking fluids earlier in the day so they
don't have to get up as early.

o Limiting your fluids can create imbalances in your body that can result in
confusion. Maybe we need to adjust the timing of your fluids.
After a hip fracture a patient is thirsty and has minimal UO.
o Renin is released by the juxtaglomerular cells of the kidneys in response
to decreased renal perfusion. Angiotensin-converting enzyme converts
angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor
properties, increases arterial perfusion pressure and stimulates thirst. As
the sympathetic nervous system is stimulated, aldosterone is released in
response to an increased release of renin, which decreases urine
production.

Kidney Surgery

Respiratory

Community Acquired Pneumonia

CAP occurs either in the community setting or within the first 48 hours after
hospitalization or institutionalization.
Most common in adults 65 years and older.
Streptococcus pneumonia is the most common cause of CAP in people younger
than 60 without comorbidity and those older than 60 with comorbidity.
o It may occur as a lobar or bronchopneumonic form in patients of any age
and may follow a recent respiratory illness.
Haemophilus influenza causes a type of CAP that frequently affects older adults
and those with comorbid illnesses.
o The presentation is indistinguishable from that of other forms of bacterial
CAP and may be subacute, with cough or low grade fever for weeks
before diagnosis.
Mycoplasma pneumonia is spread by infected respiratory droplets through
person-to-person contact.
o Can be tested for mycoplasma antibodies.
o Spreads throughout the entire respiratory tract, including bronchioles,
and has the characteristics of a bronchopneumonia.
o Earache and bullous myringitis are common.
o Impaired ventilation and diffusion may occur.
Viruses are the most common cause of pneumonia in infants and children but
are relatively uncommon causes of CAP in adults.
In immunocompromised adults, cytomegalovirus is the most common viral
pathogen, followed by herpes simplex virus, adenovirus, and respiratory
syncytial virus.
With pneumonia, the inflammatory process extends into the alveolar area,
resulting in edema and exudation.
The clinical s/s are often difficult to distinguish from those of a bacterial
pneumonia.
Risk Factors for Pneumonia:
o Cancer
o Cigarette smoking
o COPD
o Neutropenic patients
o Prolonged immobility and shallow breathing pattern
o Depressed cough reflex
o Aspiration of foreign material into the lungs during a period of
unconsciousness
o Abnormal swallowing mechanisms
o NPO status
o Placement of NG, OG, or ET tube
o Supine positioning
o Antibiotic therapy
o Alcohol intoxication

o General anesthetic, sedative, or opioid

o Advanced age
o Respiratory therapy with improperly cleaned equipment
o Transmission of organisms from HCP
Clinical Manifestations
o Streptococcal pneumonia
Sudden onset of chills
Rapidly rising fever
Pleuritic chest pain that is aggravated by deep breathing and
coughing
Tachypnea
Signs of respiratory distress (SOB, accessory muscles)
o Relative bradycardia may suggest viral infections (Mycoplasma or
Legionella)
o Some exhibit signs of Upper resp. infection and the onset is gradual and
nonspecific.
Predominant symptoms:
HA
Low-grade fever
Pleuritic chest pain
Myalgia
Rash
Pharyngitis
o Orthopnea
o Appetite is poor
o Diaphoretic
o Tires easily
o Rusty, blood tinged sputum
o Severe pneumonia:
Cheeks are flushed
Lips and nail beds demonstrate central cyanosis
o Immunosuppressed patients:
Fever
Crackles
Consolidation of lung tissue
Increased tactile fremitus (vocal vibration on palpitation)
Percussion dullness
Bronchial breath sounds
Egophony (when auscultated E becomes A)
Whispered pectoriloquy (whispered sounds easily auscultated
through chest wall)
o COPD
Purulent sputum or slight changes in respiratory symptoms may be
the only sign.
Assessment and Diagnostic Findings:

Was there a recent respiratory infection?

Physical examination
Chest X-ray
Blood culture
Sputum examination
Rinse mouth with water
Breathe deeply several times
Cough deeply
Expectorate the raised sputum into a sterile container
o Bronchoscopy
Prevention
o Pneumococcal vaccination reduces the incidence of pneumonia.
o A one-time vaccination of pneumococcal polysaccharide vaccine is
recommended for all patients 65 years and older and those with chronic
disease.
o A second PPSV revaccination dose is recommended for all adults 65 years
and older who were previously vaccinated with one dose if 5 years or
more have elapsed since the previous dose.
o For those who were first vaccinated at 65 years or older, only one dose is
required regardless of medical condition.
o
o
o
o
o