Running Head: THERAPEUTIC NURSING INTERVENTION

Therapeutic Nursing Intervention

Erin Keim

Old Dominion University

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Introduction

In the Post-Anesthesia Care Unit (PACU), the biggest issue in patient care is pain

management. Any patient that has a procedure or surgery done has a potential for acute pain.

Being aggressive with pain treatment, as well as safe with the patients respiratory status,

cardiovascular status and mental status, is key. Effective pain management can increase the

success of recovery. Ineffective pain management can lead to prolonged hospital stay,

immobility which can lead to gastrointestinal complications, pneumonia or atelectasis, increased

cost to both patient and facility for repeat visits for pain control, and overall, longer length of

recovery. According to NCBI, The under-treatment of postoperative pain has been recognized

to delay patient recovery and discharge from hospital. Despite recognition of the importance of

effective pain control, up to 70% of patients still complain of moderate to severe pain

postoperatively. (NCBI, n.d.)

I work in the PACU within an urban hospital in Richmond, VA. There are typically 6-9

nurses working throughout the day. A typical day consists of 30-50 cases, all coming to a PACU

consisting of 16 bays. Each nurse working can have a maximum of two patients at a time.

Exceptions to that ratio would be any case consisting of a pediatric patient, a critical patient that

would be going to the Intensive Care Unit (ICU), or a patient on contact precautions. The PACU

generally runs from 8:00 am to 9:30 pm. Any cases that come out of the Operating Room (OR)

after 9:30, the call nurse is called in, as well as a nurse from Same Day Surgery. Any cases

occurring on the weekends, the call team is called in as well. We have three techs that work on

our unit, usually 2-3 working during the day. They usually help the nurse with transporting

patients, emptying Foley catheters and drains, checking blood sugars and helping with many

different small tasks.

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Clinical Problem

Pain management is one of the many focuses of a PACU nurse, with others being:

respiratory and cardiovascular statuses, nausea, as well as many other complications arising from

anesthesia or the surgery itself. Surgeons try to prepare each patient in the pre-operative phase

as to the expectations after surgery and going into recovery. Post-op pain and nausea are

discussed and how they will be managed. Those who are on chronic pain medications are

usually warned of the difficulty treating post-op pain.

Types of Pain and the Evaluation of Pain

Most of the post-op patients that we see experience acute pain directly related to the

surgery itself, whether it be incisional pain, gas pain from the CO2 inflation in their abdomens

for the surgery, cramping pain, or the feeling of pressure in that surgical region. Every patient

experiences pain differently. PACU nurses typically use a pain scale 0-10, where 0 is no pain at

all and 10 is the worst pain imaginable. Pain is subjective- it is whatever the patient says it is. I

have seen some patients carry on conversations, asking about when they can eat, and even

laughing. When you ask what number their pain is at, they state a 10. I usually explain the pain

scale in a little more detail to make sure they understand it correctly. Some people will grimace

and moan, but state their pain is a 2/10. Again, I usually explain the pain scale a little more.

Each patient has an anesthesia sign out sheet that has a patient label on it as well as a pain

scale using smiley faces. It is a great resource for those who do not understand the numerical

pain scale. I will usually ask the patient to point to the face that best represents them and their

pain.

Every time a medication was given or an intervention completed, the nurse must

reevaluate the patients pain. If the pain is not at a tolerable level, usually a 3/10, the nurse must
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continue to treat the pain with medication and interventions. The patient cannot be discharged

from the PACU with intolerable pain and/or nausea.

Treatment of Pain

It is up to the nurse to determine which medication is best for each patient. It is critical

that each nurse is aware of the patients medication allergies, if they have chronic pain that they

take medications for, and if they are prone to nausea with pain medications. Patients have an

anesthesiologist assigned to them, even though a Certified Registered Nurse Anesthetist (CRNA)

was the one who put them to sleep for the case. The anesthesiologist looks through the patients

chart and reviews allergies and adverse reactions to medications before ordering medications to

be used in the post-operative phase. They will typically order intravenous medications such as

Dilaudid, Fentanyl or Morphine, as well as oral medications such as Hydrocodone or

Roxicodone. There are usually two options of antiemetics given: Zofran and Phenergen. Some

doctors will also order anti-inflammatory medications like Toradol, anti-itching medications like

Benadryl, and Demerol for chills. With each IV narcotic, such as Dilaudid, the doctor will order

different dosages based on the severity of the patients pain. They typically order 0.25 mg IV

Dilaudid for mild pain, 0.5 mg IV Dilaudid for moderate pain, and 1 mg IV Dilaudid for severe

pain. Nurses can give such medications every five minutes for a maximum dose of 4 mg for

Dilaudid, 20 mg for Morphine, and 200 mg for Fentanyl. It is the responsibility of the nurse to

effectively and safely treat the patients pain in a timely manner, but to also determine which

medication would be most beneficial for the patient. For example, I would not give a patient

who just arrived to the PACU an oral pain medication. I would treat their pain with intravenous

medications until the patient was more awake, not experiencing nausea, and pain was more

tolerable. It is important to understand the patient has not had anything to eat or drink since the
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day or night before. They are likely to become nauseated if oral medications are used

prematurely.

It is also vital for the nurse to know how much of each medication was given by the

CRNA. For instance, if I had a female patient who underwent a tubal ligation, I would want to

know if the patient has had Toradol in the operating room. If not, I would verify with the

surgeon that the patient could be given Toradol (also checking labs for kidney function).

Toradol is a wonderful medication for surgeries like tubal ligations, joint replacements and any

other gynecology surgery. It works well for cramping pain and aching pain from joint surgery.

It is a great option to give along with narcotics to treat pain. The CRNAs are usually great about

letting the PACU nurse know if the patient is more sensitive to pain medication or not.

Current Practice

Pre-operative Phase

Those patients who are on chronic pain medications such as narcotics, gabapentin,

muscle relaxers, antidepressants, and such are usually asked to take their medications the

morning of their surgery. For those who are not on those medications, there is not anything they

take before surgery to control pain post-operatively.

Those patients who are on medications such as Methadone or Suboxone need more pain

management planning that is usually correlated between their pain management doctor, the

surgeon, and the anesthesiologist. Patients on these medications require a different approach to

pain management and will often require huge amounts of medications to control pain as well as

multimodal approach.

At the hospital I work at, some of the gynecology surgeons who perform hysterectomies

will allow the patient to go home as outpatient rather than staying one night in the hospital.
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These patients have certain criteria that have to be met. First, the surgeon must approve the

discharge according to how the surgery went and they need to discuss this as an option before the

day of surgery. Secondly, the patient must meet the age criteria of being 65 years old or

younger. In the pre-operative phase, the patient is given Gabapentin and Tylenol 1,000 mg.

During the surgery, they are treated with antiemetics and different pain medications such as

Toradol as well as narcotics.

Perioperative Phase

Depending on the type of surgery, the amount of blood loss, kidney/liver function,

dictates which medications the CRNA or anesthesiologist will use during the surgery. Some

surgeries do not allow the use of Toradol, such as those with large amounts of blood loss.

Typically, Versed and Fentanyl are given as well as a longer-acting medication like Dilaudid.

The CRNA usually has the patient on some infusion like ketamine or remifentanyl as well.

Some medications are given right after extubation or towards the end of the case.

Many surgeons will use regional blocks or use local anesthetics to help relieve pain.

Most knee and hip replacements will have spinal blocks. This delays pain for a while and can

help aid in the recovery process, getting through the most acute phase of post-surgery.

Post-operative Phase

Large, open abdominal surgeries such as Whipple procedures for pancreatic cancer as

well as extensive exploratory laparotomies will come out of surgery with epidurals and will have

Patient-Controlled Epidural Analgesia pumps (PCEA). The anesthesiologist typically orders a

basal or continuous dose as well as a patient-controlled (PCEA) dose. These doses may need

adjusting based on patients mental/neurological status and hemodynamics. Other surgeons may

order Patient-Controlled Analgesia (PCA) pumps for those patients who may require additional
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medications such as some hysterectomies and womens surgeries. The goal of the PCA pumps is

to get the patient through the acute phase of pain right after surgery. PCA pumps are typically

discontinued the next day or shortly after.

In the PACU, patients are given different types of pain medications including opioids

such as Morphine, Dilaudid, or Fentanyl, anti-inflammatory medications such as Toradol, and

oral pain medications such as Roxicodone or Hydrocodone. We usually do not see Percocet

given. For those patients who have had neck or back surgeries, medications such as Flexeril or

Valium are ordered to help control back spasms. Male patients who have had prostate surgery

and have catheters usually experience bladder spasms. Bella Donna and Opium (B & O)

suppositories are used due to their effectiveness of treating pain next to the prostate.

Nursing Interventions

Intervention #1: Preemptive Analgesia

According to Up-to-Date, there are many medications that could be given before the first

incision is even made. The use of anti-inflammatory medications such as Tylenol, diclofenac,

and ketorolac could be used to decrease the amount of opioids used post-operatively.

Gabapentin, anti-depressants and even Magnesium could be used.

According to this article, Magnesium is an antagonist of the NMDA receptor. IV

magnesium has been found to be an effective adjuvant for reduction of opioid requirement. It

may be useful in opioid-tolerant patients or when there are medical concerns related to opioid

dose. (Up-to-Date, 2017) There is still much research to be done on the effects of Magnesium

being able to decrease post-operative pain, but so far, the research is in favor of its use with those

who are tolerant to opioids. Magnesium works like ketamine. Albrecht et al published a large

meta-analysis of 25 trials with 1,461 subjects, which evaluated the effect of perioperative
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intravenous magnesium, compared with placebo, on postoperative pain. Intravenous magnesium

infused 15 minutes before anesthesia induction, intraoperatively, or postoperatively was found to

reduce the 24-hour cumulative postoperative morphine consumption by 24.4%. (Castro, 2017)

The 0-10 pain scale is used throughout surgery and recovery with each patient.

According to Ms. Rowland, We need to educate our patients about what the NRS is and what

their pain score describes to us. We can then define our actions based on the rating that they

provide. Ideally, we should discuss the NRS with the patient during the preoperative period. This

allows ample opportunity to explain nursing assessment techniques while setting an acceptable

pain goal for the patient. By providing education about the assessment and options to relieve

pain, we create a more empowered patient. (Rowland, 2015) By discussing this pain scale in

detail before surgery, the patients might be able to more accurately rate their pain.

Intervention #2: Perioperative Analgesia

During the perioperative phase, a multi-modal approach could be more effective if

everyone would do it. Some CRNAs do not give Toradol, even when the surgeon, surgery, and

lab work suggests the use of it. Some are used to using only certain medications and refuse to

change anything. Other CRNAs do an excellent job putting the patient on ketamine or

remifentanyl drips, medicating with anti-inflammatory medications like Toradol, using anti-

emetics and Benadryl as an anti-emetic. Typically, those patients do better in the PACU and

require less opioids than those who are not medicated multi-modally.

Intervention #3: Post-operative Analgesia

The use of non-pharmacological interventions can be helpful in treating pain. The use of

heat can be beneficial for those with cramping pain from gynecology surgeries. Ice can be

beneficial for those who underwent joint replacement. Some patients complain of pain in
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shoulders and hips after surgery due to positioning for their surgery. Ice can be very helpful to

these patients. The patient will feel the cold within 1 to 3 minutes after the application, then

feel a burning and pain sensation within 2 to 7 minutes and the pain and lethargy will decrease

within 5 to 12 minutes, a breaking occurs for the pain-spasm vicious-circle and transmission of

the nerve fibers in the area will decrease. An increase will occur for the metabolism within 12 to

15 minutes after cold treatment and a reflex vasodilatation occurs on the deep tissue. Thus, the

edema and the pain will reduce and the tissue will be nourished with vasodilatation that will

develop 15 minutes later. (Demir, 2012)

Repositioning is necessary. Patients who underwent abdominal surgeries may not be

comfortable laying back or sitting upright. Cervical fusion patients complain of pain between

their shoulder blades, so putting a pillow behind their shoulders can help relieve the pain.

Conclusion

Pain management and treatment is an essential aspect of PACU nursing. It must be

approached using varying medications and non-pharmacological interventions in pre-op, periop,

and post-op. It is up to each department to prepare the patient with the ultimate goal being a

decrease in opioid requirements and a decrease in pain after surgery. If each department follows

the suggested interventions on top of what is currently being done, there will be an increase in

patient satisfaction, decrease in hospital length stays, decreased chronic opioid use, and less

anxiety and stress for the patient. Poor pain control has significant physiological consequences

that can ultimately result in impaired recovery, decreased function, and reduced quality of life.

(Cooney, 2016)
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Resources

Castro, J. (2017). Intravenous Magnesium in the Management of Postoperative Pain. Journal of

Perianesthesia Nursing. 32 (1). 72-76. Retrieved June 30, 2017, from

http://www.jopan.org/articles/S1089-9472(16)30418-X/fulltext

Cooney, M.F. (2016). Postoperative Pain Management: Clinical Practice Guidelines. Journal of

Perianesthesia Nursing. 31(5). 445-451. Retrieved June 30, 2017, from

http://www.jopan.org/article/S1089-9472(16)30282-9/pdf

Demir, Y. (2012, January 18). Non-Pharmacological Therapies in Pain Management. Retrieved

June 29, 2017, from http://cdn.intechweb.org/pdfs/26152.pdf

Mariano, E.R. (2017, May 19). Management of acute perioperative pain. Retrieved June 29,

2017, from https://www.uptodate.com/contents/management-of-acute-perioperative-

pain?source=search_result&search=Preemptive%2Banalgesia&selectedTitle=1~12

Pyati, S., & Gan. T.J. (n.d.). Perioperative pain management. Retrieved June 29, 2017, from

https://www.ncbi.nlm.nih.gov/pubmed/17338592

Rowland, E.B. (2015). Improving Post-op Pain Management. Nursing Made Incredibly Easy, 13,

7-9. Retrieved June 30. 2017.