Pain in the Surgical Client
TERMS
acute pain
anesthesia
anxiety
chronic pain
comorbidities
complementary therapies
conscious sedation
deep vein thrombosis
fluid accumulation
general anesthesia
hematoma
ileus
incisional pain
inflammation
informed consent
neuropathic
nonsteroidal anti-inflammatory (NSAID) therapy
patient-controlled analgesia
preoperative pain
regional anesthesia
somatic
surgery
swelling
triage
visceral
QUICK LOOK AT THE CHAPTER AHEAD
Despite the multiple risks of surgery, the clients who are about to have surgery primarily fear pain: “Will it hurt? How will I deal with it? How can it be treated or prevented?” Pain is a common phenomenon in instances of surgical intervention and trauma. Although acute pain is a primary concern for surgical patients, two types of chronic pain are important to consider in the client who has had surgery: (1) pain as a result of the surgery, trauma, or illness, and (2) pain unrelated to the surgery that must be managed during the immediate postoperative period. The goals concerning surgical pain include management of pain prior to surgery, prevention of intraoperative pain or sensation, and prevention or relief of postoperative pain during recovery and rehabilitation. A wide variety of alternatives for pain management for the client with surgical pain exists, from medication of multiple types and dosage routes to traditional and nontraditional alternative therapies. Medications are very often prescribed for the surgical client. Comprehensive assessment and planning are necessary to manage a client’s postoperative pain.
Opportunities for preoperative assessment and preparation for pain management are rare with increased movement of clients into and out of facilities pre- and postoperatively. Thus, the healthcare team faces two new challenges: timely and appropriate client education regarding pain management, and telephone triage to manage pain issues outside of the inpatient facility.
CASE STUDY
Mrs. R. is a 47-year-old woman who was admitted to an emergency department while on vacation in North Carolina, complaining of severe epigastric pain radiating to the right side, with nausea and vomiting. She reported consuming onion soup au gratin, quiche, and ice cream for dinner on the evening the pain started. Following blood work and testing, she was determined to be suffering from cholylithiasis. Her pain was controlled with meperidine, and she returned home to New York for an elective laparoscopic cholecystectomy.
On the morning of her admission, she is quite anxious about her surgery. After suffering severe pain with the onset of her illness, she fears that she will have severe, uncontrolled pain after the surgery. With this in mind, the plan of care includes admitting her to an inpatient unit for the night following her surgery, and using a patient-controlled analgesia (PCA) pump after surgery. The PCA routine is reviewed, and the admitting nurse reassures Mrs. R. that other alternatives are certainly available if PCA does not seem to be effective enough.
PAIN AND THE CLIENT HAVING SURGERYPain is an almost universal phenomenon in instances of surgical intervention and trauma. Surgery is an invasive intervention with the intention of treating, controlling, curing, or stabilizing a medical problem. Surgery has many inherent risks, as attested to by the process of informed consent for both surgery and anesthesia. Despite these risks, clients who are about to have surgery primarily fear pain: Will it hurt? How will I (the client) deal with it? How can it be treated or prevented? Surgical intervention is an alternative for most client populations, from the very young to the very old. The invasive intervention of surgery is even a choice for clients in special populations who require specific and different assessments and interventions for the resulting pain. It is a primary reason for admission to an acute care facility.
Invasive diagnostic procedures and surgery all carry the threat of pain before, during, and after the procedure. It is the responsibility of the healthcare team to assess, prevent, and relieve that pain.Surgery can be emergent in nature, unexpected, or planned. In these cases, pain management is purely postoperative. In other cases,
the operative procedure is elective, allowing for a plan of care to prevent or manage pain, as well as client education in utilizing pain management techniques. Although prior preparation would seem to be the preferred alternative, it is a responsibility of the healthcare team to attempt to manage pain in either alternative. Surgical intervention is a choice of treatment for countless conditions. It is used to repair traumatic damage in the case of accident or injury, treat congenital anomalies, remove foreign bodies or disease, reduce inflammation as a pain-relief alternative, improve function, change appearance, facilitate childbirth, or as an exploratory or diagnostic procedure. An operative procedure may be curative, restorative, controlling, or palliative. Considering the reasons for surgery, as well as prior preparation and the personal meaning of the procedure to the client, are all-important in planning for pain management.
the operative procedure is elective, allowing for a plan of care to prevent or manage pain, as well as client education in utilizing pain management techniques. Although prior preparation would seem to be the preferred alternative, it is a responsibility of the healthcare team to attempt to manage pain in either alternative. Surgical intervention is a choice of treatment for countless conditions. It is used to repair traumatic damage in the case of accident or injury, treat congenital anomalies, remove foreign bodies or disease, reduce inflammation as a pain-relief alternative, improve function, change appearance, facilitate childbirth, or as an exploratory or diagnostic procedure. An operative procedure may be curative, restorative, controlling, or palliative. Considering the reasons for surgery, as well as prior preparation and the personal meaning of the procedure to the client, are all-important in planning for pain management.
Optimal management of surgical pain addresses preoperative pain, intraoperative pain, postoperative pain, and acute and chronic pain during rehabilitation.
Lack of prior client preparation for postoperative pain management should not decrease the effectiveness of pain relief.Preoperative Preparation
Historically, surgery was done in a hospital environment. The client was admitted to the facility, sometimes days before the procedure. The preoperative time was used for assessment, physical preparation, and client education. Recently, changes in technology and reimbursement issues have resulted in changes in where surgery is performed, as well as opportunities for preoperative assessment or client preparation. Now, surgical procedures may be performed in acute care hospitals or inpatient or outpatient units, in freestanding surgicenters, in physicians’ or dentists’ offices, in clinics, and in birthing centers. Minor surgical procedures previously done in the hospital, such as inserting central venous access lines, may now be done in a long-term care facility or even in the client’s own home. When elective surgery is performed, even as an inpatient, clients are rarely admitted to the facility days prior to the procedure. Commonly, admission to the surgical facility takes place on the day of surgery through
a day-surgery unit. Postoperatively, the client may recover on the day-surgery unit and go home that afternoon or evening or be admitted to an inpatient unit. In either case, opportunities for preoperative assessment and preparation for pain management are rare. With increased mobility of clients into and out of facilities pre- and postoperatively, the healthcare team faces two new challenges: timely and appropriate client education regarding pain management, and telephone triage to manage pain issues outside of the inpatient facility. Client education will be discussed later in this chapter.
a day-surgery unit. Postoperatively, the client may recover on the day-surgery unit and go home that afternoon or evening or be admitted to an inpatient unit. In either case, opportunities for preoperative assessment and preparation for pain management are rare. With increased mobility of clients into and out of facilities pre- and postoperatively, the healthcare team faces two new challenges: timely and appropriate client education regarding pain management, and telephone triage to manage pain issues outside of the inpatient facility. Client education will be discussed later in this chapter.
Comprehensive assessment and planning are necessary to manage a client’s postoperative pain.
TELEPHONE TRIAGETelephone triage is a method of assessment by phone used to evaluate the condition of the client, as well as provide appropriate interventions for presented client problems. It is a therapeutic exchange that requires the participation of a trained professional who can legally engage in assessment and treatment activities. It should not be left to an office secretary or answering service.
Triage is a formal procedure, with assessment parameters arranged to identify emergent or life-threatening symptoms and appropriate interventions, which may include activation of emergency services. Assessment criteria are also used to evaluate for less threatening problems. A triage manual with written protocols for assessment and interventions should exist for the practice. Complete documentation of each triage contact, including assessment, interventions suggested, client response, and resources used, is essential. A system for follow-up evaluation is also a good idea, and it enhances client satisfaction.
Triage for the management of postoperative pain and potential complications should be available 24 hours a day, and it is imperative that the client and family are aware of how to seek out assistance from the triage service.
Variations in surgical settings as well as rapid discharge after surgery require resources for evaluation and management of postoperative pain.
ACUTE PAIN RELATED TO SURGICAL PROCEDURESAcute pain is pain that lasts for a relatively short duration, usually no more than 3 to 6 months. Clients rarely anticipate that operative pain will last that long. The goals concerning surgical pain include management of pain prior to surgery, prevention of intraoperative pain or sensation, and prevention or relief of postoperative pain during recovery and rehabilitation.
Preoperative pain is a result of disease or injury. Postoperative pain arises from a wide variety of sources and causes. It is important to evaluate and treat the specific types of pain during the pain experience.
Incisional Pain
Because surgery is invasive, most clients will complain of incisional pain, occurring secondary to impaired skin integrity from a scalpel or trocar entry into the body. Incisional pain can be quite severe, because it is cutaneous or peripheral pain. The skin and subcutaneous tissues have a rich supply of nociceptors, which readily transmit the pain message to the central nervous system. It is frequently described as cutting, searing, burning, or sharp pain. It can be more severe in certain areas of the body. For example, incisional pain is often quite severe in the axillary area following an axillary node dissection. Incisional pain can also occur in response to stretching or pulling of skin tissues during surgery and irritation from surgical prep solutions such as povidone iodine (Betadine®) or tape placed against the skin after surgery. Anxiety can also impact incisional pain, such as when a client manifests fear of disfigurement. The incision is usually covered with dressings immediately after surgery, and clients are often left to imagine what it looks like. With a fear of disfigurement, the incision and resultant scar can become a critical source of anxiety, reinforcing or exacerbating perception of incisional pain. Allowing clients to view the incision, as well as careful client teaching regarding the mode of closure (stitches,
staples, Steristrips), may help reduce anxiety in these situations, leading to improved pain control.
staples, Steristrips), may help reduce anxiety in these situations, leading to improved pain control.
Could anxiety be exacerbating the client’s incisional pain, or are there signs and symptoms of complications of incisional healing?
Complications in incisional healing can be indicated by redness, swelling, hematoma or drainage at the incision, fever, changes in other vital signs, or increased pain.Surgical Pain
Somatic and visceral types of pain are commonly associated with surgical intervention. They are a result of surgical manipulation or removal of target organs for treatment purposes, as well as pressure from manipulation of surrounding tissues. These types of pain may also be related to swelling, fluid accumulation, or hematoma formation around the surgical area. Somatic pain arises in muscles, bone joints, ligaments, or fascia. It is structural pain and may occur at rest or with movement. Visceral pain is organ pain. It arises in the abdominal, pelvic, thoracic, or cranial cavities. Both are the result of stimulation of deeper nociceptors. Visceral pain can be diffuse and poorly localized; somatic pain is more specifically localized. Both may be constant or intermittent in nature. Client descriptions vary from sharp and severe to dull and achy. This type of pain is rarely described as burning or searing. It is the “expected” type of pain experienced after surgery or childbirth. Successful relief measures include a variety of pharmacological and nonpharmacological alternatives. Anxiety can also be a significant component in this type of pain, resulting in increased muscular tension with an accompanying increase in levels of pain.
Neuropathic pain is another type of pain frequently associated with surgery. It occurs because of surgical disruption or destruction of nerve fibers, either superficially on incision or deeper within the body. It can also be related to pressure or inflammation as irritants to the nerves in the surgical area. A client’s description of neuropathic pain is usually characteristic—there is a hot, burning, or searing quality. Neuropathic pain is frequently resistant to common interventions for postsurgical pain and requires specific interventions.
Relief from neuropathic pain may result from medications traditionally used to prevent seizures.Pain Unrelated to the Surgical Procedure
Many clients will complain about pain or aches that seem unrelated to the surgical procedure. Some common complaints include a sore throat, lower back pain, and limb or joint pain. Although it is important to assess each
client who offers these complaints individually for signs of infection or injury, quite often these symptoms are related to the process of surgery. A sore throat may be related to intubation during anesthesia. A client undergoing a procedure including general anesthesia will often have an endotracheal tube placed to facilitate the delivery of anesthetic gases and oxygen, to maintain an open airway, and to protect from aspiration. The tube is usually placed after the client has entered an anesthetic sleep, and unless intubation and ventilation are required after the surgery, the tube is removed in the operating room or post-anesthesia care unit (PACU) before the client is aware of it. The irritation of the tube against the back of the pharynx may leave the client with a sore throat.
client who offers these complaints individually for signs of infection or injury, quite often these symptoms are related to the process of surgery. A sore throat may be related to intubation during anesthesia. A client undergoing a procedure including general anesthesia will often have an endotracheal tube placed to facilitate the delivery of anesthetic gases and oxygen, to maintain an open airway, and to protect from aspiration. The tube is usually placed after the client has entered an anesthetic sleep, and unless intubation and ventilation are required after the surgery, the tube is removed in the operating room or post-anesthesia care unit (PACU) before the client is aware of it. The irritation of the tube against the back of the pharynx may leave the client with a sore throat.
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