Module 1: Pain and Surgey

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

PAIN PERCEPTION

• the conscious experience of discomfort.

• Children and elderly perceived pain differently than Adults

• Infants (1-2 days old) are less sensitive to pain. A full behavioral response to pain is apparent at 3-12 months of age

Pain threshold

the level at which someone experiences pain. 

PAIN TOLERANCE

• the maximum intensity or duration of pain that a person is willing to endure once the threshold has been reached.

• varies greatly among people and in the same person over time;

• a decrease in pain tolerance is evident in the ELDERLY

• WOMEN appear to be more tolerant to pain than MEN

Components of Pain

• stimuli

• perception

• response

• intensity

• threshold

• tolerance

Nociceptive Pain

Pain caused by the activation of pain receptors in response to tissue injury or damage in either the surface or deep tissues of the body. .

somatic pain

Pain originating from skin, muscles, and joints, often described as sharp or aching.

viscera pain

Pain that arises from internal organs, often described as deep, squeezing, or dull.

neuropathic pain

Pain caused by damage or disease affecting the nervous system, often characterized by burning, tingling, or shooting sensations.

psychogenic pain

Pain influenced by psychological factors, often without a clear physical cause.

Acute Pain

usually of short duration (less than 6 months) and often described in sensory term such as sharp, stabbing and shooting and accompanied by observable physical responses.

• Recent onset

• Symptomatic of primary injury or disease

• Specific and localized

• Severity is associated with acuity of the injury or disease process

• Responds favorable to drug therapy and requires gradual decrease in drug therapy.

• Diminishes with healing

• Suffering decreases as pain decreases.

Chronic Pain

• Remote onset

• Uncharacteristic of primary injury or disease

• Nonspecific and generalized

• Severity is out of proportion to the stage of the injury or disease

• Responds poorly to drug therapy

• Requires increase in drug therapy

• Persists beyond healing stage

• Suffering intensifies

Intermittent Pain

produces a physiologic response similar to acute pain.

Persistent Pain

allows for adaptation (functions of the body are normal but the pain is not relieved)

Referred Pain

used to describe discomfort that is perceived in a general area of the body, but not in the exact site where an organ is anatomically located.

Myofascial Pain

trigger points, small hyperirritable areas within a m. in which n. impulses bombard CNS & are expressed at referred pain.

Sclerotomic & Dermatomic Pain

deep pain; may originate from sclerotomic, myotomic, or dermatomic nerve irritation/injury.

INTENSITY THEORY

State that pain is the result of excessive stimulation of sensory receptors.

PATTERN THEORY

Describes that painful and non-painful sensation s are transmitted by nonspecific receptors through a common pathway to higher centers of the brain.

SPECIFICITY THEORY

Describe four types of cutaneous sensation: touch, warmth, cold and pain. It focuses on the direct relationship between the pain stimulus and perception but does not account for adaptation to pain and the psychosocial factors that modulate the stimulus.

GATE CONTROL THEORY

• Nerve fibers carry touch and pain impulses from receptors on the skin to the spinal cord

• Nerve cells in the SG of the spinal cord receive these touch and pain impulses

• Impulses then proceed through transmission cells to the brain

• Fibers from the brain send inhibiting information to the Substantia Gelatinosa (SG) in dorsal horn of spinal cord w/c serves as a gate for control of pain

• Gate - located in the dorsal horn of the spinal cord

• Smaller, slower n. carry pain impulses

• Larger, faster n. fibers carry other sensations

• Impulses from faster fibers arriving @ gate 1st inhibit pain impulses (acupuncture/pressure, cold, heat, chem. skin irritation

Provocation

How the injury occurred & what activities ¯ ­ the pain

Quality

characteristics of pain --> Aching (impingement), Burning (nerve irritation), Sharp (acute injury), Radiating within dermatome (pressure on nerve)

Referral/Radiation

• site distant to damaged tissue that does not follow the course of a peripheral n.

• follows peripheral n.; diffuse

Severity

How bad is it? Pain scale

Timing

When does it occur? p.m., a.m., before, during, after activity, all the time.

McGill Melzack Pain Questionnaire

a multidimensional assessment tool composed of 20 words descriptors grouped into 4 namely:

• Simple Descriptive Pain Intensity Scale

Simple Descriptive Pain Intensity Scale

from No pain to Worst possible pain scale

Pain Management

refers to the techniques used to prevent, reduce or relieve pain.

Adjuvant Drug Therapy

are defined as drugs that are on the market for indications other than pain but may be analgesic in selected circumstances. They include a very large number of drugs in numerous drug classes

• antidepressant

• anticonvulsant

• GABA agonist

• N-methyl-D-aspartate

• Corticosteroid

Non opioid Analgesics

    Includes acetaminophen or paracetamol, dipyrone and nonsteroidal anti-inflammatory drugs or NSAIDs). The NSAIDs are nonspecific analgesics and can potentially be used for any type of acute or chronic pain.

Because they are both analgesic and anti-inflammatory, NSAIDs are particularly useful for pain related to joint problems and other musculoskeletal disorders.

• salicylates

• proprionic acids

• acetic acids

• oxicam

• napthlyalkanones

• fenamates

• pyrazoles

Opioid Analgesics

This includes all drugs that interact with _____ receptors in the nervous system. These receptors are the sites of action for the endorphins, compounds that already exist in the body and are chemically related to the opioid drugs that are prescribed for pain.

Transcutaneous Electrical Stimulation

The device is an electrical unit that delivers different frequencies and intensities of stimulation to the skin through electrodes.

Acupressure

is a method of sending a signal to the body via needles or other means, to turn on its own self-healing or regulatory mechanisms.

Percutaneous Electrical Nerve Stimulation (PENS)

combines electro-acupuncture and TENS which uses acupuncture like needle probes as electrodes placed at dermatomal levels corresponding to local pathology.

Surgery

• branch of medicine concerned with disease or conditions requiring or amenable to operative or manual procedures.(Science)

• comprises perioperative patient care encompassing such activities as preoperative preparation, intra operative judgment & management, and post-operative care of patients. (Art)

Objectives of Surgery

1. Correction of deformity and defects;

2. Repair of injuries;

3. Alter form or structure;

4. Diagnosis & Cure of disease process;

5. Relief of suffering;

6. Prolongation of life.

Operating Room / Operating Theatre

room in a health care facility in which patients are prepared for surgery, undergo surgical procedures and recover from anesthetic procedures required for surgery.

Perioperative

is a term used to describe the entire span of surgery, including before and after the actual operation.

Perioperative nursing

includes activities performed by the registered nurse during the pre operative, intra operative, and post-operative phases of patient’s care.

OR nurse

duly licensed registered nurse legally responsible for the nature and quality of the nursing care patients.

Surgical Conscience

awareness which develops from a knowledge based on the importance of strict adherence to principles of aseptic and sterile techniques.

Asepsis

freedom from infection or absence of microorganism.

Aseptic Technique

– methods by which contamination of microorganisms is prevented.

Disinfection

- process of destroying all pathogenic microorganisms except spore bearing ones.

Sterilization

- process of killing all micro-organisms including spores.

Surgical Intervention

- therapeutic process rendered to restore or maintain health (i.e. the ability to function).

Surgical Procedure

- invasive incision into the body tissues or a minimally invasive entrance into a body cavity for either therapeutic or diagnostic purpose during which protective reflexes or self-care abilities are potentially compromised.

Antiseptic

- substance which combat sepsis and cause bacteriostasis.

Anesthesia

- insensibility to pain and trauma with or without loss of consciousness.

Informed consent

• is a legal document that provides evidence of patient’s agreement to allow a procedure to be performed on him/her

• is legally regarded as VALID for a period of about 6 months or for as long as the patient consents to the same procedure. Institutional policy may vary.

Preoperative phase

begins with the decision to perform surgery and continues until the client reaches the operating area.

Intraoperative phase

• begins with the placement of patient on the operating table, including the entire surgical procedure and extends until transfer of the client to the recovery room. The implementation component of the nursing process is performed here.

Postoperative phase

begins with admission to the RR (recovery room) / PACU (Post Anesthesia Care Unit) and continues until the client receives a follow – up evaluation at home or is discharged to a rehabilitation unit. Evaluation component of the nursing process is completed in this phase.

Unrestricted / Unsterile Area

• this area is isolated by doors from the main hospital corridor or elevators and from other areas of the OR suite.

• serves as an OUTSIDE-to-INSIDE access area, i.e. vestibular/exchange area.

• Street clothes are permitted.

2. Semi-restricted / Semi sterile Area

• personnel should be wearing OR scrub suit with cap.

• this area includes peripheral support areas and access corridors to the OR like PACU, SICU, offices for anesthesia department & administrative OR nursing personnel, etc.

Restricted / Sterile Area

• personnel should be wearing complete OR scrub suit including mask.

• this area performs sterile procedures.

• includes OR suite room, scrub sink areas, sub sterile rooms where unwrapped supplies are sterilized.

Infection Control

is the most basic and important procedure in nursing care, and it will deter-mine the quality of care given in a facility.

Bacteria (bacterium)

• single-celled microscopic organisms that multiplies rapidly. Some are beneficial to humans while others can cause infection.

Fungi (fungus)

• microscopic, single celled or multi-celled plants that live either on plants or animals. - can infect the mouth, vagina, skin, feet & other body parts.

Protozoa (protozoan)

• single-celled, microscopic animals, usually living in water and can cause disease.

Rickettsiae

• found in fleas, lice, ticks and other insects; spread to humans by insect bites. Person infected may experience fever, chills, headaches, rashes, etc.

Virus

• smallest known living infectious agents that grows in living cells.

Nosocomial Infection

• infection that is required as a result of being in the health care facility environment.

Cross Infection

• occurs when one patient or staff passes the pathogens to another patient, staff or visitors.

Community Acquired Infection

• these are natural disease process that developed or were incubating before the patient is admitted to the hospital.

Causative Agent or Source

• is the pathogen that causes the infection or disease (bacteria, virus, fungi, protozoa).

Reservoir

• is the place where the causative agent is able to live and reproduce.

- Humans with active disease

- Humans who are carriers

- Animals

- Fomites or objects

- Environment

Portal of Exit

• is the means by which the pathogens leave the reservoir like human secretions.

* urine, feces

* saliva, tears

* drainage, excretions

* blood

Method of Transmission

• the way the pathogen is transmitted from one reservoir to the new host’s body.

Contact  Transmission

• most important and most frequent route.

• Direct – contact = direct body-surface-to-body-surface contact &  transfer of pathogens.

• Indirect – contact = involves contact with a contaminated objects like needles, instruments, un-washed hands and gloves

Droplet Transmission

• occurs when droplets containing microorganisms are sent flying a SHORT DISTANCE through the air & are deposited on the eyes, nose or mouth (sneezing, coughing, and droplets).

Airborne transmission

• occurs when evaporated droplets containing pathogens remain in the air for LONG PERIODS OF TIME and are carried along by air currents.

Common vehicle transmission

• occurs when pathogens are transmitted by contaminated items like food, water, medications, hospital equipment and machines.

Vector – borne transmission

• occurs when intermediate hosts such as infected rats, flies or mosquitoes, transmit the microorganisms.

Portal of Entry

• is the means by which the pathogens enter the body such as:

* cuts or breaks in the skin or mucous membrane;

* respiratory tract;

* gastrointestinal tact

* genito-urinary tract;

* circulatory system;

* passage from mother to fetus

Susceptible Host

- is the individual who harbors the pathogens where they reproduce and cause infection.

Clean Technique

• practices and procedures to maintain a clean environment by removing or destroying the pathogens.

• Medical Asepsis

Sterile Technique

• practices and procedures that keep an area or object totally free from all microorganisms.

• Surgical Asepsis

Stage 1 - Onset/ Induction

from administration of anesthesia to the time of loss of consciousness

Stage 2 - Excitement/ Delirium stage

• from loss of consciousness to the time of loss of lid reflex

• characterized by shouting, struggling of the patient, irregular breathing

Stage 3 - Stage of surgical anesthesia

• from loss of lid reflex to the loss of most reflex

• surgical procedure is started

Stage 4 - Danger stage

• characterized by respiratory & cardiac depression due to overdose of anesthesia

• not breathing, little or no pulse