Pain Management, Surgical Care, and Introductory Pharmacology Study Notes

Pain as the 5th Vital Sign

• Always assess pain together with the four traditional vital signs (temperature, pulse, respiration, blood pressure).
• First screening question: “Do you have any pain?”
  • A “yes” triggers a complete pain assessment.

Acute Pain vs. Chronic Pain (Create a 2-column comparison table while studying)

• Nature
  • Acute: temporary, protective, warning of tissue damage/disease.
  • Chronic: persistent, debilitating, NOT protective.
• Duration
  • Acute: lasts only until tissue healing; short term.
  • Chronic: >6 months; extends beyond expected healing; may last a lifetime.
• Physiological response
  • Acute: ↑HR, ↑BP, sweating, anxiety.
  • Chronic: little/no vital-sign change; produces emotional (depression) & physical (fatigue) effects.
• Behaviors
  • Acute: grimacing, moaning, flinching are visible.
  • Chronic: often no outward signs; patients adapt.
• Treatment focus
  • Acute: eliminate underlying cause → pain dissipates.
  • Chronic: symptom relief, quality of life, adjuvants (e.g., antidepressants).
• Transition
  • Untreated acute pain can transition into chronic.
  • Chronic pain has no further “transition.”

Nociceptive Pain vs. Neuropathic Pain

• Origin
  • Nociceptive: tissue damage or inflammation.
  • Neuropathic: nerve damage/dysfunction.
• Mechanism
  • Nociceptive: activation of pain receptors (nociceptors).
  • Neuropathic: abnormal signal processing along damaged nerves.
• Patient description
  • Nociceptive: throbbing, aching, sharp, localized.
  • Neuropathic: burning, stabbing, shooting, “pins & needles,” persistent; often resistant to typical analgesics.
• Examples
  • Neuropathic: phantom-limb pain, diabetic neuropathy, post-herpetic neuralgia.
• Treatment
  • Nociceptive: opioids (e.g., morphine) & non-opioids (e.g., aspirin).
  • Neuropathic: adjuvant meds—antidepressants, muscle relaxants, topical agents.

Physiology of Nociceptive Pain (Maria & the Hot Pan)

1. Transduction – heat damages skin → converts to electrical signal in nociceptors.
2. Transmission – impulse travels via nerve fibers to spinal cord/brain (neurotransmitters modulate speed).
3. Pain Threshold – minimum intensity at which stimulus is perceived as pain.
4. Pain Tolerance – amount of pain one is willing/able to endure; lowered by fatigue, stress, lack of support.
5. Perception – brain interprets signal; cognitive-emotional meaning assigned.
6. Modulation – spinal reflex pulls hand away before full perception; endogenous systems dampen signal.

Pain Assessment Frameworks

• Mnemonics:
  • PQRST (Provocation/Quality/Region-Severity/Timing).
  • OLDCARTS (Onset/Location/Duration/Characteristics/Aggravating/Relieving/Timing/Severity).
• Location: ask patient to point; note radiation/referred/deep vs. superficial.
• Quality descriptors: sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, heavy, tiring, exhausting, sickening.
• Intensity scales
  • Numeric 0–10 (explain scale).
  – 7–10 = severe
  – 4–6 = moderate
  – 1–3 = mild
  • Wong–Baker Faces for children/non-verbal adults.
• Timing: onset, duration, frequency, constant vs. intermittent, “What were you doing when it started?”
• ADLs/Function: sleep, mobility, work, social interaction.
• Associated symptoms: fatigue, anxiety, nausea, depression.
• Aggravating/Relieving factors: movement, meds (prescription, OTC, herbal), positioning, heat/cold.
• Principles:
  • “Pain is whatever the patient says it is.”
  • Consider age, genetics, cognition, prior experience, coping style, culture.

Surgical Client Overview

Three Phases of Perioperative Care

1. Pre-operative – preparation & informed consent.
2. Intra-operative – from OR entry to PACU transfer; focus = patient safety & sterility.
3. Post-operative – PACU until discharge/home; focus = stability & complication prevention.

Pre-operative Nurse Responsibilities

• Complete health & surgical history form (past illnesses, meds, allergies, social habits).
• Head-to-toe assessment; baseline vitals.
• Ensure informed consent is signed & witnessed.
• Physical prep: CHG bath, remove dentures/prostheses, establish IV access (if inpatient), NPO status, pre-medications.
• Emotional support; anxiety reduction.

Informed Consent

• Purpose: uphold autonomy, protect patient & providers.
• Surgeon responsibilities: explain procedure, benefits, risks, alternatives; answer questions; verify comprehension; obtain signature.
• Nurse responsibilities: witness voluntary signature, clarify information, assess understanding; call surgeon if questions remain; provide emotional support.

Special Populations & Risk Factors

• Older adults: high surgical volume; chronic comorbidities; prone to post-op delirium → prevent via good pain control & med selection.
• Obesity: ↑ risk respiratory issues, anesthesia complications, VTE, wound problems.
• Smoking: impairs oxygenation & healing; ↑ pulmonary complications.

Common Intra- & Post-operative Complications

• Post-operative nausea & vomiting (PONV): risk of aspiration & electrolyte imbalance → give anti-emetics.
• Venous thrombo-embolism (VTE)
  • DVT signs: swelling, pain, redness, warmth.
  • Prevention: anti-embolic stockings/compression devices, early ambulation.
  • Pulmonary embolism: chest pain, dyspnea, tachycardia, hypoxia → urgent anticoagulation.
• Fluid imbalances: hypovolemia or hypervolemia—monitor I/O, labs.
• Atelectasis: alveolar collapse due to ↓ surfactant from anesthesia
  • S/S: ↓SpO₂, respiratory distress.
  • Prevention: incentive spirometer, deep-breathing, coughing, early ambulation.
• Wound infection (often staphylococcal): pain, redness, swelling, purulent exudate, foul odor → aseptic care, antibiotics.

Universal Protocol (Joint Commission)

• Goal: prevent wrong patient / site / procedure errors.
• Steps:
  • Pre-procedure verification (ID band, consent, orders).
  • Site marking with patient involvement.
  • "Time-out" immediately before incision—entire team confirms identity, procedure, site.

OR Team Roles

• Circulating Nurse: non-sterile; coordinates care, documents, supplies equipment, labels specimens, monitors sterility.
• Scrub/CST (or Scrub Nurse): maintains sterile field, prepares instruments, performs counts (sponges, sharps, instruments) before & after surgery.

Surgical Environment & Asepsis

• Strict sterile technique.
• OR temp & humidity tightly controlled to retard bacterial growth.
• Skin prep: hair removal, antiseptic solution (e.g., chlorhexidine).

Types of Anesthesia

• Local – numbs small area; patient awake.
• Regional – blocks larger region (arm/leg) ± light sedation.
• General – patient unconscious; requires airway & full vital monitoring.
• Moderate (conscious) sedation – patient drowsy but maintains airway; common for bedside/minor procedures.

Post-operative Assessment Highlights

• Neurological: level of consciousness, orientation (monitor for delirium).
• Cardiovascular: HR, BP, rhythm, DVT signs.
• Respiratory: airway patency, breath sounds, SpO₂, signs of atelectasis.
• Pain: reassess with scale; match analgesic to severity level.
• Integumentary: incision/wound inspection, dressing drainage.
• GI/GU: bowel sounds, nausea, output, voiding.
• Safety: fall precautions, side rails up, call-light in reach.

Pharmacology Foundations

Medication Naming

• Chemical name – full molecular description (e.g., acetylsalicylic acid).
• Generic (official) name – standardized, used on NCLEX & guidelines (e.g., aspirin).
• Trade/Brand – manufacturer’s name (e.g., Bayer).
  • One generic may have many trade names.

Drug Classification & Key Examples

• Drugs are grouped by action, therapeutic use, body target, ingredients, pregnancy safety.
• Example:
  • Lisinopril – ACE inhibitor (antihypertensive).
  • Glipizide – antidiabetic; ↑ pancreatic insulin release.
  • Digoxin – cardiac glycoside; therapeutic serum level 0.8\text{–}1.2 ng/mL.
  –
• Adverse effect example: Gentamicin → ototoxicity.
• Contraindication example: Tetracycline avoided in children <8 yrs (tooth discoloration).
• Interaction example: dual β-blockers may blunt each other or cause excessive bradycardia.
• Adjuvant meds: drugs designed for other conditions but provide analgesia (e.g., antidepressants for neuropathic pain).

Prescription Types

• Routine/Standing – scheduled until discontinued or completed (e.g., antibiotics x 10 days; azithromycin x 3 days).
• Single/One-time – given once (e.g., pre-op antibiotic dose).
• STAT – administer immediately.
• NOW – similar to STAT but slightly less urgent (generally within 90 min).
• PRN – “pro re nata,” give as needed per specified parameters.
• Protocol/Standing Orders – pre-authorised actions for specific situations (e.g., code blue meds during cardiac arrest).

Preparation, Dosage & Administration

• Route options: PO, IV, IM, SubQ, topical, etc.
• Dose individualized by patient factors & therapeutic window.
• Example: Morphine available PO, IV, PCA—dose differs by route & severity level.

Use these bullet-point notes as a complete study replacement for the original lecture. Re-draw tables, add personal mnemonics, and practice applying every concept in clinical scenarios or NCLEX-style questions.