Transcript of { Post-operative Pain Management Paula Jarzemsky, Kari Hirvela, Cassie Voge UW Madison School of...
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- { Post-operative Pain Management Paula Jarzemsky, Kari Hirvela,
Cassie Voge UW Madison School of Nursing Spring, 2011
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- { All names and characters in the following slides are
fictional. The protocols, patient education forms, etc. are current
as of May, 2011. Please see reference list near the end of the
module for due credit to prior authors works which made this module
possible. To hear audio clips, be in Slide Show mode and have your
volume at an appropriate level. Disclaimer
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- Informatics: navigate an Electronic Health Record (EHR); use
high- quality information sources Patient-centered care: provide
compassionate, coordinated care based on respect for patient
preferences, values and needs Evidenced-based practice: locate a
relevant clinical practice guideline; discriminate when to modify
EBP based on clinical expertise or patient preferences QSEN
Competencies In this module you will learn more about:
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- The place... The University of Wisconsin-Madison (UW) Hospital
& Clinics
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- Meet Carmen... Shift to Shift Hand Off Note Jen Smith, RN (day
shift) gave verbal report to Chris, RN (PM shift) regarding the
care of Carmen Gonzales using the standardized SBAR report. Carmen
is a 56-year-old female with a history of CAD, CHF, HTN, type 2
diabetes mellitus. She was admitted through the emergency
department on Sunday with osteomyelitis and gangrene of her leg and
underwent wound debridement today (Monday). She returned to the
surgical unit an hour ago. AVSS Oxygen: RA Pain: stable though
6/10, 2 mg IV morphine with relief Vascular access device sites
intact Other tubes/lines Dressing CDI (clean, dry, intact)
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- Chris, RN. You completed a nurse residency program at UW
Hospital and now carry your own patient assignment without direct
supervision of a preceptor. Today, you will take care of Carmen
after her surgery. Click the icon below to hear the verbal
handoff/SBAR (shift-to-shift) report from the AM shift nurse... And
you are...
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- Decision #1 (gather information) After hearing shift report,
you decide to: Check the EHR (Electronic Health Record) EHR Talk to
a colleague See the patient All the nurses on your unit are really
busy right now, so this is not an option right now. What would you
like to talk about anyway? Continue scenario...
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- Check the EHR... Flow Sheets Physicians Orders MAR (Medication
Administration Record) After viewing all 3, click here to go back
to decision #1
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- Flow Sheets Back to EHR Sedation Score 1 1500 VS:
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- MD Orders Back to EHR
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- MAR Back EHR
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- Initial observation of Carmen: Carmen is sitting up in bed,
eyes closed and moaning quietly. Dressing clean, dry, and intact
over L lower leg. Pulses 2+ bilateral. L foot is warm, with +
movement and sensation. When asked about pain, Carmen begins to
cry, reporting 8/10 pain at the surgical site. Click audio clip:
See the patient... Back to decision #1
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- You need to make a decision based on this information with the
current order, you cannot administer any more pain medication (Jen
Smith, day shift RN last administered 2 mg of IV morphine at
2:30pm). What next?
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- Cli ck the below icons (in order) to listen to conversation :
You decide to call for an order change : Chris, RN Dr. Sakei
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- Decision #2 Now that a range order is available (2-6 mg
Morphine IV every 2 hours PRN), you need to decide how much to give
within this range. Keep in mind it is 3:30 pm and Carmen received 2
mg of IV morphine at 2:30 pm. 1 mg 2 mg 3 mg 6 mg
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- Try again. This is less than the desired dose. 1 mg Back to
Q#2
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- Try again. This is less than the desired dose. 2 mg Back to
Q#2
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- Correct! If pain goal is not achieved, try 50% greater than the
previous dose 3 mg Continue scenario... Link to Pain Management
Reference
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- Try again. This is higher than the desired dose and may cause
negative side effects (nausea, sedation, respiratory depression)
Click to view an evidence-based protocol: 6 mg Respiratory
Depression & Narcan
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- Decision #3 At 1600, you return to reevaluate Carmens pain. She
describes her pain as moderately better, but still reports a pain
rating of 6/10. She drifts off to sleep once during the
conversation, but is arousable. Respirations are shallow and
regular, at a rate of 14/min. She denies any nausea. As you think
about your assessment of Carmen,you decide to: Give more IV
morphine, as her pain rating is 6/10. Give no morphine and call Dr.
Sakei to alert him of your assessment. Give no morphine, as she
describes her pain as moderately better and continue to monitor
Carmen
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- Try again. Administering more morphine may bring Carmens pain
rating below a 6, but she is already experiencing side effects
(sedation). Remember to look at the big picture and not just the
pain rating: Carmen verbalized moderate pain relief. Give more
morphine Back to Q#3
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- Try again. The MD will likely ask you to continue monitoring
the patient something you would do anyway. Call the MD Back to
Q#3
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- Best choice! Carmen seems groggy, so your best option is to
hold off on giving any more morphine for now. Reassessment after
giving a pain med is key: Carmen described her pain as better, even
though she rated it as 6/10. Reassessment after giving a pain med
is key: Carmen described her pain as better, even though she rated
it as 6/10. Monitor, no morphine Continue scenario...
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- Decision #4 It is 1645. You respond to Carmens call light and
she has a pain rating of 8/10. What dose should you give and why
Decision #4 It is 1645. You respond to Carmens call light and she
has a pain rating of 8/10. What dose should you give and why: 0 mg:
Tell Carmen she needs to wait until 1730 for her next dose. 2 mg:
This dose provided minimal side effects. 3 mg: This dose provided
best pain relief with manageable side effects. Try again. A pain
rating of 8/10 needs intervention. Try again. This dose was
ineffective previously. Best choice, nice job!
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- Decision #5 The next morning, Jose (Carmen's husband) comes to
visit. Last night, Carmen Decision #5 The next morning, Jose
(Carmen's husband) comes to visit. Last night, Carmen experienced
good pain relief and no side effects (other than yesterdays
transient sedation that you monitored well!). Jose does not like
that she is taking IV pain medication. Carmen asks what other
options she has. At this time, it is most appropriate for you to
explain that: Postop pain is best managed with IV meds. Lets stay
with what works. I can reduce the dosage lets try 1 mg the next
time you need medication. If Carmen feels ready to transition to
other pain relief measures, lets discuss options with the team. If
there are alternatives to pain medication that have worked for you
in the past, lets talk about them. Try again. This is not the most
patient- centered response. Try again. While this is a more
collaborative approach, it may not achieve effective analgesia.
Good choice, nice job! There is another good choice... Good choice,
well-done! There is another good choice...
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- Always assess your patient Know how to access your facilitys
pain algorithm and resources. Consider cultural perspectives and
involve the patient and family as much as possible in clinical
decisions. Understand the importance of integrating EB guidelines
(pain algorithm, etc.) into your practice. Click on the icons for
other resources related to this scenario: Key Points Pain Algorithm
(UWHC) Pain Management Reference (UWHC) Cultural Aspects of Pain
Management (UWHC) Click page down to view references.
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- References You have completed the Post-Operative Pain
Management Module. Gordon, D. & Pellino, T. (2005). Incidence
and characteristics of Naloxone use in postoperative pain
management. Pain Management Nursing 6 (1), pp. 30-36. Gordon, D.B.,
Dahl, J., Phillips, P., Frandsen, J., Cowley, C., Foster, R.L.,
Fine, P.G., Miaskowski, C., Fishman, S., & Finley, R.S. (2004).
The use of as-needed range orders for opioid analgesics in the
management of acute pain: A consensus statement of the American
Society for Pain Management Nursing and the American Pain Society.
Pain Management Nursing, 5(2), 53-58. Pasero, C., Manwarren, R.
& McCaffrey, M. (2007). IV opioid range orders for acute pain
management. American Journal of Nursing 107 (2), 52-60. Pasero,C.,
Portenoy, R.K., & McCaffery, M. (1999). Opioid analgesics. In
M. McCaffery & Pasero (Eds.), Pain: clinical manual 2 nd ed
(pp. 161-299). St. Lous: Mosby. Cultural Aspects of Pain Fast Fact
- http://www.eperc.mcw.edu/fastFact/ff_78.htm and University of
Wisconsin Hospital and Clinics (Madison, WI)
http://www.eperc.mcw.edu/fastFact/ff_78.htm Respiratory Depression
from Opioids Fast Fact University of Wisconsin Hospital and Clinics
(Madison, WI) Pain Algorithm University of Wisconsin Hospital and
Clinics (Madison, WI), adapted from Memorial Sloan- Kettering (New
York, NY) Pain Management Reference University of Wisconsin
Hospital and Clinics (Madison, WI) Sedation Assessment Scale -
University of Wisconsin Hospital and Clinics (Madison, WI) Images
of Carmen, EHR, MAR modified and used with permission from Elsevier
SLS system. All other images & audio clips from ClipArt within
PowerPoint software application
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- EB Pain Algorithm Back to Key Points
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- Pain Management Reference (UWHC 2011) Click here to continue to
Question #3 Back to Key Points
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- Cultural Aspects of Pain Back to Key Points
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- Respiratory Depression Back to Q#2