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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