"You spin my head..."
sx cluster head ache
unilateral head, pain behind one eye
Nursing interventions specifically for a pt post op post-tonsillectomy
no red food dyes (ie. popsicles, jello)
advanced airway equipment at bedside in event of airway closure
1st nursing intervention for pain management
start with non pharmalogical methods first
What are examples of non pharm interventions?
patient edu with general anesthesia
patient should not opperate heavy machinery, not drive within 24 hrs, make big life decisions (including informed consent), etc.
Nursing assessments before and after opioid administrations
Monitor pain with pain scale, LOC, RR, bowel movements
pt at risk for resp. distress, decreased LOC
treatment for a patient with a tension head ache
muscle relaxants
What are nursing interventions the nurse should consider with total joint replacement patients
same-day ambulation, Ice site, manage pain with PO meds, perform ADLs and proper wound care
Why is early ambulation after surgery important?
prevention of venous thromboembolism, skin breakdown, and improves recovery
complications of surgery
blood clots (DVT/PE), atelectasis, hemorrhage, surgical site infection, dehiscence, etc.
What findings may indicate that the patient requires better pain management
elevated HR and BP, poor cough and I.S. effort, decreased mobility, shallow breathing
sx of migraine
photophobia, phonophobia, vision changes, nausea/vomiting (emesis), stiff neck, throbbing temples, unilateral head pain, sensory aura
What should the nurse consider when providing education
written information, does the patient have deficits (cognitive, visual, hearing, language, etc.)
Provide necessary equipment for deficits: hearing aids, glasses, translator
When should the nurse pre medicate a patient for pain?
about 30 min before working with PT or doing wound care (esp. partial and full thickness care)
Components of a time out prior to the start of surgery
patient ID, ID site, ID allergies, ID procedure,
Vitals sign changes associated with pain
increased respirations, BP and pulse
sx of tension HA
palpable muscle tension in neck and shoulders, tenderness to neck and shoulder muscles
Bonus: what is a treatment specific to tension HA
How does the nurse know education is effective
patient restates or return demonstrates back to RN correctly
A patient is having 6/10 pain post knee surgery. IV Ketorolac q 6 hrs prn for moderate pain was given 20 minutes ago.
PRN meds:
Tylenol extra strength 650mg PO q 8hrs for mild pain or headache
Ketorolac 0.5mg IV q6 hrs for moderate pain
Morphine 1mg IV q4 hrs for severe pain
What should nurse do next?
call the dr and request change in orders; pain is not controlled with prn medications as ordered.
Morphine is indicated for 8-10 pain on 0-10 pain scale and not appropriate for pain 6/10
components of informed consent
patient still has questions about procedure, says they don't understand, or make comments that show they do not understand
What would indicate informed consent is NOT complete?
patient/family education with pca pumps
the patient is the only one who should be pushing the PCA button to administer programed pain medication
therapeutic environment for migraine
rest in a quite dark room
Nursing considerations for managing pain for a patient with advanced Alzheimers disease (confused) with no orientation to person, place, time, or situation
use FACES scale to assess pain, they are not able to sign an informed consent, establish advanced directives and goals of care with the patient's power of attorney
Considerations for a patient with HTN or DM day of surgery
clarify with surgeon and anesthesiologist what meds should and should NOT be taken day of surgery and educating the patient, frequent monitoring of BG pre, intra, and post op, Monitor BP
Higher risk for complications post op (i.e. impaired wound healing)
what are nursing assessments for these and interventions that prevent complications from occurring?
IS, DVT/PE protocol heparin, early ambulation etc
A patient is in the PACU complaining of pain 8/10. They are drowsy and easy to arouse. VS: 110/85, P67, R 8, T 97.8
What action by the nurse is best
do not give pain medication dt low respiratory rate, continue to monitor, encourage deep breathing