Learning Objectives
By the end of this section, you will be able to:
- Define how to assess the patient’s postoperative pain
- Describe how to manage the patient’s postoperative pain
- Discuss the nurse’s responses when pain interferes with healing
Pain assessment and management are essential nursing duties to ensure patient comfort during the postoperative recovery phase. As patients wake from anesthesia, they frequently experience various degrees of discomfort caused by surgery, necessitating an extensive and tailored postoperative pain management plan developed in collaboration with the patient’s health-care providers. To create a baseline for developing a successful plan, the nurse must understand key information about a patient’s pain experience, including the location and quality of the pain and any aggravating or alleviating factors. Depending on the patient’s pain, nurses can implement various therapies to alleviate discomfort and aid recovery, including administering analgesic drugs as prescribed or encouraging nonpharmacological techniques such as positioning, relaxation techniques, or distraction methods to promote patient comfort.
Assessment of Acute Postoperative Pain
Postoperative pain assessment is at the core of comprehensive nursing care during the postoperative recovery phase. As soon as a patient transfers from an operating room to the PACU, nurses take on the responsibility of evaluating postoperative pain severity. The first tasks of the pain assessment entail developing effective communication with patients and ascertaining their subjective experience of pain. An important consideration is that the expression of pain is subjective and should not be judged by the nurse to be different than what the patient claims it is.
Pain Scale Consideration
Nurses play an invaluable role in early recognition and management of acute postoperative pain, aiding patient comfort while speeding recovery time. Their attentive observation skills, effective communication, and use of assessment tools makes a substantial contribution toward early pain recognition and management, ultimately optimizing recovery process and recovery outcomes. The numeric pain scale is used most often, having the patient rate their current pain on a scale of 0–10 with zero being no pain and ten being the worst pain they have ever felt. Nurses must carefully consider specifics of the surgical procedure when assessing a patient’s pain, while examining surgical sites for signs of inflammation or swelling that could worsen postoperative pain. Furthermore, nurses investigate potential factors that exacerbate or relieve postoperative pain such as patient movement or changes to body position. This continuous assessment allows for the development of personalized pain management plans tailored to each patient’s unique needs and responses in the recovery phase.
As discussed in Chapter 7 Pain Assessment and Management, culture plays an essential role in shaping individual perception, expression, and management of pain, affecting patient experiences with the health-care system. Culture shapes how individuals communicate and display pain and may also affect health-care providers’ assessments and interpretations of patients’ pain, affecting the accuracy of pain assessments and decision-making regarding treatment decisions. Patients may also use complementary or alternative therapies alongside mainstream medical interventions, as dictated by their culture.
Methods of Pain Management
Postoperative pain management is an integral aspect of patient care, comprising various strategies designed to mitigate discomfort and promote recovery. Pharmacological interventions are a primary approach, employing various analgesic medications such as opioids and nonopioids. Medication choices depend upon several factors, including type of surgery performed and patient medical history. Regional anesthesia techniques like epidural analgesia and peripheral nerve blocks offer targeted pain relief by temporarily impeding pain signals at specific spinal sites. During the PACU phase, IV narcotic analgesics are very effective for acute pain. Typical opioids used in PACU settings include fentanyl, hydromorphone, morphine, oxycodone, oxymorphone, and tramadol (Mayo Clinic, 2024). An important concept for patients to understand is that postsurgical use of narcotics for acute pain will not lead to narcotic substance use disorder as it is meant to be short-term. An important note, however, is that for those who have a substance use disorder, higher doses to control postsurgical pain may be needed (Pashkova, 2020). Nonpharmacological interventions for postoperative pain management that can be used outside of the PACU may include physical therapy, heat and cold therapy, acupuncture and acupressure, rest, distraction, and position changes, which also provide a holistic approach for managing postoperative pain beyond the PACU setting.
Patient education and counseling play an essential part in providing pain management while encouraging active involvement in the recovery processes. Psychological interventions such as cognitive behavioral therapy and relaxation techniques aim to address psychological aspects of pain perception, while innovative techniques like virtual reality and distraction techniques may offer alternate forms of relief from postoperative discomfort. Health-care providers strive for comprehensive yet personalized management of postsurgical pain, tailoring interventions according to each patient’s specific needs and the nature of the surgical procedure to optimize postoperative pain control management and achieve comfort for their patients.
Pharmacological Pain Management
In hospital settings, various pharmacological interventions are utilized to effectively manage postoperative pain and increase patient comfort. The provider may prescribe opioid analgesics such as morphine, oxycodone, and hydromorphone, which can provide effective pain management after surgery for moderate to severe discomfort. These medications work by acting on the central nervous system to relieve pain. Depending on the provider’s order, the nurse will administer these medications intravenously, orally, or via a patient-controlled analgesia system. A patient-controlled analgesia (PCA) system is a method of pain management that allows the patient to push a button that administers the prescribed medication via an IV site. The nurse is responsible for regularly monitoring the PCA for proper functioning.
Nonopioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or ketorolac, play an integral part in pain management strategies. Acetaminophen has long been recognized for its analgesic and antipyretic effects in postsurgical settings. Meanwhile, nonsteroidal anti-inflammatory drugs (NSAIDs) provide relief in muscle-skeletal surgeries. Local anesthetics may be administered using epidural catheters or nerve blocks in specific surgical locations to provide targeted pain management. Adjuvant medications, such as gabapentin or pregabalin, also known as anticonvulsants, have increasingly become part of postoperative pain management plans to enhance the effectiveness of analgesic medications and provide enhanced analgesia relief. Adjuvant medications work by modulating nerve signals, making them effective treatments for neuropathies like neuropathic pain conditions. By employing a multimodal approach, health-care providers hope to maximize pain relief while simultaneously minimizing any potential adverse side effects linked with any single class of medication.
These same medication classes may be given at discharge for the patient; however, they are transitioned from IV route with a fast onset, to the oral route, which has a more extended release. IV pain medication should not be administered prior to discharge because the patient must be monitored for signs of respiratory depression. Manageable pain control is a criterion for discharge (Certain et al., 2022).
Nonpharmacological Pain Management
Nonpharmacological pain management strategies form an integral component of holistic health care both within hospital settings and as self-care practices in daily life at home. While in the hospital, a provider’s order needs to be obtained before these modalities may be applied. Table 27.3 outlines nonpharmacological methods that can be used in both the hospital and home setting (Skelly et al., 2020).
| Method | Mechanism of Action for Pain Management |
|---|---|
| Physical therapy | Muscle relaxation helps to relieve pain by releasing endorphins. Muscle strength and endurance training help prevent pain. |
| Heat/cold therapy | Vasoconstriction and vasodilation are known to relieve pain at the nerve endings. |
| Massage, acupuncture, acupressure | Increase circulation, which encourages oxygenated blood flow to the muscle area. |
| Transcutaneous electrical nerve stimulation (TENS) units | Stimulation of the nerve cells blocks pain signals to the brain. Electrical pulses also release endorphins, a natural pain chemical. |
| Cognitive behavioral therapy (CBT) | Pain is managed by altering one’s thought processes and repetition of behaviors to reduce pain. |
| Guided imagery, deep breathing exercises, and progressive muscle relaxation | Relaxation techniques are used to distract the pain sensation and redirect the pain gate signals. |
| Art, music, and pet therapy | Activities stimulate an increase in oxytocin, which induces relaxation and diversion from pain process. |
Cultural Context
Culture and Expressions of Pain
Varying cultures have diverse beliefs about the expression of pain. Some cultures encourage stoicism and may view the outward expression of pain as weakness, whereas other cultures embrace the expression of pain through crying loudly. Communication styles also impact how patients describe their pain, including language and euphemisms, making it important for the nurse to clarify what the patient means. Gender roles influence expressions of pain such as men downplaying their pain to be perceived as strong, whereas women may be more vocal about their pain. Family dynamics can also impact expressions of pain as some may rely on the patriarch or matriarch of the family to verbalize the pain of the patient.
When Pain Interferes with Healing
Painful events can greatly disrupt the natural healing process and present difficulty for patients recovering from surgeries or injuries. Compromised immunity can slow healing while increasing the risk for infections or any related ailments. Painful experiences often elicit physiological responses such as release of cortisol hormone; in excess, cortisol may impair immunity function, increase blood glucose levels, and hinder the overall healing process. Persistent pain may increase inflammation levels and contribute to a prolonged delay in tissue repair and an increase in scar formation, which can exacerbate existing conditions and cause greater scar formation. Painful conditions may restrict mobility and discourage patients from engaging in necessary physical activities and rehabilitation exercises that would support restoration of function and strength, further impeding healing efforts.