This document outlines principles of pain management in surgical patients. It discusses the pathophysiology of pain, categories of pain including nociceptive, neuropathic and mixed pain. It describes tools for assessing pain such as word description, intensity scales, location, duration and aggravating/alleviating factors. Pharmacological management of surgical pain is discussed including the WHO analgesic ladder and non-opioid analgesics, opioid analgesics, local anesthetics and adjuvant drugs. Non-pharmacological approaches are also mentioned. Post-operative pain management is described depending on the extent of surgical trauma.

1. PRINCIPLE OF PAIN MANAGEMENT
IN SURGICAL PATIENT
By:- Lemessa Jira
February7,2017pp.byAtsede
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2. PRESENTATION OUT LINE
Session Objectives
Introduction To Pain
pathophysiology of pain
Categories of pain
Pain Assessment
Management in surgical pain
Possible Nursing care plan for surgical
patient
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3. Summery
References
Acknowledgement
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4. SESSION OBJECTIVES
Describe about pain and nociceptive pain process with
there management
Describe about types of pain
describe pre,intera and postoperative pain by
pharmacological and non pharmacological
Describe and proceed assessment of pain with different
tools.
Describe which drug is used for which types of pain and
tissue damage in surgical patient
 describe possible Nursing care plan for surgical patient
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5.  Pain and physical discomfort is common in the surgical
patient as a result of injury, invasive procedures, or
preexisting illnesses.
(Orlando Regional Medical Center 2005)
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6.  Unrelieved pain may contribute to patient
discomfort, anxiety, exhaustion, disorientation, agitation,
tachycardia, increased myocardial oxygen consumption,
pulmonary dysfunction, impairs immune function, which
slows healing and increase susceptibility to infections and
dermal ulcers.
Orlando Regional Medical Center 2005
February7,2017
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7. Effective pain control
to improving patient comfort
decrease the incidence of many complications
in the postoperative patient.
Orlando Regional Medical Center 2005
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8. CATEGORIES OF PAIN
Postoperative pain can be divided into
acute pain and chronic pain:
Acute pain is experienced immediately after
surgery (up to 7 days);
Pain which lasts more than 3 months after the
injury is considered to be chronic.
Hanna Misiołek1 etal, 2014 and Orlando center2005
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9. Classified by inferred pathophysiology:
1.Nociceptive pain
2.neuro pain
3.mixed type
Minsteri of health in Rwanda September 2012
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10. 1.Nociceptive pain:
Nociception is the activity in peripheral pain
pathways that transmits or processes the
information about noxious events associated
with tissue damage.
Minsteri of health in Rwanda September 2012
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11. Nociceptive pain can be: somatic or visceral pain
• Somatic pain:
Pain originating from bone, muscle, connective tissue etc. This
type of pain can be described as aching, sharp, stabbing,
throbbing and is well localized.
Minsteri of health in Rwanda September 2012
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12. • Visceral pain:
Pain originating from organs such as pancreas,
liver, GI tract etc. This type of pain is described as
cramping, dull, colicky, squeezing, often poorly
localized, and may be referred to other areas.
Minsteri of health in Rwanda September 2012
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13. 2. Neuropathic pain:
It is caused by an injury or dysfunction of the peripheral or
central nervous system. It is often described as: burning,
shooting, stabbing, numbness or tingling. It has the following
types:
Minsteri of health in Rwanda September 2012
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14. A•Central neuropathic pain :Example: Post
stroke pain, Spinal cord injury, multiple
sclerosis and syringomyelia.
Minsteri of health in Rwanda September 2012
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15. B• Peripheral
→ Focal: Examples: Trigeminal neuralgia,
Carpal tunnel syndrome, failed back surgery
syndrome with nerve root fibrosis, post -
herpetic neuralgia.
Minsteri of health in Rwanda September 2012
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16. Multifocal: Exemples: Vasculitis, diabetes
mellitus and brachial or lumbar plexus
Symmetrical : Examples: Diabetes mellitus,
ethanol abuse, toxins (e.g.: vincristine) and
amyloidosis.
Minsteri of health in Rwanda September 2012
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17. C• Other sensations of neuropathic pain
→ Dysesthesia (bugs crawling on the skin, pins and
needles)
→ Allodynia (pain to a non painful stimulus)
→Hyperalgesia (increased pain sensation to a
normally painful stimulus).
Minsteri of health in Rwanda September 2012
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18. 3.Mixed
This involves both Nociceptive and
Neuropathic types of pain.
Minsteri of health in Rwanda September 2012
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19. ASSESSMENT OF PAIN
A variety of tools and assessment scales have
been advocated to document the degree of
pain. The most reliable and valid indicator of
pain has been shown to be the patient’s self-
report.
 Assessment of the patient experiencing pain is
the cornerstone to optimal pain management.
REGINA FINK, RN, PHD, AOCN ,July 2000
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20. Using the WILDA approach ensures that the 5 key
components to a pain assessment are incorporated
into the process.
REGINA FINK, RN, PHD, AOCN ,July 2000
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21. 5 .component of WILDA approach pain assessment
 word
• What does your pain feel like?
• Because various pain types are described using
different words
 Intensity express what pain feels like. The ability to
quantify the intensity of pain is essential when caring
for persons with acute and chronic pain.
REGINA FINK, RN, PHD, AOCN ,July 2000
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22.  Facial expressions
 Verbal rating scale
 Numerical rating scale
 Visual analogue scale (VAS):
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23. February7,2017
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24. universal adoption of a Classified using a standard 0(no
pain) to 10 (worst possible pain) scale.VAS and
NRS(common scale)
1.Mild pain- rating of 1-3,
2.Moderate pain- rating of 4-6,
3.Severe pain- reaching 7-10 and is associated with worst
outcome.
/ MOH/P/PAK/257.12 (HB), in October 2013 and REGINA FINK, RN, PHD, AOCN ,July 2000/
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25. 3.Location
Most patients have 2 or more sites of pain.
Thus, it is important to ask patients, “Where
is your pain?” or “Do you have pain more
than one area?” .
REGINA FINK, RN, PHD, AOCN ,July 2000
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26. 4.Duration Patients need to be asked, “Is your
pain always there, or does it come and go?” or
“Do you have both chronic and breakthrough
pain?”.
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27. 5.Aggravating/alleviating factors
Asking the patient to describe the factors that
aggravate or alleviate the pain will help plan
interventions.
REGINA FINK, RN, PHD, AOCN ,July 2000
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28. MANAGEMENT OF SURGICAL PAIN
1.Pharmacological
2.non Pharmacological
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29. 1.Pharmacological
Pain is prevented and/or treated using various
pharmaceutical agents. These medications can be
divided into four general categories:
1.Non opioid analgesics (aspirin, acetaminophen,
naproxen, NSAIDS and cyclooxygenase
inhibitor/cox 2 inhibitor
2. Opioid analgesics
weak opioid Codeine and Tramadol
Orlando Regional Medical Center,2005
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30. Strong opioid
(morphine, Diamorphine ,Pethidine, Piritramide
,hydromorphone, fentanyl, oxycodone, hydrocodone).
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31. 3. Local anesthetics (lidocaine, bupivacaine)
4.Analgesic adjuvant drug that has a primary
indication other than pain (tricyclic
antidepressants,antihistamines,benzodiazepines,s
teroids,phenothiazines,anticonvulsants,clonidine)
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32. February7,2017
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Produced in consultation with the European Society of Regional

33. WHO analgesic ladder
- Step 1
• Non opioid ±adjuvant :
ASA, Paracetamol, NSAIDs/COX-2s±adjuvant
- Step 2
• Opioid for mild to moderate pain± nonopioid ±
adjuvant:
Codeine, Tramadol, oxycodone, ± NSAIDs/COX–
2s, ± adjuvants. .
Minsteri of health in Rwanda September 2012
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34. - Step 3
• Opioid for moderate to severe pain, ± non
opioid,
±Adjuvant:
Oxycodone, Morphine, Hydromorphine,
Fentanyl, methadone, ± NSAIDs/COX – 2s, ±
adjuvants
- Step 4:
• Nerve block, epidurals, PCA pump, neurolytic
nerve blocks,. .
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35. February7,2017
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36. Monitering a patient with analgesics
1.To provide effective analgesia for patients
2.To detect serious and potentially dangerous side
effects and complications of analgesic techniques
monitor? Respiratory Rate ,Sedation Score , Pain
Score , Blood Pressure , Pulse Rate .
MOH/P/PAK/257.12 (HB), in October 2013
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37. Sedation Score
0= Awake and alert
1= Mild (occasionally drowsy)
2= Moderate (frequently drowsy but easy to
arouse)
3= Severe (difficult to arouse)
S= Sleeping .
MOH/P/PAK/257.12 (HB), in October 2013
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38. Determines when to give the next dose of
analgesic drug in techniques that use intermittent
bolus doses
 High Pain Score (≥4) inform doctor
 Low Pain Score (<4) maintain present dose.
MOH/P/PAK/257.12 (HB), in October 2013
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39. The doctor or anaesthesiologist on call should be
informed if
1. Sedation score > 2, respiratory rate < 8
2. Sedation score > 3, does not matter what respiratory
rate is
3. Pain score is >4 in 2 observations
4. Vomiting is persistent despite anti-emetics
5. Hypotension (systolic < 90 mmHg) .
MOH/P/PAK/257.12 (HB), in October 2013
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40. pain relief in adults according to the extent of
surgical trauma surgical procedures .
1. slight tissue damage procedures of small
extent and post-operative.
pain intensity < 4 points according to NRS or
vas.
postoperative pain persists for 3 days.
Hanna Misiołek1 etal, 2014
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41. A. pharmacotherapy before surgery (preventive
analgesia) non 0p0ied
metamizole (1–2.5 g), intravenous or oral,
paracetamol (1.0–2.0 g), intravenous or oral ,
ketoprofen (50–100 mg), intravenous or oral,
ibuprofen (200–400 mg), oral,
diclofenac (50–100 mg), oral, other NSAIDs (oral) .
Hanna Misiołek1 etal, 2014
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42. Local Analgesia
Before surgery, the anticipated incision line
should be injected with
10–20 mL lidocaine 1%,
5−10 mL bupivacaine 0.25−0.125%,
5−10 mL ropivacaine 0.2%, to induce the
effect of pre-emptive analgesia; after
completion of the surgery, depending on its
type, re-injection of the wound.
Hanna Misiołek1 etal, 2014
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43. B.Pharmacotherapy After Surgery: (non
opioids)
metamizole (1 g–2.5 g, max. 5 g day-1),
intravenous or oral every 6–12 hours and/or
paracetamol 1.0 g, intravenous or oral, every 6 h
(max. 4 g doba-1) combined with a non-selective
NSAID in a continuous infusion or orally or a
selective COX-2 inhibitor, oral .
Hanna Misiołek1 etal, 2014
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44. Later (post-operative day 1) oral analgesics can be
used in fractionated doses:
metamizole 500 mg, and/or, paracetamol (0.5–1 g)
combined (or otherwise) with a non-selective or
selective NSAID,
ketoprofen (50 mg) p.o., every 6−8 h or,
 dexketoprofen (25 mg) p.o., every 6−8 h or,
Hanna Misiołek1 etal, 2014
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45. diclofenac (50 mg) p. o., every 8 h or,
ibuprofen (400 mg) p.o., every 8 h or,
naproxen (250–500 mg) p.o., every 8 h or,
nimesulide (100 mg) p. o., every 12−24 h or,
meloxicam (7.5 mg–15 mg) p.o., every 24 h.
Hanna Misiołek1 etal, 2014
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46. 2. surgical procedures associated with
moderate tissue damage and NSR or VAS
post-operative pain intensity levels > 4 and
post-operative pain persists for 3 days
Hanna Misiołek1 etal, 2014
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47. A.Pharmacotherapy Before Surgery
clonidine tablets 75−150 μg, 1 h before
surgery or as a slow intravenous infusion, 150
μg directly before the induction of
anaesthesia,
dexmedetomidine 200 μg, a slow intravenous
infusion directly before induction of
anaesthesia and/or,
gabapentin, oral, 600 mg 4 h before surgery
or pregabalin, oral, 50−75 mg 1 h before
surgery and/or,
.
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48. lidocaine 1.5 mg kg-1, a slow intravenous
infusion before the induction of general
anesthesia and/or, ketamine 50 mg i.v. bolus
before induction of general anesthesia.
B .Intraoperative:
Lidocaine 1.5−3 mg kg-1 h-1
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49. C.Pharmacotherapy After Surgery:
metamizole (1–2.5 g, max. 5 g day-1) every 6–12
h, intravenous, and/or,
paracetamol 0.5–1.0 g, intravenous, every 6 h
combined (or otherwise) with
ketoprofen (50 –100 mg) in an intravenous
infusion every 12 h or dexketoprofen (50 mg) in
an intravenous infusion every 8 h, and/or,
lidocaine 0.5−1 mg kg-1 h-1.
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50. Additionally, in the case of pain, on demand — small
doses of i.v. opioids using nurse-controlled analgesia
(NCA; lockout interval 10 min): opioids
tramadol (10–20 mg) or,
nalbuphine (10 mg) or,
morphine (1–2 mg ) or,
oxycodone (1−2 mg).
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51. Beginning on post-operative day 2, oral analgesics
can be administered (unless contraindicated) in
the following fractionated doses:
NON-OPIOIDS:
metamizole 500 mg (max. 5 g day-1), and/or,
paracetamol 500 mg (max. 4 g day-1),
with (or without) NSAID:
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52. diclofenac 50 mg (max. 200 mg day-1), or,
ketoprofen 50 mg (max. 200 mg day-1) or,
dexketoprofen 50 mg (max. 75 mg day-1), or,
naproxen 250−500 mg (max. 1250 mg day-1),
or,
nimesulide, 100 mg (max. 200 mg day-1)
and/or,
meloxicam 15 mg (max. 15 mg day-1).
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53. OPIOIDS:
tramadol 5−20 drops every 6–8 h ( max. 400
mg day-1) or,
oxycodone 10−20 mg, controlled-release
tablets (max. 10−20 mg every 12 h) or,
buprenorphine 0.2−0.4 mg every 6−8 h
(max. 2.4 mg day-1).
).
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54. Local Analgesia:
Before surgery (for pre-emptive analgesia), the
anticipated incision line can be injected with:
lidocaine 1%, 10–20 mL (when an intravenous
infusion is used, the total lidocaine dose should
be verified) or, bupivacaine 0.25–0.125%, 5–10
mL or, ropivacaine 0.2%, 5−10 mL.
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55. 3.Surgical Procedures Associated With
Substantial Or Extensive Tissue Damage NRS
or VAS anticipated post-operative pain
intensity levels > 6 and duration of post-
operative pain longer than 5 days
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56. A.Pharmacotherapy Before Surgery (Preventive
Analgesia) non opioid
metamizole (1–2.5 g), intravenous or oral,
paracetamol (1.0−2.0 g), intravenous or oral,
ketoprofen (50–100 mg), intravenous or oral,
ibuprofen (200−400 mg), oral,
diclofenac (50−100 mg), oral other NSAIDs,
oral.
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57. Additionally, the following drugs, selectively or
combined: adjuvant analgesic
clonidine tablets 75−150 μg 1 h before surgery
or as a slow intravenous infusion 150 μg
directly before the induction of anaesthesia or,
dexmedetomidine 200 μg, a slow intravenous
infusion directly before the induction of
general anaesthesia, gabapentin, oral 600 mg
4 h before surgery or,
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58. pregabalin, oral 50−75 mg h-1 before surgery,
lidocaine 1.5 mg kg-1 body weight, a slow
intravenous infusion before the induction of
general anaesthesia, ketamine 50 mg,
intravenous bolus before the induction
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59. B.Intraoperative
Lidocaine 1.5–3 mg kg-1 h-1.
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60. C.Pharmacotherapy After Surgery:
metamizole (1 –2.5 g, max. 5 g day-1),
intravenous, every 6–12 h; and/or,
paracetamol 0.5–1.0 g, intravenous, every 6 h
combined (or otherwise) with ketoprofen
(50–100 mg), an intravenous infusion every
12 h or, dexketoprofen (25 mg), an
intravenous infusion every 8 h.
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61. lidocaine, an intravenous infusion 0.5-1 mg
kg-1 h-1, a continuous infusion of an opioid
(e.g., morphine, oxycodone, fentanyl,
sufentanil, nalbuphine)
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62. morphine, a single intravenous bolus 2.5−10
mg; the dose can be repeated after 4–6 h or a
continuous infusion 0.8−2.5 mg h-1 or lockout
interval 5−15 min,
oxycodone, a single intravenous bolus, 1–10 mg
for 1–2 min; the dose can be repeated after 4 h
or a continuous infusion, 2 mg h-1, lockout
interval 5−10 min,
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63. fentanyl, single bolus 50−200 μg; a dose of 50 μg
can be repeated after 20−40 min or a continuous
infusion, 0.05−0.08 μg kg-1 min-1 lockout
interval 5−10 min,
 During the next post-operative days, the
analgesic management provided should be
modified based on the level of pain intensity
determined using the chosen scale.
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64. Local Analgesia
In the majority of cases in this group of
procedures, regional analgesia is a continuation
of surgical anaesthesia. Continuous epidural
analgesia, together with PCEA using LAs and
opioids, is currently recommended only for
select procedures .
Hanna Misiołek1 etal, 2014
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65. Caution! Metoclopramide and ondansetron should not
used in patients who are receiving tramadol. In the case
of nausea and vomiting in patients who have been
administered tramadol, small doses of levomepromazine
can be given as an antiemetic (12.5−50 mg, intravenous
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66. SEVERITY OF PAIN MILD PAIN MODERATE PAIN SEVERE PAIN
Type of Surgery Myringotomy
Submucous resection
Excision of nasal or aural
polyps
Biopsy of oral lesions
Excision of tongue tie
Dilatation and Curettage
Hysteroscopy
0ther minor gynaecological
surgery
Excision of breast lump
Removal of other lumps and
bumps
Orchidopexy
Circumcision
Lymph node biopsy
Toenail surgery
Cataract surgery
Reduction of nasal fracture
Tonsillectomy
Adenoidectomy
Removal of dental bone plates
and wires
Surgical removal of wisdom tooth
Cone biopsy of cervix
Termination of pregnancy
Laparoscopic tubal ligation
Marsupialisation
Cystoscopy
Herniotomy
Ligation of Varicose veins
Ligation of Hydrocoele
Vasectomy
Excision of thyroid nodule
Bunion surgery
Dupuytren‟s contracture surgery
Carpel tunnel surgery
Excision of ganglion
Excision of chalazion
Wisdom teeth extraction
Wide excision of breast lump wit
axillary clearance
Open hernia repair
Laparoscopic hernia repair
Laparoscopic cholecystectomy
Haemorrhoidectomy
Varicose vein surgery
Anal fissure dilatation or excisio
Arthroscopic surgery
Removal of orthopaedic implants
Preop analgesia Oral NSAIDs/Cox-2inhabitor + Oral NSAIDs/cox-2 inhibitor + Oral NSAIDs/Cox-2 inhibitor +

67. 2.Non-pharmacological approaches
Techniques proven to be useful in acute pain
management:
1. Psychological approaches:
 Music- reduction in postoperative pain and
opioid consumption.
 Pre-operative information- effective in
reducing procedure-related pain.
Srinivas pyati and tong j.gan CNS 2007
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68. Distraction- effective in procedure-related pain
in children
 Cognitive methods-training in coping methods
or behavioural instruction prior to surgery,
reduces pain and analgesic use.
Hypnosis and relaxation-inconsistent evidence
of benefit in the management of acute
Srinivas pyati and tong j.gan CNS 2007
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69. 2. Complementary therapies and other techniques:
including massage, acupuncture,
Tens(transcutaneous electrical nerve stimulation),
hot and cold packs.
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70. POSSIBLE NURSING CARE PLAN FOR SURGICAL PATIENT
Nursing Diagnosis Expected Outcome Nursing Intervention
1. Knowledge defcit
related to unfamiliarity
of procedure
environment
1. Patients will verbalize
understanding of
procedure and
necessary
preparation
B. Perform pre-op/post-op education
C. Assess barries/readiness to learn
and response to teaching
D. Use age/developmentally specific
statements when instructing patients
E. Reassure the patient, encourage
feedback and questions
F. Review discharge instructions and
follow up with written copy for patient
2. Anxiety/fear related to procedure 2. Anxiety will be managed or relieved A. Assess patient’s level of anxiety
B. Acknowledge patient’s anxiety
C. Reassure patient/family, encourage
verbalization and questions
3. Percentage of surgical
Infection
3. Patient is infection free A. Patients will receive ordered
antibiotics prior to procedure
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Preoperatively by Rockland & Bergen Surgery Center,

71. INTRA OPERATIVELY
1. Anxiety related to
surgery/procedure and
possible finding
1. Patient verbalizes
and/or demonstrates
decreased anxiety level
A. Assess patient’s knowledge of operative routine
• Instruct of operative routine
• Provide clear, concise explanation
B. Remain with patient as much as possible
C. Offer emotional support
• Discuss concerns and possibilities
2. Potential for injury
to musculoskeletal
and/or neurological
systems related to
movement.
transfer, position, or
length of procedure
2. No injuries, falls,
redness, bruises, or skin
abrasions evident on
arrival to PACU
A. Assess skin condition pre-op and document any
unusual markings
B. Keep side rails up on stretcher during
transportation
C. Lift or roll patient with extra help when transferring
from stretcher to table
D. Check for and relieve all potential pressure areas,
ie., elbows, coccyx, popliteal
• Pad bony prominences
• Smooth out sheets under patient
E. Document placement of safety strap above knees
unless otherwise indicated
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Diagnosis Expected Outcome Nursing Intervention

72. 3. Potential loss of
privacy and dignity
related to physical
exposure or disclosure
of confidential
information
3. Reasonable privacy/
dignity maintained
throughout procedure.
Confidentiality
maintained
A. Keep doors closed
B. Limit traffic of personnel
C. Avoid unnecessary exposure by
limiting skin exposure only to area
needed for peop
D. Make chart available only to
authorized personnel
4. Potential impairment
of skin integrity r/t
• Prep solutions pooling
• Improper placement of
electro-surgical
grounding pad
4. No unusual loss to skin
integrity demonstrated
by absence of redness,
bruises, abrasions,
blisters and/or burns
A. Assess for allergies to skin prep.
• Obtain appropriate solution
• Place towel along skin edges of
surgical site to absorb excess solution
and
remove when prep. complete
B. Check grounding pad site
5. Potential for infection
• Contamination of wound
or steril fileld
• Peripheral lines
5. No contamination of
sterile fileld, wound.
invasive lines or tubes
A. Supervise skin prep. for correct
procedure
• Ensure personnel are clad properly
• Maintain an aseptic environment
B. Record insertion site and ensure
integrity of IV sites with dressing or
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intraoperative

73. 1. Potential for alteration
in comfort
1. Patient will verbalize
pain tolerable or relieved
A Assess pain level
B. Acknowledge patient’s
perception of pain
C. Position for comfort
D. Administer medications as
ordered by physicians
2. Potential for postoperative
complications
2. Patient will meet discharge
criteria (Phase I & II)
A. See policy “Nursing Care in
the PACU-Phase I":" Transfer of
patients from Phase I to Phase
II”; “Nursing Care in the PACU-
Phase II”
B. Written discharge order from
physician noted on chart
C. See policy “The Center
Discharge Criteria”
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postoperative

74. SUMMERY
 Pain is must be asses for all patients who are preoperatively
,interaoperatively ,postoperatively.
 Asses the patient based on WILDA approach and 4 pain intensity
scale.
 For all surgical patient who are on analgesic assessed for B/P
,R/R, sedative score,pain intensity by VAS and NRS.
 Give an analgesics drug depend on pain scale,severity,duration
,tissue damage
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75. REFERENCE
1. Orlando Regional Medical Center,Revised 4/08/03 and 6/21/05
pain management in surgical patient.
2. Minsteri of health in Rwanda September 2012,pain management
guide line.
3. REGINA FINK, RN, PHD, AOCN ,July 2000Pain assessment: the
cornerstone to optimal pain management .
4. Produced in consultation with the European Society of Regional
Anesthesia and Pain Therapy, Postoperative Pain Management –
Good Clinical Practice.
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76. 5. Hanna Misiołek1 etal, 2014, guidelines for post-operative
pain management.
6 .MOH/P/PAK/257.12 (HB), in October 2013 ,pain
management handbook.
7. Srinivas pyati and tong j.gan CNS 2007,preoperative pain
management
8.Barbara kuhan timbyed,9th July 2013 Fundamental Nursing
Skills and Concepts on pain management.
9. Rockland & Bergen Surgery Center, 2013,nursing care
plan in surgical
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77. Pain can kill you!!!
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78. Thank you!!!
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