N201 Pain and Post-Op Complications

• Pain theories:

  -       Balanced analgesia: using multimodal meds to treat pain

  -       ATC dosing: primarily orders are PRN so you decide the frequency, but the goal is to optimize for continuous relief 

  -       WHO ladder: step 3 down to step 1 as surgical patients move from acute pain down to mild pain and discomfort 
• Dealing effectively with pain (routes and uses)

  -       Oral

  -       SUBQ

  -       IV bolus 

  -       PCA

  -       Regional

  -       IM
• Peripheral Arterial Disease (PAD)


  Peripheral Artery Disease
• Symptoms of PAD


  • Pain - Intermittent Claudication
  • Parasthesia - Pins and needles in toes/feet due to nerve ischemia
  • Pallor, Paralysis & Pulses
  • Poikilithermia (Polar) - Cool skin, risk of total occlusion
• If the vessel that supplies the limb occludes completely then the distal portion will turn white and feel cold! This is Acute Arterial Ischemia and requires surgical intervention within 12-24 hours.
• Goals of Interprofessional Care for PAD

  • Risk factor modification
  • Medication therapy
  • Exercise therapy
  • Nutritional therapy
  • Complementary and alternative therapies
  • Interventional radiological catheter-based procedures
  • Surgical interventions
• Balloon Angioplasty


  Surgical treatment for PAD
• Arterial Bypass


  Surgical treatment for PAD
• Anticoagulant Medications


  • Warfarin - Dosed on INR results aiming for 2-3x normal INR
  • Heparin IV - Dosed on PTT results, used for sudden & complete occlusion pre-op
  • Low Dose Heparin SC - Not dosed on lab values but need to watch platelets for HIT
  • LMWH - Dalteparin SC, not dosed on lab values but need to watch platelets for HIT
• Antiplatelet Medications


  • ASA - Antiplatelet PO OD
  • Clopidogrel (Plavix) - Antiplatelet
  • Ticagrelor (Brilinta) - Antiplatelet
• Lipid Lowering Agents


  Reduce the risk of new or worsening symptoms of intermittent claudication, reduce risk of MI, Stroke and death by 30%, target LDL (bad fat) is < 100mg/dl
• Lipid Lowering Medications


  • Atorvastatin (Lipitor) 20-40 mg po OD
  • Lovastatin (Mevacor)
  • Rosuvastatin (Crestor)
  • Simvastatin (Zocor)
• Blood Sugar Control


  Target range of fasting blood sugar is 4-7 mmol/L, controlled with diet and medications like Metformin (Glucophage), Glyburide, Rosiglitazone, Glipizide
• Aneurysms


  Outpouchings or weakening in the wall of arteries, primarily asymptomatic until rupture
• Symptoms of Ruptured Aneurysm

  • Diaphoresis
  • Pallor
  • Weakness
  • Tachycardia
  • Hypotension
  • Abdominal, back, groin, or periumbilical pain
  • Changes in level of consciousness
• Types of Aneurysms


  • Thoracic aortic aneurysm
  • Abdominal aortic aneurysm
  • Renal artery aneurysm
  • Popliteal artery aneurysm
  • Cerebral artery aneurysm
• Diagnostic Tests for Aneurysms

  • Chest/Abdominal Xrays - abnormal widening of aorta
  • ECG - rule out MI
  • Echo - assess aortic valvular function
  • US - screening and monitoring of AA
  • CT (2D or 3D) - most accurate to determine size and thrombus presence
  • MRI - assess site/severity
  • Angiography - map out aortic system and involvement of other vessels
• Goals of Interprofessional Care for Aneurysms

  • Prevent aneurysm rupture
  • Conservative management
  • Nursing implementation
  • Health promotion - lifestyle, medications, etc.
  • Acute intervention
  • Preoperative care - monitor for s/s bleed (shock)
  • Graft patency
  • Perioperative care - post op usually to ICU before ward
  • Cardiovascular status
  • Respiratory status
  • Infection
  • GI status - s/s of paralytic ileus
  • Neurological
  • Peripheral perfusion
  • Renal perfusion
• EVAR


  Endovascular aneurysm repair, less invasive than open repair
• Open AAA Repair


  Open abdominal aortic aneurysm repair, more invasive than EVAR
• Post-Op Care for Aneurysm Repair

  • Vigilant and ongoing assessment
  • Priority assessment of BP, urine output/renal perfusion & peripheral pulses (NVS Q4H)
  • Prevention of graft occlusion by administering anti-platelet medications as ordered & BP meds
  • Monitor for S&S of aneurysm rupture (diaphoresis, pallor, weakness, tachy, hypotension, sudden & severe back pain, & decreased LOC)
• Peripheral Venous Disorders


  Includes phlebitis, venous thromboembolism, chronic venous insufficiency and venous leg ulcers
• Venous Thromboembolism (VTE)


  Thrombus formation due to inflammation of vein, includes DVT and pulmonary embolism
• Blood Tests for VTE

  • aPTT
  • INR
  • ACT
  • Hb
  • Hct
  • Platelets
  • D-Dimer
• Medications for VTE


  • Warfarin
  • Heparin
  • LMWH (enoxaparin)
  • Apixaban
• Goals of Interprofessional Care for VTE

  • Prevention
  • If DVT diagnosed: pain relief, decreased edema, prevention of skin breakdown/ulceration, prevention of complications related to anticoagulation therapy, prevention of PE
• Chronic Venous Insufficiency


  Can be acute or chronic, common in older people and women, often painful and debilitating, due to weak/damaged valves leading to blood pooling, swelling, skin changes, wounds, ulcers
• CEAP Classification System


  Clinical, Etiology, Anatomy, Pathophysiology
• Compression


  Treatment for chronic venous insufficiency