Pain Control After Surgery Patient Information
What is Pain? Pain is an uncomfortable feeling that tells you something may be wrong in your body. Pain is your body s way of sending a warning to your brain. Your spinal cord and nerves provide the pathway for messages to travel to and from your brain and the other parts of your body. Nerve cells in and beneath your skin sense heat, cold, light, touch, pressure, and pain. You have thousands of these nerve cells, most sense pain and a few sense cold. When there is an injury to your body; in this case surgery, these tiny cells send messages along nerves into your spinal cord and then up to your brain. When you take pain medication it blocks the messages or reduces their effect on your brain. Sometimes pain may be just a nuisance, like a mild headache. At other times such as after surgery pain that does not go away even after you take pain medicine, may be a signal that there is a problem. Why is good pain control important? People used to think that severe pain after surgery was something they just had to put up with. However this is not true. Good pain control can help you feel more comfortable and maybe even get well faster. With less pain, you can start walking, do your breathing exercises, and get your strength back more quickly. Good pain control may avoid problems such as pneumonia and blood clots and with good pain control you may even leave the hospital sooner. How can I be involved in my pain control? You can talk to your doctors about how much pain you might get after your surgery. With your doctors you can help to decide on a pain control plan before your surgery. You can be involved in reporting your pain. The nurses and doctors will often ask you about your pain. They will usually ask you to score your pain somewhere between 0-10. This means that you have to imagine that 0 is no pain and 10 is the worst pain you could ever imagine, then you tell the nurse or doctor what your pain is on that scale. There is no right or wrong answer. Everyone is different. We use your pain scores to guide pain treatment. If you find pain scores difficult to use you can just say if you are comfortable or not. What can I do to help with good pain control? Before Surgery Pain Assessment 0 1 2 3 4 5 6 7 8 9 10 No Pain Mild Moderate Severe Very Severe Excruciating Understand what operation the doctor is doing, why it is being done, and how it will be done. Tell your doctor before surgery if you are already on pain medications or you take drugs recreationally, for example marijuana. Learn how to do deep breathing and relaxation exercises (see examples on Pages 11). 2 3
After Surgery Pain medications may not prevent ALL your pain. Instead, we aim for enough pain medication to make you comfortable. We want you to rest to allow recovery; but at the same time we need you to deep breathe and cough comfortably and also to be up walking and to return to normal life as soon as possible. So you should ask for pain control when you first start to feel uncomfortable. If you are uncomfortable but the pain medication is making you very sleepy it may not be safe to give more of some kinds of pain control drugs, such as morphine. In this case, your nurse will contact your doctor. You should tell your nurse or doctor if any pain medication they give you does not seem to be working, or working well enough. It is important to remember that some medications may take about one hour to have an effect. Also tell your nurse or doctor if you have any side effects that you think might be due to the pain medicines. This includes nausea, vomiting, itching, difficulty passing urine, constipation or any strange feelings or dreams. Although the side effects are quite common after surgery and although they are not always caused by the pain medication your nurses or doctor can often treat these side effects whatever the cause. How is pain after surgery (acute pain) treated? We often use the word analgesia when we talk about pain control. Analgesia means pain control or no pain. The medications that are used to control pain are called analgesics. The type of analgesia you will need and how it is given will often depend on the kind of surgery and the amount of pain that is expected. It may also depend on your age and general fitness. Some types of analgesia may be especially useful in patients who are elderly or who have had major surgery. You may only need tablets or injections for the control of your pain. Or for some types of pain you may be offered a more advanced method of pain control. At Vancouver Acute and St Pauls Hospitals the two most commonly used methods are patient controlled analgesia (PCA) and epidural analgesia. Your Attending Physician or the Pain Anesthesiologist may order tablets, injections and/or PCA. However, epidurals are only ordered and managed by the Pain Anesthesiologist. If you are under the care of the Pain Anesthesiologist, this anesthesiologist will evaluate your pain management progress daily until your pain is controlled by oral medication only. At St Paul s Hospital a Pain Specialist Nurse will also evaluate your pain management progress. 4 5
What pain-relieving medicines are used? A number of different kinds of pain medicines may be used. Some may be better for some types of pain than others as all pain is not the same. They are often used together to achieve improved comfort with fewer side effects. Please let your doctor or nurse know if you have tried some pain medicines before and it did not agree with you, or you were allergic to the medication. Some of the common types of pain medicines are: Acetaminophen (Tylenol) is commonly ordered either by itself or with other stronger pain medicines. It can be very useful especially if taken on a regular basis. There are a maximum number of tablets that you can safely take each day. It may not be safe to take acetaminophen if you have liver disease or drink a lot of alcohol. Anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin and other medications commonly used for treating arthritis pain. Examples include Advil, Naprosyn and Celebrex. Opioids are pain-relieving medications like morphine. They include morphine, hydromorphone, fentanyl and oxycodone. These are the strongest of pain medications however they are not needed for all types of pain. How do the nurses monitor the effects of pain medicines? Your nurse will check you at regular intervals. As well as asking you what your pain score is, they will also check for any side effects of the pain medications. This is done for your safety as well as comfort, so it means that they may need to check you during the night. Hopefully your sleep will not be too disturbed. Can I get addicted to morphine-like medicines? When you take pain-control drugs like hydromorphone, morphine and oxycodone for acute pain, such as the pain that happens after operations or accidents, the risk of addiction is very, very, very small. It is very important not to let the fear of addiction stop you from using enough of the medicine to be comfortable or to stop you from moving or coughing. 6 7
If I have high pain scores, will I always get more pain medication? Usually, but not always. If you are very sleepy or have depressed breathing your nurse cannot safely give more opioid pain medication. More would not be safe until you are more awake. There are also some kinds of pain that are not easily treated with opioid drugs such as morphine. In these cases, it is not sensible to give bigger doses because this could lead to side effects from the drug. It may be that other kinds of pain medicine are needed. If you usually take strong pain-relieving medicines at home, such as hydromorphone, morphine or oxycodone, it can be a little more difficult to treat pain because your body is used to the medication. This is especially so if you have been taking high doses at home. This does not mean that we will not try to get good control of your pain. It is just that finding the dose that is right for you may be more difficult and take more time. It can also be difficult to treat pain if you take some kinds of recreational drug. As suggested earlier, tell your doctor before surgery if you are on pain medications or if you take drugs recreationally (such as marijuana) Things to remember when taking pain control medications Acetaminophen (Tylenol) Although Tylenol on its own may not be strong enough to control the pain after surgery, it is a useful additional drug to reduce the amount of other analgesia that may be required, and the side effects that come with these other medications. Remember: You should not take more than the recommended daily dose. You should also NOT take other medications containing acetaminophen (Tylenol) if you are already taking plain Tylenol. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Naproxen, celebrex, ibuprofen (Advil, Motrin), and other NSAIDs reduce inflammation that cause pain. There is no risk of addiction to these medicines. Depending on how much pain you have, these medicines can lessen or eliminate the need for stronger medicines (for example, morphine or other opioids). Remember: Most NSAIDS interfere with normal body function. They may cause stomach upset and are a cause of stomach bleeding. They can also cause kidney problems. Tell your doctor or nurse if you have stomach or kidney problems. Always take NSAIDs with food or with a glass of milk. Opioids Morphine, hydromorphone (dilaudid), oxycodone and codeine are the opioids most often used for acute pain, such as pain after surgery. Remember: Opioids may cause side effects Tell us if you have drowsiness, nausea, constipation, itching, or difficulty passing urine. It is extremely rare for a patient to become addicted as a 8 result of taking opioids for pain after an operation. 9
Non-drug methods that may help with pain control These methods can be effective for mild to moderate pain and to increase the effects of pain medication. Patient teaching Learn about the operation and the pain expected afterwards (for example, when coughing or getting out of bed or a chair). Relaxation (see example opposite) Simple techniques, such as abdominal breathing and jaw relaxation, can help to increase your comfort after surgery. Relaxation techniques are easy to learn, and they can help to reduce anxiety. After instruction, you can use relaxation at any time. No equipment is needed. Physical agents Some of the non-drug pain control methods that might be used following surgery are: Cold packs, massage & rest. In general, these agents are safe and have no side effects. Distraction is very effective. This can include visiting with family or friends, reading watching TV or listening to the radio. Slow Rhythmic Breathing for Relaxation 1 2 3 4 or 5 6 7 Breathe in slowly and deeply. As you breath out slowly, feel yourself beginning to relax; feel the tension leaving your body. Now breath in and out slowly and regularly, at whatever rate is comfortable for you. You may wish to try abdominal breathing. If you do not know how to do abdominal breathing, ask your nurse for help. To help you focus on your breathing and breathe slowly and rhythmically; breath in as you say silently to yourself, in, two, three. Breath out as you say silently to yourself, out, two, three. Each time you breath out; say silently to yourself a word such as peace or relax. You may imagine that you are doing this in a place that is very calming and relaxing for you, such as lying in the sun at the beach. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes. End with a slow deep breath. As you breath out say to yourself I feel alert and relaxed. Additional points about relaxation breathing If you intend to do this for more than a few seconds, try to get in a comfortable position in a quiet place. You may close your eyes or focus on an object. This breathing exercise may be used for only a few seconds or for up to 20 minutes. 10 11
Acknowledgements Vancouver Coastal Health acknowledges information obtained from: The ACHPR Pain Control After surgery. A Patient s Guide. AHCPR Pub. No. 92-0021. Rockville, MD: Agency for Health Care Policy and Research. Public Health Service, U.S. Department of Health and Human Services. February 1992. The Royal Adelaide Hospital S.A. Australia Pain Relief after surgery Patient Brochure Revised by VCH Acute Pain Steering Group 2010 Reviwed by Clinical Nurse Specialist - Perioperative Pain - VGH 2011 Reviewed by PHC Pain Management Initiative Committee 2011 For more copies, go online at http://vch.eduhealth.ca or email phem@vch.ca and quote Catalogue No. FM.820.P161 Vancouver Coastal Health, January 2011 The information in this document is intended solely for the person to whom it was given by the health care team. www.vch.ca