Under the Covers: My Experience With Post-op Pain Control
You have to have surgery. Surgery is scary. From the moment it is scheduled there is a lot of planning to do. I recently had surgery, and being in the hospital bed, although not brand new to me, isn’t where I would choose to be. My recent experience refreshed my memory of my previous experiences with immediate post op pain control, or lack of.
As nurses, we are used to being in control. We help manage our patient's medications, their diet, and activity. No matter where nurses work, we have to organize our day in order to get everything done. Much of the time we feel like we are barely keeping our heads above water. Nursing has changed so much over the years, and it feels like more responsibility is added all the time.
At some point, we will all find ourselves under the covers instead of standing at the bedside. It is unnerving to say the least. We must at that point put ourselves in the care of the nurses, nurse anesthetists, anesthesiologists, doctors, and surgeons. It makes me nauseous just thinking about it. Knowing so much can be a blessing and a curse at the same time. Personally, I don't announce that I'm a nurse, but they usually figure it out when I start asking questions or requesting certain things.
Very recently, I found myself under the covers. I felt like throwing up, crying, and running out the door in my lovely hospital gown. Things began running through my head, what if I die? Throw a clot? Stroke? Wake up on a ventilator in ICU? I have seen too many things happen. My husband sat in the chair next to my bed with no idea of what was going on in my head. I took a deep breath and reminded myself that I had prayed about this, and I had to put my trust in God.
My admitting nurse did a great job, and the nurse anesthetist and anesthesiologist made me feel taken care of and listened to. With a tendency for post op nausea, they gave me a scopolamine patch and marinol. The marinol was new to me for post op nausea and vomiting. Everything worked well, because I did not have any nausea or vomiting.
I don't remember PACU, but I do remember being rolled back to day surgery. I heard the nurse give report and then nothing. When you are in that space of waking up from anesthesia, you can go from sleeping to awake with severe pain. Any pain medications given at this point were probably given towards the beginning of the surgery and this is hours later, or one may have gotten pain medication in PACU. Anesthesia is pain blocking, but as it wears off, one can still have severe pain.
My husband took a picture of me when I first got back to day surgery and I was grimacing and crying in pain. As my head cleared, I looked around and saw that I had a blood pressure cuff on but it wasn't attached to anything, in fact, there was no monitor in the room. Not once was my pain level assessed or not one vital was taken. No temperature, B/P, heart rate, or pulse. I was flabbergasted. Someone came in the room and brought me a ginger ale and a cup of ice. They placed it on the bedside table at the end of the bed. I had no idea it was there. My husband helped me out of course, but what if he wasn't there?
Aside from the neglectful nursing, my point here that I am trying to make is that there seems to be a misconception about the post op period in regard to pain management. I remember when my mother-in-law had lumbar surgery. I was sitting in the chair just being there for her. She would wake up and cry out in pain, say a few words then drift off back to sleep. I told the nurse when she came in that she was in pain, and the nurse refused to give her anything because she had her eyes closed.
One thing I do know, is that once a pain level gets severe, it is really difficult to get under control. The period of waking up from anesthesia is often confused as the patient being comfortable. If the patient wakes up and cries, grimaces, any of the pain indicators, then they are having pain. If the patient's pain is well controlled initially, then they will recover faster. They will move more, eat better, therefore help to prevent surgery related sequela such as pneumonia.
Several years ago, I had another major surgery. For this one, I was admitted overnight on the orthopedic floor. I don't remember much about the day of surgery, but that night, I was more awake and beginning to shake off the effects of anesthesia. The nurse came in and I told him I was in a lot of pain. He replied in a very sarcastic manner that I had a pain pump, with the button on the left side of my bed. What!? I looked over and sure enough, there was the magic button. I began pushing that button until I felt better physically and emotionally.
I had no idea that the pain pump was available to me. Once again, it is forgotten that patients need to be assessed and reassessed. I feel that the nurse should have walked over to the bedside and put the pump in my hand and explained it to me, more than once if need be.
My whole point of writing this is to voice my experience with post op pain control. I feel that sometimes it can be inadequate due to the nurses' misconception of the role of anesthesia and pain control in post op care. Pay attention to nonverbal cues as well as when a patient complains of pain. Give pain med when appropriate, it will help the patient recover.
Has anyone else experienced this? Please share your experience.Last edit by tnbutterfly on Jun 15, '18
About Brenda F. Johnson, BSN, RN
Joined: Oct '14; Posts: 231; Likes: 850
RN at Gi Lab; from TN , US
Specialty: 25 year(s) of experience in Gastrointestinal NursingSep 29, '17Occupation: allnurses Asst Community Manager, APRN Specialty: 25 year(s) of experience in Nephrology, Cardiology, ER, ICU ; From: US ; Joined: Apr '00; Posts: 53,709; Likes: 27,036Thanks so much for this article.
I recently had major surgery and had excellent pain control. That said, pain is very subjective. I've talked to multiple people who have had surgery similar to mine and they complained that they had horrific pain for weeks afterwards. I was actually back to work 8 days later. So...pain is very much what the patient says it is. Its not OUR interpretation of what the patient SHOULD experience. Its very individualSep 29, '17From: CA, US ; Joined: Jul '06; Posts: 2,977; Likes: 7,097So sorry this happened to you. It's appalling. All I keep thinking is DUH. Of course your mother-in-law was in pain. Sure you may have been told 20 times about the pain pump button but DUH anesthesia and pain meds cause amnesia!
If I had a dollar for every time a post op patient asked me the exact same question over and over I'd be rich!Sep 29, '17Specialty: 10 year(s) of experience ; From: SE ; Joined: Jan '13; Posts: 1,523; Likes: 11,916My husband took a picture of me when I first got back to day surgery and I was grimacing and crying in pain. As my head cleared, I looked around and saw that I had a blood pressure cuff on but it wasn’t attached to anything, in fact, there was no monitor in the room. Not once was my pain level assessed or not one vital was taken.
Generally speaking, I'm not overly concerned by the fact that a patient isn't on a monitor once they've left the PACU (assuming they are stable) but the fact that your pain level wasn't regularly assessed and reassessed (and treated) and that your vitals weren't checked is in my opinion unsatisfactory.
OP, I'm very sorry you've experienced this and I hope that you have healed well after your surgery.
My whole point of writing this is to voice my experience with post op pain control. I feel that sometimes it can be inadequate due to the nurses’ misconception of the role of anesthesia and pain control in post op care.
I think that some nurses believe that the undertreated pain is only temporary in nature (a short-lasting nuisance) and that it can't have any negative long-term effects. Not true. Undertreated pain comes with a host of unwanted effects and can actually lead to persistent postsurgical pain that can last a lifetime, which of course will affect quality of life. (All surgical procedures can result in chronic pain but some carry a higher risk of that complication, for example; cardiac/thoracic surgeries, breast surgeries and amputations). Treat your patient's pain!
To completely understand the human body's stress response to surgery and the harmful effects of unrelieved pain, one has to commit many hours to studying. (A good place to start for those who are so inclined might be the HPA axis ( hypothalamic–pituitary–adrenal axis)).
In short unrelieved pain triggers and prolongs the endocrine response; ie the release of various hormones such as (but not limited to) cortisol, catecholamines and glucagon. Insulin levels decrease. The increased endocrine response in turn initiates a slew of metabolic, cardiovascular, respiratory and genitourinary effects. What effects can you expect from unrelieved pain? Well, cardiovascular effects like; increased heartrate and cardiac workload, increased systemic, peripheral and coronary vascular resistence, increased oxygen consumption and hypercoagulation & dvt's. Respiratory effects; decreased tidal volume and decreased functional capacity. Increased risk of infection, atelectasis and hypoxemia. Also many metabolic effects; hyperglycemia, insuline resistence and muscle protein catabolism. And of course; urinary retention/decreased urinary output and fluid overload. (I'm too lazy and tired to look up the proper references/sources so this is from memory, but I think I got it right).
Surgery and postoperative pain is a humongous stress on the human body (surgery is traumatic). We have the power to if not remove, at least minimize the amount of stress inflicted on our patients.
Please, just treat the damn pain!Last edit by macawake on Sep 29, '17Sep 29, '17Joined: Sep '16; Posts: 548; Likes: 1,656In my experience pain level skyrockets when the anesthesia of a block wears off, then you have to rely on narcotics to do the job. As the blessed sweet relief of the block begins to wear off the throbbing pain of newly awakened nerves make their feelings known - loudly. They will NOT be ignored.
It's ironic that people think if a pt is asleep that they are pain-free - au contraire mon frair. If post-op pain management isn't long acting, or properly timed pt's can wake up very much in pain (after all, you can't stay awake forever).
Nothing makes one more acutely aware of post-op pain management needs like experiencing it for yourself (I remember an anesthesiologist at a hospital I worked at years ago was hit by a car while riding his bike - after his own surgical experience and discomfort of receiving cold IVF's he began warming the IVF's he administered to his pt's).
I'm so sorry your recent post-op pain control experiences were lacking, but I bet the pt's in your care thereafter were kept very comfortable by your conscientious attention.Sep 29, '17Joined: Oct '07; Posts: 674; Likes: 1,292My son was injured in Iraq and eventually received OAT surgery for an area on his foot. We were all there when he woke up...in pain. He did have a PCA and as he started to wake up (took him about half hour) I was pushing that PCA every chance I could get. The staff told me to eave it alone and if he was in pain he would tell them. When he wok up he was crying in pain. It took the nurse 20 mins to just come into his room, no apology no nothing just OK what do you want. She wanted him to try his PCA before she gave him the big stuff.
I went to track down a physician and they did give him a shot...this was about 45 mins from the time he woke up to the time he got his shot. No one cared about his pain at all but me...his mom...a nurse. He was released 5 days later and on the day of release he had a heavy therapy session. They gave him no pain pills...nothing. All I had was naproxen at home. I have dear friends who could prescribe and they did just that for my son. This was a VA hospital. When my son went back for his check up a week later someone had tagged his chart that he was drug seeking. Well at the time HE WAS, he was in pain seeking for pain medication. He has never asked for pain medication since even going through PT for weeks he just took some NSAID prior to therapy. I instructed him to get the record amended, went to QA at the hospital and they finally took that out of my sons records. Today he continues with the National Guard and is a mechanical engineer. I will never understand why people do what they do.Sep 29, '17Occupation: Critical Care Specialty: 10 year(s) of experience ; From: US ; Joined: Nov '10; Posts: 9,503; Likes: 26,488You've made some good points, particularly the importance of early adequate pain control as this reduces the cumulative amount of opiates required to control pain and improves outcomes, as well as the fact that ability to sleep does not indicate that excessive pain is not present.
But you also bring up some examples of misunderstandings between nursing staff and patients.
The first being that often the first memories someone is able to retain after surgery is after they have completed the initial close observation period. It's not unheard of for patients to adamantly believe that nobody was watching them immediately post-op, or in or case that nobody checked any vitals or did any assessments, even though they have been in post-op recovery for that last hour and frequent vitals are no longer indicated.
The second is patients who aren't really sleeping, but significantly somnolent/obtunded in between twinges of pain, and that it's generally fine to give these patients additional opiates. This requires more assessment, and it's not unheard of that the short bursts of pain are just going to have to be tolerated because in between those short bursts the patient has no room for additional CNS depression.Sep 29, '17Joined: Dec '16; Posts: 901; Likes: 3,662I'm a month out from major surgery. I had a block given to me for the first time. I kept telling the nurse in PACU I had no pain. Then on my way to my room, the block wore off and the pain was excruciating. It wore off all of the sudden, not gradual like my mind thought. I was in tears when we got to the floor. The PACU nurse felt awful and I felt bad for her, and I kept reassuring my floor nurse it was not her fault...... I will tell you, I was asking for my narcs q4h because I did not want to be in that pain again. It took 2 doses to get it under control. So that took about 6 hrs or so.
My nurses were great, but I felt like maybe they thought I was a clock watching addict because I was clock watching. Just because I didn't want to be in pain again. Every single one was awesome, but I was scared of what was being said at the nursing station. Were eyes rolling? Was I a pain? I never wanted to be that.
Being on the patient side can change your view. My recent surgery was not the first time I have been a patient, but it's always a reminder that I need more compassion. And I'm a huge advocate that you don't ever undertreat pain. But I've been reminded there is more I can do.Sep 29, '17Joined: Dec '16; Posts: 901; Likes: 3,662And I'd like to add, I'm still in significant pain a month out. I've been looked at, all is good, but I'm struggling moving around. I was up and out of bed within 12 hours of my surgery. But my incision hurts. I'm trying hard to suck it up. Been a week without narcotics and have been taking ibuprofen only. But it's not cutting it and my activity has dropped putting me at a very high risk for a blood clot with my history. The narcotics helped me move which I felt helped reduce my clot risk and helped me heal due to movement.Sep 29, '17Joined: Feb '11; Posts: 440; Likes: 1,148I work in PACU and am so sorry you had a poor experience in your phase 2 of recovery. I know many patients don't remember PACU, even the ones that have been chatting with me. I love when family is there when I take them into phase 2 and I can give the families a mini report of the things that I've been doing.
I agree that dosing off is not an indicator there is no pain, I have many times used a pain scale for unconscious patients (FLACC or CPOT) to assess and start treating pain before a patient wakes up or can verbalize they are hurting.
But I also have many patients that dose off and "forget" to breathe, and when I stimulate them (verbal or sometimes a light sternal rub) to get them to breathe... they are crying in pain again. In these cases, I explain (over and over) that while I realize they are experiencing pain their body cannot handle any more opioids. If I have to choose pain relief or breathing, I chose breathing every time.
There is where multimodal pain relief is so important. Some of our surgeons are now giving Celebrex, Lyrica, Tylenol and oxycodone p.o. pre-operatively. Our anesthesiologists give IV toradol and lidocaine. With the exception of the oxy, none of these medications cause respiratory depression, but they work on nerves and pain in different ways, and together can help decrease the amount of opioids needed to get pain under control. And then there are non-pharmalogical interventions (elevation, positioning, cold/heat, splinting....) There are also regional anesthesia pumps that release an analgesic med like bupivocaine through a catheter for several days into the surgical site (On-Q's are one type).
In cases where a patient is having pain, but I have done all I can with non-opiod/non-pharmalogical and they are too somnolent to get more IV meds, I will discharge onto the next phase if they met the other criteria. Sometimes oral meds work better and last longer then the IV stuff... with less respitory depression. Sometimes they need to give the meds a chance to catch up (I can admin fentanyl every 5 mins and dilaudid every 10m). Often pt pain will go down within minutes of receiving these medications, but they don't peak for hours... and if I give too much they can all peak at the same time. So we do have to be mindful, no-one wants to have to administer narcan, especially a patient who is then left in excruciating pain. Sometimes (with laparoscopic surgeries especially) they need to get up and start moving for the pain to come down.
We need to educate ourselves and others, to ask for multimodal pain relief... to use the Tylenol and NSAIDs around the clock (just like we give our kids when they are teething) and supplement with opioids... which means we need to ask (for ourselves and our patents) Dr's for narcotics that don't have the Tylenol/or NSAIDS in them so we don't overdose on those.
My beef is not with giving patients pain medications, it's with surgeons that tell their patients that it's an easy surgery and the patient wakes up wondering why they hurt... DUH, someone just sliced you open, of course that's going to hurt!!! And it makes me sad to know that I may have a patient that thinks I did nothing for their pain... because they don't remember that I treated it, until I needed to hold and wait for things to wear off so they would spontaneously breathe with out prompting.
I am certainly not saying this is your case OP, and in your case I would ask for a referral to a pain specialist before you develop chronic pain... there is a lot they can do with nerve blocks, ON-Q catheters and physical therapy to get rid of the pain... the sooner you start the better off you will be.Last edit by HeySis on Sep 29, '17 : Reason: spelling/poor typing skillsSep 30, '17Occupation: Certified Registered Nurse Anesthetist Specialty: 9 year(s) of experience in Anesthesia, Trauma, Palliative, Tele ; From: IL, US ; Joined: Aug '17; Posts: 25; Likes: 43Thank you so much for sharing this. As a nurse anesthetist I always try and make it a point to circle back to check on my patient's in PACU as I finish up my other cases. Your article has definitely reminded me to take another look at my patients and ensure their pain is managed in this very hazy post anesthesia time. Appreciate you!Sep 30, '17Joined: Jan '12; Posts: 756; Likes: 1,738I experienced severe pain waking up from my cholesysectomy. A 10/10 is probably a 2/10 for most people but I just do not have a very high pain tolerance. That, and the combo of the gas rising into my chest really made me feel like I was dying. Apparently I was a nightmare but I do not remember much of it other than going in and out of sleep in agonizing pain. The recovery nurse even told my husband (who later told me) that I do not wake up from anesthesia very well and that in the future I should let them know ahead of time so they can have more pain medications prepped. Uh, ok? Doubt that would ever happen. It has definitely made me nervous for surgery in the future, particularly the c-section I'll most likely end up having.Sep 30, '17Joined: Oct '15; Posts: 8; Likes: 26I had minor surgery a year ago, and was offered 1-Norco 5/325 or a Motrin after I woke up from anesthesia for a pain rating of an "8." Seriously? I think with all of the recent concern over opioid overuse and abuse, pain control has become less of a "necessity" and almost like an unwelcome burden to the provider and facility. Our facility can't seem to get it together for a cohesive pain management protocol. We are told to only give pain meds if the patient is experiencing pain, and it had better be above a "6" for any narcotics. However, you can about guess when a surgery block is about ready to wear off, and I like to give my patients "preventitive" pain meds about an hour or two before, but because they're rating their pain at about a "2 or 3", by protocol, I shouldn't be giving anything more than Tylenol, and then BOOM! An hour later they are wincing and telling me their pain is a 6 or above. Just because the nation is in an opioid crisis doesn't mean that post-surgical pain just magically disappeared and that opioids and narcotics aren't proper ways to treat it! There needs to be thoughtful, reasonable discussion about how to treat people's pain without going overboard, but also being realistic. After ortho surgery, and being stuck on a table with saws, files, etc. being used to do your surgery, you're going to hurt like hell without any pain meds. Giving someone oxycontin would be appropriate. If they're STILL needing Oxy 3 weeks post-op, then something is terribly wrong, and THEN needs to be addressed but not post-op. This is one of the most frustrating parts of my job.
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