How to Set Expectations in Acute Pain
The patient's ability to perform activities after a surgical procedure or while hospitalized with a medical condition is an important part of healing and returning to normal functioning. Often orders will be written to allow for particular activities such as ambulating in the hall, working with physical therapy or advancing diet. But do you consistently think about the patient's ability to accomplish these tasks when you are considering the pain regimen?
If so, GREAT! You are on your way to delivering comprehensive care and understanding how these various activities are interconnected.
If you admit to yourself that you don't give this a thought, no worries. This post will provide some tips on how to best prepare the patient for their first steps in recovery and discharge home.
As an anesthesiologist and pain physician, I often wonder how my anesthetic will affect the patient's recovery in the immediate post-surgical period. Will any of the medications I provide cause them to be too sedated to meet the surgeon's expectations? This question benefits not only me but also the other members of the healthcare team and obviously the patient. I think it is beneficial for patients to have an understanding of what they will be expected to do while in the hospital or at home after surgery. Patients deserve to be well-informed and most will embrace the sharing of your expectations with them. This starts a conversation of what they might find challenging or what they are looking forward to. Rather than leave their activities to chance, providing a goal for the patient to achieve is just proactive care.
Healing Means Getting Back to Life
Although these activities may seem trite (wash face, brush teeth), these activities may actually be very impactful in empowering the patient to feel more capable of slowly returning to normal activities of daily living. Bathing, brushing your hair and teeth can have a significant impact on your sense of well-being; there is comfort in some of the normative activities we undertake on a daily basis.
Verbalizing these expectations also models to the patient that no activity is inconsequential and small gains add up to becoming more functional. Some tasks may be overwhelming for the patient to consider; if they are broken down to simpler tasks, the patient may feel more capable of completing these tasks. Communicating these expectations to patients also provides them with a sense of accomplishment, especially if these are represented clearly on a whiteboard in the patient's room or otherwise visible to the patient and the care team.
In the PreEmpt Pain app, at least one page will be dedicated to expectations. As the hospital stay progresses, the expectations will likely increase and may involve more prolonged activity. While some of the expectations may be passive (wash hair, bathing), others will require you to explain a rationale supporting the recommendation and to consider how a pain management plan can facilitate the activities.
Mobility expectations of working with physical therapy, moving from bed to chair, or ambulating in the hall require a balance of adequate pain management while minimizing sedation and fall risk. As such, the first-line agents and non-pharmacologic strategies are optimized to reduce the need for opioid medications which could cause sedation. Having said that, the timing of medication administration related to physical activity is very important. In those instances, receiving a first-line agent 30 minutes or so prior to activity can be helpful in minimizing discomfort if you expect that activity to result in increased pain. Preparation of the patient for the possibility of some increased pain normalizes the situation while you assist the individual to increase their stamina and reconditioning.
In most cases, diet will be advanced when appropriate. The patient may not have an appetite for meals but at the same time there can be negative consequences from skipping meals. Some anesthetic medications or opioids, or even the surgical procedure itself, can decrease gastric motility temporarily resulting in anorexia or lack of appetite. However, I usually encourage the patient to take something to eat at every meal time, even if this consists of a cracker or piece of toast. This helps to reset the normal rhythm of meal time and can have a positive impact on bowel habits, nausea, medication tolerance. Rather than the patient relying on what her body is telling her, it might be of greater benefit to 'eat by the clock' rather than waiting for the sensation of hunger to appear. Furthermore, it may be perfectly acceptable for the individual to have small snacks or foods during the day to maintain nutrition and satisfy hunger pangs. In my opinion, foods are an important part of the healing process and need to be included in the expectations communicated to the patient. This cannot be understood by the patient if you do not specifically communicate it.
Minimize the Possibility of Constipation, Nausea, and Vomiting
The expectations surrounding the intake of food also drives our pain and symptom management decisions. Whether or not the diet is advanced and the patient is tolerating a regular diet will drive your medication choices. Assure that you have made available a PRN (as needed) dose of an anti-emetic if the patient is at high risk of nausea. Similarly, it would be prudent to consider the need for stool softeners, especially if opioid medications have been used or if the patient suffers from constipation at baseline. Some individuals may be constipated prior to their surgical procedure; this is a worthwhile question to ask if they have regular bowel movements defined as a BM every day or every other day and/or not having to strain to have a bowel movement. Dehydration, unfamiliar surroundings, pain, fasting, anesthesia, medication side effects can all contribute to constipation and nausea.
Be Involved in Activities that Make You Feel Good
Healing after surgery also involves returning to the activities you enjoy. Some of these activities can be done while in the hospital such as reading, puzzles, drawing, and listening to music. These strategies are valuable tools that help distract from pain and signal the gradual return to life outside of the hospital. The power of these activities has been recognized; that's why we have Child Life Therapists and book carts to deliver reading material. Pet therapy helps to release mood-boosting chemicals in your body that improve the postsurgical experience. Don't wait to hospital discharge to think about these. Suggest to your patients that they are mindful of what they enjoy and bring a book or sketchbook to the hospital with them.
Putting It All Together
Recovery after a surgical procedure is not always easy. While some individuals will intuitively return to their typical functioning, others will need some guidance along the way. Rather than leaving this to chance, we need a better way of standardizing this approach to recovery after a surgical procedure (or after hospitalization for any reason). Make sure you address these areas (and ask the individual if they have specific concerns about their recovery):
Activities of daily living (ADLs)-bathing, dressing, brushing teeth, personal grooming
Physical activity-out of bed to chair, ambulating for short distances, walking outside, participating with physical therapy, improving strength, climbing stairs, getting into a car
Hydration and nutrition-carry a water bottle, eat something at every meal regardless of hunger
Constipation-this causes bloating, nausea and/or vomiting; consider stool softeners, adequate hydration, regular eating, physical activity
Enjoyable activities-reading, music (listening or making), drawing and other crafts, time with friends, puzzles, intellectual activities, television and movies
Do you have suggestions for setting appropriate expectations? If you've had surgery, have your physicians prepared you for what happened after the surgery? Share your thoughts in the chat. I'd love to hear from you!