Early to Rise, Early to Home

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• Early to Rise, Early to Home
• Standing Patients on Day of Surgery
• Trish Davidson, PT
• Langley Memorial Hospital

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Mobilizing Patients on Day 0

• Communicate plans with nursing staff
• Physiotherapist Altered hours of work for the
  last 3 months
• Transfer/mobilize patients with RN/LPN instead
  of PTA

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Mobilizing Patients on Day 0

• Developed criteria for safely mobilizing patients
  on Day 0
• PO Day 1 get patients up closer to lunch time
• Book patients 60 days in advance of surgery

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Post-Operative Pain Control

• Langley Memorial Hospital

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Non-narcotic analgesic

• Acetaminophen
• ? 650 mg po q6h X 72 hrs then change to 650 mg
  po q4-6h PRN
• ? 975 mg po q6h X 72 hrs the change to
• 975 mg po q6h PRN
• ? 650 mg suppository pr q6h X 72 hrs then change
  to 650 mg pr q4-6 h PRN

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Nonsteroidal anti-inflammatory

• Celecoxib OR Diclofenac
• ? Celecoxib 200 mg po daily X 3 days
  (contraindicated in SULFA allergy)
• ? Diclofenac 50 mg po q8h X 3 days (may give
  first dose PR
• ? Diclofenac 50 mg pr q12h X 3 days

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Sustained Release Preparation

• ? OXYCOCONE SR 10 mg po q12h (if less than 60
  kg or opioid sensitive) if necessary after 18
  hours may increase to 20 mg q12h
• OR
• ? OXYCODONE SR 20 mg po q12h if necessary
  after 18 hours may increase to 30 mg q12h

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Sustained Release Preparation

• ? HYDROMORPHONE SR 3 mg po q12h (if less than 60
  kg or opioid sensitive)
• OR
• ? HYDROMORPHONE SR 6 mg po q12h if necessary
  after 18 hours may increase to 9 mg po q12h

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Breakthrough Analgesia

• ? Oxycodone immediate release 5 10 mg po q3
  4 h prn for Break Through Pain (BTP) if less
  than 60 kg or opioid sensitie
• ? Oxycodone immediate release 10 20 mg po
  q3-4h prn for BTP
• ? Hydromorphone immediate release 1 2 mg po
  q4h prn for BTP if less than 60 kg or opiod
  sensitive
• ? Hydromorphone immediate release 1 4 mg po
  q4h prm for BTP if gt 60 kg

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Advantages to Oxycodone SR

• Around the Clock (ATC) Dosing
• prevents pain
• maintains a pain rating that is satisfactory to
  the patient
• maintains a stable analgesic blood level
• based on the knowledge that less drug is needed
  to prevent the recurrence of pain than to relieve
  it
• prevents the undertreatment of pain in patients
  who are hesitant to request medication
• eliminates delays patients encounter waiting
  for caregivers to prepare and administer pain
  medication

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Advantages to Oxycodone SR

• Reduced incidence of nausea and vomiting
• Reduced need for antiemetics
• Oral administration
• I.V. can be discontinued or converted to a
  saline lock one less hindrance to mobilization

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Adjustments to the Regime

• Medications ordered q12h are automatically
  given at 1100 and 2200
• ? need for PRN medications
• Rapid response from anesthesiology resulted in
  specific direction to administer the Oxycodone SR
  at 0800 and 2000 hours

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Pain the fifth vital sign

• A study in which 353 hospitalized patients were
  experiencing pain
• Fewer than half the patients with pain (45) had
  a member of the health care team ask them about
  their paitn or not it in the record
• Donovan, Dillon, McGuire 1987

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Pain the fifth vital sign

• A study of 242 hospitalized patients with pain, a
  review of their records revealed that no
  assessments of pain intensity were documented by
  any caregiver.
• Gu, Belgrade 1993

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Discharge Pain Regime

• Why change what is working?