Postoperative pain management - Essay Example

?Reflective Essay: Postoperative Pain Management Introduction Management of pain following a surgical procedure is one of the major challenges and source of concern for health care providers (Berge et al, 2004). Management of pain following a surgery employs oral or rectal analgesics, intramuscular opioid injections, systemic opioid analgesia, continuous subcutaneous infusion of analgesics, and patient-controlled analgesia (PCA). However, surveys have revealed that hospital postoperative pain management, such as opioid intramuscular injections are frequently inefficient, resulting in unrelieved pain in approximately 50% of patients (Steinberg et al, 2002). Various studies have shown that postoperative pain has significant influence on the recovery of the patient, length of stay in the hospital, mobility, cost of hospitalization and also postoperative morbidity like cognitive dysfunction and pulmonary complications (Pain Management Guideline Panel., 1992). According to Sommer et al (2008), moderate to severe pain occurs in more than 50 percent of patients who undergo abdominal surgery It is crucial to control postoperative pain and currently in every hospital in the western world, control of post operative pain is given utmost importance. An understanding of pain management in the postoperative period can be enhanced through reflection. Reflection is evaluation and examination of thoughts and actions of oneself. For health practitioners, reflection means focusing on the interaction of oneself with colleagues and environment in a particular situation so that they are able to evaluate their own behavior. “Reflection gives scope for better understanding of oneself so that existing strengths can be used to build-up for future actions "(Somerville and Keeling, 2004). In order to be an effective practitioner, one must be able to identify one's strengths in approaching a problem, assess one's level of competency and improve on what one thinks are the weaknesses so that when the same problems arise in the future, the right approach can be adapted. Reflection is also an opportunity for professional growth and development to increase competence in the nursing practice (Alexander, Fawcett and Runciman, 2006). Reflective practice is very essential for nursing clinical practice because it helps the nurse to understand, assess and learn through the experiences during clinical practice (Burns and Grove, 2005). In the following assignment, I shall discuss about management of a patient with postoperative pain based on Gibbs (1988) Reflective Cycle. This is because, Gibbs Reflective Cycle is a straight forward and recognized framework for reflection wherein it enables clear description of the situation of the patient, the analysis of feelings, evaluation of the experience, analysis to make sense of the experience, conclusion where other points are considered and reflection upon experience to examine what you would do if situation arose again. Case description Mr. X was a 67 years old male patient, who I looked after in a Surgical High Dependency Unit (SHDU). He was transferred from theatre following Whipples, where a total pancreatectomy was performed along with the removal of Gall Bladder and Duodenum. Past medical history included hypertension and chemotherapy 2 years ago following the diagnosis of pancreatic cancer. He was also underweight. The patient was transferred to SHDU in a stable condition. On the 1st day post op, the Epidural Analgesia’s catheter was dislodged by accident and according to the protocol (NHS 2009), it could not be used anymore. Although, the patient had prescribed oral pain reliefs as required, Mr. X showed discomfort and pain, once resting and moving in bed. Because of the risk of post operative complications including pressure sores and chest infection, the issue was highlighted to Pain Management Nurse, who prescribed Patient Controlled Analgesia (PCA). The Pain Management Nurse provided short educational session for Mr. X, as he never used PCA before and appeared to be anxious about using the button by himself. When the nurse left, the patient admitted to myself that he did not really understand the nurse, when he spoke to him about the use of PCA. Mr. X asked me for more clear explanation and for more information about the device. As a student nurse, I did not have enough knowledge and experience about the PCA, so I clearly explained to Mr. X that I have to ask somebody else to come and speak with him. Evaluation As a student nurse, I was inexperienced and was not much aware about various strategies to treat post operative pain following abdominal surgery. First of all, we could not save the epidural line which was offering good pain relief. Secondly, the patient could not be educated properly about patient-controlled analgesia because of lack of experience. The patient trusted that I was aware about PCA. Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or he enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surroundings, relationships and situations. Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The role of nursing is authenticated in helping people move towards independence in all activities of daily living. They take up the role of a family member. Their actions have an impact on the individual and affect their levels of dependence/independence (Roper et al, 2002). The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). Reflection is important for nurses in particular for a number of worthy reasons. According to the NMC, (Somerville, and Keeling, 2004), nurses have a duty bested upon them to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues. They are obliged to act as per the expectations of their profession. In order to make it possible for them to constantly update their professional knowledge and skills, reflective practice becomes essential. Also, nursing is a profession which thrives on mutual support and understanding between colleagues. This interaction and communication are essential aspects of this profession. Self-awareness, self-direction and keeping in touch with environment help to build the culture of mutual understanding (Somerville, and Keeling, 2004). All this is possible through reflective practice wherein there is feedback on the impact of their actions on their patients, the families of the patients, their colleagues and ultimately on the organization. Thus, this incident helped me learn more about pain management in the postoperative period. Every nurse-patient encounter is unique and there are no fixed solutions to many nursing problems. Advances in the 21st century are seeing many new developments in the field of healthcare forcing the nursing faculty to reinforce effective and appropriate education. This becomes of primary importance by virtue of the nature of the profession nursing is. As such, the primary goal of nursing is to provide quality health care to patients. Reflection is now the corner stone of the professionalism of nursing. Hence many nursing educators have incorporated reflective practice as a part of nursing education. Deliberate and systematic use of reflection is an effective learning tool and must be applied consciously with effort every time it is used man (Bulman and Schutz, 2004). I with this because; in order for an objective to be achieved, one must formulate a process or a series of steps in order to have a guide for the plan of action to be effective. Analysis Pain is a symptom of injury or illness in the part of the body from where the pain arises. Pain may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP, 1986; cited in NHS, 2006, p.3). Pain affects not only the physical well-being of the person, but also the cognitive and emotional aspects. The functioning of the individual, his or her social and family life and ability to work at employment (NHS, 2006) can also be affected. Coll (2006) agrees with this definition of pain, but also adding the sensory and emotional responses felt by a patient is experienced in a unique and individual way, making pain a personal and subjective experience. Pain relief in Mr. X was based on the WHO's Pain Relief Ladder (WHO, 2009). This ladder is a useful guide to prescribe pharmacotherapy for pain. There are 3 steps in this ladder and the lowest step is that of mild pain. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The last step is that of severe pain. This pain interferes with most of the daily living activities. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan, Librach & Beyene, 2004). If treatment with above medications is not effective, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. The dose of acetaminophen for relief of pain is 650mg- 1000mg every 6 hours. It rarely causes side effects. Aspirin is given at doses of 500 mg 3-4 times a day. It can cause gastritis and gastrointestinal bleeding. For those who cannot tolerate aspirin, acetaminophen is a good substitute. The most commonly used NSAID is Ibuprofen. It acts by decreasing prostaglandin synthesis. It can be given at doses 400-800 mg every 8 hours. Naproxen sodium is another NSAID useful in mild- moderate pain. It acts by decreasing cyclooxygenase activity which further reduces prostaglandin synthesis. The dosage can be either 275 mg 3 times a day or 550mg 2 times a day (Mann and Carr, 2006). Nurses must be aware of the WHO ladder for acute pain management. They must also be aware of drug to drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When a patient reports side effects, the nurse must record, manage and monitor the symptoms, guide the consultant about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as teachers by educating the patients about the dosage of the drugs and about the need for good pain control (Delphi Study, 2007). Therefore for Mr.X, initially, intravenous paracetamol was administered for pain relief. When this did not help, diclofenac was given. When the patient continued to complain of pain, tramadol, a moderate opioid was given in combination with paracetamol. Following this, patient controlled analgesia or PCA was administered to enable self control of pain. Therefore for Mr.X, the analgesia used was morphine, which is the most widely used analgesic drug in PCA. PCA was used in Mr.X for 24 hours following which he was started on oral tylex 30/500mg for one day. At the time of discharge, he was advised to take paracetamol every 4-6 hours. Patient-controlled analgesia (PCA) and epidural analgesia are among the most commonly used analgesic techniques for the control of postsurgical pain (Weber et al, 2007). A recent study by Werawatganon, and Charuluxananan, publihed in the Cochrane review revealed that epidural analgesia is a better mode of control of pain in patients undergoing abdominal surgery (Werawatganon and Charuluxananan, 2005). Similar reports were demonstrated by Wu et al (2005) Nevertheless, there is no congruent evidence to strongly recommend epidural analgesia in the postoperative period to patients undergoing abdominal surgery. Researchers who have evidence that epidural analgesia is superior to PCA in control of pain are confused, and suggest further evaluation to ascertain as to which is a better mode of pain relief, keeping in mind the complexity of the procedure, patient satisfaction and risk versus benefit ratio. Patient-controlled analgesia (PCA) is a type of intravenous opioid infusion that allows the patient to control the loading of analgesia to the body by using a PCA pump. The patient is independent in controlling his/her pain, eliminating administration delays and nursing intervention. It also eliminates frequent injections (Mann et al, 2000). The medications used for PCA can be any opioid. These medications are delivered through pumps known as PCA pumps. Some of the drugs administered via PCA are morphine, fentanyl, remifentanil or tramadol. The use of PCA in managing pain was introduced more than 20 years ago and was later considered as the gold standard in the management of acute pain (Lehmann, 2005). The pumps are computerized and the dose of drug administered whenever the patient presses the button is set by the nurse. The nurse also sets the 'lock out' dose which is the maximum dose of the medication permitted during a certain period of time for the age, sex, weight and condition of the patient. This 'lock out' facility is a means to prevent excess intake of medication (Lehmann, 2005). PCA administration is generally safe. However, it may be associated with many side effects, like any other treatment strategies. Medication errors can occur due to wrong programming, defective functioning of the pumps, wrong drug dosage calculation or administration of medication by proxy. Other side effects may occur due to the drugs itself. Research has demonstrated the safety of PCA in the management of postoperative pain following various types of surgery including abdominal surgery. Nonetheless, some inconveniences in the form of nausea, sedation, hypoxemia, pruritus and respiratory depression are expected to occur. While several studies have demonstrated the efficacy of epidural analgesia in the relief of postoperative pain in abdominal surgery patients as against PCA, motor blockade continues to be a problem worth considering because of which epidural analgesia is yet in evaluation stage. Pain specialist nurses are essential in the diagnoses and treatment of pain in all types of settings of health care. Since they are closest to the patients, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of postoperative pain. Nurses can be the first persons to evaluate pain and then can advise pain relief was appropriate. Nurses can also evaluate the effects of the analgesia prescribed. There are many pain assessment methods/tools that can give an accurate assessment of pain an example is the Numerical Rating Scale (NRS), Pain Drawing, and McGill Pain Questionnaire. Dougherty and Lister (2004) mentions, that accurate assessment of a patients’ pain is a prerequisite of effective pain control and an essential part of nursing care. Furthermore, in order for surgical pain to be effectively controlled, it must be frequently assessed. Pain assessment starts prior to surgery and continues until discharge. Pain assessment tool must be selected based on the cognitive status of the individual and staus of visual acuity. Inappropriate selection of pain tols may lead to deficient or over dose of medication, improper control of pain and side effects to medications. As for Mr.X the pain is mainly due to surgery and arises from the skin and muscles of the front of the abdomen. The pain is acute in nature. While managing post-operative pain, assessment of pain is a very important and crucial for appropriate pain management. Mr.X, since the source of pain is obvious; the most important aspect in the assessment of pain is evaluation of the intensity of pain. There are several tools to ascertain the intensity of pain. The mixed Descriptor/Rate Scale of 0-3 was used to evaluate pain. This scale was used 0 being no pain 1 being mild, 2 moderate and 3 severe . Mr. X was happy to use this tool. It is also important for the nurse to take into account non-verbal indications that Mr.X was in pain as well as checking his baseline Obs. Higgs (2009) highlights that by ignoring pain, the nurse may miss opportunities to improve mortality and reduce morbidity. Furthermore, there are important factors to consider when choosing a pain assessment tool it should be easy to understand, valid and able to incorporate Mr.X’s own perception of pain. The Verbal/Mixed Descriptor/Rate Scale was used to assess Mr.X’s pain and was an appropriate tool for use in Mr.X’s case as it allowed the nurse to carry out an accurate pain assessment. Mr.X also said this was an easy tool to use when describing his pain severity, however, had Mr.X had been cognitively impaired or hard of hearing, this tool may not have been the most appropriate for use. This scale is popular with the local health trust and the private hospitals and is used on a daily basis. Mr.X’s observations and pain score were monitored and recorded at thirty minute intervals. , and whilst her modified early warning score (MEWS) was slightly high. The nurse continually visually observing Mr. X and always asked for Mr. X’s pain score when carrying out the routine Obs. The nurse also checked Mr. X for non-pharmacological problems, and was aware that Mr. X had a dressing over his abdomen therefore checked for leakage and that the drains were intact. Mr.X had pain at the site of surgery and thus was feeling uncomfortable. His heart rate and respiratory rate were high because of the pain. The pain also prevented him from moving. Based on these nursing diagnoses plan of action were determined. Planning is a process of setting health related goals that are aimed to resolve the potential health problems identified by means of nursing diagnosis. The nurses discussed these nursing diagnoses with the consultant and ascertained a plan of action and then implemented them. Implementation is the means of delivering the plan to achieve the set goals. The nursing interventions and medications for pain management and mobility were implemented as per plan of action. In order to keep the patient comfortable pillows were placed under knees so that her knees would always be in flexed position, thus keeping the abdomen lax and allowing drainage of any excess fluid. Mr.X was started on intravenous fluids until he could take food and liquids orally. The bladder catheter was removed within 24 hours after surgery and the patient was encouraged to call for help whenever he wanted to pass urine or empty his bowels. After 12 hours after surgery, once bowel movement and sounds had returned, he was given clear liquids and when he began to tolerate them, soft diet was initiated. Intravenous fluids were discontinued after the patient began to tolerate diet and oral fluids. Conclusion Management of postoperative pain in patients undergoing abdominal surgery is a challenge. While several strategies are there to cause relief of pain, improved pain relief both at rest and during activity like coughing is provided mainly by epidural analgesia and PCA. Hence many experts have been using these strategies or a combination of these to cause analgesia in the postoperative period. In this patient, pain relief was achieved through use of PCA, a novel strategy for pain relief. This incident was a good feed for reflection and further learning about pain management in the post-operative period. Action Plan In a similar situation, when epidural analgesia cannot be continued further, PCA will be initiated immediately and the patient will be educated about it properly. References Alexander, M.F., Fawcett, J. & Runciman, P.J. (2006) Nursing Practice Hospital and Home: The Adult. Third Edition, Churchill Livingstone: Edinburgh. Bell et al. Randomized trial comparing 3 methods of postoperative analgesia in gynecology patients: patient-controlled intravenous, scheduled intravenous, and scheduled subcutaneous. American Journal of Obstetrics & Gynecolog 2007; 197: 472.e1-472.e7 Bulman, C. & Schutz, S. (2004) Reflective Practice in Nursing. 3rd Edition, Blackwell Publishing: Oxford. Burns, N., and Grove, S. K.. (2005). The Practice of Nursing Research: Conduct, Critique and Utilisation, 3rd ed.. Philadelphia: W. B. Saunders Co. Coll, A.M. (2006). How can I make it better? A guide to pain management for day surgery nurses. Salisbury. APS Publishing. Delphi Study. (2007). WHO Normative Guidelines on Pain Management. Retrieved on 26th April, 2011 from http://72.14.235.132/search?q=cache:XaoHa1yWUgkJ:www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf+Delphi+Study.+(2007).+WHO+Normative+Guidelines+on+Pain+Management&cd=1&hl=en&ct=clnk&gl=in Dougherty, L. Lister, S. (ed). (2004). 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Retrieved on 26th April, 2011 from http://www.who.int/cancer/palliative/painladder/en/print.html Read More