Anaesthetic and Post-Anaesthetic Care Nursing - Essay Example

ACUTE PAIN MANAGEMENT: SCIENTIFIC EVIDENCE ANAESTHETIC AND POST-ANAESTHETIC CARE NURSING INTRODUCTION: The National Health and Medical ResearchCouncil (2005) Report, Acute Pain Management: Scientific Evidence, second edition is a comprehensive report of evidence-based best practice in the management of acute pain, by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. The authors have clearly explained the state of the art in acute pain management. The report gives authoritative and relevant information, useful for pain medicine physicians and health care practitioners in out patient clinics as well as in hospital settings. Burkey (2006) and Carns (2005), in their respective reviews of the NHMRC Report, have recommended it as an excellent guide for more effective treatment of patients in acute pain, using the best available evidence. The aspects of the report which are related to central neural blockade, regional anaesthesia, local anaesthesia and intravenous sedation have implications for patient care, especially from a peri-operative nursing perspective. DISCUSSION: Effective management of acute pain is a major priority for both patients and healthcare providers. Inadequate control of acute and postoperative pain can lead to adverse outcomes that include pulmonary and thromboembolic complications and additional time in hospital or intensive care, with associated increased costs. It can also have negative effects on mobility and function, emotional well-being, quality of life, and overall recovery. Although significant advances have been made in the understanding, assessment, and management of acute pain, further improvements in clinical practice are required. Therefore, evidence-based, up-to-date guidelines are required, state Walker, et al (2006). The NHMRC (2005) Guidelines on Acute Pain Management The National Health and Medical Research Council (NHMRC) guide is around 325 pages in volume, clearly written with statements backed up by significant work done by researchers, showing the level of evidence available. Chapters are divided into major pain medicine categories, and then each category is further delineated into more specific topics. Key messages are highlighted at the end of sections to further clarify main points of discussion. These key issues which consolidate the main points are given also at the beginning of the document, as a summary. By reading through them, the reader’s interest is evoked to go through the related chapters. The main chapters start with the physiology and psychology of acute pain, the assessment and measurement of acute pain, provision of safe and effective acute pain management, and cover all aspects such as the analgesic drugs which are systemically administered, those which are regionally and locally administered, and the routes and techniques of drug administration. Non-pharmacological techniques and specific clinical situations such as post-operative pain, acute spinal cord injury, etc are also discussed. Each chapter is sub-divided into specific topics. Acute pain is produced by a wide range of physiological and pathophysiological processes, and includes inflammatory, neuropathic, sympathetically maintained, visceral, and cancer pain. Awareness and diagnosis of these different components can alter management, and mechanism-based treatments have been proposed to improve future pain management strategies (Woolf and Max, 2001). Pain assessment must encompass not only measurement of pain intensity to assess severity of pain and response to treatment, but also a detailed pain history (site, quality, aggravating and relieving factors, response to treatment, pre-existing pain conditions) as this may have diagnostic implications and influence management, state Walker, et al (2006). Therefore, “Acute Pain Management: Scientific Evidence” incorporates information from multiple aspects of pain management (e.g., neurobiology, pain assessment, pharmacological and non-pharmacological management) and includes clinical evidence relevant to different patient populations (e.g., elderly, pediatric, and obstetric) and specific medical conditions (e.g., burns, spinal cord injury, neurological diseases). Analgesics are the mainstay of perioperative pain relief. Combinations of drugs and routes of delivery achieve maximum analgesia with minimal side effects, that is: ‘multi-modal analgesia’ (Griffiths and Justins, 2006). Due to the complexity of nociceptive transmission, multimodal therapy directed at different aspects of pain signaling has been recommended (Carr, et al 2005). There is evidence that effective perioperative analgesia may prevent the development of chronic pain. Walker, et al (2006) state that evidence supporting a number of combinations, such as the opioid-sparing effects of acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs in the postoperative period and the use of adjuvant drugs for control of neuropathic pain are of significance. There is increasing recognition that pain cannot easily be separated into “acute” and “chronic” management. The management of acute pain can have an impact on the likelihood of persistent pain, and acute episodes of pain in patients with chronic pain conditions can present specific management issues (e.g., opioid tolerant patients). Effects on physical and emotional function may impact on overall outcomes, and current evidence for non-pharmacological and psychological interventions (for example, transcutaneous electrical nerve stimulation, cognitive-behavioral strategies) is also outlined. Results from controlled trials in postoperative patients are presented (Walker, et al, 2006), and there are efforts to include current best evidence and practice points for specific patient groups. The Aspects of the NHMRC (2005) Report which are concerned with Central Neural Blockade, Regional Anaesthesia, Local Anaesthesia or Intravenous Sedation are: Chapters: 6. ROUTES OF SYSTEMIC DRUG ADMINISTERATION. 7. TECHNIQUES OF DRUG ADMINISTERATION. 9. SPECIFIC CLINICAL SITUATIONS. 10. SPECIFIC PATIENT GROUPS. The Implications for Patient Care From a Peri-Operative Perspective Effective pain management can be achieved through a collaborative, interdisciplinary approach using an individualized proactive pain control plan. Frequent assessment and reassessment of pain, use of drug and drug-free therapies, and implementation of an institution-wide programme is necessary. However, implementation of clinical practice guidelines in a large setting is a complex process. The challenge for organizations is to incorporate these principles into their philosophy and care practices, states Collins (1999). Nurses must identify local influences and attempt to address the issues specific to their own work environment that interfere with optimal pain management. Without the combination of evidence, context identification and facilitation of implementation, little change in nursing practice and patient can be brought about. The safe and effective delivery of pain relief during the perioperative period using existing drugs, techniques and nursing care, is the responsibility of practitioners, nursing staff and other health care personnel involved in acute care. Pain intensity should be measured routinely and regularly after surgery. Treatment regimens should be selected for each patient. The potential benefits of an analgesic regimen must be balanced against the potential risks. Each institution must provide adequate staffing levels and a safe environment to guarantee good pain relief and to prevent harm. Griffiths and Justins (2006) state that the basis of high-quality control of pain is that health care professionals listen to their patients and respond appropriately to reports of unrelieved pain. The NHMRC guidelines (2005) advocate the frequent and appropriate use of pain-rating methods such as categorical rating scales or visual analogue scales. In addition, careful pain histories should be obtained in order to understand patients’ usual responses to pain and pain relief strategies. Nurses’ pain assessment skills: Several studies have demonstrated nurses’ perceptual ability to understand the complex physiological and psychological responses of patients experiencing pain. However, this ability seems to be more readily demonstrated verbally when nurses are asked about their patients’ pain response but is poorly documented.The introduction of pain assessment parameters onto patient observation charts may help to encourage nurses to conduct and document pain assessment procedures as readily as other routine observations such as blood pressure, pulse and temperature. Rutledge (1999) suggested prioritizing pain assessment as the fifth vital sign. Harmer and Davies (1998) demonstrated that pain needed to be assessed at rest, during movement and on deep inspiration. They found that the introduction of formal assessment and recording of pain led to an overall reduction in the percentage of patients who experienced pain at rest from 32% to 12%. Another significant assessment issue relates to nurses’perceived preoccupation with physical indicators of pain as compared with subjective indicators. In an Australian Delphi survey, the defining characteristics that were considered most important for nurses’ assessment of pain were guarding the affected area, abnormal positioning, increased pulse rate and decreased mobility. However, data involving verbal complaints of pain, altered facial expression, crying, moaning and requests for analgesia were identified as minor defining indicators of pain.These findings have been confirmed in other studies (Nash, et al 1999; Stannard, et al, 1996). While pain is generally acknowledged as a multidimensional complex phenomenon, where the patients’ subjective views are critical, the apparent priority accorded to physical assessment requires further examination (Bucknall, et al, 2001). Nursing Documentation of Post-Operative Pain Management: As part of a trust-wide practice development project to improve post-operative pain management, a descriptive study was conducted on sixty-five patients in the orthopaedic directorate of a large teaching hospital in the north of England. Findings indicate that individual assessment of pain was poorly documented and that the nurses’ record of the patient’s post-operative pain experience differed from the patient report. Reliance on pharmacological methods of pain relief was evident and interventions to help patients cope with night time pain were rarely documented.. Implications for practice: Following this study of nursing records and further audit of patients in pain, a multidisciplinary group of interested nurses, physiotherapists, pharmacists and anaesthetists developed Hospital Guidelines and Principles for Acute Pain Management, and their implementation across the Trust has resulted in improvements in practice, such as improving the assessment of patients in pain and increasing the number of patients benefiting from patient controlled analgesia systems. An acute pain link nurse network has been established and its members are responsible for implementing the guidelines in their area. The findings of this study support the need for systematic pain assessment and highlight possible benefits to be gained from documenting the pain experience when it occurs rather than at the end of a shift. Incorporating pain scoring into temperature, pulse and blood pressure charts may facilitate this and bridge the gap between nurse and patient reports. Reliance on pharmacological methods of pain relief was evident from this study and non-pharmacological methods such as information giving and relaxation were rarely cited. More emphasis needs to be given to these powerful ways of reducing patients’ pain experience and methods to improve information giving should be considered. The need for increased patient involvement is also highlighted (Briggs and Dean, 1998). Patient-controlled analgesia (PCA): According to Bucknall, et al (2001), the active involvement of patients in the assessment and treatment of pain is essential to ensure that patients and clinicians share common goals and that patients communicate changes in the severity or nature of their pain. Patient involvementincludes preoperative preparation of patients, obtaining a pain history and frequent consultation with patients to determine adequacy of analgesia. This is supported by the NHMRC Guidelines (2005). Patient-controlled analgesia is not restricted to a single route or method of analgesic administeration or a single class of analgesic drug, but means that patients can control when and how much analgesic they receive. PCA has generally been associated with better pain relief and greater patient satisfaction than intermittent opioid injections. For patient-controlled analgesia, trained nursing staff with adequate understanding of the PCA mechanism, drugs and doses used, monitoring requirements and management of common problems, should be responsible for administering care. Nurse-Initiated Intravenous Sedation in the Emergency Department: A research study was conducted by Fry and Holdgate (2002) at a University teaching hospital in Sydney, Australia: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia. The authors concluded from the results that experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain. Regional Anaesthesia: In recent years, there has been a great increase in the use of regional techniques for surgery and postoperative pain management. Because they can completely stop pain transmission, regional techniques using local anaesthetics can provide excellent pain control. In addition, they are inexpensive, simple to use, and relatively safe for a wide variety of patients. Local anaesthetics can be applied topically or injected subcutaneously before a procedure to numb a small area, infiltrated pre-operatively into the surgical site, administered as a regional neural blockade to cover a large area, given intraspinally for ongoing pain relief, or infused into the operative site through a pump (Rawal, 2007). Managing the Patient Receiving Local Anaesthesia: (Standards, Recommended Practices and Guidelines, 2007): 1) Patients should be assessed preoperatively by a perioperative registered nurse and an individualized plan of care developed. 2) The perioperative registered nurse should provide information to the patient regarding expected outcomes, benefits, risks, surgical experience, and recovery process related to the operative or invasive procedure. 3) The perioperative registered nurse should be knowledgeable about medication administration and be able to recognize both desired responses and adverse reactions to anesthetic medications. 4) The perioperative registered nurse managing the nursing care of the patient receiving local anesthesia should monitor and interpret the patient’s physiological and psychological responses throughout the procedure. 5) Holistic care interventions should be considered and offered to the local anesthetic patient to promote an atmosphere of comfort throughout the procedural experience. 6) The perioperative nurse should document information to facilitate continuity of care and provide retrievable information for evaluating the care given. 7) Policies and procedures for managing the patient receiving local anesthesia should be developed, reviewed, and revised at regularly scheduled intervals by a multidisciplinary team and be readily available in the practice setting. Central Neural Blockade: Post-operative pain is a major concern after orthopaedic limb surgery. It not only causes the patient discomfort but also compromises early physical therapy, which is the most influential factor for post-operative rehabilitation and ambulation. Post-operative pain relief can be achieved by a number of techniques, such as parenteral opioids or central neural blockade. However, intra-venous patient controlled analgesia (PCA) with morphine does not provide efficient analgesia on movement and induces side effects such as nausea/vomiting or sedation. Epidural analgesia is more effective in relieving pain on movement, but is associated with catheter-related problems and a high incidence of side effects such as urinary retention or arterial hypotension. Continuous peripheral nerve (interscalene or axillary brachial plexus, “3-in-1”, fascia iliaca, psoas compartment, sciatic) blocks are the most appropriate analgesic techniques available after orthopaedic limb surgery (Singelyn, 2001). CONCLUSION: Scientific evidence in acute pain management provides a basis for treatment choices for individual patients and for the development of local protocols and procedures that are specific to a given clinical setting. As treatment settings vary in size, resources and complexity, there can be no treatment recommendation that would suit all patients; hence, the efficacy of any intervention must be assessed for individual patients. Walker et al (2006) support the view that coordinated approach at multiple levels of healthcare provision, from education of staff to best use of available resources, is required to improve practice. Effective implementation of evidence-based guidelines also requires local audit and follow-up to evaluate compliance with new measures and impacts on clinical practice. Acute pain management is a dynamic field, with ongoing changes in our understanding of pathophysiological mechanisms, ability to assess the severity of pain and its impact on outcome, and the availability of new treatment strategies. Upto-date and accessible evidence-based guidelines assist improvements in clinical practice and management. ------------------------------------- REFERENCES Briggs, Michelle; Dean, Katherine L. (1998). “A Qualitative Analysis of the Nursing Documentation of Post-Operative Pain Management”. Journal of Clinical Nursing, 1998, Vol.7: pp.155-163. Burkey, Dell R, MD, University of Pennsylvania, Philadelphia, USA. (2005). “Book Review: Acute Pain Management: Scientific Evidence, Second Edition, 2005”. Pain Medicine, Vol.6, No.5, 2005: p.397. 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