How Addressing a Patients Pain Improves Concordance - Essay Example

Nursing Diagnosis

Goal

Intervention

Rationale

Evaluation

1. Pain associated with the leg ulcerations, characterized as 8/10 in the Visual Analogue Scale, with 10 being the most severe pain

To reduce pain to a level of 3/10 or to a point where it is comfortable or tolerable. 

To relieve patient anxiety and stress

1. Administering pain relievers/analgesia as ordered by the physician

2. a. Involve Mrs. X in activities available, based on hobbies and interest

b. Providing moral support and encouragement during each pain experience.  Holding the patient’s hand and keeping the patient company during the worse pain experiences.

c. Encourage family and friends to visit more often to reduce the anxiety level

d. Encourage pain expression and verbalization

e. Carry out relaxation activities including guided imagery and other distracting activities

3. Encourage Mrs. X to take prescribed meds on time and just half an hour before the dressing change

·       Pain relievers block pain receptors.  Pain may be nociceptive or neuropathic (Flanagan, Vogensen, and Haase, 2006) with nociceptive pain manifesting as a normal physiologic response to a stimulus.  Where there is soft tissue injury, inflammation and stimulation of the peripheral nerves are often seen and as a result, even minor stimulations cause intense pain (Flanagan, et.al., 2006).   

·       Patients with varicose leg ulcers experience nociceptive pain caused by soft tissue damage as seen in the crater-like formation in their legs (Flanagan, et.al., 2006).  This is the same for the current patient.  These patients feel a continuous pain because there does not seem to be a respite from the injury in the leg (Briggs, 2007, p87).  Moreover, being an open wound often risks the ulceration to friction and to coming in contact with objects which further exacerbate the pain felt by the patient. 

·       During active treatment for this patient, a consistent analgesic medication is important in order to provide continuous pain relief (Flanagan, et.al., 2006). 

·       Pain relief is an important element of nursing management because pain can cause significant anxiety in a person’s life.  It can monopolize the patient’s life, causing sleepless nights, fatigue, and making it difficult to deal with daily activities (Briggs, 2007, p87).  These activities can provide distractions to the pain being experienced.

·       Can relieve stress and mental anguish which patients often report with each severe pain experience.  Patients report feeling like they would go crazy from the pain and how they think of nothing else but the pain and how to get through their pain.  Moral support can make them feel less alone and reduce their anxiety during the height of their pain experiences. 

·       Visits from relatives can relieve stress of pain and of confinement.  Relieving stress is crucial to recovery because stress can exacerbate the pain experience, thereby leading to a cycle of pain and stress for the patient.  In this case, the pain that the patient is feeling is causing her much anxiety and stress and in turn, her stress is making her pain experience worse, causing her to focus on her pain without allowing thought for anything else.  

·       Keefe and Gil (1986, p716) discuss that there is a pain-anxiety-tension cycle which often accounts for the series of events wherein pain causes stress and anxiety; with such tension, the pain experience is worsened. 

·       Helps motivate and relieve patient anxiety.  Anxiety delays wound healing and the unrelieved pain can also cause significant discomfort on the patient (Chen, Chang, and Yeh, 2000, p944).  In order to manage effective pain relief, the psychological and physiological elements must therefore be considered and resolved.  

·       Distraction tactics can redirect the patient’s preoccupation with pain and thereby relieve anxiety. 

·       Continuous pain is causing the patient much anxiety and is also making her fixate on her pain to the exclusion of other activities and considerations in her life.  The importance of managing the pain is therefore important (McCaffrey, Frock, and Garguilo, 2003, p281).

·         To ensure continuous pain management

Pain levels were reduced to 3/10 after two weeks of continuous pain medication intake

Patient anxiety was relieved after 2 weeks of anxiety and pain-relieving activities.

Increased socialization after 4 weeks of continuous nursing interventions

Patient able to carry out independent pain-relieving activities after three weeks of continuous nursing interventions

Inadequate wound healing associated with poor blood circulation

Identify factors that may increase the risk infection (i.e. poor nutrition, poor hygiene maintenance, and poor wound care)

To ensure adequate wound healing

To prevent recurrence of leg ulcers

1. Monitor wound site  and skin carefully for signs of infection and inflammation

2. Monitor wound site for signs and symptoms of wound infection such as elevated temperature, wound swelling, warmth, tenderness, smell, and the number of exudates from the wound.

3. Use of the Ankle Brachial Pressure Index (ABPI)

4. Using Doppler ultrasound in assessing leg ulcer

5. Application of moist wound dressings, followed by dry wound dressings.

I applied barrier cream cavilon cream to the surrounding area, then anti microbial silver-impregnated dressing (equal) to the wound bed. Next, I applied a secure secondary dressing(resorb) then, KTWO calibrated two-layer compression dressing where the first layer is used as an absorbent dressing and as protection for the wound bed.

The second layer is an elastic bandage applied in a spiral with 50% (percentage) overlap on each turn, applied at a full stretch.

6. Continued wound monitoring

7. Gaining consent during each wound change

8. Applying an aseptic technique with each wound change

9. Record each wound dressing change and patient progress

• Monitoring the leg for possible infection and swelling would help ensure the early management and prevention of infection

• To prevent infection and ensure early management of infection

• As an adjunct to the visual assessment of the leg ulcer
• it can also be used in conjunction with pedal pulse palpation and physical assessment of the leg wound (Moffatt, et.al., 1994, p67). 
• ABPI is a tool used to rule out any arterial disease and to establish if compression therapy would be appropriate for the patient (RNAO, 2004, p47). 
• For ABPI results at less than 0.6, referral to a vascular surgeon would be essential. 
• The monitoring of the patient’s wound healing would also establish the necessity of referral to a specialist for the management of underlying health issues, for suspected malignancy, reduced or increased ABPI, rapid deterioration of ulcers, for pain management, and for assessing patients with suspected sensitivity reactions (Registered Nurses of Ontario, 2004, p35). 

• To allow the detection of arterial insufficiency which could then lead to other inappropriate therapy.   In instances when pain increases or the color or temperature of the foot changes, the Doppler ultrasound must be repeated (RCN, 1998). 
• The Doppler ultrasound would also have to be carried out in order to establish the presence of peripheral arterial occlusive disease (RCN, 1998). 

• Moist wound dressings are preferred because they provide the best environment for healing. 

• Moisture is important for cells involved in healing to survive; and they help maintain the growth factors and enzymes which are needed in wound healing (Registered Nurses of Ontario, 2004, p35).  These enzymes are needed in autolytic debridement and must therefore be maintained. 

• The occlusive dressings also prevent the entry of bacteria and dirt.  The efficacy of these dressings has been seen in cases where wounds with occlusive dressings have yielded lower rates of infection as compared to wounds with nonocclusive dressings (Bolton, Monte, and Pirone, 2000, p51S). 

• Wound dressings must also be changed frequently during the initial stages of wound management in order to avoid the development of irritant dermatitis on the skin surrounding the ulcer (Kunimoto, 2001, p41). 

• Continued monitoring of the wound is important in order to detect if re-epithelialization has occurred.  If this stage is reached, the dressing changes would have to be decreased. 

• As new layers of the skin are formulating over the wound, dressing changes must be decreased in order to prevent the new layers from tearing off.  Non-adherent dressings are therefore needed during this stage (Kunimoto, 2001, p41). 

• Protect patient autonomy and independence

• Prevent infection.  Infection can prolong the healing process. 

• To promote legal documentation and monitoring for each patient and to ensure easy access of other health professionals to patient care.

After one week of nursing interventions, no signs of infection or inflammation were seen

After three weeks of nursing interventions, the patient’s wound was healing well

3. Inadequate nutrition necessary for sufficient wound healing and management of hypertension

To provide adequate nutrition for wound healing

1. Protein supplementation (educate the patient on foods high in protein and adequate portions per meal)

2. Vitamin C supplementation (educate the patient on foods high in Vitamin C, including the portions needed.

3. Zinc supplementation (educate the patient on foods high in zinc, including the portions needed).

4. Promote a healthy diet through fruits, vegetables, and low cholesterol food choices

5. Encourage the patient to exercise and to be active

6. Teach the patient how to manage a low carbohydrate and low sugar diet.  

7. Monitor patient’s food and fluid intake (at least 8-10 glasses a day)

8. Monitor the patient’s weight weekly

• Protein replacement where deficiency is seen in the patient is important in the management of leg ulcers.  With protein replacement via parenteral routes, fibroblast activity manifests significant improvement (Law and Ellis, 1990, p107).  Collagen synthesis is also improved through protein replacement therapies.

• Vitamin C supplementation has also been crucial for patients manifesting Vitamin C deficiency because this deficiency interferes with wound healing and tensile strength (Kunimoto, 2001, p41).  About two grams per day may be needed in order to restore adequate tissue levels for patients with burns and leg ulcers. 

• Zinc supplementation has also been helpful in wound management, and zinc deficiencies among patients have often contributed to delays in wound healing (Kunimoto, 2001, p41). 

• Reduce her weight and help manage her hypertension. The importance of a healthy diet among patients is also important in order to promote the health of the patient and prevent conditions that exacerbate the patient’s condition, including hypertension and diabetes (Irish Health, n.d, p2). 

• To reduce her weight and help manage her hypertension.  Hypertension can increase the risk for thrombus formation which may later cause other health issues for the patient. 

• To prevent the risk of diabetes.  Diabetes is also another chronic condition that would likely delay the patient’s wound healing (Irish Health, n.d., p2). 

• To ensure adequate nutrition and hydration. 

• To manage the patient’s UTI

• To ensure the patient’s BMI (body mass index) is at a normal level. 

After two weeks of nursing interventions and patient education, the patient was eating healthily and eating foods that promote adequate wound healing. 

Summary

The patient is Mrs. X, a 73-year-old widow who is suffering from bilateral varicose leg ulcers primarily caused by her hypertension.  Her health deteriorated since her leg ulcer recurred and it significantly reduced her mobility, causing her to be isolated from her friends and family.  Both her legs are suffering from leg ulcers.  Mrs. X presented with severe pain and discomfort upon admission and the cause of her pain was her leg ulcers, later specifically diagnosed to be varicose leg ulcers on both legs.   Her medical history indicates health issues associated with hypertension, venous leg ulcers, varicose vein leg ulcers, angina, and recurrent urinary tract infection.  Her present medications include Aspirin (75 mg OD); Lactulose Elixir (15Mbls BID); Oramorphene (2.5mg to 10mg PRN); Co-codamol (30/500 BID); Paracetamol (1g QDS); Ramapril (5mcg BID); and Simvastatin (49 mg OD).  Her care was composed of a multidisciplinary team that included community/district nurses, tissue viability nurses, practice nurses, and her general practitioner who was involved in promoting her much-needed care.  A tissue viability nurse was consulted in order to monitor the wound and its healing as well as its dressing (Johnstone, 2009, p2).  A dietician and nutritionist were also consulted in order to establish an appropriate diet plan for the patient (Lin and Bono, 2010, p320).