Nursing the Patient in Pain - Essay Example

?Research Report – Nursing the Patient in Pain, How Effective is an Epidural Analgesia in Relieving Post-Operative Pain? Introduction This essay is concerned with justifying an intervention according to evidence based practice. It will consider the setting – post operative; the perspective – aiming at patient safety and satisfaction; the intervention – describing what happens ; comparing this method with other analgesics; and finally an evaluation, as in the Spice framework ( Gerrish and Lacey 2010) . This essay will consider in detail an article by Chumbley and Thomas ( 2010) and consider how it supports evidence based nursing when epidural analgesia is chosen postoperatively. This article was chosen because it covers many aspects of the subject , it describes the process in its postoperative hospital setting; the perspective - how the concern is for patient satisfaction while keeping them safe; what happens as a result of this intervention; it compares the method with other forms of pain relief and evaluates the method , including both positive and negative aspects. Searches will be made based upon these 5 aspects of epidural anaesthesia, using as a beginning the references supplied by Chumbley and Thomas. Epidural analgesia is now a commonly used technique used to manage the acute pain which comes after surgery, usually being a planned procedure, the best time to consider postoperative pain relief actually being before surgery begins. The method first became available in the 1960s ( Klein, 2011) and has increased in use especially since the1980s (Wheatley et al, 2001). Usually it is given for from 2 to 5 days postoperatively , this depending upon the surgery type undergone. After this period the patient should have recovered enough to cope with oral medication for their pain relief. ( Chumbley and Thomas, 2010, page 40). The method is especially used after any major surgery which involves the thorax or abdomen, as well as that involving the lower limbs ( Chumbley and Thomas , 2010, page 36). I t is a useful method after vascular surgery of any kind, as the medications used result in widening of the arteries which helps to maintain arterial grafts. It can quickly produce complete or almost complete, freedom from pain. If managed effectively, according to evidence based practice, this method reduces any risk of major adverse outcomes according to Chumbley and Thomas ( 2010, page 35). Both opioids and local anaesthetics can be used . These medications can however themselves produce serious, possibly fatal, side effects. Usually the epidural cannula will be put in place while the patient is still in the operating theatre. The role of the attending nurse is to monitor and assess patients receiving epidural anaesthetics, and to work with the evidence obtained , reporting any possible causes for concern, and so work towards preventing the development of these adverse effects. The College of Anaesthetists ( 2004 , 4.1) describe how it is the responsibility of the department of anaesthetics to ensure that properly qualified staff and appropriate protocols are in place in order that epidural analgesia can be undertaken safely and effectively with the anaesthetist, pharmacy and nursing staff working together. The epidural space into which the medication is inserted by a doctor is the potential space between the outer membrane, the dura mater, surrounding the spine and the bony vertebrae. This space contains blood vessels, nerves, connective tissues and fat. The nerves which are present work in various ways, such as passing on messages regarding movement. They also relay messages via the sympathetic nervous system to the brain about pain, touch, and temperature. This potential epidural space is present from the base of the skull down as far as the sacrum, but the spinal cord itself only extends as far as the second lumber vertebrae ( Macintyre and Schug, 2007). The patient is usually placed with their spine curved as this makes insertion somewhat easier. The needle is pushed in until it reaches the hard layer of the ligamentum flavum. It is then pushed on a little more until the saline or air in the syringe can be easily inserted due to a relative lowering of resistance. This is still outside the dura mater and the drug does not mix at any time with the cerebro-spinal fluid. A catheter is then used to either provide a continual infusion or can be used to add medication in repeated injections. At the level of vertebra a pair of nerves pass through the epidural space on their way to a particular area of the body, and it this area where benefits are perceived. All types of nerves, sensory and motor, as well as the autonomic nerves, are affected by the use of epidural analgesia. Thesis Where used properly and appropriately, and in the presence of suitably trained staff, epidural anaesthetic gives the best possible standard of post-operative pain relief. Contraindications Epidural anaesthetic may be the gold standard of pain relief, Chumbley and Thomas 2010, page 36, but there are some reasons why it may not be suitable. The Royal College of Anaesthetists ( 2004, section 3.1) stress that each patient being considered for this intervention should undergo a risk versus benefit analysis preoperatively. If the patient has an infection for instance this increases the risk of developing an epidural abscess. This would then cause pressure on the spinal cord and could even lead on to paraplegia (Parizkovea and George, 2009) Infected blood could be directed into the epidural space if the person has a systemic infection, or from the skin, if they have such things as infected pressure sores. If the patient has any problems with their clotting mechanisms then this is a contra-indication as it increases the person’s risk of developing a haematoma. A deformity of the spine might make it impossible to use this method, as might any previous spinal radiotherapy, because this can damage the epidural space and so affect the way in which the medication is able to flow around. If the person has higher than normal intracranial pressure there is a risk of the needle going into the subarachnoid space. Decreased blood volume, as might occur after a road accident, is also a contraindication until the blood volume is back to normal. Chumbley and Thomas, ( 2010, page 36), also list a lack of suitable staff, which means that complications might pass unnoticed, and finally they cite the patient’s possible refusal to give their consent to the procedure. Advantages of Post-Operative Epidural Anaesthetic Rodgers et al ( 2000), having considered 141 studies carried out over a period of 30 years and involving almost 10,000 patients, half of whom received epidural anaesthesia, describe how this method reduces ‘adverse responses to surgery’. They describe how it reduces the risk of such possible consequences of surgery as deep venous thrombosis, pneumonia, haemorrhage and pulmonary embolism. Commenting on their results Pronovost ( 2001) does point out that some studies considered only looked at limited numbers ( >50) of patients , and he considers that this perhaps should raise concerns about the validity of the results offered. He considers the advice anaesthesiologists should give to their patients. He points out that the results do seem to indicate increased survival rates and fewer complications as a result of using epidural anaesthetic, but does go on to suggest that more recent research needed to be carried out. During Epidural Anaalgesia. While the epidural cannula is in place there is a possibility of clots forming, or a bleed occurring , especially because it is possible that a blood vessel becomes damaged during the procedure. For this reason patients need to have normal clotting mechanisms in place at the time of insertion and removal. Mitchel ( 2009) points out how any clot formed can become dislodged when a cannula is being removed. The person can however receive anti-coagulants while the cannula is in place. Any haematoma which forms could place pressure upon the spinal cord, because the bony structures are rigid. The longer the cannula is in place the more likely it is that complications will occur. The nurse needs to be aware of this and look for signs that a haematoma or abscess is forming by checking that the patient does not have tingling in the lower limbs or sings of deep bruising at the site and also checking their temperature for signs of the fever that could accompany an abscess. Requirements for Successful Epidural Analgesia Appropriate medications in sufficient quantities are needed. This needs to be enough to produce numbing all around the surgical wound and any drain sites. The nurse needs to assess how effective the pain relief given is in practice, adjusting amounts within prescribed limits.. Local anaesthetics work by both preventing the conduction of nerve impulses The catheter needs to be placed in an appropriate position i.e. in the centre of the dermatome which the incision in the epidermis crosses. If too low for a thoracic operation for instance, then sensations of pain will not be eliminated. ( Chumbley and Thomas, 2010 , page 37). Medications used include the opioids Fenatyl and Diamorphine. These are much more effective given in this way than if they were taken orally as none is excreted before being used. This means that quite low dosages are effective ( Chumbley and Thomas, 2010 page 37) and so patients are less likely to have medication side effects such as hallucinations. Dolin and Cashman ( 2005) having looked at 532 studies on various aspects of the topic, do point out that itching ( pruritus ) may occur, especially when results were compared to those who received intramuscular pain relief medication, but was problem was not severe enough to require medical treatment . Local anaesthetics which might be used include bupivacaine and ropivacaine ( Dougherty and Lister, 2004). The Role of Nurses. According to the Royal College of Anaesthetists (2004) patients should only be returned to wards where a suitably qualified and trained nurse is able to undertake their care round the clock, and where the patient can be easily observed, i.e. not tucked away in a side ward, in the immediate post –operative period. Nursing care and any interventions are based upon knowledge of how epidural anaesthesia works and its possible negative consequences, as described in the literature available.. Both oxygen and resuscitation equipment and staff must also be in place in case of need. If either staff or necessary equipment is not available the operating theatre staff must be informed. When shifts change information must be given about who is undergoing this procedure to the incoming staff. When the patient comes back to the ward staff should check that the infusion catheter is fixed in place and that the insertion site is clearly visible despite any dressings. There will be local guidelines in place and staff must always adhere to these. The epidural system should be a closed one, with no possible injection ports and an anti-bacterial barrier should be in place. If bolus injections are required these should be carried out using the syringe within the pump. The epidural infusion line must be very clearly identified as such. The National Patient Safety Association ( 2009) suggests that distinctive yellow tubing is used. The Nursing Times advice ( 2002) points out the positive ‘often removing all pain sensation’ and that the method often results in ‘lower levels of respiratory depression and sedation’. They also describe however the way in which the quantity of medication used needs frequent reassessment if the person is to remain pain free with the minimum dosage. If the patient is controlling their own pain relief then safeguards need to be built in so that it is impossible for the person to give themselves an overdose. Observations are usually documented using a dedicated epidural infusion sheet, which also has the drug prescribed on it. Because several different types of nerves are affected a variety of observations are required – temperature, respiratory rate, pulse, oxygen saturation level, whether or not the person is experiencing pain or itching , their sensory level, motor block and the blood pressure all need to be noted. Hypotension is a possibility as sympathetic nerves which control blood vessels are blocked. The cumulative drug dosage, the rate of the infusion and any boluses used, especially in patient controlled epidurals, are also recorded. The site of the infusion needs to be checked daily for any signs of tenderness, infection or even leakage. Oxygen is required , 2 l/a minute given via a face mask or nasal cannula for 48 hours and at night for any more nights. In some cases continuous oxygen may be needed as long as the person is receiving opioids. Remembering that there will be a loss of normal sensation pressure areas will require care and the patient should be encouraged to empty their bladder regularly, especially if the anaesthetic is given in the lumber region. Many patients will have a urinary catheter in place when they return to the ward from the operating theatre to help overcome this possible difficulty. If there is no catheter the nurse must take extra care about the patient’s urinary output, measuring output and letting medical know if there is no passage of urine within 6 hours. Because motor block is a possibility, mobility will need to be restricted and controlled, so all staff need to be aware that the patient has an epidural infusion in place and the effects this has. No other opiates should be given as long as the infusion is being used. Intravenous access should be left in place until 24 hours after the removal of the epidural catheter, in case problems develop. Chumbley and Thomas ( 2010 page 36) point out that in various areas there may be a difference in opinion as to when the catheter can be most safely removed. Opioids may remain active for up to 12 hours after the infusion ceases, which of course means that there remains a possibility of side effects during this period so observations should be continued ( Macintyre and Schug, 2007). These side effects could include sedation, depression of respiration, nausea and vomiting, itching and hallucinations. Chumbley and Thomas ( 2010, page 37) suggest possible treatments for these side effects. If local anaesthetics are the drugs of choice these too can produce side effects – low blood pressure, motor block, bradycardia and the retention of urine ( Doherty and Lister , 2004). Failure of Epidural Analgesia Wheatley et al ( 2001) report failure rates as high as between 30 and 50 % among those who have epidural anaesthesia. They point out that pain is subjective and that very low pain levels obtained in an intensive care unit are not realistic in a large ward. The authors also state that epidural anaesthesia is complicated in that a number of different medications can be administered at one of a number of points. They show that local spinal anaesthetics often needed to be supplemented with the use of opioids. Conclusion Although there can be problems with the administration and maintenance of epidural anaesthetics, for most people postoperatively, most of the time, it is both effective and relatively safe, despite the reported high rates of failure. Research shows that the method actually cuts the rates of several possible complications, including fatalities, as shown by the review undertaken by Rogers et al ( 2000). It does however require specialist training, both to administer it and for nurses to care for patients while the infusion continues. It also means that much more time is actually needed to care for these patients, taking and recording the many observations required and acting upon those results. The results in terms of pain relief and patient satisfaction seem to justify such care and attention to detail, although on the rare occasions when things do go wrong this can have massive negative repercussions. The method does of course result in more successful pain relief than other methods, and patients who are pain free are likely to make a better recovery. The presence of severe pain limits the patient’s ability to breathe deeply, to cough and to perform other activities needed for recovery. The method is not always chosen however – Wheatley et al ( 2001) point out that clinicians often still question the effectiveness and safety of the method, and judging by the high failure rates recorded back up their diffidence. For the patients though who receive this method of pain relief successfully, there is no question of its efficacy. Reports such as that by Chumbley and Thomas help nurses to carry out their evidence based nursing role in order to bring this about. References Chumbley,G. and Thomas,S.,June 20th 2010, Care of the Patient Receiving Epidural Analgesia, Art and Science , Nursing Standard, November 3rd 2010, Volume 25, number 9, available online at < http://www.academia-research.com/filecache/instr/e/b/654535_ebp_article.pdf> , accessed 22nd March 2012 Dolin, J., and Cashman, S.,( September 16th 2005), Tolerability of postoperative pain management: nausea, vomiting, sedation, pruritus and urinary retention. Evidence from published data, British Journal of Anaesthesia, 95, 5, pages 585-591 – 223. available online at < http://bja.oxfordjournals.org/content/95/5/584.full.pdf>, accessed 22nd March 2012 Dougherty, L. and Lister,S.( 2004), Pain Management: Epidural Analgesia, The Royal Marsden Hospital Manual of Clinical Procedures, Sixth Edition, Oxford, Blackwell, pages 519-535. Gerrish, K. and Lacey,A., ( 2010) 6th Edition, The Research Process in Nursing, West Sussex, Blackwell Publishing , Klein, M., (February 3rd 2011), Epidural Analgesia - a delicate dance between its positive role and unwanted side effects , part one, available from http://www.scienceandsensibility.org/?p=2010, accessed 22nd March 2012 Macintyre,P. and Schug,S. , (2007), Acute Pain Management : A Practical Guide, 3rd Edition, Edinburgh, Saunders Elsevier Mitchel, J., (2009), Risk management in perioperative management, In Cox ( editor) Perioperative Pain Management, Oxford, Wiley Blackwell, pages 277 to 293. Parizkova, B. and George,S.,( 2009), Regional anaesthesia and analgesia, part 2, central nerve blockade. In Cox, F., 2009, Perioperative Pain Management, Oxford, Wiley Blackwell, pages 144-160 Pronovost, P. (2001), comment upon Rodgers, A., Walker,N., Schug,S. et al , 2000, Available online from , accessed 22nd March 2012. Rodgers, A., Walker,N., Schug,S. et al , (2000), Reduction of postoperative mortality and morbidity with epidural anaesthesia; results from overview of randomised trials, British Medical Journal 321, 7275, pages 1493- 1497. Available online at http://ebm.bmj.com/content/6/4/124.full.pdf , accessed 22nd March 2012. Royal College of Anaesthetists, (2004), Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting, London, Faculty of Pain Medicine, Royal College of Anaesthetists, Available online from http://www.rcoa.ac.uk/docs/EpiduralAnalgesia2010.pdf, accessed 22nd March 2012. The National Patient Safety Association, (2009), Patient safety alert: Safer spinal ( intrathecal) , epidural and regional devices – Part B, London , available from < www.nrls.npsa.nhs.uk/resources/?Entryld45=65259>, accessed 22nd March 2012 The Nursing Times,( 3rd December 2002), NT Skills update: Postoperative Epidural Analgesia, available from http://www.nursingtimes.net/nursing-practice-clinical-research/nt-skills-update-postoperative-epidural-analgesia/205762.article> , accessed 22nd March 2012 Wheatley,R., Schug,S., and Watson,D., (2001), Safety and Efficacy of Postoperative Epidural Analgesia, British Journal of Anaesthesia, 87 (1), pages 47- 61, available from , accessed 22nd March 2012 Read More