Adverse Consequences of Hypothermia in Post Anaesthetic Care Unit - Essay Example

Monika Kovacs monika.kovacs@southend.nhs.uk Location: Buckinghamshire Campus/Butterfield Park Campus Post Anaesthetic Care Unit BSH014-3Academic Supervisor: Dr Toby Reynolds (toby.reynolds@gmail.com) Date of Submission: 13th July 2015 Word counts: Table of Contents Adverse consequences of hypothermia in PACU 3 Opioid-induced respiratory depression (OIRD) and Laryngospasm 10 Post-Operative Acute Pain and its Management 17 Adverse consequences of hypothermia in PACU For this piece of reflection, I will be reviewing the potential consequences of postoperative hypothermia. I will use a Gibbs reflective model to discuss how I have dealt with a situation in the Post Anaesthetic Care Unit. This reflective cycle promotes systematic thought concerning the phases of a case (Gibbs 1988). I am a general staff nurse, band 5, and have been working in this local hospital and Post-Operative Recovery Ward for three and a half years. I started my shift at 10am and was allocated with another staff nurse to a satellite theatre and four-bedded recovery area, where mainly orthopaedic operations were carried out. On arrival at the ward I learnt that the ward was checked and stocked up by night staff and signed in the logbook. Soon after starting my shift our first patient was wheeled to a bay by theatre staff. I put on personal protective equipment and approached the patient. I connected the patient to the monitoring and their airway to the central oxygen. I learnt from the anaesthetist that the patient Mrs Brown (not her real name) hemiarthroplasty of her right hip operation under general, plus regional anaesthetic. She was in theatre for almost two hours and was stable throughout the operation. Mrs Brown is a 72 years old lady of 57kg, had a fall two days ago that fractured her neck of femur. Her medical history was dementia, untreated hypertension (high blood pressure) and high cholesterol. She had no-known allergies and was not taking any regular drugs except painkillers when needed. In theatre she induced with sevoflurane, was given a fascia-iliac nerve block 100 mcg Fentanyl intravenously on induction, 100 mg Propofol, 30 mg Rocuronium, 4 mg Ondansetron, 3.3 mg Dexamethasone, 50 mg Cyclizine , 75 mg Voltarol, 1 gr Paracetamol, 10 mg Morpheine and Glycopyrronium Bromide 0.5mg and Neostigmine Metilsulfate 2.5 mg at the end of surgery. The theatre nurse estimated blood loss of 500 millilitres. The patient had two Bellovac drains in situ that were unclamped and had started collecting in theatre, and the wound was dressed using a Mepilex dressing. After the handover was given I started to carry out the ABCDE assessment, using the look, listen and feel approach, which is recommended by the Resuscitation Council UK (2010) A- Airway - the patient’s airway was patent. She had an oropharyngeal (Guedel) airway used as a bite block size 2 (green), and an endotracheal tube size 7 in situ connected to a water circuit and to 10L central oxygen. The bag was moving, and the endotracheal tube was misting. B- Breathing - Mrs Brown was breathing spontaneously. Her respiratory rate was 12 per minute and shallow in depth, bilateral air entry was present with equal chest expansions, and no accessory breathing muscles were used. The patient was pink, well perfused, and her oxygen saturation was 100%. Expiratory CO2 was 5.6 kPA indicating her capnography was within normal parameters. C- Circulation - Her blood pressure was 93/49 mmHg, heart rate 72 per minute, and capillary refill was 3 seconds on the peripheries. The patient felt cool to the touch, therefore I attempted to measure her temperature using a digital thermometer in her left axilla. I applied a forced-air warming blanket set at a medium setting, and gave warmed intravenous fluids. D- Disability - I used the AVPU system (Alert, responsive to Voice, responsive to Pain, Unresponsive), recommended by the Resuscitation Council UK (2010). The patient was still to come round from the anaesthetic and unresponsive and sedation level was 4 out of 4. Her pupils were size 2 equal and reacting to light. E- Exposure - I checked the patient’s wound site looking for any bleeding whilst ensuring dignity and privacy were maintained. There was one Bellovac drain in situ which was patent. Normal Body temperature varies between 35 and 37.5 and varies from site to site. Hypothermia is a core temperature of less than 36°C. There are three categories of hypothermia: mild (32°C-35°C), moderate (30°C-32°C), and severe (below 30°C) (Fiona and Sylvia (2007). All perioperative patients are potentially at risk of inadvertent hypothermia. It is important for nurses to use clinical skills to ensure early detection and appropriate management of the common problems of hypothermia. Patient was intubated for 35 minutes, she was breathing but wasn’t fit the extubation criteria. Mrs Borwn was retaining secretion, there was an audible noise to her breath sounds and these were required clearing with suction catheter. Patient was closely monitored observations carried out every 15 minutes. Even mild hypothermia triples the risk of heart attack, surgical wound infections, increases blood loss and transfusion requirements, and prolongs recovery and hospitalization. Hypothermia impairs the body’s natural ability to fight infection and extends recovery time. We performed close monitoring of the patient while under the forced air warmer blanket on medium setting. Temperature was still unrecordable after 35 minutes of warming and the rest of the other vital signs were stable. Patient showed signs of awakening, respiratory rate was picking up, patient was reaching to her mouth and frowning, asked her to squeeze my hand to check if muscle tone returned and she will be able to maintain her own airway post extubation. Mrs Brown obeyed my command and I decided it was safe to remove endotracheal tube. Cuff deflated, suction applied and tube gently removed according to hospital policy. Post extubation I immediately applied a Hudson facemask to deliver 40% oxygen. Once extubated it is vital that patient is observed continuously so that any deterioration in her condition can be acted upon immediately. Her airway was reassessed again, patient was misting to the mask respiratory rate was 16 per minute and normal depth. Mrs Brown maintained her own airway and oxygen saturation remained at 98-99%. Her sedation level was 2 out of 4 and she was responding to voice, her heart rate was 87 per minute, blood pressure 152/97 mmHg, patient was confused and restless. She was reaching to the operation site and she said she was in pain. Intravenous Morphine administered in 1 mg doses. Patient was in pain and received Oramorph 10 mg 2 hourly. She was confused, restless and probably that was the reason why nurses couldn’t take the observations. Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based practice to meet the patients needs (National Institute for Health and Care Excellence April 2008). There was no record maintained for her temperatures during operation period. I reassessed the situation continuously as it progressed and this seemed to facilitate continuity in our action. After 40 minutes of active warming she managed to gain a body temperature of 35.0°C axillary with an electric thermometer and was gaining consciousness. Low body temperature affects vary on different body system. Elderly are at higher risk of developing hypothermia and its unfavourable effects. I wanted to warm her gradually because of the heat shock to the body. Most patients find it uncomfortable to have temperature taken and it can be unsafe if they are shivering, restless or confused. Usually we measure orally but in PACU if patients are intubated temperature can be obtained axillary or in the groin. After 55 minutes of passive external rewarming and pain management patient settled and she wasn’t shivering anymore. She was co-operating and seemed more comfortable. After attaining an oral temperature of 36.3°C the warming device was disconnected. Blood pressure was 135/89 mmHg, heart rate 79 per minute patient was alert, responsive and sedation score 0 of 4. Capillary refill was 2 seconds. Patient was in PACU for an hour and thirty minutes, observations were stable and fit the discharge criteria. The final observations obtained were documented and we transferred her back to the orthopaedic ward. On handing over Mrs Brown to the nurse mentioned her about the procedures, drugs administered, and additional drugs prescribed and further plan. Mentioned that I was unable to measure her temperature and she was warmed actively for 55 minutes and she was normotherm prior returning to the ward. On revisiting the experience I think it is very important to make sure all patients in theatre meets the requirements and fits criteria. Early detection of hypothermia is very important probably if the patient was warmed or covered up before going to theatre she would have experienced less consequences of hypothermia (MacArthur-Rose & Prosser, 2007). She could have been warmed in theatre suit throughout the operation and her temperature may not have dropped that low. Implications for future practice would be on arrival to the hospital every single patient’s temperature should be measured accordingly. There should be adequate warming devices and quality thermometers. Also, education and trainings for health care assistants and nurses should be offered to gain better understanding of the early detection and importance of hypothermia to detect early deterioration and act appropriately. References Gibbs, G. 1988. Learning by Doing: A guide to teaching and learning methods. Oxford: Oxford Polytechnic. Retrieved on 6th July 2015 http://www.nmc.uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF https://www.resus.org.uk/pages/guide.htm MacArthur-Rose, F. J. and Prosser, S. 2007. Assessing and Managing the Acutely Ill Adult Surgical Patient. Oxford: Blackwell Publishing Ltd. http://www.nice.org.uk/guidance/cg65/chapter/patient-centred-care http://www.nice.org.uk/guidance/cg65/chapter/1-guidance#/postoperative-phase https://ispub.com/IJA/27/2/10779 Opioid-induced respiratory depression (OIRD) and Laryngospasm For this assignment I will be reviewing a patient in PACU who suffered from laryngospasm, and the management. Calder says (2011) laryngospasm occurs during and after anaesthesia and it is a protective mechanism to prevent secretion entering the larynx. I will be using Driscoll (2000) reflective model to discuss the event and to review and reflect upon my experience. “Reflective practice is something more than thoughtful practice. It is a practice which seeks to problematize many situations, of professional performance so that they can become potential learning situations and so the practitioners can continue to learn, grow and develop through their practice” (Jarvis, 1992, 174). I will be use ABCDE (airway, breathing, circulation, disability and exposure) to assess and recommendation. I was allocated to care for ENT (ears nose and throat) surgical patients Post Anaesthetic Care Unit (PACU). I received a male patient Mr Brown (not his real name) who was 52 years old, overweight with BMI of 28.9 (184 cm, 98 kg BMI 28.9). Nurses have a duty of confidentiality to patients who are under their care and responsible to make sure that all information about them is shared appropriately. The patient had a Septoplasty operation done under general anaesthesia and was in theatre for two hours. In theatre he received 100microgram Fentanyl, Propofol 200 milligram, Augmentin 1.2 gram, Atracurium 40 miligrams, Ondansetron 4 miligram, Dexamethasone 3.3 miligram, Morphine 10 miligram, Paracetamol 1 gram, Voltarol 75 miligram, 1000 mililiter Hartmann’s solution intravenous fluid. According to Calder (2011) opioids and volatile agents, blunt response to hypoxia and alter the carbon dioxide response curve. Moyle (2002) states that it is important to remember that pulse-oxymetry indicates the level of oxygen in the blood and if oxygen is being given it may not warn in mild degrees of respiratory insufficiency. On arrival to PACU the anaesthetist and theatre nurse handed over the patient, the anaesthetic and operation had been uneventful. I connected the patient to monitoring and carried out ABCDE assessment. A- Airway was patent, patient had endotracheal tube size 8 in situ, secured with tape and balloon inflated with 15 millilitres of air, connected to water circuit and to central oxygen 10 litres. Capnography is not routinely used in recovery unless complications occur. Equal chest expansions were present and a Guedel airway had been inserted as a bite-block and to ensure a secure airway. B- Breathing. Patient was misting on the tube, water circuit bag was moving, good tidal volume, equal air entry to lungs and chest expansions, used look listen and feel approach. Oxygen saturation was 100%, respiratory rate 18 per minute and normal depth pattern (rhythm) of each breath, patient was pink and well perfused. C- Circulation. Heart rate was 65 per minute, blood pressure 98/60; capillary return to the sternum was less than 2 seconds. D- Disability, patient temperature was 36.3°C axillary. E- Exposure, patient had an internal nasal splint and bilateral totally occlusive nasal packs, no visible ooze noticed. The anaesthetist handed over that Mr Brown was a healthy fit male who suffers from mild asthma and uses a Ventolin inhaler when needed, smokes 10 cigarettes per day and has hypertension. To detect physiological changes, close monitoring is essential during anaesthesia and the post-operative period to detect any changes deterioration and require intermediate intervention (Spry, 2009). The patient started to wake up, frowning, rolling over the bed and trying to reach for the tube. I instructed the patient to squeeze my hand to see if he was able to obey command, there was no response and the patient was getting more agitated and distressed, unable to tolerate tube. Opioid-induced respiratory depression (OIRD) and postoperative apnoea (POA) can lead to airway obstruction during the peri- and post-operative period (Voscopoulos et al., 2014). I decided to extubate the patient, deflated cuff, applied positive-end expiratory pressure ( PEEP) to the breathing system reservoir bag and removed the endotracheal tube, applied suction under direct vision to clear mouth from secretion and noticed haemorrhage, airway cleared. When looking after a patient with an artificial airway, we need to consider whether there was any previous airway problems or whether there is a risk of difficult airway. Patients should be extubated awake, breathe spontaneously, able to obey command and open their eyes (Karmarkar et al., 2008). The patient was still distressed and started to drop oxygen saturation to 92% and 89%. I used bag-valve-mask with jaw thrust and high flow oxygen 15 liters to improve oxygenation and ventilation, whilst calling for help. According to Calder (2011), residual neuromuscular blockage impairs the function of respiratory, laryngeal and upper airway muscles and is associated with impaired airway protective reflexes, upper airway obstruction and decreases hypoxic ventilator response. Post-operative airway problems are the second most common complications in PACU. It can develop in the post-operative period and require early treatment in order to maintain patient safety (Gogarty, 2014). I talked to the patient and reassured, instructing him to take small breaths and calm down. His breathing was noisy, had an audible stridor and wasn’t able to generate an adequate cough. As he was trying to breathe he was getting more distressed, de saturated, and cyanotic. Ikari and Sasaki (2008) suggest that extubation is usually carried out at end-inspiration when the glottis is fully open to prevent trauma and laryngospasm. Direct laryngoscopy, suctioning of the posterior pharynx, administration of 100% oxygen, ventilation to aid washout of inhalation agents, and positive pressure breath at extubation to prevent atelectasis are routine maneuvers before extubation” (Karmarkar et al., 2008, p. 214). Patient was cyanotic and bleeding from the operation site. Airway suctioned again with yankuer suction under direct vision to clear the pharynx from blood, and used the Larson’s manoeuvre jaw thrust, applied bilateral digital pressure to the ‘laryngospasm notch’ (between the posterior border of the mandible and the mastoid process) with bag-valve-mask using good seal with two-hand technique with high flow oxygen. Tight-fitting facemask with continuous positive airway pressure was applied with high flow oxygen. I made sure intravenous access was there, fluids were running. I managed to increase the patient’s oxygen saturation to 89%, but the patient remained cyanotic. Patient was quite distressed and was trying to tell us that he couldn`t breathe. Effective management and early recognition of a respiratory insufficiency with timely intervention will often prevent further deterioration and patient safety (Loftus, 2010). Help arrived, and the anesthetist requested Propofol. Gentle chin lift jaw thrust was done and an oralpharangeal airway was inserted to keep the airway open and enhance oxygen entry. The anesthetist gave intravenous Propofol 100 miligram and I was maintaining the patient`s airway. I then made sure that his airway was clear of any secretion and continuous ABCDE assessment carried. The patient went back to sleep and his oxygen saturation was 100% on high flow oxygen. After 10 minutes the patient woke up, frowning, he was not tolerating the Guedel airway or the jaw thrust. No further bleeding was observed from the operation site. I changed the oxygen delivery to a simple mask on 40% oxygen, and saturation remained 100%. According to Calder (2011), incidence of laryngospasm can be reduced if patients are undisturbed. Patient managed to maintain his own airway. The respiratory rate was 18 per minute. He was in recovery for two hours, observed closely every 15 minutes according to local policy. He remained alert and observations were stable. I removed the artificial airway, to avoid distressing the patient and prevent it from blocking the airway due to secretion and aspiration of blood. After all, the patient was breathing on his own spontaneously for 10 minutes and his oxygen saturation was 100%. I was concerned about the patient when his colour started to change, wasn’t sufficient air entry into the lungs, could hear the stridor and his oxygen saturation dropped to 92%, and called for help. The reason for deciding to extubate is that patient started to bite on tube and couldn`t tolerate anymore. This had to be weighed up against the consequences of airway obstruction and manual airway management. Sometimes leaving in tube too long or taking it out too early can cause problems. I used my clinical judgment based on best evidence and up to date knowledge, at all times considering the local national guidelines (Voscopoulos et al. 2014). I can use this learning experience when dealing with airway laryngospasm again and when mentoring student nurses as an example I would discuss this case, the management, my feelings with them and how they may react and feel in a similar situation. This experience helped me to recognize what knowledge I have surrounding extubation and areas for development. Next time I look after patients who are at risk of developing laryngospasm I would be more prepared. I would get emergency drugs prepared and in reach. I would stay calmer and make an action plan to deal better in acute situation like this. The care that patient receives has direct potential to improve through reflective practice. Structured reflective practice also has the potential to develop staff and improve the implementation of professional standards (Karmarkar, 2008). Whilst remaining professional and used my own clinical judgment. References Calder, I. and Pearce, A. 2011. Core Topics in Airway Management 2nd ed. Cambridge: University Press. pp158-166. Gogarty, D.S.J. and Majeed, A. 2014. Irish Journal of Medical Science. 183/4 1(S136), pp. 0021-1265 Jarvis, P. 1992. Reflective Practice and Nursing in Nurse Education Today vol.12, No.3 pp174-181 Johns, C. 2000. Becoming a Reflective Practitioner. Oxford: Blackwell Science Ltd. Chapter 3 pp. 34-36. Karmarkar, S. and Varshney, S. 2008. Tracheal extubation Contin Educ Anaesth Crit Care Pain. [Online]8 (6): pp. 214-220. [Accessed 15 May 2015]. Available from: http://ceaccp.oxfordjournals.org/content/8/6/214.full Loftus, I. 2010. Critically Ill Surgical Patient. 3rd ed. London: Hodder Arnold, an imprint of Hodder Education part of Hachette Livre UK. p.26. Moyle, J. T. B. 2002. Pulse Oximetry. 2nd ed. London: BMJ Books pp106- 114. Voscopoulos, Christopher, J. et al. 2014. Journal of Trauma and Acute Care Surgery. 77/3(0-), p.21630755 Spry, C. 2009. Essentials of perioperative nursing. 4rth ed. London: Jones and Bartlett Publishers p.285. http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdf https://www.resus.org.uk/resuscitation-guidelines/a-systematic-approach-to-the-acutely-ill-patient-abcde/ Post-Operative Acute Pain and its Management Severe pain is a personal familiarity and measurements should be based on patient`s own reports because most staff underrates pain and exaggerate effects of treatment (McMahon, 2013). In this assignment I will discuss a case happened in PACU (post anesthetic care unit). The reason I choose this topic is because the management of post-operative pain continues to be a major healthcare challenge. Nurses play a pivotal role in treating post-operative pain and monitoring the side effects of administered analgesia. Gynecology surgery is often associated with acute pain after surgery, which can develop into chronic pain. I dealt with a patient who had an emergency laparoscopic salphingo oophorectomy operation. She was in lots of pre operation pain and lower abdominal pain. She was a 38 years old female patient with no medical history, no regular medication and no known allergies. She was having intravenous and oral Morphine on the ward pre surgery. She weighed 133 kg (21 stone), her height was 165 cm and BMI (body mass index) was 48.8. Obesity and pain have a complex interwoven relationship as explained in this article. Obesity is recognised as being in a proinflammatory state, the subsequent inflammation causing pain to the individual. Inflammatory cytokines cause chronically raised levels of circulating cortisol, which may eventually lead to insulin resistance and, consequently, metabolic syndrome. The increased mechanical stresses of obesity, particularly on the lower limbs, cause chondrocytes to produce proteins which break down cartilage matrix as well as yet more proinflammatory cytokines. The inflammatory cytokines produced in obesity have been shown to shift the balance of serotonin/kynurenine production from tryptophan in favour of kynurenine, the reduced serotonin levels contributing to depression and increased pain experience. Both depression and pain contribute to avoidance behaviour and adoption of a sedentary lifestyle, further precipitated by joint immobility resulting from cartilage degradation. Although a sedentary lifestyle appears to reduce pain exacerbation, it actually contributes to physical deconditioning and obesity, which results in a greater pain experience for the individual. Furthermore, eating is used both as a coping mechanism and as a form of analgesia, which temporarily reduces pain and depression but leads again to further weight gain and greater pain experience (British Journal of Pain, 2013). Anesthetic was uneventful, she was in theatre for almost 3 hours. Fentanyl 100 microgram, Propofol 300 miligram, Augmentin 1.2 gram, local anaesthetic 30 mililiters of 0.5% Chirocaine, Rocuronium 50mg, Morphine 10 miligram, Paracetamol 1 gram, Voltarol 75 miligram, Cyclizine 50 miligram, Dexamethasone 3.3 miligram, Ondansetron 4 miligram and one liter of Compound Sodium Lactate solution intravenous infusion. Hawthorn and Redmond (1998) claims there are various factors involved in surgery that affects the physiological events of pain, as any surgical procedure presents an enormous insult to nociceptive pathways. High levels of stimulation can cause changes that result in a hyper excitability of the system with the result that pain will be much greater or elicited more readily. On arrival to the recovery I conducted ABCDE assessment A – Airway she had an artificial endotracheal airway in situ, size 7 connected to water circuit and 10 litres high flow central oxygen. B – Breathing, respiratory rate was 18 per minute, equal chest expansion good rhythm and depth. Patient was pink, misting on the tube C – Circulation, blood pressure was 122/45, heart rate 68. D - Disability, her temperature was 36.8°C, pupils are equal and reacting to light. E - Exposure/ Examination, laparoscopic sites were clean and dry, abdomen soft, nil vaginal loss observed. The Patient fit to the extubation criteria and tube removed according to the local policy and evidence based practice. The patient became very restless, rolling over in bed and groaning in pain, I shortly obtained information from patient and observed her behavioural changes. Parsons and Preece (2010), states that inadequate post-operative analgesia contributes to the development of avoidable complication that jeopardizes patient’s recovery. Unrelieved pain produces immobility, which leads to muscle loss and weakness and impairs pulmonary function. Lack of movement and reduced tissue oxygenation is a contributing factor to the development of deep vein and pulmonary thrombosis (Parsons and Preece, 2010). Other complications that can arise include coronary ischemia myocardial infarction, pneumonia, poor wound healing and infection. Bromley and Brander (2010) argue the commonest reason for under treatment of pain is the failure to assess pain and pain relief. Assessment of pain should be done at frequent and regular intervals and should be documented. Her blood pressure rose to 155/ 68 and she was tachycardic with heart rate of 105 per minute, patient was restless and experiencing a lot of muscle spasms. I prepared Intravenous Morphine and gave in 2 mg doses every 5 minutes while regularly assessing patient’s pain and documented on Trust TPR chart every 15 minutes. I utilized IV flush of Sodium Chloride 0.9% to flush the administered opioid through the cannula and was running Hartman’s intravenous infusion to ‘flush’ the Morphine to minimize side effects and signed prescription chart. I evaluated the outcome of intravenous opioid bolus administration and communication of patient care with the multidisciplinary team. McMahon (2013) claims that opioid have been the mainstay in the management of moderate to severe postoperative pain because it interacts with the most powerful endogenous pain-reducing system of the body. Opioids cross the blood-brain barrier and act in both the brain and the spinal cord. According to McQuay and Moore (2002), Nurse administered intermittent opioid injection requires good staffing levels to minimize complications; Patient controlled analgesia overcomes this logistical problem. Parsons and Preece (2010) states respiratory effect of unrelieved pain produce reduced respiratory performance and the ability to cough. This can result in patient developing atelectasis, chest infection, pneumonia, chest infection, hypoxia and possible respiratory failure. Bromley and Brander (2010) argues that numerical rating scales are used for adults where the patient rates the pain from 0 to 10, 0 being no pain 1-2 mild pain, 3-5 moderate pain, 6-7 severe pain 8-10 unbearable pain. After reassessing her again observations, sedation score, blood pressure, respiratory rate, observed for possible haemorrhage, all parameters were within recommended limits. The patient was given more morphine that caused drowsiness. The sedation level dropped her respiratory rate to 8 per minute. The rest of the observations were stable, and oxygen saturations remained 100% on 6liter oxygen. A decrease in respiratory rate is recognised as unreliable observation (Macintyre & Schug, 2007). She wasn’t responding to stimulations, was very sleepy, sedation score was 3 out of 4, 0 being alert 1 drowsy easily roused, 2 very drowsy, easily roused, 3 somnolent, difficult to rouse 4. Following the injection of intravenous, Morphine may take 15 to 30 minutes before Morphine takes the effect on the central nervous system (Macintyre & Schug 2007). According to McMahon (2013) drug-induced respiratory depression in the post-operative period remains a serious patient safety risk factors associated with significant morbidity and mortality. Naloxone was administered to reverse the respiratory depressant effect of opioids and excessive sedation while still retaining reasonable analgesia, A 3 mililiters of Sodium Chloride with Naloxone 0.4mg/400mcg (1ml), (i.e 0.1mg/100mcg Naloxone per ml of solution) was administered to the patient. After 30 minutes patients respiratory rate went up to 14 per minute and sedation score was 2 out of 4 and started experiencing pain again. Morphine CADD PCA (patient controlled analgesia electronic cassette) and administered while the patient was closely monitored. According to Bromley and Brander (2010) the principal of PCA is that the patient should administer analgesia when they feel the pain is sufficient to justify further drug. Accurate, valid and reliable measurement of pain is essential if we are to better understand the factors that determine pain intensity, quality and duration; improve diagnosis and treatment of pain and ensure accurate evaluation of the relative effectiveness of different therapies McMahon et al (2013). Approaches to the measurement of pain include verbal and numerical self-rating scales, visual analog scales and, behavioral observation scales, and physiological responses. Because pain is subjective, the patients self-reports provide the most valid measure of the experience. In our local Thrust 0-10 pain scoring system is used the most. For postoperative pain control, individualized pharmacologic treatment preferred. This reflective piece of work provided me the opportunity to learn and reflect on clinical practices. It inspired me to advance my practice by actively engaging in the on-going debate about what continuous advanced and advancing nursing practice within the context of pain management. The number of people experiencing unrelieved pain and the care available to them highlights the need for care which better meets their needs. The barriers impending the effective delivery of care relate to the patient, the professionals and the organisations in which pain management takes place. (Carr, E. Layzell, M. and Christensen, M. (2010) Will try to be more aware of how could have improved patient safety and reflect on this in the future. It gave me understanding of the epidemiology pathophysiology of pain and helps me to pay greater attention in the future. I aspire to help my patients relieve pain, improve quality of live, increase functionality, and reduced hospital stay. We are accountable and responsible for the care of a patient receiving intravenous opioid analgesia. All registered nurses should effectively administer Intravenous Opioid Analgesia for the management of acute pain without compromising patient safety while working within identified wards/departments. Education for nurses should increase competency in the administration of intravenous opioids. Reference Aids Medical Writers. 2014. Manage Pain before, during and after total knee arthroplasty using a multimodal approach to analgesia. Drugs & Therapy Perspectives [Online]. 30, ( 9) pp. 321-324 [Accessed 10 June 2014]. Available at: http://link.springer.com/article/10.1007%2Fs40267-014-0138-0#page-1 Bromley, L. and Brandner, B. Acute Pain. 2010. 1st ed. Oxford: Oxford University Press. Carr, E. Layzell, M. and Christensen, M. 2010. Advanced Nursing Practice in Pain Management Oxford Blackwell Publishing Ltd. Hawthorn, J. and Redmond, K. Pain Causes and Management. 1998. 1st ed. Oxford: Blackwell Science Ltd. Holdcroft, A. and Jaggar, S. Core topics in Pain.2005 1st ed. Cambridge: Cambridge University Press. McMahon, S. B., Koltzenburg, M., Tracey, I., Turk, D. C. Wall And Melzack`s Textbook of Pain, 6th ed. 2013. Philadelphia: Elsevier Saunders Ltd. Parsons, G. and Preece, W. Principles and Practice of managing Pain A Guide for nurses and Allied Healthcare Professionals. 1st ed. 2010. England, Berkshire: Open University Press McGraw-Hill Education. Macintyre, P. E. and Schug, S. A. 2007. Acute Pain Management: A Practical Guide. 3rd ed. Philadelphia: Elsevier Limited McQuay, H. and Moore, A. 2002. An Evidence-based Resourse for Pain Relief. 1st ed Oxford: University Press Oxford. McVinnie, D. S. 2013. Obesity and pain. British Journal of Pain. [Online] [Accessed 10 June 2015]. Available at: http://bjp.sagepub.com/content/early/2013/04/08/2049463713484296.full.pdf+html Read More