Care of the acutely ill

The following assignment will focus on the subject of postoperative pain management. It will use an example of a patient cared for on placement to generate effective arguments in relation to postoperative pain management. The care given to the patient will be analysed using psychological, sociological and physiological theory. The aspect of care of postoperative pain management was chosen because it was observed on an orthopaedic surgical ward as one of the main problems in postoperative recovery and rehabilitation of the operated limb.

As the poorly controlled pain often stops the patient mobilising early and effectively which are necessary to range of motion in the limb and facilitating safe hospital discharge. To adhere to the Nursing and Midwifery Council the code: standards for conduct, performance and ethics for nurses and midwifes (2008). Pseudonyms will be used to maintain confidentiality; the patient depicted within this assignment shall be referred to as Vikki. Vikki was cared for on a twenty-two bedded elective orthopaedic surgical ward.

Vikki is a seventy-eight year old woman who has had a total hip replacement athroplasty (THR) following a diagnosis of osteoarthritis several years ago. Prior to surgery Vikki’s hip had caused severe disablement and had impacted greatly on her daily living activities. Vikki returned onto the ward with an intravenous-patient-controlled-analgesia (IVPCA). This contained morphine an opioid based pain relief also prescribed was one gram of Paracetamol four times a day orally.

The physiological basis for pain within the human body is generated by the nervous system. Avidan, Harvey, Ponte, Wendon and Ginsburg (2003) state there are three different types of pain nociceptive, neuropathic and psychogenic. Furthermore, according to Kneale and Davis (2005) the nervous system is a communication system and in regards to pain. Sensory nerve fibres relay information to the brain that the body is experiencing pain. The brain then sends information to the motor nerve fibres to react to that pain sensation.

This communication system is called the pain pathway which includes four stages (Wood, 2008). The first stage of transduction is when the nociceptors detect a chemical stimulus of prostaglandin, bradykinin, lactic acid, potassium, histamine, substance P and serotonin. This in Sylvia’s case occurred when the tissues were damaged through surgery. The second stage is transmission this is when the nociceptors send electrical impulses through A delta fibres and C fibres into the spinal cord through the dorsal horn and into the thalamus of the brain.

Then during stage three; perception, the electrochemical impulses are sent out across the brain and the pain itself becomes a multidimensional experience. The forth and final stage is modulation, this is when the brain changes or inhibits the impulses entering the spinal cord. The production of substance P is halted as endogenous opiates are released in the dorsal horn of the spinal cord by descending neurones. They connect with the opiate receptor sites on the pain fibres which in turn cancels the production of substance P.

According to Albery and Munafo (2008) theories of pain today include elements of both the Specificity theory which was proposed by Muller and developed by Von Frey in the mid-to-late 1800’s and the Pattern theory of pain proposed by Goldshnieder. However the most predominant philosophy in current pain theory is the Gate Control Theory, this was developed in the 1960’s by Melzack and Wall (1965). The most affirmed component of the Gate Control Theory is the physiological gating mechanism. The gate is believed to be situated within the dorsal horn of the spinal cord.

Certain physiological, cognitive and emotional factors attribute to the opening and closing of the gate to allow or prevent the pain sensations through to the brain (McLean, Huntingdon, McArthur-Rouse, 2007). This is an accurate theory in relation to Vikki however it does not include relevant sociological factors that could increase or decrease her pain these will be discussed further on in the paper. The morphine included in Vikki’s IVPCA allows the gate to close by inhibiting the release of neurotransmitters and mimicking the action of endogenous opioids (DeLeo, 2006).

There are many other pain medications available however; morphine is the gold standard postoperatively unless it is contraindicated according to the guidance published in the local trust policy (2006). Vikki in her postoperative state is experiencing nociceptive pain. Vikki’s surgery of a THR was on bone and joint rather than a visceral organ, she is therefore experiencing somatic pain which is localised and will decrease over time (Hall, 2000).

Considering this, Kerr and Kohan (2008) state that local infiltration analgesia (LIA) is the best method for pain relief following THR; it allows for virtually immediate mobilisation and faster discharge from hospital. However, Sylvia returned back onto the ward with an IVPCA which controlled her pain when she was awake to press the bolus infusion button, but often awoke after dozing, in pain. Alternatively, a study by Roth, Kling, Gockel, Ri?? melin, Hessmann, Meurer, Gillitzer and Jage (2005) state that IVPCA is an effective treatment for postoperative pain compared to other conventional analgesic strategies.

Nevertheless it would appear that the current evidence states that as LIA is a localised analgesia rather than a systemic analgesia such as morphine IVPCA there are fewer side effects and it also includes the added benefit of improved pain control (Andersen, Pfeiffer-Jensen, Haraldsted and Si?? balle, 2007). Another consideration when dealing with postoperative pain management is previous exposure to opioid medication. Sylvia has been suffering with osteoarthritis for several consecutive years to control her pain prior to surgery she has been dependent upon opioid medications.

This individual variable was a reason for the particular choice of postoperative pain treatment used. According to Gordon, Inturrisi, Greensmith, Brennan, Gobal and Kerns (2008) if a patient has been on a dose of opioid analgesia for a continuously long time it may affect the intensity on which the treatment for pain works postoperatively on the patient. MacIntyre and Ready (2001) also concur with this statement and themselves state that a patient such as Vikki who has a chronic non-malignant pain with her osteoarthritis will need a larger dose of medication postoperatively to counteract the opiate dependency she already has.

Vikki was only prescribed Paracetamol and morphine intravenously all her other opioid medications and usual analgesia had been omitted this caused Vikki an unacceptable level of pain. According to Kneale and Davis (2005) it is necessary to continue the patient’s usual doses of opioid medication to control their original pain prior to surgery and additional medication is also needed postoperatively.

Vikki’s pain was assessed by the nurse in her acute postoperative pain stage using a verbal numerical rating scale (VNRS) which calculated severity of pain from 0-3, also checked at this time were normal vital sign observations, nausea score, sedation score and pump volume. Vikki’s pain was assessed every 15 minutes on returning to the ward for a one hour period. Then every 30 minutes for a two hour period, every hour for a four hour period and then two hourly thereafter.

Local policy (2006) states that the IVPCA assessment should be completed according to this management plan, it is acceptable for most patients receiving an IVPCA infusion. However, if any abnormalities arise in the collection data appropriate action should be taken with regards to frequency of observations or interventions. Vikki commented that her pain throughout the numerous assessments remained on a one or one and a half, however on occasion it did increase to a three and Vikki stated that when this was she hadn’t pressed the button for a while.

The nurse subsequently told her to press it whenever the pain increased. Within the elderly a barrier to effective pain assessment and management is the problem that they don’t want to be a bother and it is an inevitable part of aging (Carr and Mann, 2000). A more holistic pain assessment such as the McGill Pain Questionnaire could be completed to gain a better view of the pain felt by Vikki however, time is a great issue within nursing today and a quick and easy VNRS is easier to complete.

The view proposed by Searle and Bennett (2008) is that there is widespread evidence that pain intensity ratings reflect the intensity of emotional distress more than intensity of physical sensation. Therefore, an accurate measure of pain through the use of these tools such as the VNRS is almost unachievable unless effective communication techniques are used. Another consideration with morphine IVPCA is the possible side effects that can occur, such as hypotension and respiratory depression which can be fatal especially in elderly patients (Kieta, Geachan, Dahmani, Couderc, Armand, Quazza, Mantz and Desmonts, 2003).

However, respiratory depression according to Ko, Goldstien and VanDenKerkhof (2003) is a very rare side effect but patients on opioid medication should always be closely monitored for such effects. This is another reason for completing the vital signs over the time period stated above, according to local policy (2006) these should be completed by a member of staff competent in the use of IVPCA. A failure to notice these significant changes could be fatal to the patient as commented upon in the report by the National Patient Safety Agency (2008).

It was observed that post surgically Vikki had not used much IVPCA when asked about it she replied she was having difficulty in staying awake once she pressed the button as she went straight to sleep then she only awoke again once she was in pain. This mild sedation of Vikki was noted by the health professional staff as Vikki responded to voice when her pain was assessed and it was concluded at the time that it was satisfactory. However, the morphine was not really appropriate to Vikki’s needs as it was not controlling her pain continuously.

Within the elderly systemic analgesia works quickly and this could explain the rate at which Vikki fell asleep after pressing the button for a bolus infusion (Kneale and Davis, 2005). A small amount of morphine is usually prescribed initially in elderly patients postoperatively as they are more susceptible to the adverse effects (Wilder-Smith, 2004), this in itself can cause the problem of poorly controlled pain. This would be another reason for LIA to be used on a patient such as Vikki.

When this was noted by the nurse Vikki should have been referred to the acute pain team. However, she was not this according to the document produced by the National Health Service Quality Improvement for Scotland (2004) was bad practice as there was an obvious need for Vikki to be referred to alleviate her pain and control her sedation levels. They could have prescribed an alternative analgesia or even include a background infusion with the IVPCA which can also benefit an opioid tolerant patient as discussed earlier in this assignment (Pasero and McCaffery, 2004).

The Gate Control Theory discussed earlier within this paper also allows for psychological factors experienced by patients to be part of the pain experience rather than just physiological factors. According to Albery and Munafo (2008) anxiety or depression can open the gate and allow for a greater pain sensation and happiness and relaxation can close the gate which decreases the pain felt by the patient. The concept that anxiety and/or depression is interrelated to pain intensity is also supported by Mok and Lee (2008).

Vikki in her postoperative state was experiencing a great amount of anxiety because she was concerned about her husband (Albert) and how he was coping alone as he suffered from a moderate form of dementia. Vikki’s anxiety was identified within the pre-assessment clinic using an effective tool as discussed by Crockett, Gumley and Longmate (2007). Gilmartin and Wright (2008) support the previous statement and also propose that evidence has found that a vast number of patients find their anxiety and worries dispersed during the pre-assessment clinic.

So therefore, this is a very good way to deal with the postoperative problem that anxiety may cause the patient. Vikki’s daughter assured Vikki and the nurse that Albert would be well looked after and there was no need to worry. However, when this was reaffirmed to Vikki by her daughter in the pre-assessment clinic and postoperatively she still remained anxious and she stated that she was the only person that could look after him properly and she just wanted everyone to hurry up, stop talking about it so she could get home and look after him.

Therefore, according to Carr, Thomas and Wilson-Barnet (2005) Vikki was likely to experience a greater amount of pain in her acute postoperative state than another individual who was less anxious. The study also suggests that in patients similar to Vikki an intervention, or referral should be completed to ease the anxiety for the patient. Further evidence by Runshagen, Schnabel, Standl, Schulte and Esch (1999) also concurs with this statement and they themselves remark that intervention or referral by a health professional to reduce anxiety has a positive impact on a patient’s pain control.

The Locus of Control (LOC) theory according to Ogden (2007) produced by Wallston and Wallston in the 1980’s generates the concept that an individual can differ to external situations through individual perceptions. An individual may believe that they control situations and events presented before them this is called an internal LOC, or an external force beyond their control is responsible for these situations and events this is referred to as an external LOC.

As Vikki has been prescribed IVPCA the doctor has taken into account the need for Vikki to combat the external LOC (surgery) with the ability to control her own pain medication and empower her internal LOC. This is a view supported by Salmon and Hall (2003) which in their research state that doctors now feel that empowering patients is a major part of medicine and treatment. However, it has been noted that Vikki has strong Roman Catholic beliefs; she believes that “God” wishes her to have these afflictions and to experience this trauma; she has stated that “it is Gods will”.

In relation to this it would seem that Vikki is a patient that would fall under the category of external LOC. Therefore, from the research by Brandner, Bromley and Blagrove (2002) Vikki would have been a better candidate to receive another form of postoperative pain treatment such as LIA as she would not benefit from an empowerment of an internal LOC. There are three different subjective-affective-cognitive processes (Ogden, 2007) two of these are relevant to Vikki the first is the role of affect this is where anxiety or fear increases the pain perception for the patient.

Vikki is experiencing anxiety for Albert which will have increased the levels of pain she has experienced. The other is the role of cognition which includes different categories self-efficacy which is interrelated with the health LOC model and attention. Greater attention to pain by an individual has been proven to exacerbate pain whereas those who are distracted show a decreased level of pain intensity (Ogden, 2007). Studies by Huang, Good and Albert (2007) have shown that distraction techniques such as music can have a positive effect on the decrease of pain intensity felt by an individual.

This research is also supported by Good, Stanton-Hicks, Grass, Anderson, Lai, Roykulcheroen and Adler (2001) who agree that postoperative patients benefit from adjuvant therapies such as relaxation techniques and music. Therefore, an intervention of relaxation technique or music could have been used to reduce Vikki’s anxiety. However, this may not always be appropriate or services available on a ward. The article by Power (2005) states that there are many benefits to non-pharmacological therapies and also contains the added bonus of being devoid of any significant side effects but unfortunately it is not often used in practice.

The use of music therapy within hospitals within the United Kingdom is not impossible according to Cancer Research UK (2007), however as these sessions must be carried out by a qualified and registered member of The Association of Professional Music Therapists according to Department of Health (2007) they can be expensive and are not offered free of charge to most patients and those who do qualify must meet certain criteria.

Ethnicity and culture has a large impact on postoperative pain management, studies by Lasch (2000) have shown that the amount of analgesia required for postoperative pain is occasionally dependant on their ethnic groups and cultural perception of pain. However, the study does report that more research is needed into this field as the current research has taken into account the culture of subjects yet individual sociological variables were not considered.

However, more recent research completed by Tam, Lim, Teo, Goh, Law and Sia (2008) state that there are significant differences in pain perception between different cultures. Therefore according to their research, Vikki as a white British female should have a higher pain threshold compared to that of an Indian or Asian. Culture is not necessarily accounted for in Vikki’s case and a reasonable understanding of different cultures and their perceptions to pain must be comprehended by the health professionals treating the patient to ensure that this individual variable is not overlooked.

According to research by Rosseland and Stubhaug (2004) significant differences were found in postoperative pain perceptions between genders, within this study woman reported more pain than men. However, this is not conclusive evidence that the pain experience is greater in woman than men. Sociological theory discussed by Haralambos and Holborn (2008) who support the work by Connell on masculinities state that generally in most cultures men should be strong and be able to bear pain in a masculine way.

Therefore, men may not report pain as readily as woman. It is unclear in Vikki’s case whether the sociological variable of gender had been considered in relation to her postoperative pain management as it was observed that most patients undergoing the THR procedure had IVPCA. However, on the pain assessment criteria and monitoring sheet gender is not accounted for. To conclude, the assignment has analysed the management of postoperative pain in an acutely ill patient.

The nursing practice has been evaluated in relation to the best available evidence and the physiological rationale has been discussed for the care interventions. There are many different theories that relate to postoperative pain management these often conflict with one another and it is possibly necessary for more research to be completed in this field in relation to a holistic approach incorporating physiological, psychological and sociological concepts.

Yet every patient is an individual and will experience these pain sensations differently and pain must be treated as an individual experience for every patient. It is believed that Vikki had poorly controlled pain and the management of which was not sufficient to her needs. Unfortunately this is often the case for individuals postoperatively and further research and guidance needs to be produced to allow a conclusive effective procedure in the case of postoperative pain management.

Taking into account all of the individual variables and physiological, psychological and sociological theory. It can be concluded that Vikki would have had better postoperative pain control if LIA had been used. It is possible that music therapy would be beneficial to patients experiencing postoperative pain. To develop current practice more research is needed into the effects of a specially designed music therapy audio tape on postoperative pain control. This could alleviate the financial difficulties faced by having a one-on-one session with a registered music therapist.

Effective communication and knowledge are imperative to effective postoperative pain management. In Vikki’s case if the nurse had more knowledge about the alternative analgesia and had possibly attended a study day Vikki could have received better postoperative pain management. Therefore, adequate time, good clinical observation skills and effective communication should always be used in a pain assessment and greater knowledge to the alternative analgesics will ensure good future nursing practice.

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