Effective Pain Management in an Acute Ward - Case Study Example

Effective Pain Management in an Acute Ward Introduction The pain experience can be particularly traumatizing for most people. Pain associated with an illness or a disease can even be more traumatizing to patients. It can be continuous or intermittent pain often unrelieved by analgesics and the usual pain medications. Health care professionals have the responsibility of relieving these pain symptoms; they are also responsible for helping the patient emotionally and physically cope with pain. But pain management by health professionals may not always be effective. Some methods of pain management may work for some patients, and other methods may not fit the symptomatology and condition of the patient. Current practice is now focused on evidence-based management which emphasizes on individualized and patient-centred care. This paper shall explore effective pain management in an acute care ward. It shall particularly focus on the effective pain management techniques that may be applied to a postoperative elderly patient. The physiology underpinning the pain perception shall be discussed in this paper. Also, an analysis of the appropriateness of the strategies utilised in the pain management shall be undertaken. This paper shall also discuss the contribution of the World Health Organization analgesic ladder and the non-pharmacological management techniques that may be applied in pain management. Patient The patient is a 63 year-old male adult who has just undergone partial hip surgery. He is experiencing post-operative pain at the operative site, particularly at his right hip area. He has difficulty gaining and maintaining mobility due to the pain and is often not confident in moving because he fears he might fall again and experience more pain. He is a widower and he lives alone; he is visited occasionally by a cleaning lady and once a week by his children and grandchildren. The community nurse also checks on in him every 3 days. Two days prior to admission, he slipped on his bathroom floor and had a fracture of the femoral neck (at his right hip). He described the pain that he feels as dull, and based on the Verbal Numerical Scale he rates it to be 7 out of 10, with 10 being the highest degree of pain. He often feels pain when he moves, when he walks or stands up. I first informed him of the case study that I will be conducting and how I wanted him to be the subject of my case study. I explained to him what information I will be needing for the case study and that information gained will be used for academic purposes only and will be kept confidential at all times. He agreed to be a part of the case study and he later signed the confidentiality agreement in relation to this research. Main Body The post-operative pain that the patient experienced may be described as a “complicated response to the vascular dilation and inflammation, due to tissue injury or underlying disease” (Javid, et.al., vol. 9). Due to tissue injury and the subsequent surgery he went through, the patient perceived pain. Pain is perceived by nociceptive receptors which then transmit and relay the stimulus from nerve impulses; these impulses then reach the central nervous system through afferent fibres (Lautenbacher & Fillingim, p. 4). Pain is perceived by the nociceptive receptors from the tissues in his hip area and then transmitted to the central nervous system through the afferent fibres. The above precepts of pain are very much related to the Classic Theory of Pain Perception. This theory basically advocates that “there are specific pain receptors in the skin and other organs whose stimulation results in sending coded electrical impulses along specific nerve pathways straight through the ‘pain centre’ in the brain where interpretation occurs and perception develops...” (Beasley, p. 418). Pain is defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage” (International Association for the Study of Pain, as quoted by Macintyre & Schug, p. 25). This definition makes pain a subjective experience. It is largely based on the patient’s condition and a host of other factors ranging from the biological to the psychological. It is important for nurses and other healthcare professionals to realize that pain is not a natural and harmless consequence of surgery that can be undertreated. Under-treatment of pain can have adverse effects on the patient like myocardial ischemia and pneumonia. “Severe acute pain after surgery may also increase the risk of persistent (chronic) pain” (Macintyre & Schug, p. 3). Severe and persistent pain can cause the increase of catecholamine in the system, leading to an increase in blood pressure; it can also exaggerate pulmonary dysfunction impairing the muscles of the diaphragm and consequently one’s ability to cough; it can also delay gastric emptying (Macintyre & Schug, p. 4). Some practitioners also claim that unrelieved pain causes urinary retention and possibly hypokalemia; it can cause muscle spasms at the site of tissue damage; it can cause immobility and increase the risk for deep vein thrombosis (DVT); it can also cause depression of the immune function, making the patient susceptible to infection and pneumonia. Unrelieved pain can also have cognitive and psychological effects like anxiety and depression. These conditions usually lead to disturbances in the normal activities of the patient like: diet, exercise, work, sleep patterns, and other activities of daily living (Middleton, p. 28). It is therefore important for healthcare professionals to acknowledge pain complaints, especially after surgery in order to avoid the further aggravation of the patient’s physical and mental condition. Physical trauma, surgery, and other forms of tissue damage “cause a reaction at the site of tissue disruption or damage and a physiological response throughout the body” (Carr, p. 5). Such tissue damage will then cause the release of chemicals that react with each other and with nerve endings. Tissue trauma at the site of the fracture and at the surgery site caused biological responses from the body which then ultimately culminated to the pain experience in the elderly patient. The Gate Control Theory can help further explain the patient’s perception of pain. According to Melzack & Wall, there is a gating mechanism in the dorsal horn of the spinal cord. Pain sensory impulses have to pass through this gate before being relayed to the brain to be perceived as pain. “The gate control theory suggests that information can only pass through when the ‘gate’ is open and not when the ‘gate’ is closed” (Clancy, et.al., p. 244). The gate is opened or closed based on the release or inhibition of neurotransmitter chemicals. The patient’s perception of pain as explained by the Gate Control Theory stems from the opening and closing of the gate. Based on the release or inhibition of neurotransmitter chemicals, the patient may or may not get to experience pain. The Gate Control Theory also sets forth that psychological factors affect the experience of pain. The Gate Control Theory postulates that “peripheral stimuli interact with cortical variables, such as mood and anxiety, in the perception of pain” (Turk & Gatchel, p. 4). This theory also advocates that somatic and psychogenic factors either increase of decrease the experience of pain. Pain cannot be completely owed to physiological factors because psychological factors affect or influence the ultimate perception of pain. The Gate Control Theory also claims that “cutting or blocking neurological pathways is inadequate because psychological factors are capable of influencing the peripheral output” (Turk & Gatchel, p. 5). The Gate Control Theory is the most comprehensive summary and explanation for pain perception. It is also the most widely accepted theory explaining pain and pain perception because it is an amalgam of physiological and psychological factors forming an integrated model for pain and the experience of pain. Pain Management Strategies The management of pain in elderly clients is a complex process. Briggs (p. 23) advocates the use of both pharmacological and non-pharmacological techniques aside from the use of analgesics in order to help reduce the pain experienced by the elderly client. As a nurse, part of my responsibility is to be familiar with the patient’s specific condition and the measures appropriate for the patient. After sufficiently assessing the patient, I also familiarized myself with the type of surgery he went through, the possible interventions that I can safely implement and any other useful information vital to his care. Authors emphasize that “barriers to improved pain management faced by clinicians include lack of education, poor pain assessment, and concerns about opioids especially addiction, respiratory depression, and regulatory scrutiny” (McCaffrey, p. 4). By getting rid of these barriers, it is possible to eliminate the physiological and psychological manifestations of pain in the postoperative elderly patient. Evidence-based practice is the latest and the most preferred plan of care for patients. “Effective and safe management of acute pain is best achieved by tailoring pain therapies to the individual patient” (Macintyre & Schug, p. 24). Modifications and adjustments to pain management and interventions need to be crafted based on the patient’s condition, illness, and tolerance. Some studies were able to reveal that nurses have deficient knowledge in managing pain in the clinical area and they also reveal that there has been “no change in knowledge or behaviour following education about pain management” (Twycross, p. 705). This is an unfortunate revelation because it implies that nurses are inefficient in pain management despite training and education in the area. Assessment The first pain management strategy applied in this case is to assess the patient’s postoperative pain. The location, character, quality, and severity of the pain were assessed before a plan of care was formulated. Appropriateness of assessment Assessment is appropriate because it will help determine the characteristic and the source of pain. Elderly patients are likely to experience pain from a variety of sources and for a variety of illnesses. Through this accurate assessment, it is also possible to determine the true intensity and characteristic of the pain being felt by the patient in the postoperative area. Pain felt in other parts of the body may mask the pain which is being experienced at the postoperative area, and vice versa. By isolating the source of the pain, an accurate assessment is made possible. “The guiding principle of pain assessment is to ask the patient and believe the patient’s complaint of pain” (Rosenthal, et.al., p. 161). There are moments in the process of pain assessment when the interpretation of the doctors or the nurses is given more importance than the patients’ actual assessment. Practitioners emphasize that “it is the patient, not the health professional who knows how much pain he or she has, as well as the effectiveness of any pain relief measures” (Redfern & Ross, p. 501). Sometimes the treatment is also based on doctors’ and nurses’ assessment. The assessment of the doctors or nurses is usually a lower intensity of pain as compared to the patient’s actual experience of pain. Sometimes, pain is even dismissed by doctors and nurses, especially when older patients are involved. Consequently, elderly patients often do not bother to express their pain complaints. And this lack of openness often makes an accurate assessment of the patient difficult. The patient is not open, not honest, and not cooperative during the assessment. But still, through the assessment tool, it is possible to rebuild trust and communication with the patient. By simply listening and asking questions about the pain or any other symptoms they may be experiencing, patients eventually will open up and reveal what they are truly feeling. On a psychological front, assessment will help older patients gain some confidence in expressing any other symptoms they may be experiencing. They would feel valued as patients through the interview and assessment, thereby increasing the chances of recovery and general well-being. Elderly patients face the dilemma of being near the end of their lives; this feeling often affects their psychological frame of mind. Depression ultimately surfaces in elderly patients due to their desperate thoughts. Through assessment, it is possible to give the patient a chance to control his diagnosis and treatment. The experience of pain may be different for elderly patients from a cultural standpoint. Elderly patients often have this culture or habit of silence; of not expressing the symptoms they feel or any other manifestations of illness that they may be experiencing. Some of them feel that expressing their pain symptoms will make them lose control over their life; and some others feel that their future may be affected if they admit to feeling pain. These patients also opine that the medications will not be effective. And some elderly patients admitted to hospitals often “believe that the staff are too busy to hear their complaints of pain” (Kerr “Community Education”). In the end, they just do not want to displease anyone and so they often opt to adapt a culture of silence. According to the Gate Control Theory, “complex physiologic, psychologic, and cognitive processes, such as anxiety, past experiences, and the meaning of pain, are heavily influenced by sociocultural learning” (Ebersole, et.al., p. 284). And these factors affect the perception and experience of pain, consequently also affecting the opening and the closing of the gate. Some people feel that pain in the elderly patients is only an expected symptom due to various medical conditions that they may be afflicted with. Because of this attitude, the elderly are less forthcoming about their pain symptoms. Some of them even feel that since they are already old, they should be in pain. The elderly patient in this case often felt embarrassed about expressing his health concerns and health needs. He had a very independent personality and often proudly claims how well he has managed to take care of himself since his wife died. He was also a proud man and did not want to lose his dignity by asking for help and expressing his feelings of discomfort or pain. This streak of independence often made it difficult to properly assess his condition. However, after gaining his trust and confidence, he was more open about his feelings and his health concerns. In case the patient is not particularly forthcoming about his pain symptoms, assessment of the patient’s non-verbal cues may be done. However, care must be taken in assessing non-verbal cues because biases in the interpretation of pain perceptions may colour one’s assessment (Redfern & Ross, p. 502). Non-verbal cues can only be used to verify the tolerance, characteristics and intensity of pain experienced by the patient. Practitioners also emphasize that non-verbal cues may not always be present all the time. “Patients/clients may take pride in self-control and may minimize their expression of pain in order to be a good patient” (Redfern & Ross, p. 502). They may then attempt to control their wincing and guarding in order to conceal the actual pain they are experiencing. Pharmacological After assessment, analgesics prescribed to the patient were administered based on doctor’s orders. The doctor’s order for administration of pain medication was four times round the clock, so I gave the patient the pain medication at 6:00 and 10:00 in the morning, at 2:00 and 6:00 in the afternoon, and at 10:00 and 2:00 at night. I checked with the doctor several times for possible adjustments in the administration of pain medication depending on the severity and intensity of the patient’s pain experience. Fortunately, no pain was experienced by the patient during intervals of medication administration. The patient had no side effects and adverse reactions to the pain medication. Appropriateness The administration of analgesics or pain medications to the elderly patient is appropriate because it is the quickest and safest way to reduce or eliminate the pain. However, the use of analgesics and pain medications is appropriate only after an adequate assessment of the patient is made. This assessment will include history of use of analgesics and possible adverse or allergic reactions to any of them. Adverse reactions to other medications that the patient is undertaking also need to be established. Some authors claim that “elderly people [are] more sensitive to the pain relief effects of narcotics due to alterations in receptors, changes in plasma protein and prolonged renal clearance” (Redfern & Ross, p. 506). The effect of narcotics and other pain medications is often faster and longer than in younger patients. The patient’s tolerance for pain has to be taken into account before pain medications are administered. Mild to moderate pain which does not respond to nonopioid analgesic, may respond to a weak opioid analgesic (Meiner & Luekenotte). Adjustments have to be made to fit the patient’s needs, and his physiological and psychological experience of pain. Opioid analgesics fit the patient’s needs because “opiates produce a greater analgesic effect, a higher peak and a longer duration of effect in older adults” (Ebersole, et.al., p. 358). The lowest possible dose was started for the patient, and the latter was monitored frequently after administration of the opiates. The patient responded well to the lowest dose of the medication, and so such dosage was maintained during his stay at the hospital. The opioid analgesic is also appropriate for the patient because he indicated that he has used it before and has not experienced any adverse reactions or side-effects when he took said medication. Many elderly patients taking opioid analgesics experience constipation, cognitive impairment, nausea, hallucinations, sedation, and urinary retention, among others (Rosenthal & Zenilman, p. 168). The patient in this case has not experienced any of these side-effects when he used analgesics previously. Opioid analgesic is therefore a favourable pain medication for the patient. Practitioners also favour opioid analgesics because these drugs do not exhibit ceiling effects and they also produce good analgesic effect through progressive escalation. This drug also shows low-organ toxicity even after years of use. This makes it the perfect choice for the elderly patient because his body has already gone through much wear and tear. WHO analgesia ladder The World Health Organization analgesia ladder is a three-step ladder which is basically used as a guide for cancer pain relief. The ladder basically postulates that when pain occurs, there should be immediate oral administration of drugs in the following order: “nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain” (World Health Organization, 2009). The ladder also recommends that in order to calm the patient’s fears, adjuvants should also be administered to the patient. The World Health Organization also recommends that drugs should be administered to the patient every 3-6 hours, and not ‘as needed’. The WHO claims that this three-step ladder approach is about 80-90% effective. This three-step approach was not used because following the doctor’s orders an opioid analgesic was given to the patient. Following administration of such drug, the patient’s pain symptoms was significantly reduced. There was no need to shift to a stronger drug because the patient already felt relief from pain after being given the opioid analgesic. With regard to the administration of adjuvants for the patient’s feelings of anxiety, the doctor did not recommend the administration of adjuvants. This was also in accordance with the patient’s preference. The patient did not favour taking adjuvants because he had a history of grogginess and headaches after using adjuvants. The patient indicated that he would rather deal with his fears and anxieties through non-pharmacological interventions. Since he was responding well to the relaxation and distraction techniques, the health care team decided that the patient did not need to be given adjuvants. The first step in the three-step ladder which is the administration of nonopioid pain medication was also not employed by the doctor. According to the doctor, nonopioid medications are too weak for postoperative patients. Also, about a month prior to the patient’s admission, he was given a nonopioid medication for muscle pain. Such medication was too weak for him, but he did not want to bother his physician to ask for a stronger pain medication. He endured a week of pain until his daughter finally convinced him to go see the doctor again. He was then given an opioid analgesic after the second consult and his muscle pain was greatly relieved thereafter. In assessing the history of the patient, the doctor immediately assumed that the patient would not be relieved by the nonopioid analgesic, so the much stronger drug was given instead. Given the patient’s tendency not to reveal pain experiences, the more prudent course of action would be to apply the intervention which would already work from the very start. Again, the measures employed above are appropriate and are in keeping with the person-centred approach to health care advocated by the National Service Framework for Older People. Non-pharmacological I also helped the patient move from one position to another in order to minimize pressure on his hip area. I guided the patient in practising relaxation techniques like taking deep controlled breaths. I prompted him to do the things he usually did to relax like reading a book and listening to music. I also employed distraction techniques like sharing stories and generally just chatting with him. I asked him to share stories about his children and grandchildren. I often played board games. During the times when he was able to take naps or at night when he was asleep, I made sure that he was not disturbed. This gave him time to rest and recover well. I also interviewed and conversed with the patient regarding his pain experience, his fears and concerns every time he experienced pain and his fears and concerns regarding his surgery and recovery. Appropriateness The non-pharmacological interventions that were applied to the patient were very much appropriate because they helped manage the postoperative pain without having to resort to pharmacological remedies. Non-pharmacological interventions also help improve the patient’s emotional handling of the pain experience. Relaxation techniques “seek to produce a relaxation response that decreases sympathetic nervous system activity, thereby reducing the pain-anxiety-tension cycle” (Mostofsky, p. 144). These techniques were appropriate for the patient because they helped reduce the tension that the patient was feeling after his operation. Some studies have revealed that “preoperative training in relaxation techniques can significantly reduce postoperative pain and analgesic requirements” (Rosenthal, et.al., p. 170). What may be felt as pain, may actually only be tension or nervousness. The patient was often tense because he was severely traumatized by his bathroom fall which fractured his hip. He experienced great pain and actually passed out on the bathroom floor because of the pain. And after the operation, for every twinge of pain he feels, he fears that such would again escalate to the same excruciating pain he felt when he slipped on the bathroom floor. When I asked him to take deep breaths, he felt a bit relaxed. He also felt relaxed by listening to mellow and oldies music. Controlled breathing techniques helped the patient relax especially when he felt anxious or nervous about his pain experience. Controlled breathing techniques are appropriate for patients in pain because “attention to the act of breathing and using slow, deep breaths increase oxygenation of the body and increase the sense of relaxation” (Mostofsky, et.al., p. 144). Through this technique, tension was dissipated and reduced in the patient. It was important to follow the proper technique while doing this activity because possible improper employment of this technique may cause hyperventilation. This technique is very simple to follow and very effective in helping the patient to relax and eventually to reduce pain. Distraction methods are also appropriate for the patient. Guided imagery can be used in conjunction with various distraction methods. In the case of the elderly patient, it was possible to divert his attention away from the pain he was feeling through music and reading. Distraction methods are effective because these involve “control over the focus of attention and can be used to make the patient less aware of noxious stimuli” (Fisch & Burton, p. 144). However, it is important to note which methods fit the patient. Not all patients enjoy listening to music or imagining themselves sunning on an isolated beach. Our own idea of relaxation is often vastly different from the patient’s, therefore, it is important to make an assessment of appropriate distraction techniques for each individual patient. The patient liked listening to music and reading, therefore these distraction techniques are appropriate for him. Exercise As part of the patient’s rehabilitation process, I assisted the physical therapist during his rehabilitation. Range-of-motion exercises were undertaken with the patient. Beyond the physical therapy sessions, such activities were also conducted with the patient. Care was however taken so that the exercises would not further harm or aggravate the injury suffered by the patient. Exercise that increased or caused further pain patient was modified and immediately stopped. Pain during exercise may indicate that the exercise is too intense for the patient (Prentice & Voight, p. 690). However, in general, exercise is beneficial for elderly patients, especially for postoperative patients. It “is vital for optimum physical functioning and mobility” (Mostofsky, et.al., p. 146). It helps speed up recovery and the healing process. Exercise also helps build muscle strength, thereby increasing weight-bearing ability. On a psychological plane, exercise also helps reduce depression and feelings of despair. As the patient becomes more active, he also becomes more interested in joining and participating in socialization activities. The pain management techniques employed are all in keeping with the National Service Framework goal to administer person-centred care to older people. “Older people and their carers should receive person-centred care and services which respect them as individuals and which are arranged around their needs” (Department of Health, p. 8). Based on the above provision, care administered to the patient needs to be individualized and personalized. This was applied several times during the care of the elderly patient. Pharmacological interventions like opioid analgesics provided relief to the patient; and various non-pharmacological interventions were also appropriate to his needs, his tolerance, his condition, and his interests. Better cooperation with the applied intervention was gained from the patient through the application of these patient-centred pain management measures. Many elderly patients often feel that they may lose their dignity and independence if they ask for help or if they express symptoms associated with health problems. The Mayo Clinic in the United States emphasized that elderly patients often value their independence more than the longevity of their life (Takahashi, as quoted by Mayo Clinic, 2005). Because of this preference, healthcare professionals are often left with the challenge of coming up with a plan of care which gives the elderly their independence while still ensuring their safety. The person centred approaches applied to the patient gave him independence and still managed to minimize his pain symptoms. As was previously emphasized, the measures and interventions applied to the elderly patient focus on a person-centred approach. First and foremost, an accurate assessment of the patient was performed. Through this assessment, the patient’s history, preferences, and perceptions were established. The plan of care that was formulated was then based on the assessment of the patient. The pharmacological remedy covering opioid analgesics was applied because nonopioid analgesics would be too weak for the patient. Adjuvants to relieve the patient’s anxiety were not recommended because they caused grogginess and headaches. Nonpharmacologic methods like relaxation and distraction techniques were also applied alongside range of motion exercises. These nonpharmacologic techniques were appropriate for the patient because they were easy and simple enough to adapt and apply. The patient also responded well to these techniques. He felt relaxed and distracted from the pain experience by playing board games, by listening to music, and by reading. The methods employed for the patient are in accordance with the objectives of the National Service Framework for Older People which aims for person-centred care. And by employing the above methods, this student was able to establish the importance of distinguishing one patient from another. Different patients have different needs. What may work for one patient, may not necessarily work for another. The mark of an efficient nurse and healthcare professional is one’s ability to look at and care for each patient as a person, and not just another occupied bed in the ward. Works Cited Balducci, L., et.al. “Comprehensive geriatric oncology”. 1998. London: Taylor & Francis Beasley, R. “Beasleys surgery of the hand”. 2003. New York: Thieme Medical Publishers Beers, M. “Postoperative Pain Management” 2006. 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