The Reliability of Nurses Observations on Pain Symptoms - Essay Example

Introduction The management of a patient’s symptoms can be a complicated process. Pain is one of the more difficult and complex symptoms to control and handle for any patient and for the medical health professionals. This paper shall present a critical reflection on key issues in nursing management. It shall involve the recognition of a patient’s pain and the process involved in the management of pain symptoms. It shall present literature related to the incident -- describing what may be considered as key issues in the incident. This paper shall also discuss strategies for improvement based on literature cited and relevant to the current situation being studied. Critical incident During my final posting in a busy acute orthopedic unit, I was diligently and dutifully carrying out my responsibilities when the emergency department staff wheeled in Mdm. Tan, a very frail and very depressed looking old lady. She was being admitted for bilateral knee pain and severe back pains. She also looked very sad and depressed and her expression showed that she was in an enormous amount of pain. She had no one accompanying her. I placed a reassuring hand on her arm and with a warm smile I gathered all the information necessary for her assessment. She lost her husband in an accident about 30 years ago, and after that, she lived with her daughter who unfortunately passed away 3 years prior to admission after battling cancer. Since her daughter’s death she had been living on her own. She is aware that her pains are attributed to her arthritis which she also knew to be degenerative in nature. She said that she already saw several doctors for her ailments. They gave her pain killers which did not seem to adequately relieve her symptoms. She stopped seeing doctors and she felt like she was old enough to die because she felt like there was no one to live for anymore. After performing my pain assessment on Mdm. Tan using the Numerical rating scale (pain rated from 0-10, with 0 meaning no pain and 10 indicating the most pain), Mdm. Tan rated her pain experience to be 7 out of 10. Such rating was immediately reported to the Staff Nurse in charge who then informed the duty doctor. Mdm. Tan was not reviewed until 3 hours after admission. When the doctor finally arrived and assessed Mdm. Tan, he decided to discontinue her medications Oxycontin 20 mg and Valium 5 mg because he fears that the Mdm. Tan may already have developed an addiction for her medications. Instead, she was given Celebrex 200 mg for her pain; prednisolone 30mg for her inflammations; Glucosamine 1500 mg as a supplement; and some laxatives for possible constipation. On this new regime, Mdm. Tan’s pain symptoms were not well controlled. Physiotherapy session was flatly refused due to pain. Her limited mobility and pain confined her to bed; and this made her socially isolated and severely depressed. Her temper tantrums made the nurses avoid her. As a student nurse, I feared Mdm. Tan’s unrelieved pain and suffering, along with the doctors’ and nurses’ inability to understand her would lead to devastating consequences. As a student nurse, my actions were limited in scope; but I really wished, for her sake, that I could intervene and give some suggestions for her care, such as referring her to psychiatrists for the management of her depression and referring her to a pain management team for the management of her pain using the Cognitive Behavioral Therapy. All I could do for her at that time, however, was to assist her with her meals, to encourage her to take her medications and to attend her physiotherapy sessions. It has been nearly five years now, but I think about Mdm. Tan every once in a while. I think about her agony and her pain and still wish I could have done more for her. Critical Reflection on Key Issues Based on the critical incident, I believe that the key issues are: patient’s chronic pain from arthritis; social isolation and depression, impaired mobility, psychological and physical distress. The patient’s chronic pain symptom from her arthritis is a problem which has to be adequately and correctly assessed by the nurse based on patient’s self report and the nurse’s assessment of non-verbal signs. In some instances, these reports sometimes do not coincide or correspond with each other. A paper by Teske, Daut, and Cleeland (2003) sought to establish the relationship between a patient’s self-report of pain and the nurse’s observations of pain symptoms. Their study was aimed towards determining the variables which can impact on the relationship between these measures (Teske, Daut, & Cleeland, 2003). The paper was able to evaluate the reliability of nurses’ observations on pain symptoms and on their evaluation of the intensity of pain symptoms. The paper was able to establish that although these observations are reliable, the relationship between the nurses’ inferences and the patients’ self report of pain intensity are significant. The differences in observations are even more significant in cases of chronic pain as compared to acute pain samples (Teske, Daut, & Cleeland, 2003). I also noted in my analysis of the critical incident that a nurse-led assessment of pain has an effect on self-efficacy, pain intensity, pain-related disability, and depressive symptoms in chronic pain patients. In a paper by Wells-Federman, Arnstein, and Caudill (2002), the authors set out to evaluate the nurse-led pain management program and its overall effects. They attempted to evaluate the impact of participating in a nurse-initiated cognitive behavioral treatment pain management on self-efficacy, pain intensity, pain-related disability, and depressive symptoms among patient experiencing chronic pain (Wells-Federman, Arnstein, and Caudill, 2002). There were 154 participants all in all who participated in the paper. The paper was later able to establish that there were significant improvements in all scores in the postprogram period. “Self-efficacy, pain intensity, pain-related disability, and symptoms of depression can be changed through participation in a nurse-led outpatient CBT program” (Wells-Federman, Arnstein, Caudill, 2002). In relating such results from researches on CBT pain programs, this study was able to establish that with the implementation of CBT pain programs, it is very much possible to reduce pain symptoms even in patients under chronic pain. I was able to realize that my thoughts of applying CBT for Mdm. Tan would not have been too far-fetched. They would have been able to help relieve some of her pain symptoms. I also recognized that Mdm. Tan’s social isolation and depression is another key issue or problem in her case. Such feelings of social isolation and depression are exacerbated by her pain symptoms, her limited mobility, and by the fact that she lives alone. A paper by Alexopoulos (2005) emphasized that depression often sets in among patients who are suffering from chronic medical illnesses. Moreover, factors usually seen among elderly individuals like cognitive impairment, family disruption, and disability exacerbate the already existing illness of the elderly patient (Alexopoulos, 2005). The fact that diseases related to ageing like arteriosclerosis and inflammatory, endocrine, and immune changes also affect the integrity of the frontostriatal pathways and the amygdale which can increase the patient’s susceptibility to depression (Alexopoulos, 2005). Other factors like psychosocial adversity (financial difficulties, disability, relocation, caregiving and bereavement) can also compromise a person’s physiology, thereby also increase the elderly individual’s susceptibility to depression. The treatment of depression in the elderly can also be accomplished with the administration of anti-depressants – same as in adults (Alexopoulos, 2005). There are also evidence-based interventions which are currently available and which can help in minimizing possible new episodes of depression. These guidelines improve diagnosis and treatment of elderly depression. The study was also able to point out that in North America, these programs are not readily available and programs which address elderly depression are not as effective (Alexopoulos, 2005). In the case of Mdm. Tan, her chronic illness is her arthritis which keeps her immobile and isolated from the rest of the world. The death of her daughter is also another possible factor which is contributory to her depression. Her isolation and living alone is another main factor adding to her feelings of depression. Social isolation is also a problem in Mdm. Tan’s life. She feels cut-off from the world and she has not had much of an opportunity to enjoy a healthy relationship with other people because of her limited mobility. This is common among elderly people everywhere. Findlay (2003, p. 647) discusses that “as the population ages and more people are living alone, social isolation amongst older people is emerging as one of the major issues facing the industrialized world because of the adverse impact it can have on health and well-being”. Findlay’s (2003) study covers literature from 1972 to 2002 on the effectiveness of interventions that cover social isolation among the elderly. The evaluation of Findlay revealed that even if interventions on minimization of social isolation have been implemented worldwide, not enough evidence indicate that such interventions do work (Findlay, 2003). Future interventions which are geared towards reducing social isolation must have evaluation incorporated into them from the very start. And in cases where it is possible, as cost-effective measures, the pilot or demonstration projects should be implemented before these interventions are set into place (Findlay, 2003). Through this study, it can be deduced that there is a need to assess interventions which are based on evidence in order to effectively reduce isolation among the elderly. Mdm. Tan’s social isolation is slowly linked with her limited mobility and her chronic pain symptoms. Hence, all interventions to address such isolation must be largely based on such other symptoms. Mdm. Tan’s impaired mobility due to her arthritis is also considered one of the key issues in this critical incident. It is an issue that can lead to various medical problems like falls, pressure ulcers, and constipation. In a paper by Vasallo, Vignaraja, Sharma, Briggs and Allen (2004), the authors assessed patient characteristics which contribute to falls among hospital inpatients. The paper revealed that patients who had an unsafe gait had a higher incidence of falls as compared to those with normal gait. Factors which also contributed to their falls included confusion, abnormal lower limbs, hearing defects, and the use of tranquilizers. This study indicates how Mdm. Tan’s immobility puts her at risk for falls, hence the need to address this issue in order to reduce or prevent further risks to her health. Mdm. Tan’s impaired mobility also puts her at risk for pressure ulcers. Lindgren, Unosson, Fredrikson, and Ek (2004) sought to identify the risk factors in the development of pressure ulcers among adults hospitalized as medical or surgical patients. They covered 530 adult patients who were assessed based on the Risk Assessment Pressure Sore (RAPS) scale and on variables like general physical condition, activity, mobility, moisture, food intake, fluid intake, and body temperature. The assessment revealed that 62 patients later developed pressure ulcers and they were the ones who were significantly older, hospitalized for a longer time, had lower scores on the RAPS, and who were immobile. There is therefore a need to increase Mdm. Tan’s mobility and activities in order to reduce her risk for developing pressure sores. Mdm. Tan’s immobility also places her at risk for constipation. This is a common problem among the elderly and those who have limited mobility. A paper by Read, Celik, and Katsinelos (1995) summarized the prevalence and the causes of constipation among the elderly and they were able to establish the crucial roles of immobility, low dietary fiber, and dehydration in constipation among the elderly. From a disease standpoint, rectal prolapse, rectocele, and hemorrhoids also cause constipation (Read, Celik, & Katsinelos, 1995). With this study, it is important to note, once again, the importance of mobility among the elderly in order to prevent not just constipation but pressure ulcers, and the risk of falls as well. Another key issue in Mdm. Tan’s case is her psychological and physical distress. Her psychological distress is also very much related to her depression and her general physical condition. In a study by Rapp, Parisi and Walsh (1988), the authors evaluated about 150 geriatric medical patients for the presence of psychological dysfunction using Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria methods. In their assessment, about 27% of respondents had at least one psychological disorder and about 15% had depressive disorder (Rapp, Parisi, & Walsh, 1988). Depression was also seen in patients with the highest degree of psychological distress and dysfunction and those with the poorest physical health status (Rapp, Parisi, & Walsh, 1988). The study was also able to establish that among elderly patients, depression is not adequately diagnosed and they are also the ones least likely to receive anti-depressant medications. In the case of Mdm. Tan, her psychological distress is largely brought on by her depression and isolation. Her melancholy moods and suicidal thoughts indicate that she is depressed and in psychological distress. But she was not diagnosed with depression, nor was any assessment done in her behalf to determine if she was indeed depressed. This should have been remedied while she was under hospital care because undiagnosed depression may lead to dangerous and disastrous consequences for Mdm. Tan. Strategies for Improvement Considering the things that I now know and the things I have learned from the literature review, in order to make the encounter more therapeutic, I would have employed more interventions in order to deliver care and attention to the patient. Since my role as a nurse student at that time covered limited responsibilities, I could have made the most out of the independent nursing interventions which were within my responsibilities. These independent nursing interventions include the delivery of loving care and attention to Mdm. Tan. A study by Stickley and Freshwater (2002) reveals the importance of love and its healing power. It is after all the very essence of nursing and why people join the profession in the first place. And by utilizing different nursing skills like discipline, concentration, patient, concern, and activity, it is possible to temper and fashion love and make it as a highly effective tool in the delivery of nursing care (Stickley & Freshwater, 2002). I knew I could have spent more time with her -- to listen to her and to just simply sit with her. Considering her isolation and depression, she is probably in dire need of such social interaction. This loving care would have helped lighten her spirit and her depression. It would have helped her to see that she was not alone and someone did care for her – even beyond her medical ailments and problems. I could have done things differently by also administering interventions which would have minimized her pain symptoms. A paper by Davis, Cortez, and Rubin (2005) explores pain management of older adults with rheumatic arthritis disease. The paper revealed that medication, rest, heat, distraction, exercise, and talking with others are effective interventions which can be applied to ease pain symptoms of elderly patients with arthritis (Davis, Cortez, and Rubin, 2005). Relaxation techniques are also highly effective for easing pain symptoms and a combination of these interventions can considerably decrease pain (Davis, Cortez, and Rubin, 2005). In the case of Mdm. Tan, I could have practiced some relaxation techniques with her. These include deep breathing exercises, range of motion exercises, and guided imagery. Her depression and psychological distress are factors which all contribute to her pain experience. These factors exacerbate these symptoms. By taking more time to ease her psychological distress and by helping her relax, I would have been able to help minimize her pain symptoms and eventually ease her psychological distress in the process. In my assessment, I would have also noted and further assessed her mental health, more particularly, her depression and psychological distress. Based on Mdm. Tan’s mental health and condition, her risk for suicide is high. In a paper by Alexopoulos, Hull, Bruce, and Kakuma, (1999) the authors sought to establish the clinical characteristics which can identify elderly patient with depression at risk for suicide ideation and to evaluate their prognosis. The study revealed that suicidal ideation was common among patients who have had previous suicide attempts, those who had severe depression, those with poor social support, and those with impairment in their activities of daily living (Alexopoulos, Hull, Bruce, & Kakuma, 1999). Mdm. Tan fulfills several of these risk factors; hence, I should have made a stronger and more solid effort towards assessing her depression and ensuring that her doctor addressed her depression. I could have recommended possible interventions, including possible referral to a mental health professional. I also would have performed some interventions in relation to her immobility. Her immobility actually put her at risk for pressure sores, constipation, and for falls. Since she was in chronic pain and rendered immobile by her arthritis, I could have assisted her in moving from one position to another and applied logrolling every two hours. I also could have included the use of support surfaces, mattress overlays on operating tables, specialized foam on sheepskin overlays, and improved diet (Reddy & Rochon, 2006). Applying moisturizers over bony protrusions also could have helped minimize the risk for pressure sores. These measures are preventive measures for possible pressure sores. Given another opportunity to administer care to Mdm. Tan, I would have changed her position every two hours and applied moisturizer over bony protrusions in her skin. Depression assessment scales and risk for pressure sores assessment scales needs to be in place beforehand. These scales would have helped in the assessment of Mdm. Tan’s depression. By setting this system in place, the score gained from the scale can then be made a part of the patient’s chart. The doctor would not have any option but to consider it in his diagnosis – in case the patient’s score in the scale positively indicates depression. Also, the pressure sores assessment scales can also help determine the risk and the stage that the pressure ulcer is in – from ‘no pressure ulcer’ to a full-blown pressure ulcer. This would help also determine the type of care needed for the patient and the possible interventions which are appropriate to the patient based on the stage of the pressure ulcer. Next time, I would take more initiative during patient care. I was knowledgeable of the fact that my patient was at risk for, if not, already depressed and I was aware of the fact that the doctor did not include any interventions for the patient’s depression. I would have taken a more assertive initiative to point out to the staff nurse the possibility that the patient needs anti-depressants or further interventions for her depression. Since I was able to spend more time with the patient, I was in the perfect position to observe the patient’s demeanor. This factor may influence the staff nurse to consider the patient’s depression as a comorbid condition. The staff nurse can then make the necessary recommendations to the doctor. This process in the nursing care helps set in place the importance of collaboration and coordination with the other members of the health care team. With an open coordination, it may be possible for the patient to receive the best and the most comprehensive care from the members of the health care team. Conclusion Mdm. Tan was a patient who was brought in with the following symptoms: pain due to her arthritis and signs of depression. Upon assessment, I was able to determine that she has been widowed for 30 years and since the death of her daughter three years PTA, she has been living alone. I detected signs of depression and suicidal ideation during my assessment of Mdm. Tan. There were several key issues in the incident, and these are: patient’s chronic pain from arthritis; social isolation and depression, impaired mobility, psychological and physical distress. The patient’s pain contributes to her feelings of depression and her limited mobility contributes to her social isolation, depression, and psychological distress. All these key issues are common ailments seen among the elderly, especially those who have limited social support. Mdm. Tan lives alone and has limited social support which further exacerbates all her symptoms. As a nurse student, my actions are limited; however, there are several independent nursing interventions which I could have applied while Mdm. Tan was in my care. I could have applied relaxations techniques for her in order to minimize her pain and depressive symptoms. I could have helped her increase her mobility in order to minimize and reduce her risks for constipation, falls, and pressure sores. I also could have assessed her depression and further and made the necessary recommendations to the staff nurse in order for the doctors to make a suitable diagnosis on this condition. Lastly, I could have rendered more love and attention to Mdm. Tan if only to let her know that there was someone who cared for her and what she said, what she did, and what happened to her. This critical incident has since brought forth to me crucial realities that have now made me a better nurse. Works Cited Alexopoulos, G. (4 June 2005) Depression in the elderly. The Lancet, volume 365 (9475), pp.1961 – 1970 Alexopoulos, G., Bruce, M., Hull, S., & Kakuma, T. (November 1999) Clinical determinants of suicidal ideation and behavior in geriatric depression. Archives of General Psychiatry, volume 56(11), pp. 1048-53. Davis, G., Cortez, C., Rubin, R. (23 November 2005) Pain management in the older adult with rheumatoid arthritis or osteoarthritis. Arthritis & Rheumatism, volume 3(3), pp. 127-131 Findlay, R. (2003) Interventions to reduce social isolation amongst older people: where is the evidence? Ageing and Society, volume 23(5), pp. 647-658). Lindgren, M. (8 March 2004) Immobility – a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study. Scandinavian Journal of Caring Sciences, volume 18(1), pp. 57-64 Rapp, S., Parisi, S., & Walsh, D. (December 1988) Psychological dysfunction and physical health among elderly medical inpatients. Journal of Consulting and Clinical Psychology, volume 56(6), pp. 851-855. Read, N., Celik, A., Katsinelos, P. (January 1995) Constipation and Incontinence in the Elderly. Journal of Clinical Gastroenterology, volume 20(1) Reddy, M., Gill, S. & Rochon, P. (23 August 2006) Preventing pressure ulcers: a systematic review. Journal of the American Medical Association, volume 296(8), pp. 974-984 Stickley, T. & Freshwater, D. (9 December 2002) The art of loving and the therapeutic relationship. Nursing Inquiry, volume 9(4), pp. 250-256 Teske, K., Daut, R., & Cleeland, C. (2003) Relationships between nurses' observations and patients' self-reports of pain. Pain, volume 16(1), pp. 289-296 Vasallo, M., Vignaraja, R., Sharma, J., Briggs, R., & Allen, S. (2004) Predictors for falls among hospital inpatients with impaired mobility. Journal of the Royal Society of Medicine, volume 97, pp. 266-269 Wells-Federman, C., Arnstein, P., Caudill, M. (December 2002) Nurse-led pain management program: Effect on self-efficacy, pain intensity, pain-related disability, and depressive symptoms in chronic pain patients. Pain Management Nursing, volume 3(4), pp. 131-140 Read More