Module Title: Care of the Acutely Ill Adult in Hospital

Level 3

With reference to ONE patient for whom you have cared, examine ONE aspect of care/nursing intervention in which you have participated. Explore the evidence base for this care utilising knowledge from physiological, psychological and sociological theory where appropriate.

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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, Rümelin, 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 Søballe, 2007).

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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 ...

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