Orthodox and Non Orthodox Therapeutic Interventions.

University Degree Subjects allied to Medicine

When providing care for an acutely ill adult, both orthodox and non-orthodox interventions can be used effectively on there own or combined to suite the patient. When patients are admitted to an acute care setting there needs must be assessed in a holistic manner, therefore for the purpose of this assignment I have chosen to discuss the importance of Patient controlled analgesia (PCA) machines and massage in the acute setting. Both methods will discuss the advantages and disadvantages and will identify the professional responsibilities of the nurse in relation to the interventions. PCA machines are most commonly used for Patients with acute post-surgical, trauma, cancer related pain or any acute pain when a pain relief intravenous route is preferred, which makes these machines most common in an acute setting. Anxiety is also common among patients with pain and is often associated with fear of death, complex environments and uncertain prognosis in the immediate post-admission period (Brunner and Suddarth, 1989) which is the rationale for massage been used.

Patient controlled analgesia (PCA) is a method used in order to give pain relief to a patient that involves the patient’s participation, by an appropriate and safe route. IV is the method most commonly used although there are other method which include intranasal, subcutaneous and epidural. (Thomas 1996). The PCA system is a pump that has a syringe and a timing device, the system is programmed then activated by the patient pressing a button which delivers a small dose of analgesic, this is referred to as a bolus dose. The system is set with a lock out device ensuring that the patient may only receive the desired amount of analgesia for a certain period of time. (Alexander et al 2000). There is however also a continuous background infusion of opioids which may be delivered independent of the patient, this is often used to allow the patient to sleep without been constantly woken to re-establish their pain control. (Nendick 2000). The pca machine works by reducing stress responses by blocking nerves and neurons conveying impulses to the brain or spinal cord, therefore reducing sympathetic nervous system activity, thus achieving an effective analgesic concentration with minimum side effects. (Thomas 1996).

It must also be noted that although many health professionals have an active role in treating pain it is the nurse who normally assesses pain and evaluates the efficacy of pain control. (McCaffery & Beebe, 1994). Therefore when considering pain management, it is necessary to contemplate the nurse’s attitude towards the concept of pain, as it is often criticised in literature. (Davis, 1994). It is essential that nurses remember that pain is totally subjective and that pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. (McCaffery, 1983). Some of the literature highlights the common nursing attitude, that if a patient has had X operation, they will only feel X pain. (Walsh, 1989). Walsh also criticises the incidence of analgesia given only during the “drug round”, this situation can lead patients not wanting to bother the nurse when it is not the allocated time for their medication. Therefore nurses should enforce the fact that pain relief is available at any time, not only at certain times of the day if required.

There are many advantages of this method of analgesia; it also has significant benefits from the usual intramuscular injection (IM) of a fixed dose of analgesia when required. PCA machines give a continuous dose of analgesic which replaces the Inter muscular injection which has often been reported by patients refusing the injection as it is too painful. IM injections also cause narcotic blood levels to rise and fall sharply resulting in the patient experiencing peaks and troughs of pain, there is also often delays in the patient requesting pain relief and the patient actually receiving it. (Thomas 1996) The continuous dose delivered by a PCA machine ensures that the patient’s pain is never out of control and that their pain can be monitored effectively. This has been reflected in reports suggesting that there is an increase in patient satisfaction and improved pain relief when using a PCA machine, (Nendick 2000) it has also been suggested that very few patients abuse the system of self-medication and many patients have demonstrated that less opiate medication is required when they are allowed to control it themselves. (Peat 1995). This allows the patient to be in control and not feel intimidated by constantly bothering the nurse resulting in patients moving around quicker after surgery eliminating problems and complications such as DVT or pulmonary embolisms. (Nendick 2000).

However there are disadvantages when using a pca machine and nurses must recognise the problems they may encounter with the machine, patient and there own ability. In order for the machine to be used effectively the patient must mentally make a connection between pressing the button and getting pain relief, they must also be able to physically press the button, patients with hand injuries or arthritis may find it difficult pressing the button themselves, therefore it is important that the nurse is competent in assessing the patients ability, although PCA by proxy may be used in these circumstances. The notion of PCA by proxy is suggested by Norcutt (1990) stating that a nurse or relative could press the PCA button for the individual who cannot physically press it, or whom cannot grasp the concept. Other factors include improper patient selection (not all patients are good candidates), it is essential adequate assessments are carried out to eliminate those patients who are at risk of opioids use. Example patients with chronic obstructive airway disease and head injury should not use the system as respiratory depression may be more likely to occur. (Hauer 1995).

Explanations and practical demonstrations should be introduced prior to surgery by giving the patient the opportunity to handle the PCA equipment and practise pressing the button. However this is often not the case as many patients are often shown the PCA in recovery after surgery, which in turn leaves them confused and in pain. (Carr, 1990) Some patients may also find the PCA machinery overwhelming and would prefer not to take control. Therefore nurses should value and respect this decision and discuss alternative treatment methods. (Carr, 1990).

Nausea and vomiting are also common side effects when using patient-controlled analgesia ...

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Nausea and vomiting are also common side effects when using patient-controlled analgesia (PCA) with opioids. Many patients are not tolerant and giving anti emetics has been suggested as a way to prevent these problems. (Woodhouse & Mather 1997) Anti emetic treatment should be given early as this problem is found, by many patients, to be just as unpleasant as pain. however Simmonds and Edwards (1998) criticises that pca have been blamed for the increase of nausea and vomiting and is only one method used in pain management, they suggests that the patient does not receive a greater amount of medication with this method than with any other. Therefore the patient should not experience worse side effects with one method than another when opioids are used.

Morphine is one of the most common opioids used for moderate to severe pain. However opioids may cause respiratory depression by decreasing the responsiveness of the respiratory centre to carbon dioxide in a dose dependent manner. This means if the respiratory centre detects an increase of pC02 it will result in a reduction in ventilation. This gives the patient a sensation to breathe harder. (Rutishauser, 1999). Norcutt & Morgan (1990) suggests that PCA systems are safer when used alone as background infusions may increase the risk of respiratory depression. In a study of 1000 patients with PCA in situ, it was found that 25 of them suffered from respiratory problems of some description. Due to the possibility of respiratory depression, the PCA guidelines highlights the standard actions to be taken in the event of respiration being at a rate of 10 or less per minute the correct procedure is to stop the pump, bleep the doctor, ring for the resuscitation team. (Norcutt, 1990).

Human error is also one of the main factors relating to PCA problems, lack of understanding, insufficient staff training, prescribing errors and other practice-related problems, such as ineffective monitoring of the patient's vital signs. (Quinn 2000). Therefore contra-indications must not be overlooked and nurses must still monitor the patient regularly observing vital signs such as pulse, blood pressure, respirations and oxygen saturation, as well as observing for possible side effects of the medication. It is also important for the nurse to regularly assess the patient’s pain in order to determine whether adequate pain control is being achieved as often this may be overlooked due to the patient controlling it themselves. (Thomas, 1996).

The machine its self however must not be overlooked, as no machine is entirely failsafe, although there have been very few reports of equipment malfunction it does highlight the importance of not only monitoring the patient but the machine as well. (Brown, 1997). Morgan (1990) point out some mechanical problems encountered with the PCA system. These include battery failure, software failure and display board failure. Several authors have acknowledged the potential for operator error when using PCA. All pumps require some mechanical adjustment or electronic programming in order to function. As the complexity of the programming increases, so do the possibility of user error and therefore the risk of the delivery of too much or not enough analgesia (Brown et al, 1997, Williams, 1996). It is therefore essential that adverse incidents are acknowledged when developing safe practice, this led to an incident reporting system been set up by the national patient safety agency (DOH 2001). Nurses are encouraged to learn from mistakes and reflect on the reasons things have gone wrong, the response to adverse incidents should not be to blame the user but to appreciate and highlight the problems which have occurred. (Amoore, Ingram 2002)

Complementary therapies are a popular option for health care, as they are now often thought as complementing orthodox treatments rather than as an alternative. (Thomas et al, 1991; Downer et al, 1994; Vickers 1994), However when choosing a complimentary therapy many factors are of concern. The treatment given should be based on recent and valid research findings, as a nurse has a moral obligation to provide evidence to demonstrate that their practice will benefit the patient. They must also be able to justify their chosen intervention by following an appropriate theoretical framework and only work within their limitations. Nurses must be open to criticism as not all medical professions will welcome change, this often places nurses in a vulnerable position in terms of employment, professional and legal responsibilities.

If relating a complimentary therapy to a critical care environment, massage is a non orthodox therapeutic intervention that is non invasive and may help relax the patient. Patients who are admitted to a critical care setting often feel scared, embarrassed and suffer from anxiety, and are often in pain. On the surface their needs are usually for physical care, such as medical treatment but they also have emotional needs which can only be met through warm, supportive relationships. Research has suggested that patient demand for non orthodox therapies to be incorporated into the critical care area is growing; many patients are responsive to nurses carrying out massage for relaxation purposes. (Richards 2000).

Massage is based on a series of classic massage movements, each with different effects; it is thought of as the manipulation of body tissues to produce beneficial effects on the muscular, vascular and nervous system of the body. However it must always be tailored to suit the needs of the patient. (Richards, 2000). Massage is like any other intervention, it needs to be planned following an assessment of the patient and evaluated when it has been implemented. The nurse must identify the problems that massage may be able relieve and explain the rationale for this intervention; Side effects must also be discussed. Massage is thought of as a holistic therapeutic intervention, having many benefits, it can reduce stress and anxiety by relaxing both the mind and body, creating a feeling of well-being, enhanced self-esteem and ease emotional trauma through relaxation. (Norton 1995)

Massage can work through a mechanical action and a reflex action. A mechanical action is created by moving the muscles and soft tissues of the body using pressure and stretching movement, which cleanses them of acids and deposits. This mechanical action breaks up fibrous tissue and loosens stiff joints. A reflex is created when treatment on part of the body affects another part of the body, the body is connected to each other by nerve pathways, these flows of energy are known as 'meridians'. So, by using reflex action, some nurses will treat a patient's stomach complaint by massaging the arms, and will alleviate pain in the legs by massaging the lower back. Nelson et al (1986) also identified that massage causes a rise in the production of endorphins. Endorphins are neurochemicals which alter the body’s perception of pain by preventing some of the pain impulses being registered by the brain, therefore reducing the individual’s experience of pain. (Wilkinson, 1996)

Massage has advantages and benefits which may be useful for both physical and psychological purposes. Physically, massage helps to loosen tight muscles, improve the flow of lymph fluid and release pain; this is often used by physiotherapists in settings such as intensive care when the patient is unable to move for themselves. Psychologically, massage helps to release emotional tension, balance the flow of energy in the body and aids non-verbal communication. The British Medical Association estimates that as much as 75% of an illness may be of psychosomatic origin (Davis, 1985).however It is suggested that nurses have used these basic strokes of massage for many years soothing patients, enhancing skin integrity and promoting sleep, although in an ever changing world sound research evidence is required to show that the intervention and its method of use is effective. Dracup (1988) suggests that critical care units are hazardous to psychological health and may delay recovery. This led to a study by Simpson et al (1996) being carried out on acutely ill adults, the aim of the study was to understand the reasons for patients not sleeping in a critical care area, the results showed that patients could not sleep due to anxiety, pain and difficulty getting comfortable. It was therefore suggested that if the reasons for sleep disturbances is a state of heightened anxiety and discomfort, nursing interventions such as massage which will promote comfort and relaxation. (Richards 2000).

While many nurses are interested in incorporating the use of complementary medicines in their existing role they may encounter disadvantages, these can include, the patients may be sceptical to the benefit of non orthodox therapies, which is an important concept when dealing with informed choice. (Richards 2000). It must also not be underestimated the close physical contact necessary for massage, nursing staff should not ignore the intimate nature of this treatment and should be aware that not every patient will be comfortable receiving massage therapy. (Buckley, 2002). It may not be appropriate for the nurse to provide these therapies as the environment of an acute setting as it is often busy and noisy and for any complimentary therapy to work effectively a quiet and relaxation atmosphere must be achieved. Nurses who wish to integrate complementary therapies in their practice should ensure that they provide these therapies in a manner which is always in the best interest of their patients and not to carry out unnecessary treatment for the pleasure or interest to themselves. However not all patients are suitable for massage and nurses must take into account those patients with contraindications, such as cuts or abrasions, bruising and skin disease.

The greatest problems seem to be based on cost effectiveness and availability; there is a considerable amount of nursing time taken up when carrying out a massage. This however may be overcome through evidence-based practice, an approach that was proposed by Mackerith and Gale (1994), who developed a training programme which teaches staff to perform a massage of not more than 15-20 minutes. Although there is a growing professional and public interest in these non orthodox therapies, it is still often difficult to access these therapies in the NHS. (Wilkinson, 2002) A survey suggested the majority of the NHS nurses said they spent less than 10% of their hours practising complementary therapies. They also suggested that these methods were not perceived by colleagues and managers as being an integral part of proper nursing practice (Rankin-Box, 1997), there are however many organisations such as the MNC (2002) who have supported nurses extending their roles to practice complimentary therapies and the BMA (1995) recommended that communication from complimentary therapy was an essential part of care.

Regardless of treatment, whether orthodox or non orthodox there are may legal and ethical implications concerning a nurse, as nurses today have increasing responsibilities, having to make important decisions in many situations. For this reason it is paramount for them to follow a framework of law and ethics. Legal and ethical judgements must be guided by legislation, professional code of conduct and their own moral and ethical beliefs, working within their own limitations. With any treatment informed consent is vital, this arises from the ethical principle of respect for autonomy, all patients have the right to be given adequate and accurate information regarding there treatment and should make there decision based on their own circumstances, values and beliefs with the support from the nurse. The nurse must highlight the benefits, possible harms and what the treatment will involve. It must also be recognised that consent is an ongoing process as care will change as the patient improves therefore continued discussions must take place. (Norton, 1995). Medical staff also has a legal obligation to keep all information confidential, this means that a nurse cannot pass on any information to a third party without consent. (Hendrick, 2000).

Documentation is often targeted by nurses because of the increasing amount of paperwork involved, which nurses feel is limiting the amount of time a nurse can spend with each patient. However nurses must always bear in mind the reasoning for this as litigation with regard to health care is not uncommon. (McHale 1998). Any nursing document can become a legal document, if requested by a court of law therefore it is essential that medical staff follow legislation and good record keeping. (Young, 1995). The NMC (2002) has a booklet entitled ‘Guidelines for records and record keeping,’ designed to guide nurses in their documentation. The NNC (2002) also has booklets on professional code of conduct highlighting the importance of responsibility and accountability. This gives nurses guidelines ensuring they understand the implications of there actions and working within their own limitations. Therefore if the nurse is using an orthodox or non orthodox intervention she must be able to justify the rationale for its use, have evidence based knowledge about intervention and be able to react in a professional manner if adverse effects occur. Example. When working with PCA pumps, it is the nurse’s duty of care to be acknowledgeable about the PCA, and of morphine and its side effects. Thus the nurse will be able to monitor the patient’s condition and react to any change in vital signs, before they become life threatening, i.e. respiratory depression. National and local protocols give the nurse guidelines for standard practice, and ensure that no aspect of care is overlooked. The nurse can advise the patient of its usage but must remember that pain is a subjective concept and should press the button for the patient except in the case of PCA by proxy.

In conclusion, when providing care for an adult client both orthodox and non-orthodox interventions may be utilised when caring for an acutely ill patient. Both interventions may be used simultaneously or alone as neither intervention is superior to the other and many patients may feel that one enhances the other, providing holistic care. (Alexander et al, 2000). However all treatment must agreed by the patient and often patients may feel conventional medicine is the only treatment either available or successful on use. The use of PCA machines are a vital intervention for patients to control there own pain, giving them more independence and quicker recovery, which in turn frees up valuable nursing time. However monitoring responsibilities of the nurse relate not only to the patient but also the machine, which are often overlooked as the patient is in control. (Thomas,1996). As suggested massage is a therapy which may have many benefits to patients, it may be used simply to relax a patient which in turn may help them be more comfortable or even sleep better, or for other reasons example; pain, although availability is often difficult. However the nurse’s responsibility to either intervention must be paramount as both interventions have not only advantages but also many disadvantages. Nurses today are constantly in the public eye of litigation, as there has been an increase in the number of negligence actions brought against health care practitioners. (McHale, 1998) A nurse must follow policies and procedures and not only understand the benefits of these interventions but also the adverse effects they may have, delivering them in a professional manner. (MNC, 2002).

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Orthodox and Non Orthodox Therapeutic Interventions.

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