Mrs Green was also asked if there was anything that nursing staff could do to help her feel more settled, which is when she asked that her room door remained closed wherever possible. This request was passed on to other team members and during handovers to ensure that it was carried out effectively.
Aim of care
The aim of care for Mrs Green was to accurately diagnose and manage her condition, whilst controlling her pain adequately, to ensure a speedy recovery and discharge from hospital. Whilst it was the responsibility of the medical team looking after Mrs Green to carry out diagnostic procedures and advise treatments and drug therapy, the nursing team were responsible for the day to day care, assessment and monitoring of therapeutic interventions which had been put in place to gain effective pain control. Treatment of pancreatitis commonly involves pancreas and bowel rest by eliminating oral intake, alongside the implementation of intravenous fluids and adequate pain relief. Nurses play a pivotal role in the assessment and management of pain, often influencing which analgesia is prescribed alongside prevention and management of the side effects of analgesics (Hawthorn & Redmond, 1998). Several nursing research studies have found nurses to be lacking in knowledge of pain and pain management (Mackrodt & White 2001), as well as lacking skills in pain assessment (Bergh & Sjostrom 1999). Given that nurses have more contact with hospitalised patients than any other member of the healthcare team, and the fact that they have the prime role in promoting comfort and pain relief, it is crucial that they are able to make accurate pain assessments (Miaskowski et al. 1994).
Although Mrs Green had been assessed in another ward it was important for nursing staff to independently assess her pain to ensure that all relevant information was gathered to assist with effective pain management. Accurate pain assessment is problematic due to the subjective nature of the experience and all its complexities (Thomas, 1997). Pain is a personal, subjective experience that comprises sensory-discriminative, motivational-affective and cognitive-evaluative dimensions. Approaches to the measurement and assessment of pain include verbal and numerical self-rating scales, visual analogue scales, behavioural observational scales, along with psychological responses (Wall & Melzach, 2006). As pain is subjective, the patients self-report provides the most valid measure of the experience, with measurement of pain being important for many different reasons. Accurate assessment to determine pain intensity, quality and duration can the help to diagnose, decide on the choice of therapy and to evaluate the relative effectiveness of different interventions. McGuire (1992) suggests that the primary benefit of pain assessment for patients is that their pain in legitimized, described and quantified. It is therefore essential for nurses to utilize effective listening skills, empathy and understanding alongside clinical knowledge to ensure that their assessment of the patients pain is as accurate as possible.
As previously discussed a method for assessing individual pain is by using a pain assessment tool. The tool implemented within our local trust (see appendix 1) provides a comprehensive overview of the pain experience, with five different elements being evaluated. Pain assessment tools are a useful aid for assisting nurses, providing opportunities to assess and monitor, as well as improving communication
between staff and patients (Twycross et al, 1996). Higginson (1998) noted that taking assessments directly from the patient is the most valid way of collecting information on their quality of life. By encouraging patients to take an active role in assessing their pain will therefore increase confidence and ensure that they feel part of the pain management process (Dougherty & Lister, 2004). According to a Canadian study by Bouvette et al. (2002) healthcare teams use pain assessment tools 93% of the time to assess pain. However, de Rond et al. (1999) states that while some nurses use proper tools to assess pain management, an equal number do not. McCaffery and Pasero (1999) noted that if pain ratings can be attached to an activity, such as observing vital signs, clinical symptoms could be used to provide information on existing problems. Young et al (2006) found that Nurses’ attitudes towards pain assessment ranged from somewhat negative to very positive, but they generally held positive attitudes about the use of pain management tools to improve patient outcomes. Education has a positive impact on the use and outcome of pain assessment tools, alongside a more positive attitude towards pain assessment. Carr (1997) concluded that although nurses were able to use the pain assessment tools it was suggested that the implementation of a tool alone will only partially improve pain management. Effective problem solving skills and interventions which reflect the multi-dimensional nature of pain are required for effective pain management, with a logical link between the assessment of the problem and the desired outcome. Furthermore Hurst et al (1991) found that there is evidence to suggest that nurses’ ability to problem solve is variable.
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Within the care plan for Mrs Green the issues around pain management were a priority, with opportunities to discuss how effective her analgesia was. Opportunities arose routinely during medication rounds and when observations were taken to assess pain by both verbal and visual methods. Recording of accurate documentation not only complies within our own professional code of conduct (NMC, 2004) but also promotes a comprehensive overview for all members of the multidisciplinary team. The development of a therapeutic relationship with Mrs Green enabled her to be open around the issue of her anxieties and pain control and she did not appear to have any difficultly in expressing her needs surrounding these areas.
Although Mrs Green has previously stated that she did not feel that she was dependant on alcohol, she did recognise that she had been feeling low in mood, which had meant that she had been using alcohol to cope. The need for Mrs Green to be prescribed anti-depressant was discussed with her and she had stated that she would prefer to go and visit her own General Practitioner once she was discharged from hospital. As the need for anti-depressants was not classed as being urgent, it was decided that Mrs Green could organise her own appointment when she returned home.
What is pain?
Pain is a universal experience and is the most frequent reason that a person will seek medical advice (McCaffrey & Beebe, 1997). Pain has been conceptualized as a multidimensional and highly subjective experience, with physiological, sensory,
affective, cognitive, behavioural and sociocultural factors having a contributory input into the event. McCaffery (1980) defines pain as “whatever the experiencing persons says it is, existing whenever they says it does”. The central role of emotional distress is recognised in the widely accepted and influential definition of pain disseminated by the International Association for the Study of Pain (Mersey & Bogduk, 1994). It states that pain is an ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage’. Comprehensive theoretical models of pain also recognise affective qualities as integral and essential to the experience. The influence of the gate control theory of pain (Melzack & Wall, 1965) is attributable in part to recognition that tissue stress concurrently activates both affective-motivational and sensory-discriminative components of pain. To enable health professionals to assess and manage Mrs Green’s pain, it was essential to recognise the importance of not just the physiological condition that was causing pain, but also the psychological, social and environmental factors which could also relate directly to her experience of pain. Nurses offer a unique role in caring for people with pain, simply because they spend more time with them than any other multidisciplinary team member (McCaffery & Beebe, 1997). Poor pain relief has been well recorded and has been noted in nursing literature over the past 20 years (Zalon, 1995). This reflects incompleteness in the nursing process. Suffering pain also raises ethical concerns and is a barrier to nursing goals, such as enhancing an individual’s quality of life (Montes-Sandoval, 1999).
There are two categories of pain, acute and chronic. Acute pain is characterised as briefer in duration, anywhere from onset to three to six months, which begins to subside as healing takes place. Chronic pain is prolonged, persistent or intermittent, but does not improve over time (Carpenito-Moyet, 2006). Mrs Green’s experience of pain is consistent with the definition attributed to acute pain.
Acute pain can be classified into two categories. Superficial acute pain is typically defined by sharp, prickling sensation, which tends to occur on the surface of the body. Deeper acute pain generally presents as a burning or aching sensation, originating from the deeper layers of the skin, membranes, muscles, joints or serous membranes and is indicative of tissue destruction (Thomas, 1997).
To understand what pain consists of it is important to recognise the physiological process that occurs with the body. The segments of the nervous system responsible for the sensation and perception of pain can be divided into three areas. The three areas consist of afferent pathways, the central nervous system and efferent pathways (McCance & Heuther, 2002). One of the functions of the central nervous system is to provide information about the occurrence of threat or injury. The sensation of pain, by its inherent aversive nature, contributes to this function. Highly specialized sensory fibres, alone or in conjunction with other specialized fibres, provide information to the central nervous system not only about the environment, but also the state of the organism itself (Wall & Melzach, 2006). Nociceptive receptors are free nerve endings that are widely distributed throughout the body, combining chemical, mechanical and thermal receptors (Hawthorn & Redmond, 1998).
Nociceptive are nonencapsulated and can be classified as unimodal or polymodal. The unimodal nociceptors responds to only one variety of sensory modality, mechanosensitive, found in the skin, mucous membranes and some walls lining body cavities. Polymodal nociceptors, are the majority of nociceptors, which respond to more than one sensory modality and are widely distributed in deep tissues and skin. Stimulation of nociceptors produces impulses that are transmitted through small Aδ fibres and C fibres to the spinal cord, where they form synapses with neurons in the dorsal horn. From the dorsal horn the nociceptive impulses are transmitted to various parts of the spinal cord and to the rest of the central nervous system (McCance & Heuther, 2002). Aδ fibre nociceptors are thought to evoke pricking pain, sharpness and perhaps aching pain, and as a general rule they do what C-fibres do, but do it more robustly (Wall & Melzach, 2006). C-fibres are unmyelinated, which are smaller and slower fibres, producing sensations of dull pain (Hawthorne & Redmond, 1998). Disease and injury often result in pain and hyperalgesia. These abnormal sensory events arise in part from the action of inflammatory mediators on the peripheral terminals of nocieptive neurons. Sensory nerves express a variety of receptors from inflammatory mediators. The expression pattern varies between individual mediators, but many of these receptors are found on the polymodal nociceptors. These receptors fall into three main classes: G-protein-coupled receptors, ligand-gated ion channels and the cytokine receptors or receptor tyrosine kinases. There is a considerable body of evidence that kinins contribute to the pathophysiological processes accompanying both acute and chronic inflammation. Bradykinin and the related peptide kallidin are formed from the kininogen precursor proteins following the activation of plasma or
tissue kallikrien enzymes by path physiological stimuli such as inflammation, tissue damage or anoxia (Wall & Melzack, 2006).
As previously noted the pain that Mrs Green was experiencing was categorised as acute pain. However, a factor which was taken into account when assessing Mrs Green’s pain was the impact of her anxious state, recognising that anxiety can lead to hyperalgesia, thus increasing her pain experience. Therefore the implementation of both adequate pain relief alongside the reduction of anxiety were main considerations when attempting to control Mrs Green’s pain.
Pain management
As pain can be a mutifactorial, there are a variety of approaches to treating pain. Choosing an appropriate treatment encompasses not only the clinical aspects but also the emotional, psychological and spiritual components that relate to the experience (Hawthorne & Redmond, 1998). The importance of recognising not only the physiology of pain that Mrs Green experienced but also the emotional and psychological impact was paramount to ensure that she received holistic care.
The management of Mrs Green’s pain was complex and required the multi-disciplinary team to collaborate to provide effective holistic pain control. As Mrs Green was nil by mouth during the earlier stages of her treatment, the appropriate route of administration for analgesia also needed to be assessed.
The administration of analgesia is commonly based on the three-step analgesic ladder (see appendix 2) devised by the World Health Organisation (1986). This ladder allows for each individual patient by starting at the bottom of the ladder and progressing upwards until pain is adequately controlled. As Mrs Green’s pain was severe upon admission it was decided that morphine would be administered via intra muscular injection alongside the use of paracetamol, given to reduce pyrexia and pain, which was administered via intra-venous infusion. Although paracetamol is widely used, the effectiveness for pain relief should not be underestimated and has been shown to work well in conjunction with opioids (Kenner, 1994).
Although morphine is a popular opioid analgesic for severe pain it can commonly cause nausea and vomiting. This was a consideration when focusing on Mrs Green’s pain management as she had been experiencing nausea and vomiting. Anti-emetics such as cyclizine or metoclopramide are widely used to alleviate such symptoms and can be given via intra-muscular injection or intravenous infusion for patients who are nil by mouth. act by a wide of . Some act on the contol , the vomiting centre and the chemoreceptive , whilst others the (Downie et al, 2003). Mrs Green has stated that she felt that her nausea was directly linked to her acute pain experience. Although she had been prescribed cyclizine, once the pain was being appropriately managed Mrs Green did not often feel the need to have regular anti-emetic therapy. This was another area in which the nursing team were able to monitor the effectiveness of pain management.
It was recognised that if an anti-emetic was required then it could be an indicator that Mrs Green was experiencing breakthrough pain.
Two-thirds of people with persistent pain also have breakthrough pain, which is usually related to what is causing the persistent pain. Breakthrough pain is a sudden worsening of the persistent pain for brief periods. The pain "breaks through" the relief provided by long-acting medications and becomes intense. Breakthrough pain is treatable, however medications must act quickly and then disappear from the system rapidly to avoid increasing side effects. Breakthrough pain can be alleviated by changing body position, preventing coughs and constipation, and effectively controlling any persistent pain (Tortora, 2006). Breakthrough pain must be distinguished from exacerbations of pain associated with failure of analgesia. End-of-dose failure is commonly observed as therapeutic levels of analgesia fall. This is frequently observed when the intervals between scheduled doses of medication is exceeded (Wall & Melzack, 2006). Although medication rounds are scheduled throughout the day, the reality of everyone receiving their medication at the exact time is not realistically attainable. Many nurses administer all intra-venous and intra-muscular injections as the end of their round and on a busy ward this could result in a significant delay. Although this is not intentional by nursing staff it is acknowledged as being an area of concern (McQuay & Moore, 1998) and it is therefore easy to understand how breakthrough pain due to late analgesia administration can occur. Due to the severe nature of pain that Mrs Green was experiencing, nursing staff endeavoured to ensure that analgesia was given regularly, with minimal delay, and
also advised that any increase in pain symptoms be reported to enable effective pain management.
Pain management - Administration of morphine
As previously noted the administration of morphine via intra-muscular injection was the preferred opioid analgesia implemented to provide pain management to Mrs Green. Although morphine can cause adverse reactions in individuals Mrs Green had been prescribed it on a previous hospital admission and had experience adequate pain relief and tolerated it well.
Morphine is a narcotic drug and is the gold standard against which all other opioids are tested. It interacts predominantly with the receptor. These µ-binding sites are discretely distributed in the human brain, with high densities in the posterior amygdala, hypothalamus, thalamus, nucleus caudatus, putamen, and certain cortical areas. They are also found on the terminal axons of primary afferents within laminae I and II (substantia gelatinosa) of the spinal cord and in the spinal nucleus of the trigeminal nerve (Downie et al, 2003) Morphine is a – its main effect is binding to and activating the in the . In clinical settings, morphine exerts its principal pharmacological effect on the central nervous system and gastrointestinal tract. Its primary actions of therapeutic value are analgesia and sedation. Morphine is rapid-acting and it is known to bind very strongly to the receptors, and for this reason, it often has a higher incidence of euphoria, respiratory depression, sedation,
pruritus, tolerance and physical and psychological dependence when compared to other opioids. Morphine is also a and receptor agonist, κ-opioid's action is associated with spinal analgesia, (pinpoint pupils) and effects, whilst δ-opioid’s are thought to play a role in analgesia (Greenstein & Gould, 2004). Due to the possibility of respiratory depression and hypotension, the more serious side effects that can occur, it was necessary to monitor Mrs Green after morphine had been administered. It was also important to monitor any bowel changes that may occur due to the effect that morphine can have on the peristaltic activity of the bowel, which could lead to constipation (British National Formulary, 2005). A further contra-indication for morphine administration in the case of Mrs Green was the possible complication of biliary pressure. Morphine can cause spasm of the sphincters, including the sphincter of Oddi found at the lower end of the bile duct, thus producing a rise in pressure in the biliary system. As with all medications which are prescribed there are always advantages and disadvantages. When administering medication it was acknowledged that some contra-indications will outweigh any potential benefit and were discussed with Mrs Green when implementing and evaluating pain management.
Despite knowing what is best practice, health professionals have been found to give allegiance to their own personal beliefs and work-based attitudes. Whilst practitioners might claim to respect the definition ‘pain is what the patient says it is and exists when they say it does’ (McCaffery 1965), in reality they continue to make their own judgements of the patient’s pain experience (McCaffery and Pasero 1999). Hawthorne and Redmond (1999) uncovered a plethora of myths and misconceptions about pain
management which are based on beliefs, attitudes and traditions rather than proven evidence.
In the case of Mrs Green’s pain management, whilst the adverse affects of opioid administration were acknowledged, the overall aim was to reduce the pain to an acceptable level, with close monitoring to observe any signs of adverse reaction. The Trust also employ a Pain Control Nurse Specialist who was always available to discuss analgesic advice to both staff and Mrs Green to ensure that effective pain control was achieved. Although it could be argued that Mrs Green received adequate pain management via intra-muscular injections of morphine, the reality of numerous injections, especially troublesome during nighttimes shifts, could have been eradicated. Patient controlled analgesia (PCA) has developed and progressed to the point where it now plays a major role in the management of acute and chronic pain (Lefkowitz & Lebovits, 1996). By implementing the patient controlled analgesic system (PCA), Mrs Green could have received effective analgesic control without the need for numerous injections. PCAS is a method of administering intra-venous opioid via an infusion pump which allows the patient to titrate the dose of opioid delivered to their analgesic requirement within pre-set limits as defined by the medical staff (Everett & Salamonson, 2005). The patient activates delivery of an opioid bolus by pressing a hand held button. The machine is set with a "lock-out" time during which no drug will be delivered, even if the button is pressed. PCA has been shown to be a safe and effective method of analgesia when used by clinical staff who understand the technique.
Everett & Salamonson (2005) conducted a study, focusing on the analgesic consumption and pain management between intra-muscular injections and patient controlled analgesia. Patients who were prescribed PCA self-administered more opioid analgesia compared with their intra-muscular counterparts. A possible reason for the increase in administered analgesia implies that the PCA device allows patients to self-administer pain relief without having to first disclose their pain intensity. In contrast, patients who are prescribed intra-muscular analgesia need to ask the nurse for pain relief, with some patients reluctant to bother the nurse about their pain for fear of straining the nurse–patient relationship (Carr & Thomas, 1997). Although the use of “as required” opioid analgesics in acute pain management provides flexibility in dosing to meet individual patient needs, this method is known to contribute to inadequate pain management (Gordon et al., 2004).
Upon reflection, and although Mrs Green’s pain management appeared to relieve her symptoms, the implementation of the PCA system may have been a more appropriate method of pain management. This method would have given her an active and empowering role in managing her pain, given constant and effective pain relief without the need to have numerous injections, which she may have had to wait for if nursing staff were otherwise committed.
Anxiety and pain control
The association between anxiety and pain is well known (Thomas, 1997) with heightened arousal and anxiety being a normal response to the threat of pain (Irving & Wallace, 1997).
Evidence suggests that anxious individuals experience heightened pain, with anxiety being associated with increased muscle tension and other physiological processes increasing the experience of pain (Arntz et al, 1994).
The gate control theory (Mezack & Wall, 1965) suggests that pain can be alleviated by inhibitory signals from the cerebral cortex and thalamus. Thoughts, emotions and past experiences stored within these structures may result in impulses that affect the transmission of pain impulses. Therefore pain may be relieved by reducing anxiety about pain and by increasing the patient’s feeling of confidence and control with regards to their pain relief. Often this can be achieved through the development of the nurse-patient relationship, implementing both medical and therapeutic methods to reduce anxiety levels (McCaffery & Beebe, 1997).
Reducing anxiety
As anxiety markedly exacerbates the perception of pain (Greenstein et al, 2004) it was incorporated within Mrs Green’s care plan to assess her anxiety levels and endeavour to implement methods to reduce her anxieties. It was essential that nursing staff recognised that simply being admitted to hospital would precipitate high levels of anxiety due to Mrs Green’s agoraphobia. As previously stated it was discussed with Mrs Green and decided that a side room would be more appropriate for her hospital stay. As previously highlighted pain assessment tools are implemented to assess pain. However, Manias (2003) found that while nurses were observed to perform some form of pain assessment, they rarely conducted any assessment on anxiety.
Patients were observed to communicate with nurses about their anxiety levels, but this did not appear to be addressed by them. To ensure holistic patient care, it is important that the complex influences of pain and anxiety management are recognised and addressed.
Therapeutic communication facilitates the formation of the nurse-patient relationship, fulfilling the purposes of the nursing process (Sundeen et al, 1998). Effective communication benefits both nurse and patient, helping to build understanding and trust. Naish (1996) maintains that communication is a key aspect in the development and longevity of the therapeutic relationship.
By developing an effective therapeutic relationship with Mrs Green, nursing staff were able to discuss with her and family members what methods she used within her home environment to try and reduce her anxieties. Arntz et al (1994) advocates the use of distraction techniques in helping to reduce the pain experience, with a reduction in pain leading to reduced anxiety levels in many patients. Mrs Green had mentioned that she enjoyed listening to music and watching her favourite DVD’s, so her family arranged to bring in these items from home to help her feel more at ease.
It soon became obvious that Mrs Green liked to engage in conversation. Although it was not always the case that staff could engage in lengthy conversations, mainly due to time constraints, it was acknowledged that talking to Mrs Green did have a positive impact on her mood. Listening is probably the most effective therapeutic communication technique available, and although it is considered a passive process, in reality, therapeutic listening is an active process which requires the nurse’s complete attention (Sundeen et al, 1998).
Anxiety is a powerful emotion that can hinder therapeutic nurse-patient communication. Bravermann (1990) concluded that a clients emotional state can be a potential barrier to communication, with a lack of information or feelings of being out of control increasing anxiety levels. Bravermann suggests that nurses can give information in a reassuring and structured manner, with communication being simple, concise and unhurried to help anxious patients feel more informed and included in the relationship.
Conclusion
By analysing all of the varying aspects which affect a persons pain experience, it is easy to understand why it can prove difficult to manage. Mrs Green was suffering the physical pain of her illness, emotional stress due to a change in her environment, alongside her continued anxious state. Therefore her care encompassed different issues when trying to achieve optimum pain management.
The need to develop effective communication was vital, thus ensuring that Mrs Green could express her pain and anxieties openly. By engaging in conversations with Mrs Green it gave nursing staff the opportunity to assess if methods put in place to alleviate pain and reduce anxieties were proving effective.
The effectiveness of pain assessment tools is not without problems. However, if assessment tools are used correctly they can be useful in assessing pain and its subsequent management, providing they are used in conjunction with other methods. Pain assessment tools should not be used to solely assess pain, and require regular evaluation if there is to be any value to their implementation. Controlling pain with medication also requires an individualised approach, and although Mrs Green’s pain appeared to be managed appropriately with intra-muscular morphine, the implementation of the PCA system may have been a more appropriate method of pain management.
By developing a therapeutic relationship with Mrs Green, nursing staff were able to communicate openly and effectively during her hospital stay. Providing effective pain management required a multi-faceted team approach, with regular evaluation to assess progress and implement change where appropriate. The role of nurses in the management of pain is particularly important because they are often responsible for patient assessment, administration of pain relief interventions and evaluation of their effectiveness. Nurses strive to provide holistic care to patients covering a variety of different aspects and settings. However, the reality of providing such care requires nurses to continually develop and enhance their skills to continue to provide individualised holistic care.
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