In the case of a hysterectomy, the nurse would need to be aware of the social and cultural implications. A hysterectomy may mean different things to women from different cultures for example; the woman’s role in Muslim communities is often directly linked to her fertility and can be destroyed by a hysterectomy. Some West Indians view menstruation itself as a cleansing act. In such cultures a hysterectomy may result in the women being viewed as inadequate (Walsgrove, 2001). Uncovering fears and misconceptions by giving clear advice and information is a vital part of the nurses’ role (Hughes, 2002). It would be during the pre assessment that the nurse would make appropriate plans and provision for the patients discharge, taking into account the patients’ social circumstances and making referral to other members of the multi disciplinary team if necessary, to ensure that the patient was supported following discharge (Spry, 2005).
On admission, the patient would be introduced to the nursing staff and orientated to the ward. The nurse would discuss the procedure with the patient in a sensitive manner, describing to the patient what to expect during her stay, to elevate any anxieties (Pudner, 2005). In preparing the patient for theatre the nurse would, carry out a full set of observations including weight, height and body mass index, measure and fit the patient with anti embolism stockings, to reduce the risk of deep vein thrombosis, (DVT) and ask the patient to change into a theatre gown (Dougherty & Lister, 2004). The pre operation checklist would also be completed; this may vary from trust to trust. However, typically included are things such as, ensuring that the patient is wearing the correct name band, to allow easy identification, the recording of any allergies and making sure that the patient has fasted for the appropriate length of time, six hours for food and two to four hours for fluids; to reduce the risk of aspiration pneumonia. The patient would also be asked to remove all jewellery, apart from a wedding ring which can be taped; this is to prevent diathermy burns from current concentration. Remove make up and nail varnish; to allow skin and nail beds to be observed for circulation and pass urine before the administration of any pre medication, to prevent damage to the bladder, post operative discomfort and allow complete bed rest after the pre medication has been administered (Pudner, 2005). The pre operation checklist and any other documentation including, the consent form must be completed before the administration of pre medication, as after the patient may be drowsy and information gained unreliable (Dougherty & Lister, 2004). Although valid written consent for surgical procedures is obtained by the medical staff, it is the nurses’ duty to ensure that the written consent has been obtained prior to carrying out pre operative procedures (Alexander Etal, 2000). It is also imperative that all members of the multi disciplinary team obtain consent before carrying out any interventions (Dimond, 2005).
The nurse would accompany the patient to the theatre reception. The patients’ identity and intended procedure would be confirmed on arrival. When transferring patient care to the perioperative team the patient’s safety is of up most importance, and it is vital that all relevant documentation remains with the patient. It is at this point that a nurse from the perioperative team will ensure that the pre operative check list has been completed (Scott Etal, 1999). The nurse would then explain to the patient what was going to happen, and try to elevate any anxieties (Kenworthy Etal, 2002). The perioperative nurse would remain with the patient whilst the anaesthetic was administered, to provide physiological support and reassurance (Radford Etal, 2004).
During the intra operative phase of the patients’ pathway, the role of the nurse is mainly concerned with patient safety. There are two main nursing roles within the operating theatre. One is the circulating nurse, who is responsible for marinating accurate records, positioning the patient and providing equipment needed (Alexander Etal, 2000). The other is the scrub nurse, who is responsible for monitoring the sterile field and accounting for all swabs, sutures and instruments (McGarvey, 2000). However the nurse also has a responsibility to act as the patients advocate, during this extremely vulnerable time. (Boyle, 2005)
When the operation is complete the patient is taken to the post anaesthetic recovery unit (PACU), where the nurse would assume responsibility for the patient until satisfactory levels of consciousness are regained. Before the patient can be admitted in to PACU, the nurse must be informed of the procedure that has been carried out, patients’ anxiety levels pre operatively, fluids and medication given intra operatively, drain’s and catheters that may be in situ and any untoward occurrences during surgery (Hatfield & Tronson, 2001). The nurse will then assist the patients’ recovery, by ensuring that the patients’ airway remains free from obstruction, that all observations remain within normal parameters’ and that the oxygen is administered safely. It is common for patients to report pain after surgery and it is essential that pain is managed effectively both from an ethical point and to avoid post operative complications (SjoÈstroÈm Etal, 2002). Poorly managed pain may result in postoperative complications such as, hypertension, DVT and tachycardia (Hughes, 2004). Despite this nurses have faced criticism for poor pain assessment and management, with patient pain being under estimated. Suggestions have been made that this is due to a lack of knowledge and personal attitudes of what pain should be interfering with care (SjoÈstroÈm Etal, 2002).
Before pain can be appropriately managed it must first be assessed. As pain is subjective it assessment is not always easy and there are many factors that may affect an individual’s perception and expression of pain such as culture, past experiences, gender, age and emotional state (Turk & Melzack, 2001). There are many definitions of pain but the one that is perhaps most apt for nurses is, “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1979, p11).
There are many pain assessment tools available to aid nurses in the assessment of pain; such tools also allow for pain and interventions taken to manage pain to be documented (Schofield, 2007). Pain assessment tool can be categorised in to unidimensional and multidimensional. Unidimensional tools include the Verbal rating score (VRS), which works by patients describing their pain using a pre set list that reflects pain intensity. The VRS is quick and easy to use but, has been criticised for offering too few descriptors for patient to choose from (Shorten, 2006). Furthermore a comprehensive command of the English language is required, meaning that it may be unsuitable for patients that do not have English as their first language (Hatfield & Tronson, 2001). An alternative to this is the Visual Analogy scale (VAS), when using the VAS patients’ are asked to indicate where their pain would fall on a 10cm line with zero being “no pain” (Manly & Bellman, 2002). The VAS dose offer significantly more choice to patients and allows slight changes in pain intensity to be monitored (Davey & Ince, 2000). However, this method of pain assessment may be difficult for some patients to comprehend, it is also inappropriate for patients with visual or perceptual motor problems (Wall & Melzack, 1999). Similar to the VAS is the Numerical rating scale (NRS), one of the simplest and most widely used tools available. The patient is asked to place a numerical value between one and ten on their pain this can either be done verbally of visually (Shorten, 2006). The VRS, VAS and NRS all provide a quick and efficient measure of pain intensity and are commonly used in both clinical and research settings. However, unidimentional tools do not account for the many facets of pain, it has been suggested that such tools are inadequate and do not provide a comprehensive measure of pain (Turk & Melzack, 2001).
The McGills Pain Questionnaire (MPQ) is an example of a Multidimensional pain assessment tool. The MPQ utilises a three dimensional approach to pain assessment, incorporating a body outline and descriptive words to identify the sensory and affective properties of pain. This three dimensional approach facilitates, a detailed assessment of the patients pain and is largely viewed as a consistent and reliable means of pain assessment (Schofield, 2007). Despite this it has been suggested that the list of descriptors used in the MPQ may hold little meaning in today’s multi cultural society as they were obtained in 1971 form psychology students. The MPQ has also faced criticism for being time consuming and unsuitable for patients with communication difficulties due to the descriptors (Bird, 2003). Some of these issues have been addressed by the shortened version of the MPQ which consists of, a present pain intensity scale, the VAS and 15 descriptors meaning that can be completed in a shorter time (Wall & Melzack, 1999).
It has been argued that regardless of the assessment tool being used it is assessment performance that is the key to pain management (Shorten, 2006). It is essential that the nurse use pain assessment tools in conjunction with observation of body language and facial expressions, effective communication and clinical judgment (Harper & Bell, 2006).
Once the nurse has ascertained the level of the patients’ pain, appropriate analgesia must be administered. Commonly used analgesia following major surgery includes, opiates such as fentanyl, morphine and diamorphine (Dougherty & Lister, 2004). The analgesia is usually administered via Intramuscular injection, patient controlled analgesia (PCA) or epidural. Oral medications may be contra indicated, due to the patient being nil by mouth. Intra muscular injections can be difficult to titrate correctly to the patients’ requirements and are associated with peaks and troughs of pain relief (Hughes, 2004). PCA is now widely used and allows patients to self administer analgesia, when they feel that it is required, offering the patient grater autonomy (Pudner, 2005). However PCA may not be appropriate for patients that have problems with vision or dexterity. The use of PCA should be discussed with the patient, as not all patients are comfortable with this type of administration and do not wish to be responsible for their own pain control (Dougherty & Lister, 2004). Epidurals are highly effective method of pain control but, do carry the risk of epidural haematoma. Regardless of the route of administration, common opioid side effects may be seen including repertory depression, meaning the nurse must monitor the patient very closely after opiates have been administered. Nausea and vomiting are also common and usually controlled by antiemetics such as cyclizine (Davey & Ince, 2000).
Non-pharmaceutical methods of pain control including information giving pre operatively, breathing excesses and positioning, have been show to have a positive impact on pain control when used in conjunction with appropriate analgesia (Wilson, 2002). Once analgesia has been administered it is vital that the nurse evaluates it effectiveness, to ensure that the patient pain is adequately controlled. Patients’ should not be discharged from PACU until their pain has been appropriately controlled and all interventions have been documented (Hatfield & Tronson, 2001).
When the patient returns to the ward the nurse will carry out regular observations, including wound drainage and urinary output, measured via a catheter. When carrying out these observations the nurse would be observing for singes of repertory complications, circulatory problems, haemorrhage and fluid and electrolytes imbalances (Zeitz, 2005). During the first twenty-four hours strong analgesia will usually be required (Walsgrove, 2001). The day after surgery the patient should be encouraged to mobilise, the physiotherapist may give the patient some light exercises such as leg exercises and pelvic rocking; this mobilisation will reduce DVT risk (Alexander Etal, 2000). The patient will usually start taking sips of water and then progress to a light diet. Providing the patient is progressing as expected, the urinary catheter will be removed and the intravenous infusion discontinued. However, a strict fluid balance chart will still be needed. By day three pain can usually be controlled by oral analgesia and the woman is able to mobilise to the bathroom independently (Pudner, 2005).
Most patients are discharged form hospital the fifth day after surgery, however; it may take ten to twelve weeks for patients to recover fully (Walsgrove, 2001). When preparing the patient for discharge home, the nurse must, discuss limitations regarding exercise, house work, work and sexual intercourse. It may take six to eight weeks for the woman to return to normal levels of activity; it is recommended that sexual intercourse is not recommenced for six weeks post operatively. If the patient consents, it may be useful to include the patients’ partner in the discussion. All information that is provided should be supported by written information that the patient can take away (Punder, 2005). Discharge information is given in order to reduce anxieties and complications after discharge and to enable the patient to resume self care responsibilities (Henderson & Zernike, 2001).
Throughout every stage of the care pathway form pre assessment to discharge nurses are accountable for their actions and it is essential that the nurse adheres to the Nursing and Midwifery Council Code of Professional Conduct (2004) and local policies. Ensuring that the patient is well informed, consent is obtained for all interventions and privacy and dignity is maintained at all times and that all care given is documented (The Department of health, 2001).
In conclusion the author has discussed the care pathway of an adult patient undergoing a full abdominal hysterectomy, identifying the role of the nurse in pre assessment, pre, peri, and post operative care and discharge. Describing the theories and principals of holistic care at each stage; taking into account professional and legal issues that are presented to the nurse and other members of the multi disciplinary team. The literature would seem to suggest that care pathways are beneficial in facilitating consistency of care and the incorporation of best practice within the multi disciplinary team framework. However, this can only truly be achieved in the authors view when, coupled with clinical judgment allowing the care pathway to be tailored to the needs of the patient. Within this discussion there has been a focus on post operative pain, tools used in it assessment and commonly used drugs and therapies, in the management of post operative pain. In the authors opinion after reviewing some of the commonly used pain assessment tools it would appear that nurses may need to take an eclectic approach to the assessment of pain, as no one tool seem to be universally appropriate to meet the varying need of patient’s from a diverse society. It would also appear that nurses may need further education, in order to effectively assess, manage and treat postoperative pain effectively. In short, nurses may need to draw on a wide range of concepts and linking theory to practice, using a problem solving approach to ensure that care is adjusted to meet the individual needs of the patient, regardless of age, culture or religion.
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