CNA509 Assessment And Management Of Pain

Introduction

This is a report that involves critical reasoning in the clinical area. Clinical reasoning/clinical judgment/decision making/problem solving/critical thinking is usually used interchangeably. This is a process in which the nurses and other clinicians gather cues/information, processes this information, get/come to an understanding with a patient situation/problem, planning on the care and interventions and then implementing these interventions. This is followed with an evaluation of the intervention, a reflection on the process and lastly, the lessons are learned from the process (Hoffman, 2007; Kraischsk & Antony 2011; Laure et al., 2011). The clinical reasoning is a process that depends on a person’s personality, attitudes, preconceptions and philosophical perceptions (McCarthy,2013). It is a cyclic process. In this report, the focus will be on an event/nursing problem in the clinical area that I had been rotating for the last three weeks. I rotated the OPERA (Orderly Persons Evaluation Review Assessment) ward for three weeks. The problem I identified was on effective pain management. I will evaluate the different strategies that nurses use so as to effectively manage the pain of the aged.

Pain as a result of old age

Hajjar et al., (2007) reports that multiple medical conditions; diabetes, cancer, arthritis and heart conditions/condition are the major pathological conditions that are the sources of pain in the elderly. These conditions cause acute or/and chronic nociceptive that is, somatic and visceral or/and neuropathic pain. According to Backstrom, Whitman & Flynn (2011), states that musculoskeletal degeneration is one of the most significant sources of pain in the elderly clients. The lumbar spinal stenosis is of the major problems in the aged. It causes lower back pain, causes depression and disabilities. These translate to reduced quality of life in the aged, increases risks of falls, and significant disabilities. In most cases the elderly experiences different types of pain, in different location. In most cases, the pain is treated using the standard opiates and narcotics. Most of these medications cause very serious adverse effects as the elderly patients have diminishing hepatic and renal functioning. Dalacorte & Rigo (2011), states that in most cases pain in the elderly patients, in most cases it is undertreated.

Pain assessment

In the wards, I observed the nurses using several tools/strategies to assess the client’s pain. The first strategy I saw them use was the PQRST acronym to assess pain. P stands for the place/location of pain, Q for the quality of pain, R for the radiation of pain S-severity, the effects that the pain has on the physical activity, eating and sleeping and lastly, T-timing for the duration, the frequency of pain and the duration of one episode. They also used the Numerical Rating Scales (NRS) where the patients were asked to rate their pain from 0-10). I observed them using Lowa Pain Thermometer Scales. This was done mostly on patients who had difficulty in communicating. They were shown a thermometer and asked to point the point at which their pain would be on the rising mercury. The base indicated no pain while the top part indicated a pain that is unbearable. In addition to this, the patients whose cognitive functioning was moderately or severely impaired they used observational pain measurement scales. I observed the nurses using a checklist to assess four factors; the facial expressions, social personality and mood, the activity and body movement and others; sleeping patterns, eating habits physiological and vocalization changes.

The pain assessment and measurement of the elderly requires several additional considerations when selecting the tools. They need to be easily understood and simply worded (Flaherty, 2012). Aging brings about functional impairment; vision, hearing, cognitive and many others. This means that they are unable to use a visual analog scale when assessing their pain, although they can give a self-report about their pain, the verbal rating scale. For the patients with cognitive impairment, they can benefit from Numerical Rating Scales (NRS) (Rockville, 2012; Acute Pain Management, 2012) and the Lowa Pain Thermometer Scales. They can also benefit from the observational pain measurement scales, for example, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), (Fuchs Lacelle & Hadijistavropoulos, 2014).

Pain management

I observed that the patient’s pain management was not only the responsibility of the nurses rather it involved so many parties. It was a multi-discipline procedure. It involved the nurses, pharmacists, dietician, clergy, social workers, the speech, occupational and the physical therapist. Mitchell & Golden (2015) reports that caring for the old/elderly should be a team-based health care. The major role of the nurse that I was able to detect was to coordinate all these teams. This was done through effective communication. According to Mitchell & Golden (2015) for a successful team based health care provision adequate and effective communication is very important.  It was the nurse’s role to ensure that there was effective pain management among the teams.  These teams worked together in unison so as to provide the best care to the patient and his/her family. The nurses contributed the following in the patient’s care; they performed an intensive physical assessment on the patient, took history, educated the patient/relatives on the pain management. They kept the patient’s pain diary, did a comprehensive pain assessment on the patient, assesses the patient’s compliance to pain medication, their effectiveness, and the side effects. I also observed that the care integrated the family members.

Lastly, I observed them providing both the pharmacological and non-pharmacological pain management modalities. The most common pain medications that they received included the standard opioids that are morphine, oxycodone, fentanyl, and hydromorphone. They were also given narcotics. These drugs are commonly known to cause hallucinations, cognitive impairment, depress respiration and increase agitation, gastrointestinal events (nausea, diarrhea, constipation), dizziness, sedation, and a decline of the daily activities. (Maison, 2007; Lynch, 2011) therefore, I observed the nurse’s monitoring this patient very diligently and closely. I observed that the nurses observed/monitored the patient’s bowel program so closely as opiates cause constipation. This is one of the major complications in the aged as they already get constipated as a result of old age. It can cause impaction and later on bowel obstruction.

In the non-pharmacological pain medication, which was used together with the pharmacological therapies included, physical therapy (the massage, the hot and cold compresses and electrophysical modalities). They ensured that the patient’s exercised as a way to relieve their pain. The nurses conducted psychological therapy on the patients through counseling (Prowse, 2007; Rockville, 2012). Lastly, the nurses conducted both the complementary and alternative therapies so as to ensure effective pain management (Prowse, 2007; Rockville, 2012).

Conclusion

The above clearly shows that the nurses at OPERA wards were skillful and knowledgeable in pain assessment and management in elderly patients. On pain assessment, they choose the best for the patient on the basis of the patient’s degree of functional impairment. It also shows that they were able to use their clinical reasoning as they assessed each patient individually (patient-centered care) and involved the patient’s family on the patient’s care. On assessment they were able to identify the patient’s condition(situation), come up with the goals (improve the patient’s quality of life by managing their pain), formulating action plans (to start the patient on both the pharmacological and non-pharmacological interventions), intervening by starting the patient on the given medication/therapies and lastly evaluate the interventions for effectiveness and adverse effects.

References

Backstrom, K. M., Whitman, J. M., & Flynn, T. W. (2011). Lumbar spinal stenosis-diagnosis and management of the aging spine. Manual therapy, 16(4), 308-317.

Dalacorte, R. R., Rigo, J. C., & Dalacorte, A. (2011). Pain management in the elderly at the end of life. North American journal of medical sciences, 3(8), 348.

Fuchs-Lacelle, S., & Hadjistavropoulos, T. (2014). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.

Hajjar, E. R., Cafiero, A. C., & Hanlon, J. T. (2007). Polypharmacy in elderly patients. The American journal of geriatric pharmacotherapy, 5(4), 345-351.

Hoffman, K. (2007). Unpublished Ph.D. thesis, A comparison of decision-making by “expert” and “novice” nurses in the clinical setting, monitoring patient hemodynamic status post abdominal aortic aneurysm surgery. University of Technology, Sydney.

Kraischsk, M. and Anthony, M. (2011) Benefits and outcomes of staff nurses? participation in decision-making. The Journal of Nursing Administration, 31(1), 16–23.

Lynch, T. (2011). Management of drug-drug interactions: considerations for special populations–focus on opioid use in the elderly and long-term care. The American journal of managed care, 17, S293-8.

Maison, D. (2007). A hospice physician’s perspective on medications for the relief of pain and suffering. Home Healthcare Now, 25(10), 663-670.

McCarthy, M. (2013). Detecting Acute Confusion in Older Adults: Comparing Clinical Reasoning of Nurses Working in Acute, Long-Term, and Community Health Care Environments. Research in Nursing and Health 26, 203–212

Mitchell, P., & Golden, R. (2012). Core principles & values of effective team-based health care. National Academy of Sciences.

Prowse, M. (2007). Postoperative pain in older people: a review of the literature. Journal of Clinical Nursing, 16(1), 84-97.

Rockville, M. D. (2012). Acute pain management guideline panel: acute pain management: Operative or medical procedures and trauma clinical practice guideline. AHCPR Pub No 92-0032. Agency for Health Care Policy and Research. Public Health Service, US Department of Health and Human Services, 15-26.