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Nursing : Optimal Pain Management

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Nursing : Optimal Pain Management

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Question:
Case Study
Mrs Salimah Abdallah a 44 year woman, wife, mother and devout Muslim has been re – admitted to the hospital with an elevated temperature and productive cough, after having a haemorrhoidectomy one week ago.
You are the admitting nurse and during the admission discover that Mrs Abdallah developed the cough after spending the week after surgery in bed. Mrs Abdallah states that she is finding difficult to walk small distances before becoming breathless and experiencing sharp lung pains whilst breathing in. She rates this pain 5/10 and denies taking any analgesia.
You ask Mrs Abdallah about her normal sleep routine and discover that she has not slept properly for days and feels exhausted. She is pale, drawn with dark circles under her eyes and complaining of fatigue.
Due to decreased appetite and energy levels, Mrs Abdallah has been eating very little Halal food. You ask Mrs Abdallah her toileting habits. After telling her husband to leave the room, you learn that she has not opened her bowels for the entire week as she is frightened it will be painful and that she will bleed a lot.
Mrs Abdallah normally cares for her five children aged 2 – 7 years of age. Her husband works 6 days a week in his own Halal butcher shop.
PART A: (S/NYS)
Scenario
Working in collaboration with the RN the following Nursing Diagnosis’ are formulated for Mrs Abdallah.
1. Ineffective Airway Clearance related to viscous secretions and shallow breathing.
2. Sleep Pattern Disturbances related to cough, pain, and orthopnoea.
3. Constipation related to reduced fluids, inactivity and fear of pain defecating.
4. Acute Pain (anal) related to recent surgery and constipation.
5. Activity intolerance related to breathlessness and malaise.PART B: (S/NYS)
Please discuss in your understanding of the evaluation phase of the nursing process. (S/NYS)Explain in how you will maintain the client’s cultural safety whilst applying the nursing process. (S/NYS)Discuss your understanding of the concept “person centred care” and provide 4 examples of how you can implement person centred care for Mrs Abdallah. (S/NYS)The care plan focus for Mrs Abdallah is on the acute care of this client. Once she is significantly improved, the nurse will plan for discharge. Please identify four (4) areas of discharge teaching for Mrs Abdallah. (S/NYS)
 
Answer:

1. Blood gases like O2 and CO2 should be monitored. Ineffective airway clearance may cause low level of O2 due to impaired external respiration. Moreover, in case of Abdallah, shallow breathing has been observed. This shallow breathing further negatively affects O2 level in the blood.
Nurse should advice Abdallah to cough and breathe because through coughing she can expel the viscous secretions. As Abdallah experiencing pain in the lung during breathing, it is necessary to encourage her for breathing.    
Nurse should administer Abdallah with effective expectorant with best possible schedule because expectorant can loosen the viscous secretions and it is easy to expel these secretions through cough.
Nurse should administer oxygen to Abdallah using facemask which can provide oxygen with flow rate 4-7 litre per minute. Due to shallow breathing there is the less oxygen in the blood and it is required to maintain oxygen saturation in the blood in between 94-98 %. 
Nurse should administer suitable antibiotic to Abdallah because in case of compromised lung function there are the possibility of lung infection. These antibiotics can help to arrest the growth and prevent from multiplication of the invaded bacteria (Bott et al., 2009; Berman et al., 2008).  
2. Nurse should asses the sleep pattern and usual sleep time of Abdallah. Sleep pattern is a character which varies with each individual. This assessment would help nurse diagnose the exact etiology of disturbance in sleep pattern. This assessment would help to implement nursing intervention.   
Administer pain medicine to Abdallah before going to bed because complained about her pain. It has been well proved that pain is one of the main causes of sleep disturbance. Administering pain medicine and making Abdallah relaxed for sleep would definitely improve her sleep.  
Provide appropriate environment for sleep and apply massage to patient. Few people can’t sleep in environment which is noisy and few people need dark environment for sleep. In such environment is not provided, there is the possibility of disturbance in mind of patient and resulting in the disturbance in sleep pattern. It was proved that massage can induce sleep.
Nurse should record, Abdallah’s medicine and diet. Carbohydrates can release neurotransmitter serotonin to induce sleep. Caffeine containing products disturb sleep. Bronchodilators has side effect as disturbed sleep.     
Nurse should administer cough medicine to Abdallah to relive from pain. Because contneous cough can disturb sleep pattern in Abdallah (Berman et al., 2008; Sateia, 2014). 
3. Nurse should try to make arrangements to remove bowl contents of Abdallah. This can be done by using enemas, by softening the stools and using medications like laxatives. If faecal matter remained in the bowl for long time, it can affect patient both physiologically and psychologically. Patient can have anxiety to remove faecal matter if stayed in the bowl for long time. Nurse should make note that, patient should not overuse both enema and laxative medication.      
Nurse should advise Abdallah to drink more water daily. If patient is dehydrated, large intestine soaks water from the consumed food and it leads to the hardening of the stool and it is difficult to defecate hard stool.  
Nurse should administer fiber rich food to Abdallah. This carbohydrate, through osmotic effect can increase bulk of stool and helpful in avoiding constipation.  
Nurse should make compulsion for physical activity or exercise to Abdallah. It was proved that even little physical activity or daily walk for around 30 minutes can definitely improve bowl movement and improve constipation.   
Nurse should make arrangements to provide privacy to Abdallah at the time of defecation.  As defecation is a very private act some people may face problem if they feel there is disturbance in their privacy. Nurse should make sure that door should be closed at the time of defecation of Abdallah (Schuster et al., 2015).   
4. Nurse should assess exact location, duration and frequency of pain Abdallah. This assessment can be very helpful in understanding the severity of pain and planning the intervention accordingly.
Nurse should assess the history of pain medications in Abdallah. If she has consumed earlier any analgesic, which is not effective. In case of analgesic drugs, there can be variability in its effect based on the individual person. Nurse should avoid administration of analgesic drugs to Abdallah, which were not effective earlier.
Nurse should administer medicine (analgesic) for pain management to Abdallah. Pain management medicine can give relief to Abdallah from pain and make her comfortable in her daily activities and with less fear of pain. In case of analgesics, nurse should administer nonnarcotic analgesics rather than narcotic analgesics to Abdallah.    
Nurse should demonstrate non-medicine strategies for pain relief. These strategies include relaxation and meditation. These strategies have been proved successful in managing pain and distracting the patient from pain perception. 
In case of pain at the time defecation, nurse should make a plan for smooth bowl movement for Abdallah. These smooth bowl movement strategies include more consumption of water, carbohydrate rich food and small dose of laxatives. Pain during defecation during is mainly due to the hard stool. These smooth bowl movement techniques definitely relieve from pain (Pfenninger and Zainea, 2001).     
5. Nurse should assess the exact cause of activity intolerance in Abdallah, whether it is due to physiological disturbance or it is a psychological effect. Knowing exact cause can be helpful in planning in that direction.  
Nurse should get information about timings and duration of daily activities and bed rest for Abdallah. In earlier studies it has been proved that bed rest in hospitals due to the medical conditions leads to more activity intolerance.  
Nurse should encourage, Abdallah follow suitable physical activity or exercise. Long duration immobility can lead to the shortening of muscle and augmented stiffness in the bone and cartilage. This can further lead to the immobility in the patient.        
Nurse should advise and train Abdallah for deep breathing. This deep breathing technique can help to improve external respiration, to reduce respiratory rate and to increase O2 saturation in the blood. This deep breathing not only helpful in improving breathlessness but also helpful in improving daily activities. 
Nurse should assess for the constipation in Abdallah. Less physical activity can lead to the constipation (Springhouse, 2006).
 
Part B: 1.
After completion of all the steps of nursing intervention, nurse should evaluate the outcome of intervention to get indication of patient condition. Nurse should evaluate patient condition on regular basis. If the ongoing nursing intervention is achieving the nursing goals very slowly or it is not showing positive outcome, then nursing plan should be changed accordingly. Patient should be evaluated by keeping in mind all the possible outcomes like improved condition of the patient, steadied condition of the patient, worsened condition of the patient, mortality and discharge possibility. In case of no improvement in the condition of the patient, nurse should consult physician and modify nursing intervention accordingly (Funnell et al., 2009).        
2. Nurse should provide treatment and management to the patient by maintaining the personal, social and cultural identity of the patient. Nurse should protect the identity of illness of the patient to maintain wellbeing and acceptance of the patient in the society and to maintain dignity of the patient. Nurse should maintain very healthy and friendly relation with patient with positive attitude and behavior. Through this healthy relationship with nurse can understand patient I better way and it is for nurse to convince patient for treatment. Nurse should implement different strategies for people with different values, backgrounds, education, experience and beliefs. For implementing good cultural safety nurse should be good listener, confident of own work and values and respectful to other person (Milne et al., 2016).    
3. Person centered care is a health management system in which patient and patient family members’ opinions and suggestions should be considered while implementing nursing care. In person centered care nurse should understand the values, wishes, family condition, social influence, lifestyle of patient and family. In person centered care, decisions about nursing should be discussed with patient and family members and amend according to patient comfort. Person centered care is very flexible, based on one-to-one care and should be implemented ‘along with’ patient and not ‘to’ the patient
Examples: Enquiring about comfort for sleeping, providing personnel toilet instead of common toilet, helping Abdallah in her daily activities whenever she requires (Sharma et al., 2015).
4. Abdallah should avoid constipation. For this she should drink lot of water, eat vegetables, fruits and carbohydrate rich fruit, keep practice of walking for some time and take laxatives only on doctors’ advice.
Abdallah should not drive, if she is taking opioids as pain medication.
Abdallah should take help of others in her daily activities, she should not go outside alone and specifically she should take help of others while reaching toilet because as she is feeling constipation she may under stress while going to toilet and fall risk is there.  
Abdallah should keep on practicing breathing exercise and she should do this breathing exercise in morning session because breathing in morning fresh air is good to improve her breathless problem (Zeng-Treitler et a., 2008).
5. Cough, breathlessness, fatigue and sleeplessness are the four signs indicating respiratory distress of Abdallah. Nurse should try to reduce the frequency of cough because due to cough Abdallah, feeling breathlessness, fatigue and sleeplessness. If nurse can prevent cough all these problems can be controlled to some extent. Nurse can control cough by giving medication for the cough. Along with nurse should give artificial respiration to Abdallah. Nurse should improve moral of Abdallah, so that she should not feel lethargic and if she didn’t feel fatigue, it can solve may problems of daily living. As a result, she can feel relaxed and get proper sleep.  
6. Pain in any individual is mainly a perception due to physiological, pathological and psychological factors. Pain perception in a person mainly depends on the age, gender, cultural and educational background and prior experience of pain. Behavior of a person is not always reflecting the exact severity of the person. Some of the patients may exhibit more pain to get sympathy and some of the patients may not exhibit pain at all to get rid of hospital visits and to hide their pain from family members to keep family members happy. Due to all these factors pain assessment should be devoid of ones’s opinion and it should be based on the awareness, understanding and acceptance (Roberts, 2008; Fink, 2000).      
7. Sleep restriction: Sleep restriction involves reducing the amount of time spent in the bed as compared to the total sleep time. Patients less than 85 % sleep efficiency required sleep therapy.
Stimulus control: Patient should go to sleep in case of feeling sleepy, use bedroom only for sleep activity, leaving bedroom, if cannot sleep for more than 15 minutes, keeping same time for sleep waking up in the morning.
Cognitive therapy : Patient should be aware that insomnia is a dysfunctional thought and it should be removed.  
Relaxation training : Relaxation techniques like deep breathing, body scanning and autogenic training can promote sleep (Siebern et al., 2012).
Part C:1.

Potential risks

Risk prevention strategies

Fall

Fall can be prevented by using devices like hand rails for stairways, raised toilet seat, grab bars for water tub, bare-wood steps with nonslip. 

Weakness

Weakness can be prevented by taking healthy diet, good sleep and reducing stress.

Cognitive impairment

Cognitive impairment can be best prevented by changing lifestyle such as incorporation healthy food like vegetable and fruits, regular exercise and good amount of sleep.

Pressure sores

Position change is the main for the prevention of pressure sores. This position change should be regular with extra care to evade stress on the skin and lesser the pressure on the susceptible region.    

2. While giving nursing care nurse should think form the patients’ point view and should take patients’ opinion about comfort level to the particular intervention. When touching to the patient, nurse touch should be very gentle because this gives patient feel warmth and comfortable. Nurse should keep body language and speech with the patient very gentle. Patient should not feel embarrassed with the activities and talk of the nurse. Nurse should always try to give privacy to the patient. Curtains covering the patient bed should always be covered when there is no nursing or clinical intervention.  Nurse should maintain privacy of the medical condition of the patient so that dignity of the patient should not get affected in the society (Lin and Tsai, 2011).
 
References:
Berman, A.T., Snyder, S., Kozier, B.J., and Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing, 8th Edition 8th Edition. Pearson Education.
Bott, J., Blumenthal, S., Buxton, M., Ellum, S., Falconer, C., Garrod, R., et al. (2009).  Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax , 64, pp. i1-i52.
Fink, R.  (2000). Pain assessment: the cornerstone to optimal pain management. Proceedings (Baylor University. Medical Center), 13(3), pp. 236–239.
Funnell, R., Koutoukidis, G.and Lawrence, K. (2009) Tabbner’s Nursing Care (5th Edition), Elsevier Pub, Australia.
Lin, Y.P., and Tsai, Y.F. (2011). Maintaining patients’ dignity during clinical care: a qualitative interview study. Journal of Advanced Nursing, 67(2), pp. 340-8.
Milne, T., Creedy, D.K., and West, R. (2016). Development of the Awareness of Cultural Safety Scale: A pilot study with midwifery and nursing academics. Nurse Education Today, 44, pp. 20-5.
Pfenninger, J. L., and Zainea, G.G. (2001). Common Anorectal Conditions: Part I. Symptoms and Complaints. American Family Physician, 63(12), pp. 2391-2398.
Roberts, L.J. (2008). Managing acute pain in patients with an opioid abuse or dependence disorder.Australian Prescriber, 31, pp. 133-5.
Sateia, M.J. (2014). International classification of sleep disorders-third edition: highlights and modifications. Chest, 146, pp. 1387-94.
Schuster, B.G., Kosar, L., and Kamrul, R. (2015). Constipation in older adults. Stepwise approach to keep things moving. Canadian Family Physician, 61(2), pp. 152–158.
Siebern A.T., Suh S., and Nowakowski, S.  (2012). Non-Pharmacological Treatment of Insomnia. Neurotherapeutics, 9(4), pp. 717–727.
Sharma, T., Bamford, M., and Dodman, D. (2015). Person-centred care: an overview of reviews. Contemporary Nurse, 51(2-3), 107-20.
Springhouse. (2006).  Handbook of Medical-surgical Nursing.  Fourth Edition. Lippincott Williams & Wilkins.
Zeng-Treitler, Q., Kim, H., and Hunter, M. (2008). Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs.  AMIA Annual Symposium Proceedings, pp. 849–853.

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