The importance of effective management of pain in the post-operative patient cannot be overemphasized. Its inadequate management can have profound adverse effects on patients such as sleep disturbances, mobilization difficulties, aggression, high levels of anxiety, and increased distress and suffering (Carr et al., 2005). Post-operative pain can also have unwanted physiological effects on patients and cause complications such as nausea, vomiting, paralytic ileus, and increases in blood pressure (Mackintosh, 2007). This paper will critic the pharmacologic and non-pharmacologic interventions that were used in the management of post-operative pain (rated at 6/10 on the numeric scale) in a patient who is on his first post-operative day following sleeve gastrectomy. The patient was on a combination of 10 mg IV morphine and p. o. 1g paracetamol. The non-pharmacologic measures used include heat pack application, slow deep breathing and relaxation, and reassurance. The patient was concomitantly being managed for nausea and vomiting and hypoglycemia. Following implementation of the interventions, the patient was reassessed after 30 minutes. The patient reported that the pain had reduced significantly and rated it at 2/10. He also stated that he was now able to rest and sleep comfortably.
Critique of the management of Post-Operative pain
The review of literature conducted did not reveal any articles focusing on best practices in the management of post-op pain following sleeve gastrectomy. As such, literature on management of post-operative pain and in particular pain following abdominal surgery was reviewed. A multimodal approach was adopted in the management of post-operative pain whereby an opioid (morphine) was combined with a non-opioid drug (paracetamol). The use of two or more analgesic agents in the management of post-operative pain is well backed by current nursing and medical literature (Papaioannou et al., 2009; Mackintosh, 2007; Bonnet & Marret, 2006). This is probably due to the fact that post-op pain is caused by different physiological mechanisms that are nociceptive and neuropathic mechanisms. The former mechanism causes inflammatory pain due to mechanical, chemical, or thermal stimulation of nociceptors secondary to tissue damage post-surgery whilst pain in the latter mechanism is due to the damage of peripheral nerves. Post-operative pain may be somatic (affecting muscle, skin, and bones) or visceral (affecting abdominal or chest organs) in nature. As such, the combination of two or more analgesic drugs that act via different mechanisms produces a superior analgesic effect whilst mitigating the risk of increased adverse events inherent in increasing dosages of the same analgesic drug. Research evidence from quasi-experimental studies suggests that the use of analgesic agents administered via different routes produces better pain relief than the use of agents administered via the same route. In this light, the use of intravenous morphine and per oral paracetamol for achievement of pain relief in the patient was appropriate (Papaioannou et al., 2009).
The management of the pain adhered to the WHO (1996 as cited in Mackintosh, 2007) principles on the management of post-operative pain. The principles recommend a step-wise approach to the management of post-operative pain that starts from the top of the ‘analgesic ladder’ to the bottom (strong opioids to non-opioids). Although pain has multiple etiology and a subjective component, the cause of post-operative pain is fairly obvious hence the use of pharmacologic agents is recommended. Therefore, the WHO recommendations for post-operative management of pain which recommend that strong opioids be used to manage pain in the initial period are justified. In the patient’s case, morphine, a strong opioid was combined with paracetamol.
The use of morphine in the management of post-operative pain is well supported in medical literature (Mackintosh, 2007). It is safe and effective and it has minimal adverse effects. The most common side effects of the drug are decreased bowel motility which may lead to constipation, nausea, vomiting, pruritus, urinary retention, sedation, and in rare circumstances, respiratory depression. The side effects do not affect every patient though and others such as vomiting and constipation can be controlled using anti-emetics or laxatives if they occur. As such, the merits of morphine greatly outweigh its demerits (Weetman & Allison, 2006). The other often cited concern in regard to the use of morphine and other opioid agents in the management of postoperative pain is the risk for addiction. Findings from multiple studies, however, suggest that this risk is minimal and thus addiction concerns should not limit the use of opioid analgesics (Gray, 2005). Notably, though, there is no evidence to suggest that the adverse effects of morphine were evaluated following administration of the drug. Patient evaluation is key since some of the more serious side effects of the drug such as respiratory depression and constipation may compromise the patient’s recovery process. The findings of a meta-analytic review by Cashman and Dolin (2004) also seem to suggest that the incidence of adverse effects such as respiratory depression and hypotension following administration of multiple analgesic agents in the post-op period may actually be higher than previously reported. From the data provided evaluations of the effectiveness of the intervention focused on reductions in the severity of pain which reduced from 6/10 to 2/10. Therefore, a serious omission related to the monitoring of morphine-related side effects possibly occurred.
Evidence emanating from recent studies suggests that the second drug used, paracetamol, is a highly effective analgesic agent. The studies indicate that paracetamol has opioid-sparing capacities and is more effective than some compound formulations such as codeine phosphate in some cases. The opioid-sparing effect simply means that it mitigates the use of opioid agents when prescribed together with such agents for pain management (Buvanendran and Kroin, 2007; Pyati and Gan, 2007). In essence therefore, the routine prescription of paracetamol alongside strong opioid analgesic agents for relief of post-operative pain is now considered to be good practice.
The post-operative treatment plan for the patient embodied pharmacological agents and physical and psychological comfort measures such as patient reassurance, application of a heat pack to the surgical incision site, and slow deep breathing and relaxation exercises. The combination of these two modalities is recommended as best practice for the management of post-operative pain. Mackintosh (2007) contends that these measures work best when combined together. Andres et al. (n. d.) similarly recommend the use of non-pharmacological pain interventions in conjunction with pharmacotherapy in the management of post-op pain. A systematic review by Crowe et al. (2008) that assessed the effectiveness of nursing interventions used to relieve post-operative pain also supports the use of comfort measures. The authors concluded that currently, there is no strong evidence to suggest that pharmacological interventions are more effective than non-pharmacological interventions. In essence, therefore, the management of pain in the patient did not minimize the importance of comfort measures. The three comfort measures used are primarily distraction techniques that help to shift the patient’s focus from pain. Reassurance helps to allay patient anxiety which if present can increase patient perception of pain (Smeltzer, Bare, Hinkle, & Cheever, 2009). It is particularly important to explain to patients what to expect in terms of pain post-operatively because surgery is not an everyday experience (Mackintosh, 2007). Hot packs provide tactile stimulation which in turn stimulates production of serotonin. Deep breathing exercises, on the other hand, are a form of relaxation thus they help to allay anxiety and to dissociate patients from pain (Young, Neirkerk, & Mogotlane, 2007, pp. 571-572).
Pain assessment was done pre- and post-treatment. Accurate evaluations of post-operative pain is important so as to ensure that pain is managed in an effective manner. Without assessment, it is not plausible to identify the nature, quality, or other individual characteristics of the pain, or to evaluate the effectiveness of pain management measures instituted (Sloman et al., 2005; Schafheutle et al., 2004). A patient assessment tool was used in assessing pain threshold pre and post-treatment. The patient rated the pain at the wound site at 6/10 and 2/10 pre- and post-treatment respectively. From the data, it seems that the uni-dimensional pain assessment tool, numerical rating scale was used to assess pain. Uni-dimensional tools usually assess one or two elements of pain. It is, therefore, recommended that they be used with caution because the total pain experience embodies numerous factors that should be assessed such as the location, quality, intensity, duration, variability, exacerbating and relieving factors, and onset of pain amongst others. In addition, some groups of patients may experience difficulties in rating their pain using a numerical value or as mild, moderate, or severe. Although the use of these tools is not without demerits, it is generally accepted that the use of some form of pain evaluation is better than no evaluation. The use of multi-dimensional tools which are better suited for pain assessment is limited in post-op settings because these tools tend to be complicated and time consuming (Heikken et al. 2005; Mackintosh, 2005). Although it is reported that the patient’s pain was evaluated, it is not reported whether the provided ratings of severity of pain were assessed with the patient at rest or during movement. Assessments of the presence of two kinds of pain are essential because patients tend to report minimal pain at rest and increased pain on even small movements such as coughing or deep breathing (Mackintosh, 2005). To promote effective post-op recovery, therefore, it is essential that the pain experienced during movements is addressed.
Conclusion
In summary, the available literature is silent on the management of post-operative pain following sleeve gastrectomy. As such, the management of the patient in question was critiqued based on available literature on treatment of general post-operative pain. The multimodal approach adopted in the management of the patient is appropriate and well supported by current literature. This is because it produces superior analgesic effects whilst mitigating adverse effects associated with increased dosing of one analgesic agent. The use of morphine and paracetamol reflects best practices in the management of post-operative pain. The adverse effects of morphine should have been monitored more vigorously though. The pain treatment approach is congruent with WHO’s (1996) principles for management of post-operative pain. The combination of pharmacologic and non-pharmacologic pain treatment interventions reflects current evidence-based practice. The three non-pharmacologic used relieve pain majorly through distraction. The apparent lack of pre-operative intervention measures was a serious shortcoming in pain management planning. Pain assessment was done using a numerical rating scale which is acceptable in post-op settings. No details are provided though on whether pain on movement was assessed and treated hence an important component of pain management may have been omitted. In conclusion, therefore, the management of post-op pain in the patient was appropriate although some aspects were not addressed.
The findings derived from a review of literature have important implications on general and my individual nursing practice. They highlight the need for pre-operative pain interventions, multimodal management of post-operative pain, top-down approach in post-op pain treatment that prioritizes the use of strong opioids and paracetamol in the initial period, vigilant monitoring of patients on morphine for side effects such as respiratory depression and hypotension, and use of paracetamol to reduce the use of morphine and other opioids.
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