Managing Pain after surgery

DISCUSS THE ROLES OF POST OPERATIVE NURSES IN
MANAGING PAIN EFFECTIVELY IN POST OPERATIVE CARE UNIT (PACU).

Assessment Task (Project Report)
Project Report on Nurses Role in Pain Management

Introduction
Pain after surgery is distressing to patients and it is an issue of concern for nurses
working in PACU. Ineffective pain management during the immediate postoperative period can
prolong patients stay in the PACU especially if the necessary measures are not implemented..
Nurses in PACU have a responsibility to continuously assess and give proper pain treatment to
the patient (Tedore, 2015). During my placement, I noted that nurses play an important role in
management of pain during the postoperative period. Therefore they should be equipped with the
proper skills and knowledge to be able to provide the best pain management. Furthermore, I
realized that, despite the availability of guidelines and variety of tools for pain management,
post-operative management of pain is still a challenge (Abrahamson, Fox & Doebbeling, 2012).
Moreover, increased knowledge on pharmacological and non-pharmacological pain
management results in better patient outcomes. Also, these nurses should be given ample time to
be able to follow the pain management guidelines to ensure proper pain management. My report
aims at analyzing from the relevant peer reviewed articles on nurses’ role in management of
post-operative pain and nursing issues relating to management of pain during postoperative
period putting my experience in the unit into consideration.

ASSESSMENT TASK (PROJECT REPORT) 2
Literature Review
Tedore, 2015 conducted a research and found out that proper management of post-
operative pain benefits patients in a number of ways. Mostly it contributes to better patient
comfort which is key, less cardiac complications and reduced risk of development of deep vein
thrombosis and finally the patient recovers within a short period of time.
According to Wilding, Manias & McCoy, 2012 research article, it explained that that improper
management of pain is majorly contributed by nurses. The factors that contribute to this include
poor assessment of pain, reduced knowledge and skills on pain management, fear of side effects
associated with pain management, (Wilding et al. 2012).The research conducted by (Wilding et al.,
2002) explored the contributing factors to increased pain during discharge of patients from PACU.
Use of pharmacological and non-pharmacologic therapies in pain management is highlighted in
an article by Joshi, Schug & Kehlet , 2014.The article outlined that morphine was mainstay for pain
management in PACU. It further suggests the use of the WHO recommended ladder, starting from mild
non opioids including acetaminophen and NSAIDs to strong opioids such as morphine which can be used
according to severity of the pain score. None the less, use of ice packs, distraction by use of music and
positioning are some of the non-pharmacological therapies. A study was done in PACU and the findings
were that use of non- pharmacological therapies together with analgesics yielded better outcomes in pain
management(Joshi, Schug & Kehlet, 2014). However, the outcomes varied depending on the type of
surgery performed .
According to Ramnytz, Wells & Fleming 2015, the PACU nurse has a role in assessing the
associated side effects of the pharmacological agent administered. Relieving pain is the major
goal of postoperative pain management and ensuring that minimal side effects results. Opioids
are the mainstay of pain therapy. However they are associated with unwanted effects such as

ASSESSMENT TASK (PROJECT REPORT) 3
respiratory depression, hypotension and reduced bowel movement (Ramnytz et al., 2015). In
PACU, a pulse oximetry is the best tool that can be used to monitor respiratory depression during
administration of opioids. However, the best method of monitoring respiratory depression is
through observation of the respiratory pattern and the patient’s level of consciousness.

Methodology
During my placement in the Post Anesthetic Care Unit, I interacted and engaged the nurses in
discussions pertaining their role in pain management with observations being the key technique.
Discussions
Postoperative nurses have a responsibility in assessment of pain. They should assess
paints level of pain using the most effective tool to have the best outcomes. The 10 pain
assessment scale is most preferred tool. However, it is important to incorporate both the
subjective and objective information to be in a position to determine the most appropriate
therapy for pain. There should be continued documentation of the progress of the patient so as to
determine the effectiveness of the therapy and there will be any alteration. The nurse should as
well note the source and severity. In the event there is no relationship between the site and
severity of pain, it will warrant investigations to determine if there is any related pathology.
Cultural background as well as anxiety is some of the patient factors determine the
management of pain therefore the nurse has a responsibility of assessing them and determine if
they have an effect on the patient perception. Therefore, these nurses have a role in establishing
these factors.

ASSESSMENT TASK (PROJECT REPORT) 4
Reflecting my placement in PACU, I appreciated that the hospital has a protocol for
management of pain after surgery. For moderate pain, no opioids drugs were used while for
severe pain, strong opioids were utilized. I also appreciated use of non-pharmacological therapies
in pain management. Use of both pharmacological and non-pharmacological therapies increases
efficiency (Ramnytz, Wells & Fleming ,2015). Non pharmacological therapies that were utilized
included ice packs, music therapy and in deed they were found to be effective.
Literature suggests use of different pharmacological agent in management of pain.
Similarly, during my placement, I identified those agents being utilized. For severe pain , opioids
were being used while for moderate and mild pain, agents such as tramadol, diclofenac as well as
acetaminophen were used. Nurses were very vigilant and it encouraged me when they assessed
the patients often after administration of these agents as the doses were given continuously until
the level of pain subsided. According to WHO, recommends the use of a ladder for drug
management, during my clinical placement, it was however not applied.Mariano, Miller &
Salinas (2013), advocated for use of weak opioids, and NSAIDs in management of moderate
pain. However, this was not practiced during my placement.
It is the nurse’s integral duty to assess the side effects of the analgesic agents. Knowledge
on mode of action ,drug interaction as well as unwanted side effects so that they can be in a
position to observe any side effect of the agent s and act accordingly. Likewise, I noticed that the
nurses were aware of the associated side effects of the analgesic agent and they acted
appropriately whenever they noticed any deviation from normal. After administration of
morphine, the PACU nurses were keen to observe the respiratory pattern of patients to identify if
there was any respiratory depression associated with the use of morphine.

ASSESSMENT TASK (PROJECT REPORT) 5
Conclusion
My experience in management of postoperative patients in PACU enlightened me on the
role of nurses in management of postoperative pain. I realized that continued provision of PACU
nurses with the relevant skills and knowledge will go a long way in better management of pain
after .The information I found was relevant for them included variety of pain management tools,
factors influencing pain management, different therapies of pain management as well as the side
effects associated with pharmacological managements. Finally I would recommend the
utilization of the WHO ladder for pain management.

ASSESSMENT TASK (PROJECT REPORT) 6

References

Joshi, G., Schug, S., & Kehlet, H. (2014). Procedure-specific pain management and outcome strategies.
Best practice & research. Clinical Anaesthesiology, 28(2), 191-201.
Kobelt, P., Burke, K., & Renker, P. (2014). Evaluation of a standardized sedation assessment for opioid
administration in the post anesthesia care unit. Pain Management Nursing, 15(3), 672-681.
Mariano, E., Miller, B., & Salinas, F. (2013). The expanding role of multimodal analgesia in acute
perioperative pain management. Advances in Anesthesia, 31(1), 119-136.
Marshak, C., Bertignoli, T., Mulackal, E., Reyes, E., Duran, M., & Rojo, L. et al. (2014). Excellence in
PACU pain management: How is our PACU team terforming? Journal of Perianesthesia Nursing,
29(5), e17.
McLean, G., Martin, D., Cousley, A., & Hoy, L. (2013). Advocacy in pain management: The role of the
anaesthetic nurse specialist. British Journal of Anaesthetic and Recovery Nursing, 14(3-4), 43-48.
Ramnytz, L., Wells, V., & Fleming, E. (2015). An Exploration of the post-anesthesia care unit (PACU)
nurses’ knowledge level of sedation scoring and pain management options. Journal of Perianesthesia
Nursing, 30(4), e44.
Tedore, T., Weinberg, R., Witkin, L., Giambrone, G. P., Faggiani, S. L., & Fleischut, P. M.
(2015). Acute Pain Management/Regional Anesthesia. Anesthesiology clinics, 33(4), 739-751.
Wilding, J., Manias, E., & McCoy, D. (2012). Pain assessment and management in patients after
abdominal surgery from PACU to the postoperative unit. Journal of Perianesthesia Nursing, 24(4),
233-240.

  1. Explore the post operative nurses’ roles in managing pain effectively in the
    postoperative care unit (PACU).

Assessment Task 1 (B) Project Report

  1. Introduction:
    After surgery, despite the treatment of pain management during intraoperative period,
    patients may still experience moderate to severe pain that can lead to distress and increase
    their length of stay in the PACU (Wilding, Manias & McCoy, 2009). Similarly, while I was
    on my clinical placement I have noticed that pain was a significant issue and I observed
    various nursing practices in relation to improving pain management. Thus, this report is
    written to investigate the chosen issue. Its main aim is to analyse the recent peer reviewed
    research articles, in relation to nurses’ roles in pain management strategies and also taking
    my clinical experiences into consideration. Alternatively, this project question could have
    mentioned specific surgery types to focus on pain management strategies in order to
    strengthen the report.
  2. Synopsis of the literature:
    One exploratory research article highlighted the importance of pain assessment techniques in
    managing post operative pain (Wilding, Manias & McCoy, 2009). This study also stated that
    the PQRST method is the best practice method which helps to identify the nature and severity
    of pain, mainly utilizing the verbal numerical pain rating scale which consists of a zero to ten
    score where zero is no pain and ten is the worst. Additionally, they also mentioned that
    nurses need to assess patient’s pre existing pain status, comorbidities, cultural beliefs and
    their level of education regarding pain treatment because these can impact the effectiveness
    of pain management (Wilding et al., 2009). This research was conducted in largest regional
    hospital in Victoria. It explored an insight into patients’ assessment and pain management
    needs which assisted nurses in decision making regarding the use of pain relief required post
    operatively. However, unfortunately they found higher pain scores when discharging patients
    from the PACU (Wilding et al., 2009).

Assesment-1. B Perioperative

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NRSG370 S00148938
Furthermore, Joshi, Schug & Kehlet (2014) explained about the use of pharmacological and
non-pharmacological measures for pain management. Pharmacologically, study has
highlighted the use of intravenous protocols such as titrate bolus dose of opioids, is the
common technique for pain management in the PACU. This technique reduces the risk of
exceeding drug accumulation and other opioid related side effects and prolongs their efficacy
(Hammoud et al., 2009). It further suggests the use of the WHO recommended ladder,
starting from mild non opioids including paracetamol and NSAIDs to strong opioids such as
morphine which can be used according to severity of the pain score. Non-pharmacologically,
it describes the use of hot and cold packs, positioning, music therapy, deep breathing and
coughing exercise in conjunction with the analgesics that can promote better outcomes. This
study was taken in the PACU and assessed the effectiveness of medication and patients’
experiences after the interventions. However, researchers used a small sample and efficacy of
the used techniques varied from patient to patient due to their nature of surgery and
anesthesia in their trial (Joshi et al., 2014).

Moreover, Mariano, Miller & Salinas (2013) provided good evidence based research
regarding the use of multimodal analgesia proposed to approach more than one target at a
time for maximizing analgesic efficacy and minimizing side effects. In this study, 52
randomized clinical trials were conducted. They used NSAIDS and acetaminophen in their
multimodal analgesic protocol and ended with less opioid intake and higher efficacy.
Conversely, this study does not focus only on a nursing perspective but also a whole pain
management team in PACU (Mariano et al., 2013).

According to Ramnytz, Wells & Fleming (2015), another important role of PACU nurse is to
assess sedation scores before and after administration of any opioid analgesic especially
morphine as it can lead to respiratory depression. Researchers used a questionnaire method to
assess nurses’ knowledge regarding analgesia, sedation scoring and pain management
options. 17 out of 24 nurses were included in the survey and their correct response was that
55.4% demonstrated a serious lack of knowledge of pain management. Hence, this research
revealed a need of further research and audit on nurses’ level of knowledge on pain
assessment and management options (Ramnytz et al., 2015).

  1. Methodology:

Assesment-1. B Perioperative

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Observation method and discussion with PACU nurses during three weeks’ placement at St’s
Vincent Private Hospital, East Melbourne.

  1. Discussion:
    4.1. Critical reflection on clinical observations:
    Ineffective pain management can increase agitation and discomfort to patients and prolonged
    their PACU stay. Thus accurate pain assessment including PQRST method provides an
    appropriate pain management option for nurses (Marshak et al., 2014). Reflecting upon my
    clinical placement, I observed nurses using the PQRST method to identify the pain severity
    and intensity. After assessing pain levels nurses followed hospital protocols, for example an
    order for analgesia for moderate to severe pain as analgesic administration is the first line
    treatment of post surgery pain (Joshi et al., 2014). I also noticed that nurses were
    implementing non-pharmacological approaches for mild to moderate pain. Ramnytz, Wells &
    Fleming (2015) recommend that using non-pharmacological approaches in conjunction with
    analgesics helped to increase efficacy. Most gynecological patients received hot packs and
    were reassured by nurses and I found this method the most effective. However, they did not
    use the music therapy in PACU as Joshi et al. (2014) mentioned music therapy can act as a
    pain distraction therapy.

From the pharmacological perspectives, Hammoud et al. (2009) mentioned that morphine is a
commonly used opioid for moderate to severe pain in PACU. Likewise, literature suggests
that intravenous titrated dose of opioids as a commonly used method for effective pain
management (Joshi et al., 2014). I also noticed the same practice in my clinical placement
where I saw nurses administering small doses of morphine, waiting five minutes then
reassessing pain levels and repeating the dose until pain had subsided for hip replacement
surgery patients, hence outcomes were effective. Nurses used fentanyl, tramadol and
oxycodone for moderate to severe pain, IV paracetamol individually for mild pain and
intravenous patient control analgesia for severe pain. This practice is evidently associated to
the WHO ladder as mentioned by Joshi et al. (2014). However most of the nurses did not
follow the WHO ladder, although this is the best practice method associated with my
research. I plan to follow WHO ladder in my future practice.

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Multimodal analgesic regimes were also used as an optimal pain management technique with
less adverse effects (Marshak et al., 2014). According to Mariano, Miller & Salinas (2013),
for moderate to severe pain use of NSAIDs plus paracetamol and weak opioids is the most
effective option as well as paracetamol and NSAIDs for mild to moderate pain. Likewise, I
noticed that my buddy nurse used panadeine and parecoxib as well as oxycodone for
moderate to severe pain with better effects.

Another integral role for nurses is to assess a patients’ sedation score and advocate for
patients about the use of analgesia especially morphine (McLean, Martin, Cousley & Hoy,
2013). Thus, nurses should be knowledgeable about the use of analgesics, their mechanism of
action and side effects because respiratory depression is the most common adverse effect of
opioids and patients in PACU are already at high risk of respiratory compromise due to use
of anesthesia intra-operatively (Kobelt, Burke & Renker, 2014). Similarly, I observed the
same practice performed by nurses during their care provision.

Conclusion:
This innovative project report provided me with new insight about nurses’ roles in assessing
and managing pain effectively in PACU. Pharmacologically, research articles suggest to use
of of WHO recommended ladder and multimodal approach in combination with non-
pharmacological interventions. I was able to adequately observe same practices which was
being used by nurses. However, providing frequent educational sessions and evidence based
research protocols for nurses, will strengthen better pain management outcomes in future
practice.

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References

Hammoud, H., Simon, N., Urien, S., Riou, B., Lechat, P., & Aubrun, F. (2009). Intravenous
morphine titration in immediate postoperative pain management: Population
kinetic–pharmacodynamic and logistic regression analysis. Pain, 144(1), 139-146.

Joshi, G., Schug, S., & Kehlet, H. (2014). Procedure-specific pain management and outcome
strategies. Best practice & research. Clinical Anaesthesiology, 28(2), 191-201.

Kobelt, P., Burke, K., & Renker, P. (2014). Evaluation of a standardized sedation assessment
for opioid administration in the post anesthesia care unit. Pain Management Nursing,

Mariano, E., Miller, B., & Salinas, F. (2013). The expanding role of multimodal analgesia in
acute perioperative pain management. Advances in Anesthesia, 31(1), 119-136.

Marshak, C., Bertignoli, T., Mulackal, E., Reyes, E., Duran, M., & Rojo, L. et al. (2014).
Excellence in PACU pain management: How is our PACU team terforming? Journal
of Perianesthesia Nursing, 29(5), e17.

McLean, G., Martin, D., Cousley, A., & Hoy, L. (2013). Advocacy in pain management: The
role of the anaesthetic nurse specialist. British Journal of Anaesthetic and Recovery
Nursing, 14(3-4), 43-48.

Ramnytz, L., Wells, V., & Fleming, E. (2015). An Exploration of the post-anesthesia care
unit (PACU) nurses’ knowledge level of sedation scoring and pain management
options. Journal of Perianesthesia Nursing, 30(4), e44.

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NRSG370 S00148938
Wilding, J., Manias, E., & McCoy, D. (2009). Pain assessment and management in patients
after abdominal surgery from PACU to the postoperative unit. Journal of
Perianesthesia Nursing, 24(4), 233-240.

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