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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