Introduction
Acute and chronic pain are categories of pain people encounter at a point in their lives. Poor pain management can have negative physical and psychological effects on patients and their relatives. Even though the attending physician is ultimately responsible for prescribing and managing a patient’s pain, the nurses must closely monitor patients. Nurses’ decisions and how they handle pain may impact the standard of care provided to critically sick patients. The right history-taking, physical examination, patient stability, knowledge of medication interactions and contraindications, and use of the appropriate medicine based on the cause of the pain are all necessary for emergency pain treatment.
Discussion
In my reflection, the patient encountered in the emergency department was a 62-year-woman, Joleen, who had an angina attack. On the history, the patient had underlying peptic ulcer disease that had been diagnosed five years before the presentation. Additionally, the patient had been diagnosed with class II heart failure two years before presentation at a nearby facility. The patient said the pain was sharp and radiating to the left shoulder. The medication history indicated that the patient was on ACE inhibitor captopril, ARB losartan, PPI omeprazole, and H2 blocker ranitidine (Brenner and Stevens, 2018, p.156). All the findings from the record showed that the patient had an angina attack, and the goal was to address the patient’s pain without compromising her health status by aggravating the underlying conditions. Proper understanding of the medications contraindicated in heart failure and peptic ulcer diseases were crucial.
Ensuring that Joleen was stable before initiating the appropriate management determined the patient’s outcome. I established that the patient was stable and the airway was patent. The patient’s stability in having the pain should be the top priority for the healthcare practitioner (Cameron et al., 2019, p.667). The airway can be made patent through maneuvers such as the jaw thrust and the chin lift. The practitioner must ensure that the patient is breathing before management of the pain starts. If the patient is not breathing, mechanical ventilation methods such as CPAP with appropriate masks or nasal prongs may be used. If the patient is bleeding, the source of the bleeding must be identified, and the proper interventions to arrest it. Fluid resuscitation measures can be instituted using crystalline solutions such as normal saline or ringers lactate (Curtis et al., 2019, p.156). The patient should be given rightly crossmatched blood if he is hemodynamically unstable. Joleen’s airway was patent; she was breathing well and was hemodynamically stable.
I had the proper knowledge to identify the appropriate drug to give Joleen. Improper and inadequate training among nurse practitioners leads to poor pain management. The knowledge barrier to addressing the pain reduces the patient’s satisfaction in health care. The practitioner does not correctly assess the pain assessment, such as the site, character, relieving factors, timing, and associated factors. Sharp pain originating from the left sternal border and radiating to the left shoulder or left jaw may indicate angina (Jameson, 2018, p.265). The referred pain in angina is because of the afferent neural pathways that carry pain from other regions such as the neck, shoulder, and jaw (Tortora et al., 2019, p.462). The diagnosis of angina in the emergency department may lead to the appropriate therapeutic medication. It includes nitrates such as isosorbide nitrate, NSAIDs such as aspirin, anticoagulants, beta-blockers such as metoprolol, and calcium channel blockers such as verapamil and amlodipine (Bullock and Manias, 2016, p.534). Administration of isosorbide dinitrate improved Joleen’s condition within a short time.
All efforts in my team were to ensure that no contraindicated medication was given to Joleen. The first criticism of emergency pain management in nursing is the administration of contraindicated medications. The improper taking of history and physical examination leads to the health practitioner failing to identify the underlying medical condition and administering a medication that may aggravate the patient’s condition (Jarvis, 2020, p.38). For example, Non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated in heart failure patients (Bullock and Manias, 2016, p.466). The NSAIDs potentiate sodium and water retention in patients and lead to heart decompensation. Therefore, the heart’s cardiac output fails to meet the body’s metabolic demand, worsening the patient’s condition. The NSAIDs enhance vasoconstriction leading to increased workload on the heart, thereby worsening heart failure (Seifert, 2019, p.636). The administration of these medications can worsen the toxicity of ACE inhibitors and diuretics. NSAIDs are major etiological factor observed to cause peptic ulcer disease (Sugisaki et al., 2018, 1254). Therefore, it is recommended that the nurse practitioners be aware of the contraindicated patients with heart failure complaining of pain.
I ensured that proper history and physical examination was taken in the patient. Improper history taking and physical examination can lead to the administration of NSAIDs in patients with peptic and duodenal ulcers. In critical analysis of pharmacology, non-selective cyclo-oxygenase (COX) inhibitors such as ibuprofen, diclofenac, and naproxen worsen peptic and duodenal ulcers (Bullock and Manias, 2016, p.467). The blockage of the COX enzyme prevents the synthesis of the prostaglandins, which are crucial in the protection of the gastric mucosa. Therefore, the administration of NSAIDs in patients with these ulcers may aggravate the patient’s condition leading to bleeding that may cause the patient to develop hypovolemic shock (Ralston et al., 2018). The recommended medication for pain management in gastric ulcers should be used. For example, the proton pump inhibitors (PPIs) such as esomeprazole and H2 blockers such as ranitidine and cimetidine can prevent acid production, which may relieve pain (Brenner and Stevens, 2018, p.568). The patient was already on PPI and H2 blockers, so there was no need to readminister the medication. She mentioned that she was adherent to the heart failure and peptic ulcer medications.
I ensured a collaborative team effort in addressing Joleen’s problem. Failure of nurses to communicate with other medical staff in emergency pain management leads to poor outcomes. Medicine is a collaborative profession that requires the combined efforts of numerous stakeholders to address the patients’ problems (Emich, 2018, p.568). Nurses, especially those new in the profession, may fear communicating with their senior colleagues about how to handle a particular scenario. The work experience correlates directly with a medical practitioner’s confidence in handling a clinical scenario. In Joleen’s case, a gastroenterologist, nutritionist, and cardiologists were available to offer the best advice on the therapeutic approach to the patient.
Elimination of organizational barriers was crucial in solving Joleen’s problem. The obstacles may impact the nurses’ effective pain management. Some hospitals may have hospital policies regarding drug administration by nurses (Jukiewicz et al., 2017). Therefore, the practitioner may know the drug to administer in the emergency setting but cannot because of the hospital’s restrictions. A nurse may be aware of a patient, such as a cancer patient with chronic pain, who may benefit from opioid analgesics but is restricted from administering the analgesic. They must wait for the doctors’ direction to administer the medication, yet the patient may be in deep pain. Nurses observing patients suffer from pain but are restricted from administering the analgesics may cause post-traumatic stress disorder in the practitioners (Schuster and Dwyer, 2020, p.2784). The patient’s psychological status is affected as they feel a reduced satisfaction in the health care system. I knew that nitrate such as isosorbide could help the patient and gave it.
In patients with chronic illnesses, undertreatment of pain is faced by many nurse practitioners globally. Underdosing or wrong analgesics may cause pain undertreatment by the practitioners, so the patient’s condition is not addressed (Anekar and Cascella, 2020). Another cause may be administering inappropriate drugs to alleviate the pain. For example, in patients suffering from chronic diseases such as cancer and sickle cell or having third-degree burns, NSAIDs may not help such patients (Ann et al., 2018, p.230). Such drugs will only contribute to hepatic and renal toxicity without helping the patient. In such patients, administering opiods such as morphine, tramadol, and fentanyl may help relieve the pain. Nurses should know the appropriate drugs they can give to improve the patient’s well-being.
Understanding the effects of pain in Joleen was essential in addressing the clinical case. Ignoring the harmful effects of unrelieved pain in nursing practice is a significant drawback in emergency pain control. Patients often become anxious and nervous, and some develop suicidal thoughts (Conejero et al., 2018, p.4). The patients cannot do many things they previously did without the pain. It may consequently affect their relationship with others, and they may appear as a burden to the family as they can no longer work. Pain leads to psychological stress, and the endocrine system releases corticosteroids, which cause increased protein, carbohydrate, and fat catabolism (Barrett et al., 2019, p.338). It leads to the marked weight loss of the individual, and the person’s psychological health status deranges more. Improper pain treatment increases the recovery period of the patient. The cardiovascular system responds by activating the sympathetic nervous system, leading to tachycardia, increased cardiac workload, hypercoagulability, and increased oxygen demand (Mohan and Damjanov, 2019, p.372). The augmented sympathetic nervous system can impair many gastrointestinal functions. There is a reduced section of mucus, reducing the protection of the GIT. There is an increased tone of the sphincter, which leads to delayed gastric emptying.
Recommendations
I ensured that family and patient were involved in the pain management plan to address it effectively. The family should give the patient’s history, and the health care practitioner should carefully examine the patient (Glynn and Drake, 2018, p.23). These interventions are crucial in finding the appropriate etiology of the patient’s pain. Improper training leads to the nurses failing to evaluate the pain effectively to find the best therapeutic measures to address it (Alotaibi et al., 2018, p.525). Nurses should be appropriately trained on pain management interventions so the pain can be effectively managed in the patient. The family and patient play a central role in determining the cause of the pain, thus giving the clinical proactive the best clue on handling the pain. The nurse must use verbal and nonverbal skills to take a proper patient history. Practitioners must address all the aspects of pain in the history taking to determine the relevant etiology.
Collaboration in clinical practice is necessary for determining the patient’s outcome. It is recommended that the young professionals in practice seek advice from their senior colleagues on how they can handle different clinical scenarios (Munkombwe, Petersson and Elgán, 2020, p.1645). It will lead to improved patient care and outcome in practice, consequently improved patient satisfaction in the healthcare system as their problems are appropriately addressed. Interprofessional education should be encompassed to help different professionals learn together and improve their collaborative skills. Communication is an essential tool in nursing that assists practitioners in prevention, treatment, and health promotion (Lateef, 2022, p.2). It will help equip the nurses with better approaches to pain management depending on the clinical setting. Healthcare professionals should adhere to the regulations outlined in their fields of expertise (Joshi et al., 2017, p.721). It will aid in avoiding the prescription of harmful medications to particular people for the treatment of pain.
Nurses have to improve their attitude in handling patients in pain. Proper education and training will help solve the problem of administering contraindicated drugs (Samarkandi, 2018, p.220). In pharmacology, understanding drug interaction helps prevent concurrent administration of analgesics that may have additive effects. NSAIDs may aggravate hepatotoxic, renal, and cardiac damage and thus should be cautiously administered. The opioid analgesics should be carefully administered as they have side effects such as respiratory depression, drowsiness, nausea, constipation, and drowsiness (Waller and Sampson, 2018, p.677). Proper education should be conducted to assist in carefully administering opioid analgesics to minimize side effects on patients.
Conclusion
The pain management approach is crucial in determining a patient’s outcome. A proper history taking and physical examination help determine the etiology and cause of pain and the intervention that can be undertaken. Proper education and training of nurses will help improve pain management. Nurses need to follow the specific pain management guidelines within their specific areas of practice. It will assist in avoiding under-treatment pain, a common problem globally. A collaborative effort is crucial in improving the outcome of pain in patients.
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