How to write a nursing essay on Post-Surgical Pain Management

How to write a nursing essay on Post-Surgical Pain Management

The effective relief of pain is of utmost importance to anyone providing care to patients undergoing surgery. Pain relief is considered a human right by professional organizations like the World Health Organization (WHO) and is now among the increasingly monitored quality measures postoperatively (Mark et al., 2018). The failure to provide good postoperative pain relief has various consequences on the quality of life of the patient and the quality of care provided by healthcare organizations. For instance, most healthcare facilities have emphasized patient satisfaction that is influenced by aspects like effective pain management. Although many efforts have been made to facilitate this process, pain management remains a major problem in various healthcare facilities (Levy et al., 2019). More commonly observed is the challenge of providing pain relief using the traditional opioid system compared to multimodal approaches. This project discusses postoperative pain management with a focus on multimodal opioid-sparing regimens to reduce opioid side effects.

Post-Surgical Pain Management

Proper pain management, particularly postoperative pain, is a key concern for nurses, clinicians, and patients undergoing surgery. This project stresses the importance of postoperative pain management both to the patient and the healthcare organization. Effective management of this pain leads to enhanced recovery of the patient and reduced length of stay after surgery (Nimmo et al., 2017). Poorly managed pain can lead to complications and is associated with prolonged rehabilitation. Apart from the observed effects on the patient, poor pain control decreases organizational performance. The Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) scores measure patient satisfaction with in-hospital pain management. Inadequate pain relief can affect the scores and have serious implications on reimbursements. Completion of this project will inform healthcare providers of the importance of pain management, and how multimodal approaches to postoperative pain control are the best choice compared to the traditional pain management systems.

Overview of the Problem

Proper pain management, particularly postoperative pain, is a key concern for nurses, clinicians, and patients undergoing surgery. Postoperative patients usually experience acute pain related to the surgical procedure and standard care involves treatment using analgesics to relieve the pain. While a few medications can be prescribed to address this challenge, acute pain can develop into chronic pain with a reduction in quality of life (Tan et al., 2015). Poorly managed acute pain can lead to complications that can prolong recovery or even result in death. The failure to provide good postoperative analgesia is related to various factors ranging from the preparedness of the healthcare provider to the type of drugs used to relieve pain. For instance, poor patient assessment, inadequate education on pain relief, and fear of complications associated with the drugs can result in poor pain management.

Pain is a common occurrence and is expected in hospitalized individuals, especially during the post-operative period. Despite the vast recognition of this healthcare issue, management of pain remains improper resulting in treatment and discomfort among patients (Trail-Mahan et al., 2016). Inadequate pain relief results in both physical and psychological effects on the patient. Poorly managed pain is the cause of prolonged rehabilitation in many patients after surgery. The patient may be unable to ambulate, perform deep breathing exercises, or communicate effectively during recovery. Inadequate pain control leads to delayed resumption of oral intake alongside other complications like pneumonia. The prevention of these adverse effects requires timely assessment of the patient and the use of appropriate pain medication according to the patient’s condition.

The optimal management of post-operative pain is a key component of enhanced recovery after surgery (ERAS). ERAS protocols use a standardized analgesic regimen that includes postoperative opioids, regional anesthetics, and non-opioids to decrease the adverse effects of opioids use only (Trail-Mahan et al., 2016). Emerging evidence suggests that multimodal approaches that use several therapies with distinctive mechanisms of action maximize beneficial effects compared to single drug interventions. The ongoing debates about the effects of opioids and the recent emergence of the opioid crisis have generated differences in postoperative pain management. This project brings an insight into how the use of multimodal approaches can be beneficial to patients. Some providers argue that the mainstay of pain management intraoperatively and postoperatively remains the use of opioids. This project will demonstrate the use of evidence-based research and practice to inform healthcare decisions regarding pain management using opioid and multimodal approaches.

Project Purpose Statement

The purpose of the project is to analyze how multimodal approaches to pain management effectively manage post-operative pain and the health outcome of patients. The project compares the traditional opioid pain management system to multimodal approaches to provide an evidence-based recommendation to healthcare providers regarding postoperative pain management.

Background and Significance

Postoperative pain is experienced by the vast majority of patients who undergo surgery. During recovery, control of pain plays a crucial role in facilitating resumption to normal functioning while reducing the effects associated with acute, uncontrolled pain. Even with the current knowledge and variety of analgesic agents, pain management has not changed and remains a challenge for many healthcare providers. Statistically, about 75% of patients experience moderate to severe postoperative pain (Adesoye & Duncan, 2017). This challenge is caused by many reasons including unplanned contact between patients and providers and poor choice of analgesic agents. These challenges result in undermanaged pain, especially for ambulatory surgeries. The problem observed in the institution is a lack of understanding about the relevance of pain management to enhance quick recovery after surgery. There is limited knowledge on the choice of analgesic agents with many relying on the traditional opioid pain management system.

The goal of postoperative pain control remains to reduce the negative consequences associated with postsurgical pain and to help the patient transition smoothly to normal functioning (Anekar & Cascella, 2020). Acute postoperative pain is managed mainly using opioid analgesics. The WHO provides guidelines on the choice of analgesic agents according to the patient’s condition. Step one of the ladder deals with mild pain that is managed using non-opioid analgesics like NSAIDS with or without adjuvants. Step two of the ladder deals with moderate pain that is managed using weak opioids with or without non-opioid analgesics and adjuvants (Anekar & Cascella, 2020). The third step involves the management of severe and persistent pain using potent opioids with or without other analgesic combinations. Despite the clarity of this system, pain pain management is a challenge and there are numerous setbacks to the approach.

Pain management using the three-step ladder has elicited a lot of negativity in the recent past. The design of the ladder makes it easy to use by even non-experts, yet continued referral of patients to pain experts proves otherwise. The use of opioids is observed to have various challenges to both healthcare workers and patients limiting its use. For instance, all opioid analgesics are controlled substances that require prescription and administration by specialists (Barker et al., 2020). This means that regular healthcare providers cannot offer adequate pain control in the absence of in-charge nurses or physicians. Delays in communication and dispensing of the drugs lead to inadequate pain control. Secondly, the use of opioid analgesics has significant side effects that surpass its benefits and can sometimes result in fatal outcomes. Opioids are associated with side effects like somnolence, sedation, respiratory depression, urinary retention, and abdominal discomfort (Anekar & Cascella, 2020). The use of the wrong drug or improper dosage makes it even worse because it can result in death.

Apart from the side effects associated with opioid use, a significant issue of concern is the management of pure neuropathic pain. This type of pain has complex pathophysiology and mechanisms that involve different regions of the nervous system. The use of opioids has little or no effect on the management of these patients because it only focuses on the physical well-being of the patient. Neuropathic pain may require the use of other drugs like anticonvulsants, antidepressants, and sedatives that are not proposed in the three-step ladder (Levy et al., 2019). Because of these challenges, a new approach called multimodal approach or trolley is available to demonstrate how all types of pain can be managed postoperatively. This approach is based on the notion that pain is not merely a sensory discomfort experienced by the patient but also incorporates the patient’s perceptual, homeostatic, and behavioral response to an injury or chronic illness. Healthcare providers have an opportunity of combining various pharmacological and non-pharmacological interventions according to the patient’s condition.

Multimodal pain management is a method of pain management that uses a combination of various groups of medicines for pain medication. The most commonly combined medication group include opioids, local anesthetics, and acetaminophen (Mandava et al., 2021). The key to this approach involves using drugs with different modes of action that can target different pathways in the body. Research strongly indicates that this treatment approach improves the effect of analgesia to a significant extent due to the synergistic effect of different drug classes. Because of the combination of drugs used, dose adjustment is an important feature of multimodal drug use. For example, the elderly may find it difficult to tolerate the use of several painkillers at once because of the challenge with metabolism (Brooks et al., 2017). The multimodal approach serves to reduce dependency on opioids while reducing the risk of developing dependence on certain pain medications.

The identified challenge of pain management is of significant importance to the healthcare providers, patients, and the healthcare system. The problem of postoperative pain management in the institution serves as an opportunity to correct faulty systems using current evidence to improve quality. It demonstrates that healthcare providers need to be trained on how to assess patients and select the most appropriate analgesics to reduce complications. This project serves to enlighten nurses and healthcare providers about the challenges of opioid pain management and how it can be mitigated using more advanced strategies. Secondly, the project serves to enlighten providers about multimodal pain management, how pain can be managed by targeting certain pathways, and how to improve the quality of life using appropriate pain management strategies.

Registered nurses deliver care to patients by applying validated interventions. The use of evidence-based practice (EBP) underpins the approach to this project because it highlights how one approach to pain management leads to better patient outcomes than the other. Evidence-based practice involves the integration of research evidence, clinical expertise, and a patient’s preferences to inform decisions in healthcare for quality improvement (Trail-Mahan et al., 2016). This project is significant to the healthcare profession because it helps in the expansion of approaches to postoperative pain management and debates between the best strategy that can improve the quality of care given to patients. Using relevant literature, the project analyzes the pros and cons of the opioid pain management system compared to the new multimodal approaches to determine which route can best address the challenge of pain management in healthcare. The project will help providers realize that pain management does not only include the physical symptoms but also the emotional and psychological aspects that are determinants of quality of life.

PICOT Question

The PICOT question guiding this project goes as follows:

In postoperative patients (P), does the implementation of multimodal approach of pain management (I) compared to three-step ladder model C) effectively reduce pain as evidenced by a rating of less than five (O) within the first three weeks of treatment (T)?

Literature Review

A literature review involves the process of gathering evidence from scientific research to guide conclusions about certain aspects of care. This project used the literature review approach to gather evidence from credible sources concerning postoperative pain management. Emphasis was put on the use of the WHO three-step ladder pain management strategy and the new multimodal approach to determine and propose the best strategy to healthcare providers.

The key terms used during the research included: Pain, post-operative pain, multimodal pain management, World Health Organization (WHO) analgesic ladder, enhanced recovery, opioid analgesics

Summary of Research

Even with the current knowledge and innovations on an armamentarium of analgesic agents, postoperative pain management remains challenging. Effective pain management is a key concern for nurses and clinicians because it directly influences patient satisfaction. Pain management is among the interventions that improve recovery after surgery while reducing host stress response (Levy et al., 2019). Various studies have analyzed the importance of pain assessment, management, and the use of different medications to pain control postoperatively. When left untreated, postoperative pain drives the stress response along with the surgical injury itself, with the potential to cause a variety of complications (Nimmo et al., 2017). For example, acute pain can lead to postoperative cognitive dysfunction and can exacerbate the development of chronic pain. There is sufficient evidence supporting the use of various agents like opioids, non-steroidal anti-inflammatory agents (NSAIDs), and local anesthetics for postoperative pain. When comparing these strategies, multimodal approaches are observed to provide adequate pain relief while minimizing side effects posed by opioid analgesics.

Opioids remain the mainstay of perioperative and postoperative pain management despite the adverse effects involved (Barker et al., 2020). Recent evidence has focused on multimodal approaches to counter the effects of opioid therapies. Baker et al (2020) recommend the balance between the efficacy of analgesic techniques with the adverse effects observed. In their research, it is recommended to use multimodal pain management across the three-time points; Preoperatively, intraoperatively, and postoperatively. Apart from this study, other evidence supports multimodal pain management because f the side effects observed in opioid analgesic use. A case-controlled study was conducted to evaluate whether, after hospital discharge, post-surgical acute pain could be effectively managed with a markedly reduced number of opioid doses. Upon completion of the study, it was observed that most patients achieved pain relief with the use of unrestricted opioid prescription (Mark et al., 2018). Dose adjustments resulted in adequate pain relief and shortened the period under opioid pain killers.

The use of multimodal approaches has emerged to be the most appropriate pain management strategy postoperatively across different patient populations. The use of the three-step ladder for pain management may be ineffective in some patient populations like the elderly. It can pose challenges to nurses and other providers who need to regularly adjust doses and monitor patients closely for any adverse effects (Brooks et al., 2017). The use of multimodal approaches serves to eliminate these problems despite the observed challenge of tolerating many drugs at a time. To test this hypothesis, an observational study was conducted for elderly patients undergoing elective arthroplasty. The results demonstrated that multimodal approaches can hinder the recovery of the elderly due to the inability to tolerate multiple drugs. While the approach can be much better than opioids, it is recommended to conduct a thorough assessment on the elderly and other special populations before implementation.

Critical Appraisal

The evidence presented above demonstrates strengths and weaknesses concerning multimodal pain management. The research strongly highlights the advantages of using the multimodal approach with emphasis on its minimal side effects compared to opioid analgesics. The literature provides insight into new approaches that target different pathways to provide pain relief that cannot be achieved with the use of opioids. The above evidence provides insight into the use of multimodal approaches across different populations. For instance, the elderly population may require precaution during the treatment when using multimodal approaches due to their inability to metabolize many drugs at a time (Brooks et al., 2017). Despite the above strengths, some studies do not provide exclusively supportive evidence to multimodal pain management due to the limited number of patients used for research. For example, the study by Brooks et al (2017) used only 150 elderly patients. Additionally, these studies have not considered the cost of multimodal approaches to pain management given the choice of medication sometimes is dependent on the patient’s economic status.

The presented evidence provides an opportunity for further research for more clarity on multimodal pain management options. There is a gap in healthcare worker education concerning postoperative pain management. Despite the increasing adoption of multimodal strategies, a lack of education may hinder the effective implementation of the strategy (Mandava et al., 2021). Another observed gap is the use of multimodal approaches across special populations like the elderly. Insufficient data is available to support this strategy given the challenge of polypharmacy among the elderly.

EBP Standard

The recommended evidence-based standard for pain management based on the presented evidence is the use of multimodal analgesia. This method presents a proactive strategy that can achieve analgesia through a combination of drugs with different mechanisms of action. Since postoperative pain may be of nociceptive or neuropathic origin, effective pain control should involve multimodal therapy (Nimmo et al., 2017). Drugs that can be included during pain management include NSAIDs, acetaminophen, gabapentin, ketamine, tramadol, and glucocorticoids. Additionally, anesthetic agents like peripheral nerve blocks can be used cautiously for those with chronic pain. Apart from the special populations like the elderly, multimodal strategies balance the side effects to achieve pain control. Patients may find this approach friendly compared to opioid use because of reduced side effects of sedation, respiratory distress, and insomnia (Levy eta l., 2019). The multimodal approach also gives patients and healthcare providers a variety of safe methods to choose for postoperative pain management.

Implications

The proposed project on postoperative pain management has serious implications for nursing education, practice, and research. Nursing research is used to provide evidence that supports nursing education and practice. This project identifies gaps that can be addressed through nursing research like the use of multimodal pain management for the elderly. The safety of this approach to this population is an area that can be researched in the future and used to recommend changes in postoperative pain management. Regarding the aspect of nursing education, this project demonstrates that multimodal pain management should be included in the nursing curriculum to ensure students get insight into other pain management strategies. Most syllabus focus on the traditional three-step ladder that is termed ineffective due to the side effects of opioids. Lastly, this project informs nurses that postoperative pain management is an area that requires expertise and education. Nurse leaders should advocate for the change of pain management strategies to incorporate multimodal approaches that are observed to yield better outcomes.

 

 

References

Adesoye, A., & Duncan, N. (2017). Acute pain management in patients with opioid tolerance. US Pharmacist, 42(3), 28-32. https://www.researchgate.net/publication/316935538_Acute_pain_management_in_patients_with_opioid_tolerance

Anekar, A. A., & Cascella, M. (2020). WHO Analgesic ladder. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK554435/

Barker, J. C., Joshi, G. P., & Janis, J. E. (2020). Basics and best practices of multimodal pain management for the plastic surgeon. Plastic and Reconstructive Surgery. Global open, 8(5), e2833.

https://doi.org/10.1097/GOX.0000000000002833

Brooks, E., Freter, S. H., Bowles, S. K., & Amirault, D. (2017). Multimodal pain management in older elective arthroplasty patients. Geriatric Orthopedic Surgery & Rehabilitation, 8(3), 151-154. https://doi.org/10.1177/2151458517720297

Levy, N., Mills, P., & Rockett, M. (2019). Post-surgical pain management: Time for a paradigm shift. British Journal of Anaesthesia, 123(2), e182–e186. https://doi.org/10.1016/j.bja.2019.05.031

Mandava, N. K., Sethi, P. M., Routman, H. D., Liddy, N., Haidamous, G., & Denard, P. J. (2021). Opioid requirement after rotator cuff repair is low with a multimodal approach to pain. Journal of shoulder and elbow surgery, 30(7), e399–e408. https://doi.org/10.1016/j.jse.2020.09.032

Mark, J., Argentieri, D. M., Gutierrez, C. A., Morrell, K., Eng, K., Hutson, A. D., Mayor, P., Szender, J. B., Starbuck, K., Lynam, S., Blum, B., Akers, S., Lele, S., Paragh, G., Odunsi, K., de Leon-Casasola, O., Frederick, P. J., & Zsiros, E. (2018). Ultrarestrictive opioid prescription protocol for pain management after gynecologic and abdominal surgery. JAMA Network Open, 1(8), e185452. https://doi.org/10.1001/jamanetworkopen.2018.5452

Nimmo, S. M., Foo, I., & Paterson, H. M. (2017). Enhanced recovery after surgery: Pain management. Journal of Surgical Oncology, 116(5), 583–591.

https://doi.org/10.1002/jso.24814

Tan, M., Law, L. S., & Gan, T. J. (2015). Optimizing pain management to facilitate enhanced recovery after surgery pathways. Canadian Journal of Anaesthesia, 62(2), 203–218. https://doi.org/10.1007/s12630-014-0275-x

Trail-Mahan, T., Heisler, S., & Katica, M. (2016). Quality improvement project to improve patient satisfaction with pain management: Using human-centered design. Journal of Nursing Care Quality, 31(2), 105–114.

https://doi.org/10.1097/NCQ.0000000000000161

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