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Context of Practice 5: Patient Deterioration and Management

Pathophysiology of Acute Pain for Tran

Acute pain is a pathophysiological condition that is of sudden onset (Chouhan et al., 2019). It is majorly a response to some sort of tissue injury. It results in the activation of certain peripheral pain receptors in the body. These pain receptors are followed by the activation of specific A delta and C sensory nerve fibers in the body. These C sensory nerve fibers are also known as nociceptors (Anilir et al., 2017).

Acute and chronic pain are both pathophysiological conditions related to activation of these fibers but in the case of chronic pain these fibers activates persistently. This can be a result of ongoing tissue injury. Acute and chronic pain differs from each other in terms of severity and time period. Acute pain is generally severe and last for short duration of time. It resolves with the healing of the cause (Ma et al., 2019). However, chronic pain is an underlying conditions that impacts the living standard of a person (Chakradhar et al., 2018). Persistent stimulation of the pain receptors and thus nerve fibers makes it difficult for a person to perform ADL’s with efficiency. Chronic pain is any pain that lasts for more than 6 months in the people due to any form of injury or physiological condition.

Tran is a 33 years old male with a medical history of Crohn’s disease and ulcerative colitis. He have recently had a temporary ileostomy surgery. Patients with Crohn’s disease and ulcerative colitis experience severe abdominal pain due to inflammation in their abdomen and rectum (Ohira et al., 2018). Moreover, small bowel’s obstructions in patients suffering from Crohn’s disease can also lead to acute abdominal pain which can also impact normal living if left untreated. Tran underwent a temporary ileostomy for his conditions. According to Ansell, Hughes and Torkington (2019), ileostomy is a type of ostomy surgery that ease the movement of bowels and reduce abdominal pain. According to Hada et al., (2018), people with some kind of abdominal inflammation are more likely to experience abdominal pain after an ileostomy surgery.

Tran had a medical history of Crohn’s disease as well as uncreative colitis that have led to an inflammation in the abdomen and it results in acute pain after the ileostomy. Patients after an ileostomy are suggested to avoid any kind of strenuous activities because it can lead to abdominal pain and sore abdomen throughout the day. Narcotic analgesia are drugs that target the inflammation sites in the tissues and works on them as muscle relaxants (Kim, Jung and Kim, 2019). A dosage of Narcotic analgesia for Tran can help him reduce the abdominal pain by reducing the inflammation in the abdomen. The drugs such as NSAIDs are important muscle relaxants and reduce inflammation in the target tissues hence they can be used to stop the pain receptors from activation (Kim, Jung and Kim, 2019).

Appropriate Nursing Assessments

It is important for a nurse to perform proper nursing assessments in order to provide best possible car to the patient. According to Massey, Chaboyer and Anderson (2017), patient assessment is the primary step of a medical procedure and it can prevent any kind of health deteriorations. Inappropriate patient assessment can lead to missing information and it can also bring medical accidents. According to standard 4 of the registered nurse standards for practice NMBA (2017), a registered nurse must always use a number of assessment techniques to collect accurate and appropriate patient information for providing relevant treatment. Priority based nursing assessments can reduce the risk of missing any important information hence it can be effectively performed in the case of Tran.

Primary responsibility of the nurse is to conduct a physical examination for the patient. This is because the patient has underwent a surgery and is basically non-verbal. Non-verbal patients cannot explain their conditions properly so a nurse must assess every aspect of physical examination properly. The nurse is expected to assess the consciousness of the patient through the GCS (Glasgow comma scale) assessment. According to Braine and Cook (2017), the GCS scale is used to assess the physical and motor functions of a person through a series of stimulation and observation. The patient is assessed for motor response, verbal response and eye-opening ability. Eye-opening to pain gives a GCS reading of 2, incomprehensible sounds or no response toward verbal questions results in GCS scale of 2 or 1 respectively and finally, motor activities such as withdrawal to pin bring GCS reading of 4.

Second assessment for the patient will be to physically examine the ileostomy. This will be done by following palpations near the stoma (Indrebo et al., 2020). It include gentle feel around the stoma for any type of obstruction or tenderness. It also include feel for a cough impulse followed by gentle digitation near the stoma to assess any stenosis. This step is prioritized second because it can lead to ileostomy failure or abdominal pain in the patient. Final step of the procedure will be to check the pain level for the patient. This will be done by using a non-verbal pain assessment scale. The non-verbal pain assessment scale checks the facial expressions, vital signs and activity movement of the patients (Herr et al., 2019). This step is prioritized third as managing pain for the patient is important but it is more important to check the consciousness level and causes that can lead to health deteriorations for the patient. Ileostomy examination can indicate abdominal pain and the pain assessment scale can inform about the extent of the pain for the patient.

Appropriate Nursing Interventions for Patient Presentation

Nursing interventions are the strategies that can help a nurse avoid deteriorations in a patient condition (Massey, Chaboyer & Anderson, 2017). It is important for the nurses to prioritize the health interventions for the patients because it minimize the risk of any form of health deterioration. Primary nursing priority for Tran will be to provide suitable pharmacological interventions for pain management while checking for any kind of complications related to the medication. Further the second priority will be to reduce dizziness and enhance verbal response in the patient. Ultimately, final priority for Tran will be education related to the maintenance of his ileostomy. Priority based nursing interventions provide a systematic guidelines to the nurses and it help them manage the patients more effectively.

The pharmacological interventions that will be followed for Tran involve a dosage of narcotic analgesia which contain 60mg morphine in 60 ml with normal saline 0.9%. The dose is administered to reduce abdominal pain in Tran. It is important to follow strategies that are best effective to relieve pain and impart comfort to the patient. Moreover, evidence based practice and further informing the patient about the use of the medication can be effective for the patient. Checking for side effects such as dizziness can also be effective for the patient. Second priority based intervention for the patient will be to reduce dizziness and enhance verbal response in the patient. This will require proper analysis of the medication provided to the patient with their probable side effects. Reducing the dose of morphine in the narcotic analgesia can be effective for the patient. Finally the conscious patient will be educated about the maintenance of the ileostomy (Freitas, Preto & Nascimento, 2017). He will be informed to keep the area clean and maintain precautionary measures such as avoid using alcohol based skin products to prevent infection at the site. The step is very important for the patient as infection at the site can enhance inflammation and it can result in ileostomy failure for the patient. According to Freitas, Preto and Nascimento (2017), nursing practice is not only limited to administration of medicine and monitoring patient condition but it also involve provision of relevant education and awareness to the patient on the basis of strategies that can be best effective for the patients.

Use of Medication Linked to Tran

Tran is administered with a number of drugs after his surgery in order to reduce inflammation and pain for the ileostomy. Moreover, Tran is suffering from ulcerative colitis and Crohn’s disease so it is more required for the nurses to manage his inflammation. Tran has been administered with a narcotic analgesia infusion of Morphine 60mg in 60 ml with Normal Saline 0.9%. This equals to the concentration of 1mg/ml of morphine. The infusion is done with a continuous infusion rate of 3ml/hr. Tran has been suffering from acute pain due to the inflammation caused by his medical conditions. Moreover, the acute pain caused because of the surgery is also very high and it require some strong opioids to manage the pain. The Narcotic analgesia in addition to morphine is administered for Tran to minimize his pain and inflammation. The opioid morphine act on the CNS and slow down the response of the pain receptor cells (Chen et al., 2019). Moreover reduction in the inflammation can also lead to reduced stimulation of the pain receptor cells. Morphine is highly beneficial in reducing pain and discomfort in patients after surgeries but it can lead to side effects such as dizziness, vomiting, nausea, lightheadness, and drowsiness (Chen et al., 2019). People taking morphine to reduce pain can suffer from constipation which is a serious concern for patients suffering from ulcerative colitis (Sałat, Furgała & Sałat, 2018). So, patients such as Trans can be administered with appropriate laxatives if such complications occurs.

Drugs such as Balsalazide and prednisolone are prescribed to relieve inflammation, and metronidazole id prescribed for any form of bacterial infection to the patient. Reduction of the inflammation in the abdomen can prevent activation of the pain receptors and hence it can increase patient comfort. There are a number of conditions that contradicts with morphine administration. People are often found to abuse morphine intake in form of CNS relaxing drugs. The contradictions also involve asthma attack, seizures, and COPD exacerbations in patients suffering from COPD, decreased adrenal gland function, low blood pressure and increased risk of constipation (Kosten, Graham & Nielsen, 2018). Patients that are administered with morphine require timely assessment of the vitals in order to check the side effects and contradictions of the drug. On vital assessment, Tran have a body temperature of 35.8 degrees, irregular pulse of 110 bpm, respiratory rate of 6, blood pressure of 98/55 and SaO2 of 93% 6Lt oxygen via Hudson mask. Normal blood pressure f a healthy individual is 120/80, body temperature of 37 degrees Celsius and pulse rate of 60-100bpm. Reduced blood pressure and increased pulse rate indicate contradictions of morphine for the patient.

Side effects of Morphine

Morphine is an opioid that has a number of benefits for the patients. However, it is significantly harmful for patients that show any kind of side effects for the drugs (Kosten, Graham & Nielsen, 2018). Major side effects of the drug involve loss of consciousness, dizziness, rashes on body, difficulty in breathing, changes in the pulse rate and heartbeat, loss of appetite, inability to keep an erection and swelling at eyes (Senese et al., 2020). The nurse must always look for swelling near the eyes, and breathing pattern of the patient in order to check the side effects of the drugs. It is very common for patients to feel nausea and slight dizziness after the drug administration but it is very harmful if left unnoticed for unmanaged for longer duration. The patient in the case study was administered with an intravenous dose of morphine in the form of narcotic analgesia in addition to another dose just after the surgery. This was administered to relieve abdominal pain for the patient but he experienced significant dizziness and non-verbal state after the medication. Moreover, the patient had a decreased blood pressure, body temperature and increased pulse rate which indicate that injection of the drug has hampered the physiology of the patient. This is a serious medical concern for a patient and withdrawal of the medicine with alternative dose is recommended for the patient.

Reference for Tran Case Study

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Ansell, J., Hughes, D., & Torkington, J. (2019). Laparoscopic Ileostomy and Colostomy for Faecal Diversion. In Lower Gastrointestinal Tract Surgery: Vol. 1, Laparoscopic procedures (pp. 107-124). Springer, Cham.

Braine, M. E., & Cook, N. (2017). The Glasgow Coma Scale and evidence‐informed practice: a critical review of where we are and where we need to be. Journal of Clinical Nursing, 26(1-2), 280-293.

Chakradhar, N. S., Kanaka, M. B., Sangeetha, S., & Damodharan, N. (2018). Herbal medicines and formulation approaches for the treatment of arthritis. Drug Invention Today, 10(9)

Chen, X., Cowan, A., Inan, S., Geller, E. B., Meissler, J. J., Rawls, S. M., ... & Eisenstein, T. K. (2019). Opioid‐sparing effects of cannabinoids on morphine analgesia: participation of CB1 and CB2 receptors. British Journal of Pharmacology, 176(17), 3378-3389.

Chouhan, D., Dey, N., Bhardwaj, N., & Mandal, B. B. (2019). Emerging and innovative approaches for wound healing and skin regeneration: current status and advances. Biomaterials, 119267.

Freitas, C. M., Preto, E. P., & Nascimento, C. A. F. (2017). Nursing interventions for the early detection of ward patients' clinical deterioration: an integrative review. Revista de Enfermagem Referência, 4(14), 121-130

Hada, M., Hayashi, K., Sawada, K., Oshima, M., Kato, Y., Oyama, K., & Hara, T. (2018). Anticipation of umbistoma in laparoscopic anterior rectal resection: Ileostomy and ostomy closure. Journal of the Anus, Rectum and Colon, 2(3), 77-82.

Herr, K., Coyne, P. J., Ely, E., Gélinas, C., & Manworren, R. C. (2019). Pain assessment in the patient unable to self-report: clinical practice recommendations in support of the ASPMN 2019 position statement. Pain Management Nursing, 20(5), 404-417.

Indrebø, K. L., Aasprang, A., Olsen, T. E., & Andersen, J. R. (2020). A new model of patient-reported outcome monitoring with a clinical feedback system in ostomy care: rationale, description and evaluation protocol. Health and Quality of Life Outcomes, 18(1), 1-8.

Kim, S., Jung, S. H., & Kim, J. H. (2019). Ileostomy versus fecal diversion device to protect anastomosis after rectal surgery: a randomized clinical trial. International Journal of Colorectal Disease, 34(5), 811-819

Kosten, T. R., Graham, D. P., & Nielsen, D. A. (2018). Neurobiology of Opioid Use Disorder and Comorbid Traumatic Brain Injury. JAMA Psychiatry, 75(6), 642-648

Ma, R. S. Y., Kayani, K., Whyte-Oshodi, D., Whyte-Oshodi, A., Nachiappan, N., Gnanarajah, S., & Mohammed, R. (2019). Voltage gated sodium channels as therapeutic targets for chronic pain. Journal of Pain Research, 12, 2709.

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23.

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Ohira, G., Miyauchi, H., Hayano, K., Kagaya, A., Imanishi, S., Tochigi, T., & Matsubara, H. (2018). Incidence and risk factor of outlet obstruction after construction of ileostomy. Journal of the Anus, Rectum and Colon, 2(1), 25-30.

Sałat, K., Furgała, A., & Sałat, R. (2018). Evaluation of cebranopadol, a dually acting nociceptin/orphanin FQ and opioid receptor agonist in mouse models of acute, tonic, and chemotherapy-induced neuropathic pain. Inflammopharmacology, 26(2), 361-374.

Senese, N. B., Kandasamy, R., Kochan, K. E., & Traynor, J. R. (2020). Regulator of G-Protein Signaling (RGS) Protein Modulation of Opioid Receptor Signaling as a Potential Target for Pain Management. Frontiers in Molecular Neuroscience, 13, 5

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