This reflective essay is centred on pain assessment

This reflective essay is centred on pain assessment For the purpose of the case study I intend to use Gibbs(1998) model of reflection as this model is clear, precise allowing for description, analysis and evaluation of the experience, then prompts the practitioner to formulate an action plan to improve their practice in future(Jasper, 2003). Wilkinson (2007) identifies assessment as the first phase of the nursing process in which a nurse uses their knowledge and skills to express human caring. It is important to choose an organised and systematic approach when caring out an assessment that enhances your ability to discover all the information needed to fully understands someones heath status (Alfaro-Le Fevre,2004) .This can be achieved by obtaining your information form medical record and nursing charts by physical examination of the patient and also talking to patient and their families(Wilkinson,2007). The use of objective data is more helpful in collecting information when the patient is ventilated and sedated, as they are often in the critical care setting, and this can be done by examining the patients vital sign, blood pressure, heart rate, temperature and blood results (Bulman and Schutz 2004). I have chosen pain assessment in post- operative ventilated patient. I have worked in ICU for 4 years during this time I have nursed many post- operative ventilator patients who were on continuous infusion of sedatives and analgesics. Many of them showed signs of inadequate pain relief and associated complications. Having undertaken this module I further educated myself in this field of nursing assessment I now know, or rather have an improved knowledge base and understanding of the different aspects of pain assessment tools and recognize the possibility that I have probably nursed many more patients who were demonstrating symptoms of inadequate analgesia and associated complications. Given an increased awareness and knowledge I have gained through teaching, research and current literature on this topic I now, also recognise the importance of this assessment practice in particular in relation to the ventilated, non- communicated patients in ICU. According to International Association for the Study of Pain (IASP,1979) pain is described as unpleasant sensory and emotional experience associated with actual or potential tissue damage. Clinically pain is whatever the person says he or she is experiencing whenever he or she says it does (Mc Caffery 1979) .Appropriate pain assessment is crucial to pain management. Patients self- report is the gold standard of pain assessment. However pain tools that rely on verbal self-report may not be appropriate for using non- verbal ventilated sedated patients in ICU. Pain assessment tool used in our critical care setting is based on a numerical pain rating score from 0-4, a score of 0 being no pain at all and 4 being the worst pain ever experienced. There is also a visual analogue scale for patients who have difficulty communicating, they can indicate by looking at the chart and pointing at either the happy face that has no pain or a series of faces showing different stages of pain (appendix t hree). These tools were chosen by the specialised pain care nurses working for the trust. The tools are favoured as they provide nurses with a quick, easy assessment. They are used widely throughout the trust to provide continuity of pain assessment.Both of these tools have proved successful in practice and are supported by the literature as being reliable and accurate in practice. However they depend greatly on the patient being able to express themselves or communicate verbally with the practitioner .Using these methods of pain assessment is not accurate on sedated patients with altered conscious level. In nonverbal patients the use of behavioural or physiological indicators are strongly recommended for detection of pain (Jacobi et al 2006). The patient in critical care may experience pain from many sources. Along with physical pain, psychological factors such as fear, anxiety and sleep disturbances may play a significant role in patients overall pain experience (Macintyre and Ready 2002). Urden et al (2010) states, pain can be acute or chronic, sensations are different in relation to its origin. Acute pain-duration is short corresponds to the healing process, ranges between 30 days to 6 months. Chronic pain lasts more than 3 to 6 months and can either or not associated with an illness. Somatic pain is well localised sharp, acute pain arising from skin, muscle, joints. Visceral pain refers to the deep, ill localized arising from an organ. Nociceptive pain occurs when inflammation stimulates pain receptors ( Urden et al 2010). Pain experienced in critical care patients are mostly acute and has multiple origins. Mr. Smith a 45 year old gentleman admitted to ICU following Laparotomy for small bowel perforation and faecal peritonitis. Mr Smith was cardiovascularly unstable and was unable to be extubated immediately after surgery due to secondary sepsis. He was receiving an infusion of Propofol and Fentanyl to keep him comfortable and provide analgesia. His medical notes revealed his past medical history of previous Cholecystectomy for gall bladder stones and biliary obstruction. I was assigned to nurse him on his second day in ICU. During handover the previous staff member reported that Mr. Smith became very agitated and hypertensive soon after he was repositioned to his side. Mr. Smith was given a bolus dose of Propofol infusion and the rate of Infusion increased. Whilst doing the Patient assessment I noticed Mr Smith is restless and not compliant with the ventilator. Arterial Blood Gas (ABG) performed which showed Mr. Smith is hypo ventilating. Meanwhile Mr. Smith became more agitated with e scalating non-compliance with ventilator and significant increase in his Mean Arterial Pressure (MAP) which was being monitored continuously by the arterial line and transducer. He was showing facial grimaces and moving his extremities restlessly. I tried to reassure him by talking to him, reorientating him to time, place and person, explaining to him that he is safe. Adam and Osbourne (2005) identifies that critically ill patients frequently require help with coping with many of the stresses like physical discomfort, isolation, fear of pain and death. By using strategies like communicate caring and understanding and provide information repeatedly and in sufficient detail for the patient etc. helps the patient to cope with the stress. But repeated reassurance and reorienting has not made any improvements in his current status. Pain is an important problem in critical care and its detection is a priority. Pain assessment is vital to detect pain (Urden 2010). Pooler-Lunse and Price(1992) emphasises that critically ill patients who are unable to communicate effectively are at high risk of suffering from pain. Poorly controlled pain can stress the sympathetic nervous system leaving vulnerable patients at risk of complication and can compromise recovery and negatively affect both morbidity and mortality(Puntillo et al 2004, Dracup and Bryan- Brown 1995).Mr Smith was ventilated and due to the effect of sedatives his level of consciousness was altered. In critical care factors alter verbal communication is mechanical ventilation, administration of sedative agents and the patients change in level of consciousness (Hamill-Ruth R J, Marohn L 1999 ,Kwekkeboom K L, Herr K 2001,Shannon K, Bucknall T 2003). The consequences of untreated acute pain in critically ill patients include increases in catecholamine and stress hormone levels which are potential causes of tachycardia, hypertension, increased oxygen requirements and decreased tissue perfusion (Blakely and Page 2001, Hamill-Ruth and Marohn 1991). Mr Smith was increasingly hypertensive and tachycardia. Despite giving increased oxygenation Mr.Smith was hypo ventilating due to non- compliance to the ventilator. Marshall and Soucy(2003) identifies agitation is a common problem in critically ill patients and has been shown to be associated with inadequate pain management. Agitation can have serious consequences with patience removing access lines compromising their oxygen needs by self extubating (Cohen et al 2002). Following discussion with the nurse in charge of the shift it was apparent that Mr. Smith was showing behavioural signs of pain. There were no other obvious reasons as to why he had become compromised with his ventilation.When I approached the medical team concerning Mr.Smiths increasing agitation and non- compliance to ventilation I was instructed to give a bolus of propofol and fentanyl and to increase the rate of propofol and fentanyl until Mr Smith was deemed medically manageable. I was decided to increase Mr.Smiths ventilatory support. Following the treatment Mr Smith became much more stable, he became less tachypoenic was synchronising with the ventilator; his blood pressure was within acceptable limits and monitoring in sinus rhythm. The clinician did not assess Mr Smith for signs of inadequate pain management. Unfortunately due to hypoventilation and non-compliance to mechanical ventilation, Mr Smith had to be remained on high levels of ventilation and increased levels of sedatives for the next few hours emphasising evidence by Pooler-Lunse and Price(1992), the physiological complications associated with pain including Pulmonary complications and increased cardiac workload as well as depression and anxiety and increased days of hospital stay(Desbians et al 1996).Upon further reflection I should have noted Mr Smiths agitation associated with inadequate pain relief. Had I been knowledgeable in this field Mr.Smiths agitation and physiological signs of restlessness and facial grimaces would have prompted me to carry out a detailed pain assessment. Had there been a behavioural pain assessment scale on the unit where I work that may have prompted me carry out the assessment and linked these signs as indicators of inad equate pain relief. During my further assessment of Mr.Smith I had various thoughts and feelings which included feeling apprehensive and self-doubt regarding the decision to increase sedation and ventilator support. Whilst reviewing his past medication history I noticed that Mr Smith had been on regular analgesics which are co-codomol and paracetamol and there was no indication for their use in his notes. Fink R (2000) recognises that reviewing patients past pain experiences and how did he or she usually react to it can be of good value when assessing pain and can help to decide treatment options ,by questioning patients family or significant other can provide us the information about patients pain history. Later during the visiting hours Mrs Smith came to visit Mr Smith. I have given her a brief update of his condition including the changes made to his sedation and ventilation. Then I enquired to Mrs Smith about the indication of those analgesics he was on .She revealed that Mr.Smith developed back pai n when he discharged to home after undergone cholecystectomy six months ago and he was prescribed those analgesics by his G.P(General Practitioner). She also mentioned that he had problems getting optimal pain relief post operatively even when he had cholecystectomy, and he would not tolerate lying on his sides. This co-related his agitation and restlessness happened when the night staff turned him to his side. I notified these things to the ICU doctors and raised my concern that lack of adequate pain management could be the reason for Mr Smiths earlier agitation. They also agreed on this possibility and advised to change fentanyl infusion to remifentanyl and to adjust the rate of the infusion to keep Mr Smiths pain relief optimal. Remifentanyl is potent analgesics, so ensure the patient is pain free but prevents over sedating the patient, allows rapid arousal and recovery from sedation thus facilitates daily sedation holds and neurological assessment( Dhaba et al 2004). He was also prescribed regular paracetamol and Tramadol when required. It was then decided to reduce Mr.Smiths sedation as he was haemodynamically stable, he was then able to respond and started following commands. Mr. Smith was now able to communicate if he had pain or not by squeezing my hand to command. Invasive technology can restrict the reliance on many behavioural indicators of pain (Bucknall and Shannon 2003) on the other hand it is argued that invasive lines enables constant monitoring of blood pressure (B.P) and heart rate (H.R), two commonly utilised indicators of pain and thus help to assess pain (Bucknall and Shannon 2003) .Even though Mr Smith was hypertensive and tachycardic this was presumed to be due to agitation. In a contradicting statement Bucknall and Shannon(2003) points out that the sympathetic symptoms i.e. Increasing B.P and H.R are also been found to be unreliable. Pooler-Lunse and Price (1992) emphasises that the Para sympathetic stimulation can result in less observable signs with prolonged pain, but pain intensity remains unchanged. The American Society for Pain Management Nursing (ASPMN) recommendations cited in Herr k et al ( 2002) emphasises that vital signs can be affected by other distress conditions, homeostatic changes and medications there for they should not be considered as primary indicators of pain.With conflicting evidence it is difficult to make decisions that best support this assessment practice. Anand K J S,Craig K (1996), Herr K et al (2006) states that behavioural indicators are strongly recommended for pain assessment in non- verbal patients , few tools have been developed and tested in critically ill patients. The Behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) are suggested and supported by experts for using uncommunicative critically ill patients (Li-D, Puntillo, Sessler 2008). BPS was tested and validated exclusively in ventilated, unconscious patients (Payen et al 2001,Young G 2006, Aissaoui Y et al 2005).The Behavioural Pain Scale (BPS) includes three behaviours 1) facial expression 2)movements of upper limbs3)compliance with the ventilator. Each behaviour is rated on a scale from 1 to 4 for a possible total score from 3 to 12. The BPS can be used quickly (2 to 5 minutes), most clinicians were satisfied with its ease of use (Payen et al 2001). The Critical Care Pain Observation Tool (CPOT) was tested in verbal and non- verbal critical ly ill adults (Gelinas C 2006,2007) its content validity supported by ICU experts including nurses and physicians (Gelinas C 2009). CPOT includes four behaviours 1) facial expression 2) body movements 3) compliance with the ventilator 4) muscle tension. Each behaviour is rated from 0 to 2 for a possible score of 0 to 8.Gelinas C and Hammond reports that feasibility and clinical utility of CPOT were positively evaluated by ICU nurses and agree it is easy to complete, simplicity to understand the usefulness for nursing practice. My experience of using a behavioural pain scale tool is limited, however I feel that if practitioners were able to assess pain more accurately then they would be able to manage there patients pain more effectively. Use of a behavioural pain score (BPS) evaluating facial expressions, limb movement and compliance with the ventilator has proved to be a valid reliable tool in practice. A recent study evaluating the reliability and use of the BPS consistently identified increases in pain scores after repositioning patients in the ICU. There were only small non- specific changes in the BPS after non painful intervention of eye care (Gelinas etal 2006). I nursed Mr Smith again 5 days later. He had since been extubated and was alert and oriented. Even though he could not remember the events when he was ventilated and sedated, he learned from his wife what had happened. He was very thankful to me for investigating the possible reason for his agitated behaviour and prompting the doctors about this and thus provide him adequate pain relief. Upon further reflection and evaluation of my assessment of Mr.Smith I feel there have been positive and negative aspects of the assessment. The positive aspects include- I have been able to gain further knowledge in various aspects and tools of pain assessment .By reviewing patients medical notes and gaining history from his wife I have linked his agitated behaviour and taken the possibility that these are signs of inadequate pain relief and I have managed to convince the medical team regarding this in order to act on it. Current research identifies multidisciplinary collaboration provides optimum care for the patient (Bucknall T, Shannon K 2003), this emphasises the need to perform regular, accurate pain assessment and care full documentation (Bucknall T, Shannon K 2003). When considering the negative aspects of my assessment I feel I did not use a holistic approach instead I considered Mr.Smiths agitated behaviour as a physical problem, I was concentrated to treat the symptoms and not the patient. As described in Roper Tinney L(1989) assessment tools achieving patient centred nursing is important. I could not identify Mr.Smiths behavioural indicators of pain primarily due to my lack of knowledge about this assessment tool as well as there was no unit assessment protocol which includes the behavioural assessment scale, Unfortunately this is not isolated, it is in fact a universal problem .Camp (1998) points out that like many speciality nurse critical care nurses and physicians recognises that there basics education was insufficient for caring for patients in pain. Accurate detection of the critically ill patients pain is not an easy task for ICU nurses especially when the patient is unable to self-report because of mechanical ventilation or due to the effects of sedatives. Stanton (1991) argues that pain assessment and management may be significantly improved by enhancing nurses knowledge combined with improved communication of the problem. NMC(2008)emphasises that having appropriate knowledge, skills and attitude towards pain, pain assessment and its management is essential to provide optimum patient care. Use of pain assessment tools is highly recommended by Kaiser(1992), identifies that an effective pain assessment tool as part of the documentation improves communication between patients and nurses as well as nurses and medical staff. Even though we had a pain assessment tool (0 to 4 numeric pain assessment scale) due its limitations on the use in non-communicative patients it was not contributing much in patients pain management. The previous practitioner documented the patients pain score is Unable to assess as the patient is sedated and ventilated. This highlights the inappropriate use of our pain tool currently being used in practice as a patient is unable to verbalise or communicate their pain if they are sedated and ventilated. Although todays guidelines strongly suggest that the use of a standardised behavioural pain scale to nurses who care for uncommunicative patients, further research is still needed to fully understand the behavioural and physiological responses of critica lly ill patients who are experiencing pain (Herr K et al 2008). On reflection my underpinning knowledge and confidence in this area of assessment has developed tremendously. I feel that I have gained knowledge and insight into an important patient assessment, from an initial lack of sufficient knowledge I am now able to bring evidence based practice in the clinical area which will benefit the patient and my colleagues. By understanding the physiology, pain assessment tools and the complications of poorly managed pain, I will have the knowledge and skills to manage these patients. The use of sedatives and analgesics places a great deal of responsibility on critical care nurses and they must understand how the drugs work , complications of their use and how to monitor effectiveness staff must understand sedation does not equate analgesia (Ashley and Given 2003). The use of an appropriate pain assessment tool and management algorithm is essential for adequate pain management. Since undertaking this study, it is of interest to note that our practice development nurse and the specialist pain nurse for ICU ,have jointly developed a behavioural pain assessment scale similar to the BPS and CPOT scale, and staffs are encouraged to use it routinely. I feel that my action plan and recommendations are to promote the use of the pain assessment tool by educating the nurses and emphasising the importance of this assessment to improve patient outcome. The need for education to train staff on how to use the tool would take both time and money. The NHS is already under extreme financial pressures and money for training is not readily available. However if an improvement in pain management was successful then patients stay may be shorter, thus having a beneficial effect. I am also aware of the importance of not relying solely on the assessment tools but the use of both good nursing assessment and assessment tools to improve optimal patient management, shortening the recovery time and reducing the likely hood of complications (Ashley and Given 2003). A sedated, ventilated, non-communicative patient is vulnerable and relies completely on those providing care for them but as to their family at this anxious time. Education and training will improve patient care and ultimately patient safety which is paramount. Therefore I will take the knowledge and information I have acquired back to my clinical area as I have a duty to provide a high standard of practise and care at all times (NMC 2008)

Sports Event in School

Sport events in our school Sports are very important in everyone’s life as they give pleasure, health, discipline, happiness, self-control and sporting spirit. Sports can learn students’ physical co-ordination and social lessons about winning and losing. There is a well-known proverb â€Å"All works and no play make Jack a dull boy†. It is full of wisdom. After the day’s work in class, students need some healthy recreation to refresh their minds. Education without sports is really incomplete. So, sports are important in every school for clever and healthy students.They are several kinds of sports some are outdoor and some are indoor. In our school, the schoolboys play football, volleyball, basketball, table -tennis, chess, and so on. The school playground is no less important than the school lessons. It is on the playground that we learn to face defeat with a smiling face. So, the school playground helps the students to fight the battle of life like brave soldiers and heroes. Our school has two playgrounds to play football and two for playing basketball. There will be tournaments to play football in every Grade from Grade-4 to Grade-11.There is an each team in every section and so if there are six sections in Grade-9, there will be six teams and a tournament is held until there are two teams to pay the final match. All schoolboys look active and alert with their team track-suit. There are also tournaments to play each sport. Teachers in charge will take care of their pupils in playground during tournament. They give them fresh limes and purified drinking water. The red-cross schoolboys and teachers are ready to help the injured players. The Headmaster will give the prize to the winners and the champion team who gets the first prize will take a group photograph.In January, there are interschool sports competitions that include track and field sports such as running, jumping and throwing events. The running events are sprints, middle d istance races, long distance races, hurdle and relay races. The jumping events are high jump and pole vault. The throwing events are short put, discus and javelin. Team sports can be played by two teams. A team has been organized with some players. They must have team-spirit and they fight the rival team collectively. Thus team sports make one less selfish. They know the value of team work and playing together makes them friendlier.A player must have stamina and be patient. He must not easily down-hearted. If the players of one team become excited, they may lose their chance. The carelessness of one may make the team defeated. So, players are inspired team-spirit by playing team sports. A true sportsman never thinks of winning the sports by hook or by crook. He never wins victory by foul play and we know that â€Å"Honesty is the best policy†. So team sports are essential to health, happiness, progress and unity. We gain a lot of benefits from playing sport events and student s should take part in these sport events.

Divergent by Veronica Roth Essay - 606 Words

There are many great leaders in the world today, though many don’t know what it is that makes them great leaders. In the novel Divergent, by Veronica Roth, leadership is not just shown through the main protagonist, but also through the other characters. Four is a character in the book that possesses great leadership skills. He’s dependable and provides good advice, especially to Tris who gets in a lot of troublesome situations. The qualities that make a successful leader are keeping a level head, and being ready to protect other individuals around you no matter what it may cost you. The ability to keep a level head is necessary in order to become a successful leader. For example, in chapter 16 of Divergent, Tris consoles Edward after he†¦show more content†¦In order to be a successful leader, one must be ready to give or do anything to ensure the safety of others. For instance, in chapter 13, Tris takes Al’s place when he has to stand at the target and l et knives get thrown at him. â€Å"The last thing I want to do is stand in front of that target, but I can’t back don now.†(Roth 208). Even though Tris was reluctant about taking Al’s place, she showed good leadership skills by risking her own life to save someone else’s. Another great example of this is in chapter 25.†I dart in front of him and the belt cracks against my wrist, wrapping around it.†(Roth 412) In this quote Tris takes Tobias’s place during his fear landscape. She does it to protect him, though she could have just stood there and let him get hit. She quickly reacts and sacrifices herself, she as ready to do anything to protect him. These things are done often by world leaders; they have to be prepared to protect others. Though possessing this quality sounds dangerous it is very important for a successful leader to have. They are the people others look up to and expect to keep them from harm. Sometimes to protect others wo rld leaders have to throw their own lives on the line, even if it could mean the end of them. Many great leaders’ today possess qualities that make them successful leaders, such as keeping calm, or being ready to protect others. Being able to stay calm in a situation is a majorShow MoreRelatedDivergent by Veronica Roth785 Words   |  3 PagesDivergent, by author Veronica Roth, is noted on the New York Bestseller list. It is the first book in the trilogy series of novels for young adults that further expands the look and feel of the dystopian genre in young adult fiction. It has a feeling similar in comparison to the book Hunger Games and The Maze Runner yet it has many differences. 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Essay about Breast Cancer Speech Outline - 991 Words

Topic: Breast Cancer Specific Purpose Statement: To inform my audience about breast cancer Pattern of Organization: Topical Order I. INTRODUCTION: A. Attention Grabber: I’m sure many of you know of or have heard of Giuliana Rancic. Well if not, she is a news anchor for the tv channel E! and often co-hosts red carpet events such as the Golden Globes and the Academy Awards. Giuliana is a very busy and successful woman and on top of everything that she juggles, last October she was diagnosed with breast cancer. Soon after finding out that Giuliana had cancer, she underwent a lumpectomy, which was unsuccessful in getting rid of all the cancer cells. Following that she was faced with a very painful surgery called a double mastectomy along†¦show more content†¦[Transition: Now that you have an idea of what breast cancer is and how common it is, I will tell you some options in early detection and diagnosis.] B. Main Point 2: Early detection with breast cancer can be the difference between mild or harsh treatments and even often times life or death. 1. There are many types of breast exams that can be preformed: Clinical exams, self-exams at home and the most effective exam would be a mammogram. 2. Since breast cancer is more common in older women, it is encouraged to have a routine check-up starting at age 40, however if it runs in your family it can be promoted at as young of an age as 25. [Transition: I’ve explained why it is important to detect early signs of breast cancer, now I’m going to tell you some of the procedures and treatment that are preformed after being diagnosed.] C. Main Point 3: Depending on the stage of cancer, treatments can vary. I will be telling you a few important facts provided by NationalBreastCancer.org to know going into treatments and also the different types. 1. One of the most important factors in treatments is finding a doctor that you can feel comfortable around and satisfied with in terms of his/her opinion. This is because cancer is such an emotional process and you want to be able to feel personable with your doctor. 2. Standard treatments and Clinical trials are both usedShow MoreRelatedInformative Speech Outline-Kab Essay816 Words   |  4 PagesInformative Speech Outline General Purpose: To Inform Specific Purpose: To inform Students about The Keep-A-Breast Organization Central Idea: I’d like to inform students about The History of Keep-A-Breast Organization, Who the Keep-A-Breast Organization is, and how they get young adults interested in Prevention of Breast Cancer. Introduction I. Breast CancerRead MoreBetty Ford and Her Time in Office1786 Words   |  7 Pagesliberated women and to embrace many socially taboo issues with openness. 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