Postoperative Pain Control

Pain control is the second nursing priority for Candace that needs attention. Women who undergo caesarean section experience high levels of pain during the first 24 hours post-operation (Acton, 2011). One study suggests that those women need more adequate pain relief than other surgical patients because women start to breastfeed and look after their infants while they are still recovering from major abdominal surgery (Shahraki, Jabalameli, & Ghaedi, 2012). Inadequate postoperative pain control during the postpartum period can affect a mother’s ability to breastfeed, interrupt normal development in neonates, eventually jeopardising the well-being of both mothers and newborns (Shahraki, Jabalameli, & Ghaedi, 2012). Moreover, immobility due to
inadequate pain control could lead to decreased respiratory function, dietary intake and ambulation which can lead to complications such as thromboembolism, atelectasis and pneumonia (Shahraki, Jabalameli, & Ghaedi, 2012). Therefore, the goals of the second priority are to achieve patient satisfaction with regard to pain management which will reduce the risk of post-operative complications, facilitate breastfeeding and infant care. As a result, this should facilitate a shorter hospital stay (Leifer, 2011).
Pain management includes assessment of pain level during the physical examination (Leifer, 2011). Numeric pain assessment helps to quantify the subjective experience of pain, which facilitates nurses to choose the most appropriate pain relive and acts as a guide to evaluating the amount of analgesics the patient receives (Leifer, 2011). Candace might receive epidural narcotics for long-lasting pain. These drugs can cause respiratory depression many hours after they are administered, sometimes up to 24 hours (Leifer, 2011). Naloxone and resuscitative equipment should be available whenever IV morphine is administered. Respiratory rate, pulse and level of sedation should be closely monitored until the effect of the medication has worn off (Chapman & Durham, 2014). Many women have concerns that pain medication might have negative effects on their babies when they breastfeed their babies. Therefore, she is to be ensured that adequate pain control helps her to relax so she can breastfeed better and have the energy to become familiar with her baby. She should also be advised that timing the administration of analgesia immediately after breastfeeding minimises passage via breast milk to the infant (Leifer, 2011). Through the adequate control of the pain, early ambulation and mobilisation would be promoted which would contribute to minimising post-operative complications. Breast feeding outcomes will improve. Patient’s satisfaction will be maximised through proper pain management and they will gain good experience with the procedure, as well as minimise the risk of postpartum depression (Leifer, 2011).

The last issue identified is depression or anxiety, related to any psychological distress that might be caused. Candace has a past history of post-natal depression for the previous child. Patients who undergo surgery experience acute psychological anxiety in the preoperative and postoperative period. The experience of anxiety is often persistent in the postoperative period despite all the surgery related information and knowledge they have been given prior to surgery. High anxiety may adversely influence patient recovery as well as decrease patient satisfaction. Anxiety about a surgical procedure might be reflected in many psychological symptoms in the preoperative and postoperative period. These psychological factors can increase postoperative pain, increased risk of infection, longer healing times, and decreased immune system response. Moreover, anxiety has been shown to increase postoperative analgesic needs, which can have an effect on postoperative recovery. Examples of this include slowing respirations, which therefore increases pulmonary risks, decreased mobility which can increase the risk of thrombosis and increasing risk of bowel upset.
When patients arrive in PACU, they wake up afraid in the operating suite, in an unfamiliar place. Emotional support should be provided to the patient, as well as creating a respectful atmosphere. For instance, eliminating noxious environmental stimuli and decreasing sensory stimulation would help them to relax. Privacy is to be assured whenever possible for the sake of the patient’s dignity. According to “Peplau’s model”, establishing a therapeutic relationship between nurses and patients is a central element of reducing anxiety, and this cannot be achieved without good and effective communication skills (Maghsoodi, Zarea, Haghighizadeh, & Dashtbozorgi, 2014). Assurance and explanation is to be given in calm voice that surgery is over, they are situated in the PACU or wake-up room, they are doing well, and the nurses are going to take care of them while they are awakening (Odom-Forren, 2013). Any concerns regarding caesarean birth, and baby care should be addressed with an attitude of active listening to all client and family concerns (Tharpe, Farley, & Jordan, 2016). If depression is suspected, the physician or midwife should be notified for appropriate intervention. Providing adequate emotional support will facilitate patients to gain confidence in performing postoperative actives. This will promote a speedy recovery process and minimise the risk of complications, which are also the goals of the provision of emotional support.

Person-centred care is a philosophical foundation for nurses across all nursing specialities including peri-operative area (Nursing and Midwifery Board of Australia, 2008).
The concept of person-centred care is highly aligned with notions of holism, which guide us to have an interaction with our environment, ourselves and our patients. Holism sees the whole of a person rather than only someone’s body parts and physiology (Patz, 2014). This means all aspects that can affect the patient’s health and well-being should be considered, and individual needs are to be identified in the care planning process for which nurses can provide adequate care and support for each unique person (Patz, 2014). This essay will demonstrate individualised nursing care provided to Candace. Three main issues regarding her situation will be identified through the holistic approach. Interventions and rationales based on the identified issues will be explored by utilising the Clinical Reasoning Cycle (Levett-Jones,
2013).

The main issue for Candace is a risk of complications related to the surgical procedure she underwent, a Caesarean section, as well as spinal anaesthesia, and pain medications. Primary sources of complications relating to caesarean section are haemorrhage, pulmonary embolism, deep vein thrombosis, and infections of the bladder or incision. These are the most often identified complications which occur within the first few hours post-op C-section (Durham & Chapman, 2013). Complications related to spinal anaesthesia and analgesics that might affect Candace include hypotension, respiratory depression, urinary retention, constipation, hypovolemia, nausea and vomiting. Currently, Candace’s blood pressure is slightly low. Low BP can result from the effects of anaesthetic or it can be a sign of internal haemorrhage. Regarding this nursing issue, goals of care are to prevent any post-op complications by early detection and providing prompt intervention.
Once Candace has moved to PACU, complete systematic assessment should be conducted, at least every 15 minutes, depending on Candace’s condition and the hospital policy. This assessment is to be continued until she is discharged from the PACU (Potter, Perry, Stockert, & Hall, 2016). At this time, Candace’s BP is slightly low. Her BP should be closely monitored. If critical hypotension occurs, the anaesthetist should be notified immediately and intravenous fluids and vasoactive mediations are to be administered (LeMone et al., 2014). While monitoring vital signs, the dressing site is to be inspected for any signs of infection and wound care to be performed. Elevated temperature, increased pain, swelling, or purulent discharge at incisions indicate signs of infection (Potter, Perry, Stockert, & Hall, 2016). Signs and symptoms of pulmonary embolism should also be observed, such as dyspnoea, tachypnoea, shortness of breath, hypotension, chest tightness, and decreasing SpO2 levels (Durham & Chapman, 2013) . In general, approximately 3 litres of fluids is to be replaced by intravenous infusion in the first postoperative day, making sure that Candace’s urine output remains more than 30mls/hour. IV fluids are to be continued, until she starts taking oral fluids (Saxena, 2011). Patient education plays an important part. Candace should be encouraged to practice deep breathing and coughing exercises to prevent lung complications, and encouraged to perform leg exercises and early ambulation to prevent DVT. (Potter, Perry, Stockert, & Hall, 2016) Through these nursing actions, it is expected that no infection would occur with evidence of stable vital signs and absence of purulent drainage from wounds or incisions, absence of complications, minimal pain, adequate urine output, and fluid and electrolyte balance to be achieved (Potter, Perry, Stockert, & Hall, 2016).

Post-operative care aims to minimise complications by early detection and prompt treatment of the condition, such as post-operative pain, decreased respiratory function, or other adverse physiologic effects.
PACU nurses have a key role in detecting those changes. Failure to recognise and act on changes in patient’s condition can lead to critical complications (Durham & Chapman, 2013). Established care plans should be continually reviewed and modified during the postoperative period. Expected outcomes for each goal of care will provide measurable evidence to gauge the patient’s progress toward meeting stated goals. Appropriate pain management and provision of emotional support are significantly important because they have great influence on the patient’s progress after the surgery. Unmanaged pain can increase the patient’s anxiety, causing depression, which can increase the amount of required analgesics, decrease the immune system response which eventually can increased the risk of complications (Shahraki, Jabalameli, & Ghaedi, 2012). Establishing a good nurse-client relationship, active listening and using effective communication strategies contribute to reduced patient post-operative anxiety. Perioperative nurses should have expert knowledge not only about surgical procedures but also have the ability to see the whole person and consider all aspects which can affect the person, in order to provide high quality of care and support (Bailey,
2010).