Introduction
Postoperative pain management is the main issue in the case study of Josie Elliot, a 26 years old woman who had a surgery for internal fixation of fractured right wrist- the radius and scaphoid bones.Therefore, this assignment mainly describes the importance of pain management in post-operative care and also discusses the possible effects of unrelieved pain in the case of Josie Elliot. This writing further explains the process of making clinical judgement using the Tanner’s Model (2006) and discusses its application in the management of Josie’s postoperative pain management. This assignment also includes three progress notes to document the main clinical events that occurred in three different shifts while managing Josie’s pain.
Importance of pain control in post-operative care and the potential effects of uncontrolled pain for Josie Elliot:(298 words)
Managing postoperative pain is an essential component of the postoperative care for various reasons. According to Australian and New Zealand College of Anaesthetists (2013), effective management of post-surgery pain may reduce the incidence of postoperative morbidity and facilitate earlier discharge from hospital. Some other advantages of effective post-surgery pain control include an increased patient comfort and satisfaction, earlier mobilisation, few pulmonary and cardiac complications, a reduced risk of deep vein thrombosis, faster recovery with less possibility of the developing neuropathic pain and reduced cost of care (Ramsay 2000). Furthermore, the information-subjective and objective, collected during the post-surgery pain management also supports the plan of care using the evidence based nursing practice (Vaughn 2007).

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In contrast, unrelieved acute pain can prolong hospital stay,delay return to normal activity, lower satisfaction with care and give additional financial burden (Ritchey 2006). This can have long-lasting effects on physical, emotional, social and spiritual state of the person involved and his or her family and carers. In the case of Josie, who is right handed will need assistance with self-care. She may feel the loss of her autonomy and she may be worried if she can ever do soccer and swimming again.
There are also some adverse physiological effects of uncontrolled pain. A patient could suffer from include tachycardia, hypertension, hyperventilation, decrease in alveolar ventilation, transition to chronic pain, poor wound healing, and insomnia (Shoar, Esmaeili & Safari 2012). Unrelieved pain also causes stress( ) and in response to the stress, hormones-cortisol and glucagon are released. These hormones can lead to numerous problems including insulin resistance, hyperglycemia and postoperative complications (Dunwoody et al. 2008). In the case of Josie, who is a diabetic, the consequences of insulin resistance and hyperglycemia can not be overlooked because studies indicate that patients with poorly-controlled diabetes experience increased levels of postoperative pain and need higher doses of morphine to achieve optimal pain relief (Holt 2012).
Tanner’s Clinical Judgement Model explains the way nurses make a clinical judgement. Noticing, interpreting, responding, and reflecting are the four pillars of clinical judgement. Noticing is the process of becoming conscious of the situation. Interpreting is making sense of what is noticed and selecting a course of action. Responding is the process of acting on the situation while beginning the first phase of reflecting on the action and the results of the action to allow for modifying the intervention. Reflecting includes both reflecting in action and reflecting on action, allowing the nurse to make sense of and learn from the experience (Tanner 2006).
Clinical judgement is recommended when deciding on an intervention to manage postoperative pain being mindful of factors such as side effects, risk of adverse events and patients’ needs and preferences (Chen 2013).The management of postoperative pain by nurses includes assessment of pain and decision making in regards to the need and type of pain relief. Nurses, where allowed are also involved in prescribing analgesia for pain management (Chen 2013).
Noticing
Noticing is the skill that develops over time and is amalgamation of background knowledge, contextual knowledge, and knowing the patient. This synthesis creates expectations about what the nurse is likely to encounter in the patient situation. Background knowledge includes comprehensive knowledge of appropriate physiology and pathophysiology, pharmacology, psychology, standards of practice, and past experiences. Contextual information is very useful in promoting early recognition. Finally, knowing the patient and the patient’s typical pattern of behaviour allows the nurse to notice when something is happening. For example, if the nurse is caring for an elderly patient who has been alert and oriented but is now drowsy and responds unclearly to the questions, the change in the way the patient responds can alert the nurse to potential complications. In the case of Josie, after the surgery, all her observations-Blood Glucose Level, vital signs and neurovascular limb obs are returning to normal, however her pain is increasing. Her pain rating has increased from “no pain” at 1100 hours to “some discomfort in the wrist’” at 1600 hours. She complains of “heavy aches” at 1800 hours and rates the pain 6 out of 10 on pain scale. Interestingly, she was given IV morphine 10 mg at recovery at 1030 hours.
Interpreting
Interpreting may include analytical, intuitive, or narrative reasoning. The nurse makes a conclusion based on an initial grasp of the situation and continues to refine this understanding while gathering additional data, acting to remedy the problem, and watching the results of his or her actions. The process of interpretation may require further patient assessment and may lead to interventions that may or may not relieve the problem. The patient’s response to the interventions may trigger further noticing and assessment. For example, if the patient complains of chest pain and the nurse knows that the patient had heart surgery the previous day, the nurse may interpret the pain as postsurgical pain and medicate the patient for that while continuing to monitor for signs such as relief or non-relief of pain. In the case of Josie, the pain is localised to her wrist and it is increasing. An experienced nurse can interpret the reason for increasing pain as inappropriate dosing interval of analgesia because she has not been provided with any analgesia since she had IV morphine at 1030 hours at recovery.
Responding
The third process in clinical judgement is responding. Responding is based on the nurse’s interpretation of what was noticed as well as on planned assessments. The nurse determines a course of action and implements the plan while watching patient responses. As the situation becomes clear, the nurse will modify actions or reevaluate the situation if the desired results are not obtained. In the case of Josie, a prudent nurse should administer IV morphine 5 mg immediately after confirming that she has not been given any analgesia since 1030 hours. This will rapidly decrease her pain and make her comfortable. Then half an hour later the pain level should be reassessed. She should be given paracetamol 1gram 6 hourly and tramadol 100 mg 8 hourly until she does not complain of pain and swelling disappears. This approach of combining opioid and one or more drugs such as paracetamol and tramadol to relieve pain is called multimodal pain relief. This combination may improve pain relief and reduce the side effects by reducing the need for opioids such as morphine (Mayo Clinic 2014).
Reflecting
The fourth process in clinical judgement is reflecting. Reflection occurs both during the action and afterwards. Reflection during the action is known as “reflection-in-action” and it helps nurses to evaluate the effectiveness of their nursing intervention by reading the response of the patient and improve the response in the moment. Reflection afterward is known as “reflection-on-action” and it gives the nurse an opportunity to think about how the outcomes could have been improved. This awareness prepares nurse to learn from his or her own experiences. Learning from the experience can then be integrated with the nurse’s background knowledge and be available for use in future situations. In the case of Josie, a prudent nurse will “reflect in action” by combining two or more analgesics and
References
Chen, Z 2013, ‘Post-operative Pain Management: Nursing Interventions’, systematic review, viewed 26 August 2014, .
Shoar, S., Esmaeili, S. & Safari, S. 2012, ‘Pain Management After Surgery: A Brief Review’, Anesthesiology and Pain Medicine, vol. 1, no.3, pp. 184-6
Dunwoody et al. 2008, ‘Assessment, Physiological Monitoring, and Consequences of Inadequately Treated Acute Pain’,Pain Management Nursing, vol. 9(1), pp. 11-21
Holt,P. 2012, ‘Pre and post-operative needs of patients with diabetes’,Nursing Standard, vol. 26, pp. 50-6
Mayo Clinic 2014, Pain medications after surgery, viewed 30 August 2014, http://www.mayoclinic.org/pain-medications/art-20046452>
Ramsay, A.E 2000, ‘Acute postoperative pain management’,Baylor University Medical Center Proceedings, vol.13, no.3, pp: 244–7.
Ritchey, R. M. 2006, ‘Optimizing postoperative pain management’, Cleveland Clinic Journal of Medicine, vol.73, no.1, pp. 72-6
Vaughn, F., Wichowski, H. & Bosworth, G. 2007, ‘Does Preoperative anxiety level predict postoperative pain?’, AORN Journal, vol. 85, no. 3, pp. 589-90.