Management of Trauma Patient
Acute pain refers to a type of pain that is the result of diseases or injuries and often resolves with healing (Barash, 2009). However, acute pain due to injury often results in unpleasant patient experiences and is the leading cause of patient admission to the ED (Emergency Department). Effective pain management in the ED is therefore desirable as it could involve such unpleasant patient outcomes as increased hospital stay and postoperative complications (D'Arcy, 2011). The premise of the current essay is to undertake a critical assessment of the clinical management of severe, acute pain presented by Paul, a patient brought to the ED following a car accident and the associated emergency would care/infection prevention in trauma following the accident.
Management of Acute Pain in the ED
Acute pain is quite prevalent in the ED, with 7 out of every 10 patients admitted to the ED citing pain as their primary reason for attendance. Considering pain constitutes a main incentive for patient attendance at the ED, acute care providers should give priority to pain treatment. A report by the Royal College of Anaesthetists (2015) indicated that 60% of people who undergo surgery experience severe pain following surgery. This calls for postoperative pain management to not only help reduce pain, but also prevent acute pain from progressing to chronic pain, as well as to aid in recovery and rehabilitation. While there are no published NICE guidelines on acute postoperative pain management, The Royal College of Anaesthetists under its Faculty of Pain Medicine recommends that, in the absence of national guidance, there is a need to take into account the pain management protocols that have been developed, approved and implemented in managing pain at the local health care settings, and the associated prescribing guidelines.
The nature and cause of pain could have implications on the treatment choice arrived at, along with the response to treatment (Macintyre, Rowbotham, and Walker, 2008). Acute pain could be neuropathic, nociceptive (visceral or somatic), or a mixture of the two. Taking into account the type of pain and how it impacts an injury aid in its effective management. This underscores just how important and challenging the process of assessing pain is. Accordingly, there should be a reproducible and accurate ode of assessing pain to facilitate its effective management. The key components applicable in assessing pain are a history of the pain; evaluating pain severity and treatment response; and psychological factors that might affect pain experience.
A pain history entails the intensity, underlying cause, and symptoms of pain. Pain tends to be a subjective experience and as such, its severity depends on various factors such as cultural background, anxiety, and coping mechanism, among others. This shows that a patient's perception of pain varies. Paul's initial assessment of pain in the ED was in keeping with the NICE guidelines on recording patient information in pre-hospital settings. NICE recommends that the healthcare personnel working with the trauma network should document the patient's information regarding breathing, disability, circulation, catastrophic haemorrhage, exposure, and environment (NICE, 2016).
Pain assessment is vital for the delivery of effective pain management as it improves the healthcare team's capacity to realise increased patient comfort; minimised experience of pain; enhanced psychological, physical, and physiological function; and improved satisfaction with pain management (Hall-Lord & Larsson 2006). Wood (2008) opines that while measuring pain, this ought to be accomplished using an assessment tool that enables the nurse to identify the quality and/or quantity of intensity of pain, along with the intensity linked to behaviour and anxiety. The British Pain Society and British Geriatrics Society joint report recognises patient self-reporting as the gold standard as far as pain assessment is concerned. This is because it gives the healthcare team the most valid assessment of pain. However, various factors such as sleep disturbances, medications, and mood would affect self-reporting, thus leading to inaccurate reporting of pain (Watt-Watson et al. 2004). However, nurses and other health care professionals seem not to trust patients' self-reporting of pain, and this could be a sign that health professional have their own benchmarks regarding what constitutes acceptable pain and how patients are expected to express pain (Watt-Watson et al. 2001).
If at all nurses are to offer optimal patient care, they need to possess suitable skills, attitudes, and knowledge towards pain, its assessment, as well as management. The Nursing and Midwifery Council (NMC) (2008) indicates that understanding pain, and assessing and managing it, should ideally hinge on the best available evidence as a means of protecting patients from possible harm. Dimond (2002) opines that there is no justification for patients experiencing unmanaged pain, and neither should poor understanding and inadequate knowledge of pain by nurses hinder their care delivery.
There are various pain assessment tools that could be either multidimensional or uni-dimensional. Uni-dimensional tools measure a single dimension of a patient's experience of pain (for instance, intensity). They are easy to use, accurate, simple, and understood fairly quickly. For this reason, they are mainly used in the assessment of acute pain. uni-dimensional tools are also characterised by a verbal descriptors and verbal rating scales. On the other hand, multi-dimensional tools for assessing pain give the quantitative and qualitative element of pain and demands that the patient possesses sustained concentration and good verbal skills.
To assess the patient's pain intensity of Paul's injuries, the nurse relied on a visual analogue scale in which the patient was shown a 5 cm line that is based on a numerical rating between 0 and 5. This is a form of uni-dimensional tool for measuring acute pain. In this case, 0 symbolises no pain whereas 5 symbolises the worst pain imaginable. The patient was then requested to place a mark on this scale at the point which he felt best described their pain. Thereafter, the nurse measures the distance between the 'no pain' mark and the point on the line that the patient had marked to estimate the pain. The patient had a score of 5 meaning that they were experiencing the worst imaginable pain. This scale is desirable in the assessment of acute pain as it is very simple to use and has shown sensitivity to small variations in pain as reported by the patient.
The WHO Analgesics ladder was used to develop an analgesic plan for Paul. The WHO Analgesics ladder is a multi-modal analgesic approach that assumes a stepwise approach to the treatment of pain, based on severity (Ballantyne, Kalso, and Stannard, 2016). In this case, it ranges from mild to moderate too severe. Since the patient had severe pain, he was started on step 3 which involved administering opioids.
Various analgesic agents are available to treat acute pain but these need to be matched with the patient's pain, individual circumstances, as well as analgesic requirements. Besides considering the history of pain, cause, and severity, others factors to consider in treating acute pain effectively include the nature of the analgesic agent chosen, and the most ideal method of delivery. Various factors impact the choice of method of delivery of an analgesic agent, including the patient's physical condition, preference, nature of pain, and aetiology. Oral administration of analgesic agents is by far the most commonly recommended technique in that is cost-effective, can be self-administered, is simple, and is well-tolerated.
On the other hand, it is characterised by a slow onset time. While the rectal route acts as an option for the oral route, it is characterised by unreliable absorption, in addition to the need for patient consent. The intramuscular route has found application in hospital wards as a substitute for intravenous administration on safety grounds, but such claims are not supported by the available literature. The intramuscular route is painful and is associated with infection risk, while drug absorption by this technique might be unpredictable. For this reason, the intravenous route has emerged as the most preferred parenteral route in the administration of analgesic agents in managing acute pain. The intravenous route gives the fastest onset meaning that doses can be administered in a titratable manner. However, this mode of administering analgesic agents calls for a higher level of staff training because it is associated with the highest risks of subsequent infection and adverse drug effects.
Emergency wound care
Traumatic wounds are a leading cause of patient visits to the ED accounting for nearly 5% of all visits and are also responsible for approximately 24% of lawsuits faced by the medical field (Prevaldi et al. 2016). Accordingly, provision for safe and effective wound management remains a key priority for the ED. Infections are a leading cause of death among trauma patients, coming only second after a head injury, and account for nearly 80% of all late deaths reported among adult trauma patients (Sobrino and Shafi, 2013). Infections in traumatised patients carry a five-fold risk for mortality in comparison with traumatised patients without infection (Mathur, 2008). In dealing with wound infection, it is important to consider the ANTT (Aseptic non-touch technique) procedure. This entails undertaking vital infection control precautions and techniques while undertaking invasive clinical procedures (Weston, Burgess, and Roberts, 2016) in order to prevent the transfer of infections from procedure equipment, healthcare professionals, or the patient's surroundings, to the patient (Rawley & Clare, 2011). The procures demands that healthcare professional always ensure they decontaminate hands; Never contaminate key site or key parts of sterile equipment/material; encourage healthcare staff to Touch non-key parts of equipment /materials confidently; and Take suitable infection precautions, such as during waste disposal or PPE
The NHS has developed SICP (Standard Infection Control Precautions) as a means of preventing the cross-transmission of infections from both unrecognised and recognised sources. Potential sources of infection include blood, secretions from body fluids, excretions, and contaminated items or equipment in the care environment (NHS Professionals, 2010). NICE guidelines demand that health workers have access to appropriate supplies of materials needed in hand decontamination, personal protective equipment such as gloves, and sharp containers. In keeping with the current safety and health guidelines, the selection of protective equipment hinges on an evaluation of the patient's risk of micro-organism transmission, as well as the risk of contact between patient blood, excretions, body fluids, and secretions, and the healthcare worker's clothing. Good hand hygiene remains a vital practice in minimising the transmission of infectious agents. Hands should be decontaminated prior to patient contact, prior to undertaking an aseptic/cleaning task, following exposure to body fluids, following patient contact, and following contact with the patient’s surroundings.
Healthcare workers must immediately segregate healthcare waste into appropriate disposable containers or bags, in keeping with the current local policies and national legislation. Additionally, used sharps ought to be discarded promptly by the healthcare worker who generates these into sharps containers in keeping with current standards of sharps disposal (NICE, 2017). To clean traumatic wounds the goal was to cleanse soil, bacteria, surgical debridement, as well as other debris. Use was made of the aseptic non-touch technique. In this case, ascepsis was used as this is an achievable and accurate quality standard that ensures no pathogenic micro-organisms. Normal saline was also used for wound cleansing, using the irrigation technique. as it has been shown to optimise tissue healing while also minimising trauma (Atiyeh et al., 2009).
Acute pain is a leading cause of visits to the ED. The nature and cause of acute pain impact on mode of treatment chosen. This essay is based on a case study of Paul, who was brought to the ED with injuries sustained in a car accident. Initial assessment of pain was essential to document pain history and to aid in the establishment of an effective pain management procedure. In this case, use was made of a visual analogue scale, while the analgesics pain management was done based on the WHO Analgesics ladder. Traumatic wound management is also essential in dealing with patients with acute pain post-surgery, to avoid infections from healthcare workers, equipment, and the environment. To avoid infection, the nurse relied on the ANTT procedure, including the use of protective gloves, cleaning of the wound using normal saline and the irrigation technique, and ensuring waste segregation.
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