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Pain, pain, go away – don’t come again another day

Hi there!

I cannot believe that I have already completed my first rotation in the Bass Ward and have transitioned smoothly into 4GN. All the staff in 4GN have been very friendly and supportive to us new graduate nurses.

To all the staff I worked with in the Bass Ward, thank you for your guidance, education and many laughs. You were such a great team to have worked with and hopefully I will see you all again very soon!

In the Bass Ward I definitely learned that an important aspect to nursing patients is the assessment and management of pain. I was very lucky to have watched and learned from the Acute Pain Team, who regularly helped with patients’ pain management.

They do such a fantastic job and I thought it would be great to give you all an insight into the work of the Acute Pain Clinical Nurse Consultants – Nicola and Maryanne. I asked them many questions, and I hope you find their answers just as interesting as I have! 🙂

Who is in the Acute Pain Team? 
The Acute Pain Service is a nurse led, registrar supported service. Occasionally a consultant anaesthetist joins in during pain rounds. Dr Ashley Webb, a Faculty of Pain member, is the portfolio holder.

On average, how many patients do you see per week?
The number of patients seen vary, but on average approximately 30 per week. Some patients are on the Acute Pain Service for 24 hours, some for several days and some for over a week – it depends entirely on the nature of their surgery/injury, and their recovery. Generally acute pain patients will transition quite quickly as the cause of the pain is known (surgery) and has a limited duration due to healing – aiming for oral analgesia is optimal for the patient.

What types of pain relief are given to patients?
The modality most commonly prescribed would be parenteral, in the form of Patient Controlled Analgesia (PCA) – morphine or fentanyl. 

Depending on the nature of the surgery and the co-morbidities of the patient, a PCA is often accompanied by a ketamine infusion and/or a tramadol infusion.  We will always aim to provide a multi-modal regimen of analgesia.

Paracetamol, +/- NSAID, +/- tramadol, +/- opioid, +/- ketamine. 

Regional techniques, such as epidurals, are also utilised for certain surgeries such as:

  • for major abdominal surgeries where patient’s co-morbidities may compromise them if opioids are used
  • continuous local anaesthetic infusion into a nerve (i.e. sciatic nerve for a below knee amputation)
  • as a wound soaker
  • occasionally they run continuous intrathecal infusions.

They are often asked for advice on managing pain for ward patients and upon reviewing the patients medications, it’s often as simple as rationalising the oral analgesia to incorporate a multi-modal regimen.

What is the most complex case you have come across?
There are too many cases to choose from. The most complex patients seen are often those who are opioid dependent (patients with drug addiction/s). This population often have very high analgesia requirements to adequately manage pain.  In some cases the management can be further complicated by challenging personalities and behaviour traits. They can be tricky to treat, especially if they have had major or complex surgery and don’t have access to their regular medications.  This population of patients is increasing, and it is one of the most challenging cases nurses and doctors have to manage.

What other roles does the Acute Pain Nurse provide?
Other than pain rounds twice a day, the Acute Pain nurses undertake many other roles including:

  • Education. This is an important aspect. We provide pain management education to undergraduate, graduate and post graduate nursing staff and junior medical staff and medical students.
  • Recently a huge amount of time has been devoted to the implementation of “Sapphires” the new pain management pumps, also requiring the redevelopment of policy and procedures for all acute pain CPGs.
  • Assessment of nursing staff for epidural competency in acute areas.
  • Auditing pain service – maintaining a daily database.
  • Involvement in research or quality activities being undertaken within the Anaesthetic department.
  • Involvement in other projects at Peninsula Health.
  • Attending monthly Anaesthetic department Morbidity and Mortality meetings, and at times, give pain related presentations.

Nicola is also the current President of the Victorian pain management interest group called ‘GATE’, so she has further commitments representing Peninsula Health outside of ward based pain management work.

In a typical daily round what does a patient’s general assessment involve? 
A typical assessment involves talking with the patient. We ask them to rate their pain out of 10 when undertaking ‘movement’. For example, a laparotomy patient will be asked to cough or an orthopaedic patient will be asked to move their operative limb. We ask them how that pain feels; is it aching, burning or is there pressure or spasms.

We also ask them about any relevant pain and analgesia history. We ask how they are feeling at the moment: have they slept, are there any issues with nausea and/or vomiting, have they had any side effects to medications etc.  Emphasis is always put on functionality rather than focusing on a pain score. The aim is to transition patients off IV analgesia to oral analgesia when possible as this improves their mobility and general frame of mind, which can often take quite a bit of explaining as some patients feel “IV is better”.

How did you become an Acute Pain Nurse? What qualifications do you have?
You have to complete a Masters level of education. Most pain nurses have backgrounds in theatre/anaesthetics or critical care. Maryanne’s background is theatre nursing and Nicola’s background is in adult ICU. They both have a Master of Nursing with the pharmacology unit.

What is the best part of your job?
One of the most rewarding things is when we know we have made a difference in someone’s day. Helping a patient to improve their analgesia will improve their whole day. It doesn’t always happen, and given that it is an expectation by most people that their pain will be controlled, it is a rare event when patients genuinely express their gratitude.  Also seeing a resolution in adverse effects such as nausea and vomiting is always good too. Patients look and feel so much better.

What advice can you give to us graduate nurses?
The best pieces of advice we can give: 

  • Keep it simple. Always think “multi-modal” analgesia, and preferably with one route. Before asking Acute Pain nurses about a patient’s pain ask yourself if the patient has had everything that is available to them or, if they don’t have multi-modal analgesia charted, ask the home team to review this.
  • When a patient says they are in pain remember to clarify where the pain is. It is generally safe to assume someone who has had a total hip replacement will have pain in their hip but they may also have long standing pain, i.e. back pain, and that pain could be more significant than their surgical pain.
  • Do not hesitate to ask Acute Pain nurses questions when you see them on pain rounds – they are happy to answer them!

I must thank both Nicola and Maryanne for taking the time to answer my many questions! It is an area of great interest to me and I have felt very privileged to be able to share to you all the fantastic work they do.

Until next time, happy pain controlling,

Bernadette.

 

3 Comments

  1. Doris Pulis Jul 02 2015

    Keep up the good work

  2. Doris Pulis Jul 02 2015

    So proud of you

  3. The future of nursing never looked brighter. What an encouragement to us older retiring nurses. Keep focused. Keep listening. keep learning. But most of all,keep caring. Good on you Bernadette.

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