Post operative pain assessment and delirium in the orthopaedic patient A Review of the literature

Transcription

1 Post operative pain assessment and delirium in the orthopaedic patient A Review of the literature Caroline Costello Orthopaedic and Plastic surgery Department Cork University Hospital

2 Presentation overview This presentation will identify a number of nursing problems associated with patients with a fractured hip. Pain i.e. assessment mechanisms, assessment tools CUH Inaurgal Nursing Research Conference

3 Presentation Overview Complications of inaccurate pain assessment. Delirium post-operatively Implication of education on nursing care CUH Inaurgal Nursing Research Conference

4 What is a fracture neck of femur? Types of fractures: Intracapsular fractures (lie within the joint capsule) standard treatment is insertion of screw/plate. Traction is a contraindication due to the restriction of blood flow to the head of the femur. CUH Inaurgal Nursing Research Conference

5 Types of hip fractures Intertrochanteric fractures below the neck of the femur (DHS) Sub-trochanteric fractures treated with a intramedullary nail CUH Inaurgal Nursing Research Conference

6 Incidence of a hip fracture Hip fractures are a common injury in the older person with significant associated morbidity and mortality rates. The Irish Hip fracture database (IHFD) was implemented to monitor standards of care against international standards. It covers 16 hospitals in total. Results (2014): 2,666 patients admitted with a fracture with 73% female. The age group accounted for with 720males and 1,944 females. (Dodds et al. 2009) CUH Inaurgal Nursing Research Conference

7 Hierarchy of Pain assessment techniques A framework for pain assessment has been advocated by Rasers & McCaffery (2011) to guide pain assessment tactics. Obtain self-report Search for potential causes for pain CUH Inaurgal Nursing Research Conference

8 Hierarchy of Pain assessment techniques Observe patient behaviour 6 behaviours include: - Facial expressions, - Verbalisations/ vocalisation, - Body movements, - Changes in interpersonal interactions (withdrawn), - Changes in activity patterns, - Mental status i.e. delirium CUH Inaurgal Nursing Research Conference

9 Pain assessment techniques Proxy reporting of pain status -family members involvement An analgesic test dose CUH Inaurgal Nursing Research Conference

10 Pain assessment tools Research has shown that pain is often under-assessed Assessment tools include: - Pain map, - Visual Analogue scale (VAS) - Pain intensity Index from the McGill Questionnaire - Numerical rating Scale (NRS) - Pain assessment in advanced dementia (PAINAD) (Briggs et al. 1998) CUH Inaurgal Nursing Research Conference

11 Assessment format Assess the patients pain on admission & hourly until settled, Assess regularly as part of routine nursing interventions, Offer immediate analgesia to the patient presenting at the department with a suspected # hip including cognitive impaired, Ensure analgesia is sufficient to allow movements necessary for nursing interventions, Offer paracetamol 6 hourly unless contraindicated, Opioids additionally if necessary, Non-steroidal anti-inflammatory drugs are not recommended. CUH Inaurgal Nursing Research Conference

12 Complications of inaccurate pain assessment Lack of interaction with physiotherapy leading to delayed improvement in mobility Loss of appetite Decreased interaction with health progression Delayed discharge Infection (Herr et al. 2011) CUH Inaurgal Nursing Research Conference

13 How is delirium defined? Delirium is characterised as an acute varying onset of confusion, disturbances of attention, chaotic thinking and/or changes in level of consciousness. It is linked to increased morbidity, mortality rates and increased length of stay in the hospital setting. (NICE Guidelines 2010) CUH Inaurgal Nursing Research Conference

14 Causes of delirium Issues that create an increased risk: Age, Pain Sensory deficits (Hearing/Visual), Electrolyte disturbance dehydration, Alcohol or substance abuse, Functional dependence, Post a traumatic event e.g. fall Vascular Stroke/TIA s/mi/arrythmias CUH Inaurgal Nursing Research Conference

15 Causes of delirium Infection (Respiratory tract or urinary tract), Delayed surgical time, Medication withdrawal or addition, Immobility, Constipation, Sleep (Lee et al. 2011) CUH Inaurgal Nursing Research Conference

16 Assessment of delirium PRISM-E is an assessment tool used to discover the root cause of delirium P- pain R- Retention of urine or constipation I- Infection or Immobility S- Sleep/Insomnia Or sensory M- Medication Or metabolic imbalance E- Environmental changes (Inouye et al. 2014) CUH Inaurgal Nursing Research Conference

17 Assessment of delirium Confusion mental assessment method (1990) Detection often depends on close observation by the nurse Ongoing assessment and documentation aid the detection of subtle changes Close monitoring of the patient Communication with family members (Tsang, 2014) CUH Inaurgal Nursing Research Conference

18 Importance of nurse education Orthopaedic nursing can often be seen as a difficult speciality. Nurse education in this area provides a higher standard of care for the patient resulting in a more positive outcome. Education on the management of pain, delirium and a variety of complications are essential. Training sessions can be beneficial in understanding nursing interventions required specific to the condition. Continues educating and updates can create a more enjoyable environment. (Matthews et al. 2006) CUH Inaurgal Nursing Research Conference

19 Conclusion This group of patients can provide a significant challenge to nurses and all health care professionals in delivering care. Developing our knowledge, continuing education, undertaking audits and setting standards combats the challenges faces the nurse. Our aim is to provide a safe environment and high standard of care for each individual. CUH Inaurgal Nursing Research Conference

20 Thank you for listening CUH Inaurgal Nursing Research Conference