This study was designed to describe the use of analgesics ordered pro re nata (PRN) in the management of acute post-operative pain. Specifically, the study purpose was to answer the following questions. What amounts and frequencies of analgesic are ordered PRN by physicians for patients in the first 48 hours following a cholecystectomy? What amounts and frequencies of analgesic are given by nurses to patients in the first 48 hours following a cholecystectomy? What is the patient's summational description of his/her pain at 24 and 48 hours following a cholecystectomy? A descriptive survey design was used. A convenience sample of 22 subjects participated in the study. These subjects met the study criteria and were scheduled for elective cholecystectomy at one of the two hospitals used. Data were gathered by auditing the charts for information pertinent to the prescriptions and administration of the analgesics and by interviewing the subjects. There was considerable variability in the amounts and frequencies of analgesics prescribed and in those given to the post-operative subjects. No routine patterns were identified. There was a significant difference in the amounts of analgesics prescribed and given between the two hospitals, the reasons for which were not explored. The decision to use the PRN-prescribed analgesics appeared to be made by the nurses but evidence of accountability taken by nurses for their role in assessing pain and evaluating the effectiveness of the analgesics was not reflected in the reviewed records. Analgesics for use in the Post-Anaesthetic Recovery Room in the immediate post-operative period were prescribed by the anaesthetists. All initial analgesics were given by the intravenous route in this setting. Subjects at Hospital B were prescribed and received considerably more analgesics (83%) than those at Hospital A. Analgesics for use on the ward were prescribed by the surgeons. All orders were for meperidine hydrochloride to be given PRN and all orders were unchanged for the 48-hour period studied. The amount of meperidine prescribed and given per intramuscular dose was usually within the 75 to 100 milligrams optimal dosage range for the drug. The meperidine was usually prescribed with a four hour interval between doses. Doses of meperidine were given with considerably longer intervals between doses than the duration of action of the drug. For the 48-hour period, the mean total amount prescribed, based on the maximum possible dosage was 1154 milligrams. The median total amount prescribed was 1050 milligrams. The mean total amount given was 625 milligrams or 54% of the prescribed amount and the median total amount given was 587 milligrams or 56% of the prescribed amount. Subjects on the ward at Hospital A were prescribed and given significantly more meperidine than those at Hospital B. The patients' summational descriptions of their pain emphasized the individuality of the pain experience. The physical sensations described were consistent with previous literature descriptions of postoperative pain. The subjective data collected reflected the difficulties and complexities of pain management. An often-stated assumption in the literature is that nurses use PRN-prescribed analgesics inappropriately in managing post-operative pain; that is, patients are uncomfortable because the analgesics are not given in adequate amounts or frequently enough. In this study, a relationship was not identified between the amounts of meperidine received by subjects and how they reported their post-operative pain. This finding suggests that the assumption, that increasing the analgesics used would increase patient comfort, requires further investigation. Based on the findings of this study, implications for postoperative pain management and nursing practice, and suggestions for further research were made. / Applied Science, Faculty of / Nursing, School of / Graduate

published_or_final_version / Nursing Studies / Master / Master of Nursing

No description available.

The impact of comorbidity on patient outcomes following an intervention has been largely ignored. No studies have been reported in the UK or Japan. The aim of this thesis was to assess the impact of comorbidity on the outcome of a common major surgical operation - total hip replacement. Comorbidity was measured using the Index of Co-Existent Disease developed in the USA, which reliability was assessed. Two retrospective cohorts, one in Japan and one in the UK were studied. Data were collected from patients' case notes extraction and by postal questionnaire to patients one year after surgery. After THR, patient's health status was improved in both countries and satisfaction for care was high. Significant differences in in-hospital complications were observed between Japan and the UK in terms of complication rate. type and severity, and their association with independent variables. Comorbidity was significantly associated with serious complications and with change in health status in the UK and with minor complications in Japan. A logistic regression model using the ICED and independent confounding factors suggested a significant relationship between comorbidity and complications. However, the model did not fit the data well. A multiple regression model for change in health status showed that much of the variance was explained by the preoperative health status but not by comorbidity. The low number of serious complications in Japan and the high complication rate in patients in the lowest comorbidity severity level in the UK made the predictive power weak. Finally, through the experience of this study, some recommendations for clinical practice and further research are discussed.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand , in partial fulfillment of the requirements for the degree of Master of Medicine, Johannesburg, 2013 / Postoperative nausea and vomiting (PONV) is a multifactorial, complex phenomenon that has been widely studied. Little work has been done in assessing the risk of PONV in South African population groups. The aim of the study was to compare the effect of racial background on the incidence of PONV in moderate to high-risk black versus non-black South African patients undergoing general anaesthesia. Methods A prospective, controlled observational study was carried out. After an initial power calculation, 82 patients in each group (164 in total) were required for the study. However, due to researcher availability, time constraints and a readjustment of the power calculation, 95 patients at moderate to high risk for PONV were enrolled onto the study over an extended study period of 20 months (initially the study period was planned to be 6 months). 89 patients fulfilling the inclusion criteria were divided according to race into two cohorts. Ondansetron and dexamethasone were used as PONV prophylaxis after induction of general anaesthesia. Propofol was used as the induction hypnotic with isoflurane to maintain anaesthesia. Nitrous oxide, ketamine and droperidol were avoided. Use of analgesics was unrestricted, but neuraxial and nerve plexus regional anaesthesia were avoided. If a non-depolarising neuromuscular blocking agent was used, a maximum of 2.5mg of neostigmine was given to reverse neuromuscular blockade. Nausea and vomiting were assessed by means of a visual analogue scale in the recovery room and ward. Time intervals to assess degree of PONV were 0 hours (defined by first assessment of a modified Aldrete recovery score of at least 9 out of 10 and Glasgow Coma Scale of at least 14/15), 15 minutes, 90 minutes, 180 minutes, and 24 hours. Reports of incidents of vomiting and complaints of nausea between interviews were obtained from patients through questioning. Results There were 59 black participants and 30 non-black participants. There were 17 males and 72 females. There were no differences in the black and non-black groups with regard to gender, past history of motion sickness, past history of post operative nausea and vomiting, ASA status, smoking and anaesthetic time (p>0.05). There was a significant difference in the distribution of surgical procedures in the black and non-black participants (Mann Whitney U test, p= 0.02), although this did not affect the final result. On univariate analysis there were significant correlations between black South African ethnicity and nausea at all time intervals and also vomiting. Using multivariate regression analysis, non-black South African ethnicity was identified as a risk factor for PONV. It was found that black South African patients were protected against postoperative nausea, with a RR of 0.41 (95% CI, 0.28-0.60). Conclusion In this study we found that black South African ethnicity reduced the risk of PONV as compared with non-black South African ethnicity. We found that non-black South Africans had a similar risk of PONV to that published in international literature and predicted by the Apfel score, whereas the risk of PONV in similar Apfel scored black South African patients was much lower.

Postoperative pain management is a major responsibility of nurses who provide care for patients recovering from surgery. In the postsurgical environment, the nurse has a pivotal role in assessing the patient with pain, implementing both doctor and nurseinitiated pain interventions and evaluating the patient's response to pain control treatments. Apart from its humanitarian utility, effective relief of postoperative pain is a critical element of a patient's postoperative recovery. Failure to manage pain effectively in the immediate postoperative period can produce undesirable immediate and longterm physical and psychological consequences that can severely disrupt an individual's quality of life. Despite the availability of multidimensional assessment measures, sophisticated pharmacological therapies and a greater range of complementary pain therapies, postoperative pain remains treated ineffectively by those professionally responsible for its management. In particular, evidence indicates that nurses are poor managers of their patients' postoperative pain. This thesis reports research that was conducted in two stages to explore, describe and analyse how nurses managed their patients' postoperative pain and their perceptions of factors that influenced this practice. A predominantly descriptive design was utilised in Stage 1 of the study to collect data from patients' hospital records and with a demographic questionnaire administered to nurses. This was complemented with interview data from nurses in Stage 2. / Previous studies offer limited views of the clinical realities of nursing practice in postoperative pain management. From this perspective, there is a need for research that incorporates these realities to permit analysis of clinical practice and greater understanding therefore of the problem of poor postoperative pain management. The purpose of this study was to provide an illuminative and authentic account of nursing practice in postoperative pain management. For the first part of Stage 1, data were collected retrospectively from nurses' documented accounts of pain assessment and intervention over the first three postoperative days for 100 patients in a major adult acute care teaching hospital. Analysis of nurses' documented responses to patients' reports of postoperative pain revealed that less than one-third of all responses could be considered appropriate for pain management. In particular, nurses failed to provide any pharmacological relief for 53% of patients' reports or severe and excruciating pain. Exploration of the influence of nurses' professional characteristics of education and experience on pain management practice was then undertaken in part 2 of Stage 1 with the use of a demographic questionnaire distributed to 106 nurses who were identified as signatories to the documented responses identified in part 1. Results indicated that length of professional experience accounted for most variations in practice, with older, more experienced nurses managing pain more appropriately than their younger and less experienced colleagues. Irrespective of education or experience, however, nurses failed to respond appropriately to patients reporting excruciating pain. / In Stage 2, in-depth interviews were conducted with 8 nurses caring for postoperative patients at the research site. Thematic content analysis revealed four major themes from nurses' perceptions of their practice of postoperative pain management that served to elucidate and enrich the findings of Stage 1 of the research. These were finding out about the patient's pain, making decisions about pain and pain management, individual factors affecting pain management, and interpersonal and organisational factors affecting pain management. This thesis provides an authentic account of nursing practice in postoperative pain management, and contributes understanding and insight into factors that provoke ineffective management of pain after surgery. It has implications for the development of intervention strategies aimed at improving nursing practice, at both individual and organisational levels, and suggests new directions for nursing education and research toward achieving optimum care and eliminating unnecessary pain for patients recovering from surgery.

Ph.D.

Thesis (M. Nurs.)--University of Hong Kong, 2009. / Includes bibliographical references (p. 151-162).

Thesis (M. Nurs.)--University of Hong Kong, 2009. / Includes bibliographical references (p. 73-78).

One of the most exciting developments within postoperative pain research in recent years has been the introduction of Patient Controlled Analgesia (PCA). PCA is a technique in which patients self-administer small doses of opioids intravenously and it has been shown to be more effective than the conventional intramuscular injection method (IMI). However, PCA requires costly equipment and this necessarily places constraints on its availability. Therefore it is vital to ensure that the PCA facilities which are available are used as efficiently as possible. Essential to this is an understanding of the categories of patients for whom it will be most effective. At present the basis of selection of patients for PCA is often unclear. Frequently anaesthetists use the extent of trauma as a guide, although there is no evidence that this is the most effective strategy. Moreover, it ignores numerous factors which empirical research has shown to influence the experience of postoperative pain. These include state and trait anxiety, neuroticism and coping style. Until now their importance has only been investigated within the IMI analgesic regime. The present thesis remedies this omission by investigating pain/personality relationships under both PCA and IMI regimes. A particular interest was the identification of ways of detecting the patients who would benefit most from the use of PCA in terms of personality profiles. This study investigated whether knowledge of the patient characteristics of state anxiety and trait anxiety, neuroticism and coping style can be used to predict which patients will benefit the most from PCA. This research involved two main studies, in which a sample of 164 adult female and male patients undergoing major elective surgery were preoperatively assessed in terms of anxiety, neuroticism and coping style. Postoperatively they were allocated to either PCA or IMI analgesic regimes and their pain experience was assessed at 6,18 and 24 hours after surgery. The data were analyzed using Pearson's Correlations, T tests, Analysis of Variance and Multiple Regression. The findings revealed that state anxiety and coping style were significant predictors of postoperative pain for PCA as well as IMI regimes. Patients using PCA experienced significantly better pain relief than did their IMI counterparts. However, it was the patients with high levels of state anxiety using PCA who benefited the most. The superior pain control of PCA was not found to be related to the presence of the technically sophisticated PCA machine. PCA was also associated with a reduction in the length of hospital stay and a saving of nursing time on the ward. Patients had positive reactions about being in control of their pain relief, whilst staff felt that patient control was beneficial. They were also impressed by the time saving element of PCA. The implications for the management of post operative pain and the financial saving are considered.