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Pain Management in Cardiac Surgery
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Pain Management in Cardiac Surgery INTRODUCTION: Pain is an unpleasant sensation caused by noxious stimulation of sensory nerve endings. Moseby Dictionary (1990), p 866. A nursing diagnosis accepted by the fourth National Conference on Classification of Nursing Diagnosis. As a symptom pain is defined as a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation. Moseby Dictionary (1990), p 866. Pain assessment is an evaluation of the factors that alleviate or exacerbate a patient’s pain. The patient where possible is asked to describe the cause of pain and its intensity and location. Moseby Dictionary (1990), p 866. Response to pain varies widely among individuals and depends on many different physical and psychological factors, such as pain threshold, fear and anxiety, and ethnicity of the individual involved and the way that they experience their pain. Clinical judgment in pain management in patients, appears to be inadequate as many research papers have shown over time. Lauder (1990) p 15. Post-operative pain for adult cardiac surgical patients has many facets. Mueller et al (2000) p 391. Pain can be caused by the incision, chest tubes, multi-intravenous cannulations; just to name a few. There have been numerous literature reviews and research on pain management within the last three decades, but few studies that have focussed on Cardiac Surgical patients. Meehan (1994) p 39. ANALYSIS OF RESEARCH FINDINGS Research studies of pain management of cardiac surgical patients has focussed in five major areas, and they are: 1. Types of Pain Management and its Effectiveness 2. The Knowledge of Nurses and Doctors of Pain Management 3. Education on Pain Management for Patients Pre-surgery 4. Long Terms Effects of Cardiac Surgery and Pain 5. Complications relating to Pain Management Types of Pain Management and its Effectiveness Participants in five studies used either, PCA (Patient controlled analgesia) NCA (Nurse controlled analgesia) or Epidural in the post-operative period, post-cardiac surgery. Pettersson et al (2000), Turfrey et al (1997), Tsang and Brush (1997), Boldht et al (1998), Melzack et al (1987). Unfortunately there has been only a few clinical trials on the use of PCAs among post-operative cardiac patients that have been carried out to date. Study by Tsang and Brush, used the comparative analyst in design that compared the two groups of patients receiving pain relief. The first group used the PCA the second group used the NCA. The sample size of the study, and compared well with the clinical trials of sixty to eighty sample sizes. In this study a negative attitude and lack of knowledge amongst nursing staff in ICU was recognised. Also the study of Chuck (1997), found similar results. Although scepticism among nurses existed on the use of the PCA. Tsang and Brush (1997). Also due to lack of knowledge, nurses underrated pain or expressed unreasonable concerns regarding opiate induced respiratory depression. In contrast the study of Boldt et al (1998), which was a perspective randomised study and the study of Pettersson et al (2000), which was a comparative study, both found that better pain management was obtained by using the PCA without the increased side effects compared with the traditional NCA treatment. The study of Turfrey et al (1997), performed a retrospective analysis of patients undergoing cardiac surgery which received a thoracic epidural for their pain management which resulted in good pain management without any complications. This was only one study, and further studies in this type of pain management are warranted to back up the findings of Turfrey et al. The study of Melzack (1987), reviewed patients that underwent many different types of surgery, with only nine having cardiac surgery. The study used questionnaires and observational methods as well as the pain-rating index. The results from the data collected indicated that post surgical pain is poorly controlled; Melzack (1987) p72, and can impede the patient’s recovery. Overall the method of managing post-operative pain favoured the PCA over the NCA. The Knowledge of Nurses and Doctors of Pain Management Increased knowledge about availability of resources for pain management could be expected to reduce incidents of uncontrolled pain.
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