Pain assessment and delirium in the post-operative patient...Intracapsular fractures (lie within the joint capsule) – standard treatment is insertion of screw/plate. Traction is

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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

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 2016 1 24/05/2016

Presentation Overview

Complications of inaccurate pain assessment.

Delirium post-operatively

Implication of education on nursing care


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.


Types of hip fractures

Intertrochanteric fractures – below the neck of the femur (DHS)

Sub-trochanteric fractures – treated with a intramedullary nail


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 80-89 age group accounted for with 720males and 1,944 females. (Dodds et al. 2009)


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


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- Changes in interpersonal interactions (withdrawn),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


Pain assessment techniques

Proxy reporting of pain status

-family members involvement

An analgesic test dose


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)


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.


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)


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)


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


Causes of delirium

Infection (Respiratory tract or urinary tract),

Delayed surgical time,

Medication withdrawal or addition,

Immobility,

Constipation,

Sleep (Lee et al. 2011)


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)


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)


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)


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.

18 CUH Inaurgal Nursing Research Conference 2016 24/05/2016

Thank you for listening


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Pain assessment and delirium in the post-operative patient...Intracapsular fractures (lie within the joint capsule) – standard treatment is insertion of screw/plate. Traction is