NURS5082 Assessment 1

Introduction
Postoperative pain and nausea and vomiting are both common post-operative complications
(Apfel, Laara, Koivuranta, Greim, & Roewer, 1999; Gan, 2002; Singh, Saikia, & Lahakar, 2016;
Watcha & White, 1992). Untreated pain can lead to a myriad of complications such as
pulmonary consolidation, poor wound healing (Harsoor, 2011) and the development of
chronic pain (Katz & Seltzer, 2009). Poorly managed postoperative nausea and vomiting
(PONV) can lead to postoperative pain, wound dehiscence/haemorrhage and dehydration
(Odom-Forren, 2017; Smith, Aitkenhead, Moppett, & Thompson, 2013; Watcha & White,
1992).

For these reasons, it is important that nurses are able to effectively assess and manage both
pain and PONV. This report will outline the pathophysiology, methods of identification and
assessment, pharmacological management, and nursing management, of both pain and
PONV. It will also make some relevant references to the management of our patient, Francine.

Pain
Pathophysiology of pain
Pain can be defined as an unpleasant sensory experience, marked by real or potential tissue
damage (IASP, 1994). Nociception refers to the physiological process of relaying information
from nociceptors to the central nervous system (CNS) (Brown, Edwards, Seaton, Buckley, &
Lewis, 2015; Reardon, Anger, & Szumita, 2015). Nociceptors are primary afferents that are
responsible for detecting exposure to noxious stimuli and are distributed throughout the
body in the skin, muscle, joints, viscera and meninges (Reardon et al., 2015; Schug, Palmer,
Scott, Halliwell, & Trinca, 2015)

Transduction involves the generation of an action potential (nerve impulse) by a nociceptor

after its free endings have been exposed to various stimuli (Reardon et al., 2015). Broadly,
nociceptors respond to mechanical, thermal and chemical stimuli (Schug et al., 2015).
Following transduction is transmission; the generated impulse is relayed to the spinal cord
and then towards the brain (Brown et al., 2015; Reardon et al., 2015). Initial and sharp pain
associated with tissue damage is conducted rapidly via A-delta fibres (lightly myelinated),
whereas pain with an aching and throbbing quality is conducted more slowly via C-fibres
(unmyelinated) (Brown et al., 2015).

Perception follows transmission, and is the point where a person becomes consciously aware
of pain (Brown et al., 2015). Perception occurs through processing and integration of the
impulse in various areas of the brain (Brown et al., 2015; Buvanendran & Kroin, 2009)

Finally, modulation refers to the activation of descending pathways which can inhibit or
facilitate nociceptive stimuli; possibly preventing the impulse from being perceived as pain
(Brown et al., 2015; Reardon et al., 2015). Modulation can occur at all levels of the nervous
system and involves a myriad of substances such as GABA, endogenous opioids, serotonin
and noradrenaline (Brown et al., 2015).

Identifying and assessing pain

It is important to identify and address postsurgical pain (PSP), because if untreated, it is likely
to prevent the patient from moving, coughing or breathing deeply (McMain, 2008, 2010;
Schug et al., 2015). This can result in reduced alveolar ventilation, leading to atelectasis and
pulmonary consolidation (Harsoor, 2011). Moreover, untreated pain leads to adverse
physiological responses, including tachycardia, hypertension, impaired wound healing and
insomnia (Harsoor, 2011). Finally, poorly treated PSP is a risk factor for the development of
chronic pain (Katz & Seltzer, 2009).

An important starting point for pain assessment is taking a thorough pain history; noting that
a patient’s self-report is the single most reliable indicator of their pain (Schug et al., 2015). A
pain history should determine the site, quality, severity and the presence of any aggravating
or relieving factors (Brown et al., 2015; Schug et al., 2015).

There is no objective measurement for the severity of pain, but there are a range of
assessment tools that can be used to gauge a patient’s pain level (McMain, 2008). For adults,
a review by Pasero & McCaffey (2011) recommends a modified tool comprising a combination
of a Numerical Rating Scale (a rating from zero to ten, with zero being no pain and ten being
the worst pain imaginable (Williamson & Hoggart, 2005)) and a Wong-Baker FACES Pain
Rating Scale (a series of 6 faces with varied expressions with zero being smiling/no pain, and
6 being crying/worst pain imaginable (Brown, 2008)).

Obtaining a reliable self-assessment may not always be possible, for example, if the patient is
semi-conscious, unconscious, cognitively impaired, elderly, a child, or affected by a language
barrier (ANZCA, 2007; Schug et al., 2015). In these cases, pain can be gauged by observing
behavioural responses – facial expressions, grimacing, clenched fist, moaning and rubbing the
affected area; functional impairment – shallow breathing, ineffective coughing and
immobilisation; and physiological responses – hypertension, tachycardia, sweating, nausea,
vomiting, dilated pupils and pallor (ANZCA, 2007; Brown, 2008; McMain, 2010; Schug et al.,
2015).

Pain assessment and intervention should be cyclical; information from each pain assessment
should influence future pain intervention, and every pain intervention should be evaluated
via another pain assessment (Pasero and McCaffery, 2011). This practice will maximise the
chance that a patient receives adequate analgesia (NHMRC, 1999). Since our patient
(Francine) has undergone major surgery, it would be ideal for her to have pain and response-
to-intervention assessments every 2 hours, for the first 48 hours postoperatively (NHMRC,
1999).

Management of pain
Singh et al. (2016) found that adults who had undergone abdominal surgery had a very high
prevalence of PSP. At the fifth post-operative hour, second and third-post operative day, the
respective prevalence of PSP was 84.2%, 92.5% and 96.7% (Singh et al., 2016). By the third
post-operative day, less patients were experiencing severe pain but more patients were
experiencing mild pain (Singh et al., 2016). This information indicates that Francine is very
likely to experience PSP.
Pharmacological
There are various analgesic medications used in the treatment of PSP, including paracetamol,
non-steroidal anti-inflammatory drugs (NSAIDS), and opioids (Burkitt, Quick, Reed, 2007;
Schug et al., 2015). Other adjuvant medications include anticonvulsants, antidepressants,
ketamine, and glucocorticoids (Buvanendran & Kroin, 2009; McMain, 2008).

Pre-emptive analgesia before or during the procedure is often used in order to reduce PSP,
and may involve the use of NSAIDS, paracetamol, codeine, tramadol, local anaesthetic around
the wound edge, regional nerve blocks (e.g. a femoral nerve block for lower limb procedures)
and spinal or epidural anaesthetic for abdominal or pelvic surgery (Burkitt et al., 2007; Smith,
Fox, Saunder, Yii, 2016).

The role of nurses

Thus, nurses need to be astute in their pain assessment and assessment of any pain
interventions to determine whether a patient is receiving an appropriate amount of pain
relief (Brown et al., 2015; NHMRC, 1999). The importance of conducting proper pain
assessments is supported in a study by Harmer and Davies (1998); who documented an
overall reduction in patients experiencing moderate to severe pain at rest (32 to 12%); on
movement (37 to 13%); and on deep inspiration (41 to 22%), after the introduction of a formal
pain assessment, recording of postoperative pain, and simple algorithm for administration of
opioid analgesia.

In addition to monitoring the effectiveness of pain intervention, nurses also have a

responsibility to monitor and prevent side effects associated with opioid use, such as
constipation or nausea and vomiting (Brown et al., 2015; Harmer & Davies, 1998). These side
effects should be promptly flagged with the treating team so that aperients or antiemetics
can be initiated (Brown et al., 2015).

Finally, nurses also have a role in implementing comfort measures such as touch, changing
the patient’s position, the application of heat or cold as prescribed and rewarming (Brown et
al., 2015).
Nausea and vomiting
Pathophysiology of nausea and vomiting
Nausea is the subjective, unpleasant feeling, accompanied by the urge to vomit (Brown et al.,
2015; Stein, 1982). Vomiting (emesis) is the forceful expulsion of the stomach contents
through the mouth (Odom-Forren, 2017; Stein, 1982).

The physiology of nausea and vomiting are complex and involve an interplay between
multiple structures, including the vomiting centre (VC), the chemoreceptor trigger zone (CTZ),
the vestibular system, the gastrointestinal system (GIT), the limbic system and the cerebral
cortex (Odom-Forren, 2017).

The VC is located in the medulla and receives afferent input from the CTZ, vestibular system,
cortex and GIT (Smith et al., 2013; Watcha & White, 1992). All of these structures have
different receptors associated with them (e.g. dopamine, serotonin, histamine, GABA and
acetylcholine) and activation of these receptors sends excitatory impulses to the VC,
stimulating nausea and vomiting (Smith et al., 2013; Watcha & White, 1992).

The CTZ consists of several nuclei located at the caudal end of the fourth ventricle and is not
protected by the blood brain barrier (Odom-Forren, 2017; Smith et al., 2013). Because of its
location and structure, it is able to sense chemicals within the systemic circulation and the
cerebrospinal fluid (Odom-Forren, 2017).

Identifying and assessing nausea and vomiting

Nausea and vomiting contribute to patient distress, dissatisfaction, postoperative pain,
wound dehiscence/haemorrhage, dehydration and electrolyte imbalances, delayed
mobilisation and delayed discharge (Odom-Forren, 2017, Smith et al., 2013; Watcha & White,
1992). Thus, early identification and assessment of PONV is important so that measures can
be implemented to prevent it, or mitigate it, if already occurring (Odom-Forren, 2017; Smith
et al., 2013).
To streamline the risk assessment process, a Simplified Apfel Score is widely used to to
determine PONV risk (Apfel et al., 1999). The scoring system only has four independent
predictors – female gender, smoking status, a history of PONV or motion sickness and
postoperative use of opioids (Apfel et al., 1999). Each predictor is given a score of 1, and using
the system, a score of 0, 1, 2, 3 or 4 is approximately associated with a 10, 20, 40, 60 or 80%
risk of PONV (Apfel et al., 1999). The validity of this scoring system is supported by research
from Sherif, Hegde, Mariswami and Ollapally (2015) and and Weilbach et al. (2006).

If a patient is nauseous, there are numerous signs that can be observed, including excessive
salivation, dilated pupils, tachycardia, tachypnoea, sweating and pallor (Odom-Forren, 2017;
Smith et al., 2013). If a patient does end up vomiting, it is important to make note of the
quantity, characteristic and colour of the vomit (Brown et al., 2015).

Using the Simplified Apfel Score (Apfel et al., 1999) for our patient Francine; she is female – 1
point; she is a smoker – 1 point; we are unable to determine a history of PONV or motion
sickness – 0 points; she is highly likely to be on opioids postoperatively – 1 point. With a score
of 3, Francine has an approximate PONV risk of 60% (Apfel et al., 1999).

Management of nausea and vomiting

PONV occurs in 20-30% of all surgical patients undergoing general anaesthesia (Gan, 2002;
Watcha & White, 1992) and up to 80% in high risk patients (Apfel et al., 1999; Gan, Ginsberg,
Grant, & Glass, 1996). It is a disturbing symptom, as revealed by a majority of patients who
nominated avoiding PONV more important than avoiding pain (Gan, 2002).

Pharmacological
Different classes of antiemetics act on different receptors, thus, treatment is targeted
towards the likely trigger/s of nausea and vomiting (Gan et al., 2014). The CTZ is responsible
for the majority of nausea and vomiting experienced by surgical patients; thus, medications
that antagonise its receptor signalling are essential, for example, ondansetron blockade of 5-
HT3 receptors and haloperidol blockade of D2 receptors (Gan et al., 2014; Smith et al., 2013).
Similar to pain prophylaxis, antiemetics are often administered before the end of surgery in
order to reduce PONV (Burkitt et al., 2007).

PONV prophylaxis is vital and should involve combination therapy (Apfel et al., 2004), with at
least two antiemetic agents for moderate risk patients and three or more for high risk patients
(Gan et al., 2014). Francine is relatively high risk and would probably benefit from being on
three or more antiemetic agents.

The role of nurses

In addition to dispensing medication, nurses can implement many practical interventions to
manage PONV starting right after surgery, by allowing a patient to wake up slowly, removing
any oral airway as soon as practicable and suctioning excess secretions to reduce irritation of
the upper airway (Gundzik, 2008).

If nauseated, the nurse should sit the patient up and remain with them if possible, because if
they vomit they are at risk of aspiration (Brown et al., 2015). A vomit bowl should be provided
and patients should be encouraged to take deep breaths (Brown et al., 2015; Odom-Forren,
2017). At this point, a cool washer applied to the forehead and words of encouragement from
the nurse may be soothing (Brown et al., 2015). If the patient does vomit, gauging the quantity
will help to calculate and manage any fluid imbalances, and noting the content (i.e. presence
of blood or bile) will flag any possible complications (Brown et al., 2015).

Nurses also need to ensure effective pain management because peripheral sensitisation can
occur from direct tissue injury, causing a release of chemicals that activate receptors in the
nausea and vomiting pathways (Gan et al., 2014).

Nurses may also be able to implement some alternative therapies that have been found to
have effect, including aromatherapy with ginger (Chaiyakunapruk, Kitikannakorn,
Nathisuwan, Leeprakobboon, & Leelasettagool, 2006) and isopropyl alcohol (Hines, Steels,
Chang, & Gibbons, 2012), as well as P6 acupoint stimulation (Alkaissi et al., 2002; Lee, Chan,
& Fan, 2015).
Conclusion
Francine has a high chance of both postoperative pain and PONV. Ideally she should be on 2-
hourly pain and pain-intervention assessments for the first 48 hours, as well as three or more
antiemetics. The thorough assessment and management of postoperative pain and PONV is
essential to prevent a myriad of complications.

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