Critical Thinking and Pain Management

Managing and otherwise minimising pain and suffering of patients is a core responsibility of providing nursing care. Minimising pain makes life significantly more comfortable for the patient, and allows them to recover faster, and with a positive experience. Unfortunately, this isn’t always the case, and when nurses fail to read the signs of pain and do not provide remedial action, the patients are the ones that suffer greatly. The complexity of a patients condition and comorbidities can obscure significant problems in the patient’s condition.

I was presented with this very issue during my first placement in an aged care facility. We had an elderly patient that was temporarily staying with the facility for respite care after undergoing surgery on her lumbar spine. She was transferred by ambulance, and arrived in a good mood, and got settled quickly.

I met with her briefly while doing the medication rounds, and she seemed to be well settled, but preferred to stay in bed for most of the day, which is nothing unusual after spinal surgery. Nonetheless, myself and the other nurse encouraged her to get up when she could and explore the facility, walk through the gardens, and get her back mobile again. After the first two days of her stay, I was rostered on to another building in the facility, and didn’t see her for about another week.

My first impression upon seeing her again after a week was that there was a marked change in her condition. I asked the Nurse Unit Manager about her condition, who brushed me off, explaining there were no significant changes to her condition. I decided to check her chart for any signs of trouble, but nothing significant showed up. There was a note that she requested more painkillers, but they attributed the rise in pain to her lack of mobility, and remaining in bed for the majority of the day. Seemed like a satisfactory explanation, so I went about my usual duties.

I returned early from my lunch break and decided to see how she was going before I went back on shift. It was at this point I realised something was very wrong. Her breathing was short and shallow, she was holding onto the bed rails tightly and only answering my questions in short, one-word answers. I called in the RN, who asked her a few questions, and authorised me to give her another dose of pain killers. I did so, and went about my usual duties again.

I checked back in an hour and she didn’t appear to be any better. I had some downtime with another student so we stuck around to keep her company, a decision which proved to be a turning point in her care.

I went through the usual questions; how is your pain? Etc. Eventually, she disclosed that the pain was very severe, at a 9/10 level, and coming from her left shoulder, definitely not what you would expect to be normal after lumbar surgery. My immediate thought was a cardiac-related event, and promptly carried out an assessment, which turned up nothing cardiac related, but she displayed an almost complete inability to move her left arm. I dispatched my fellow student to get the RN and took a full set of observations. Nothing major there. What could possibly cause 9 out of 10 pain in the arm after lumbar surgery? Was it just referred pain? My mind was racing with questions, nothing added up. The RN showed up and I gave her a brief of what I knew, and the assessments I had done. She agreed it was out of the ordinary, but she was already on the maximum dose of painkillers and there was nothing further we could do without the doctor.

It was about now my experience as a first responder kicked in, and I started thinking like a paramedic, and not a nurse. Her lower limb stiffness and pain is explained by the surgery, but why pain in the shoulder? There were no incisions or IV lines in the left arm, so it can’t be that. There’s no history of shoulder pain and no known drug allergies, and then it hit me… Could it possibly be trauma related?

“Have you hurt your shoulder recently?” … “No” well, there goes that theory, what else could it be?

“Have you had a fall recently?” … “Yes,” bingo! All the nurses in the room looked at each other in mutual understanding, and we promptly went about investigating the fall.

It turned out she had an undocumented fall in the hospital shortly before being transferred to our facility. In light of this, we decided to transfer her back to the hospital for investigation and stronger pain relief. She was transferred back to the hospital just under an hour later, and that was the last I ever saw of her. I did find out later from one of the RN’s that she had fractured the socket in her shoulder, and that my persistence was what brought her the care she needed at the time.

I think that thinking of every patient interaction critically is a vital part of nursing, and that we should be constantly looking for answers to questions, rather than simply accepting a patient’s condition as “normal”.

Oh, and never assume the charts show the whole story.

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