INTRODUCTION

Nursing Informatics can best be described “as the integration of data, information and knowledge to support patient’s and clinicians in decisions across role and setting, using information structures, process, and technology” (Knight & Shea,p.93). In todays dynamic health system, technology plays an important role in nursing education and practice.  Four nearly four decade’s nurse’s have been working in the field of informatics, the term “NI” has been considered a specialization in nursing resources since 1984 (Guenther & Peters,2006). Informatics tool such as technology and multimedia integrated in nursing curriculum can promote patient safety and practice. However, the integration of IT into existing health care systems has been challenging. This course is helping me to understand how health care workers and their organizations can better utilize health informatics, with the goal of improving patient outcomes and public health. The core competencies gained in this course from week 1-8 have been focused on theoretical and practical concerns related to informatics and IT. I learned about existing laws and regulations related to health informatics, coming to terms with issues like confidentiality, privacy, and data security and about the applicability of informatics tools and technologies to improve the evidence informed practice. Understand the CNO practice standards and guidelines in relation to IT, client centred care, professional practice and conclusion. Understand how technology has shaped, and will continue to shape nursing practice. Learned about the ethics linked to healthcare informatics and other medical technologies that need to be thoughtfully and carefully resolved, balancing the needs for an efficient and integrated health care system with the needs for protecting patient information, explored health care information systems and electronic health records and examine their use in the delivery of nursing care; also learned about the utility of media within the contexts of consumer health information, client education, and professional practice. Ultimately, IT have the potential to improve patient outcomes and reduce medical errors (Burwell,2015).

KNOWLEDGE GAINED

HEALTH AND NURSING INFORMATICS (week 1): “Health informatics is changing the practice and delivery of health care by providing computer technology based solutions to bridge the knowledge and information gaps experienced within the health care system”. Nursing informatics play a vital role in the health care system. It encompasses the use of computer information systems such as standardize computer forms which enables documentation to be done accurately and precisely for enhancing the quality and practice of nurses. Allowing more time can be spent caring for the client. As Burwell(2015) also points out, healthcare information technology improves cost saving and create higher value case. The ongoing development of computer technology and telecommunication, provide education, improve patient safety, and create new IT jobs within industry. It is essential for nurses to be involved in the initial design of systems to improve the quality of health care and change their culture in this regard (Darvisn & Salsali,2010), (Jenkins et al.2007).

COMPUTER AND DIGITAL MEDIA LITERACY (week2): Digital literacy has been defined by HEE (2016), Drawing on work by JISC (2014;2015a;2015b), as: ‘Those abilities that fit someone for living, learning, working, participating and thriving in a digital society. Improved digital literacy of the workforce is vital to maximise the potential of technology to enhance patient care. The health and social workforce need both the digital skills and confidence across a range of domains. With the emergence and development of technology enhanced learning (TEL) and technology enhance care (TEC), digital literacy is fast becoming a core requirement for students, academics, patients and everyone working in health and social care. Effective development of digital capabilities is essential to personal and professional development, participation and wellbeing, in the delivery of contemporary health and social care. Nonetheless, digital capabilities need to be acknowledge and embedded with in curricula to ensure learners enter workforce with both the necessary skills and attitudes/behaviors. Non professionals also need to recruited for digital literacy and for inducted, oriented and developed going forward in digital literacy capabilities. Ultimately, it is in all our best interests to provide the best care we can for individuals.

EVIDENCE INFORMED PRACTICE AND INFORMATICS (week3): All health care workers require an ability to search for information and new knowledge, and to critically examine factors that impact on people and their environment and they must be prepared to critically explore ways in which they can ensure the provision of quality care that is based on the best evidence available to them. Evidence informed decision-making is an important element of quality care in all domains of nursing practice and is integral to effect changes across the health care system. Nursing informatics and many technological applications provide nurses with up-to-date practice knowledge as well as current client information, which leads to efficient and effective quality care while also promoting client safety. New and emerging technologies and advances in the electronic capture of clinical care information present opportunities for powering the evidence continuum. Combining informatics with evidence based practice (EBP) can  help improve the care we provide to our patients.

CONSUMER HEALTH INFORMATICS (week4): Consumer health informatics(CHI) is the field that helps to connect the gap between patients and health resources. “As a consumer of health care I know what I want out from it, and how I want it to be provided”. Owen(2009) notes the movement of consumer driven health care, and the importance of preserving clients choice upon their own health. Consumers have to be literate about health in order for health care to be on a more consumer directed basis. In order to educate clients a literacy level must be established for full understanding to be applied (Booth & Donelle,2014). The world is becoming increasingly connected through internet related technologies (Booth & Donelle,2014). Patient are taking more responsibility for managing their health information. People use online communities, or support within health concerns. Several measures have been introduced to address the quality of health information on the internet, including programmes to educate consumers, encourage self labelling, and self regulation of providers, to evaluate and rate information or enforce compliance with criteria to equalise relationships between health professionals and lay people. Consumer health informatics not only use computers and telecommunications but also includes delivery of information to patient through other media. The emphasis on information structures and processes that empower consumers to manage their own health for example; personal health records, consumer friendly language, health information literacy, internet based strategies, and resource. For stakeholders who have an interest in providing health resources online (such as health portals, academics, and public health experts) a professional code of ethics have been drafted for quality control. Therefore, health professionals should not only understand consumer health applications but also ensure that these application are developed, applied, and evaluated properly.

SOCIAL MEDIA AND PRIVACY AND ETHICAL PROFESSIONAL PRACTICE (week5&6):

According to Fergusan, ”Social media allow an open dialogue between health care consumer and providers, allowing for continuous feedback and engagement”. Many types of social networking tool, such as Facebook, Instagram and twitter, focus on communicating with an established group of people. Other tools like Youtube allow users to upload video and Linkedin helps to expand professional contacts. Each of these tools in presently being used in health care for example; health care provider can use twitter to monitor epidemics. Social media can act as a platform for nurses and nursing students to communicate. Nurses can collaborate and form professional groups to carry out research work, to find vacant positions. Its use by innovative nursing professional has debatable advantages and disadvantages. It is important to consider the legal and ethical standards before incorporating social media into nursing practice. It should be used appropriately, respectfully, and safely. RN’s must reflect on the CNA’s code of ethics for RN (2017). Nurses must be aware of any applicable federal and provincial legislation such as right to privacy and confidentiality of personal and health information (Sewell,2016). Nurses need to respect professional boundaries and adhere to the guidelines and online etiquettes while using social media. It can be said that social media will continue to play larger role in health care information and “Nurses play an important role in helping patient evaluate the veracity of online information and introducing them to reliable internet resources”. Potential recruiters always tend to hire decent and qualified staff. They try to find out the reputation of their employees prior to recruiting them from their contacts or even searching them on the internet. For instance, content on facebook can be viewed by patients, colleagues, or employers. Therefore, it is now becoming necessity to build a good online reputation. To prevent risk of ruining image of nursing professional and breaching confidentiality in professional environment, nurses and student nurses should use common sense and caution while communicating on social media.

E HEALTH RECORDS (week 7&8): Digital health enables Canadian access better quality care efficiently through solutions and services such as; Electronic health record (EHR) which allows doctors to see patient’s complete health information, Electronic medical record (EMR) allows doctors to manage patient’s problem more effectively and with more efficiency, Patient portals are designed for the convenience of patients to access their personal health information. Similarly, virtual visits allow patients to connect with their health care providers with ease, Tele-homecare allows patients and clinicians to collaborate in monitoring health conditions, and by means of telecommunication technology Telehealth provides quality care for patients in remote, rural and first nations communities, and on the rise for patients in urban areas. Telemedicine is also,”a key strategy for making health care more cost effective,” (Kvedar, Coye & Everett,2014). This allows clinicians to access pertinent patient information when needed and make informed decisions. For patients, digital health means the convenience of getting their own lab results and health information online. In addition, the ability to gain timely access to lab test results and personal engagement has given a sense of empowerment, which is directly linked to improved chronic disease management. The nation is entering a new era of health care where providers can use HER to improve patient health and the way health care is delivered in this country. In the past, health history was tracked on paper only, but that’s no longer the care. Overall, EHRs are expected to reduce costs and improve quality of care.

PAST EXPERIENCE

Through out my career, I have had technological opportunities offered to me. Some of these include computerized nursing documentation, medicine indents from pharmacy through computer, an IV infusion pump, monitors, ventilators. In my previous clinical experience, I came across with an elderly client of 80years of age with the diagnosis of osteoarthritis. She was suffering from severe pain and lack of mobility. After complete assessment and collaboration with the team members doctor recommended her knee replacement surgery. I saw her that she was very upset and asked for her cause of concern. She expressed her worries and fear to me and said she does not want this surgery to be done. As a client advocate it was my responsibility to respect her decision. I talked to the health care team providers and asked them to give her informed choices regarding her disease condition, so she can opt what is best for her. Client was told other options after discussion and her choices were documented electronically. A new plan was made for her. We did research by using some health websites. We found lot of information about some natural remedies and other measures to decrease pain and some other symptoms related to arthritis. We recommended her those websites and also, some support communities for example; Arthritis foundation and Centers for disease control and prevention. By the use of digital media, we were able to helped her by giving her other options as well like; loosing weight, eating supplements, topical ointments, proper diet, acupuncture, chiro practitioner and consulting physical therapist. Through evidence based practice, clinical expertise and best research quality care was provided to the client by keeping in mind clients beliefs, values, culture and preferences. Informatics and technologies played a very vital role in getting and delivering her information.

CONCLUSION

I believe, what I learned will only impact my practice in positive ways. I will be more thorough in my gathering, relaying and retrieving of information. I will be even more self sufficient in completing tasks and take initiative in helping others who may be as technically savvy. What I learned will also help to keep me motivated on learning about the new technological advances that I may came across in the future. In regard to this course, I would say I have a better understanding of what nursing informatics is. I explored health care technology and the impact it has on individuals in the health care field.  I think informatics should be discussed and promoted more in clinical field training of all health care personnel; IT must be implemented for smooth transition. As Information and technology is becoming more advanced and most commonly used globally today, it will indeed have a positive impact on the evolution of nursing and with this course laying the groundwork for such an venture.

References

• American Nurses Association. The standards of practice for nursing informatics. Washington, DC: American Nurses Publishing, 1995. (Pub.no. NP-100). [Google Scholar]
• Canadian Association of schools of Nursing (CASN). (2012). CASN-entry-to-practice nursing informatics competencies for registered nurses. Retrieved from
  

  CASN Entry-to-Practice Nursing Informatics Competencies

• Canadian Nurses Association. (2006a). E-nursing strategy for Canada. Retrieved from
  
  http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/e-nursing-strategy-for-canada.pdf?la=en
  
• Canadian Nurses Association, & Canada Health Infoway. (2014). National survey of Canadian nurses: use of digital health technologies in practice. Retrieved from
  
  http://www.infoway-inforoute.ca/en/component/edocman/1913-national-survey-of-canadian-nurses-use-of-digital-health-technologies-in-practice/view-document
  
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• Healthcare Information and Management Systems Society. (2015). 2015 HIMSS impact of the informatics nurse survey. Retrieved from
  
  http://www.himss.org/ni-impact-survey
  
• HIMSS Nursing Informatics Awareness Task Force. (2007). An emerging giant nursing informatics. Nursing management, 38(3), 38-42 5p. doi:10.1097/01.NUMA.0000262926.85304.a6
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Pain is frequently experienced post-operatively, after cardiothoracic surgery, and is thus a core component of nursing practice (Kalso, Perttunen, and Kaasinen, 2002). This assignment introduces the concept of pain and highlights the importance of the accurate assessment of pain in terms of the Nursing and Midwifery (NMC, 2008) Code of Practice and recommended guidelines. This is followed by an evaluation of pain assessment outcome measures, with particular focus on the Numerical Rating Scale (NRS) for pain. The NRS, when used as a self-report outcome measure, is the ‘gold standard’ for pain assessment. It is a psychometrically and operationally robust pain assessment measure, as supported by the evidence presented within this assignment. Not only is the NRS associated with a number of beneficial patient outcomes, but it has also been found to facilitate communication between patients, healthcare professionals, and multidisciplinary teams (de Rond et al., 2001).

Pain in Cardiothoracic Surgery: The Numerical Rating Scale for Pain Assessment

This assignment introduces the concept of pain and highlights the importance of the accurate assessment of pain within the cardiothoracic surgery setting. This is followed by an evaluation of pain assessment outcome measures, with particular focus on the ‘gold standard’ self-report outcome measure, the Numerical Rating Scale for pain.

Background

In the UK, over 10,000 cases of thoracic surgery are carried out each year, with pain being frequently reported post-surgery (Perttunen, Tasmuth, and Kalso, 1999; Maguire et al., 2006). One study found that persistent pain lasting more than 6-months was reported by 44% of patients after a thoracotomy (Kalso, Perttunen, and Kaasinen, 2002). The prevalence of chronic pain after thoracic surgery has been reported as a significant problem that is consistently rated by patients as being one of the most difficult problems following surgery; it can impact a patient’s life for several years, severely depleting their quality of life (Maguire et al., 2006).

Despite the prevalence and burden of pain, the literature highlights many cases of poor clinical practice in the assessment and management of post-operative pain (Dihle et al., 2006; Schoenwald and Clark 2006). This is regardless of past quality improvement initiatives and changes to practice, which comprised the establishment of clinical nurse specialists, multidisciplinary pain teams, and standardised pain assessment tools (The Royal College of Surgeons of England and College of Anaesthetists, 1990).

Inadequate assessment and management of post-operative pain poses a number of implications for the patient and the NHS. For example, pain can result in increased levels of anxiety, sleep disturbance, restlessness, irritability, and aggression, as well as limitations in mobility (Macintyre and Ready, 2001; Carr et al., 2005). More importantly, post-operative pain is an unnecessary ordeal that causes heightened distress (Macintyre and Ready, 2001; Carr et al., 2005). It can also have physiological effects on patients, which may lead to complications and delayed discharge from hospital, including increases in heart rate and blood pressure, delayed gastric emptying, nausea, vomiting, and paralytic ileus (paralysis of the intestine). Difficulties coughing, resulting from increased pain on exertion, can result in chest infections and additional problems, such as deep vein thrombosis and pulmonary embolus (Sjostrom et al 2000; Macintyre and Ready, 2001). At worst, unrelieved pain can be life-threatening, especially in older people with comorbidities (Hamil, 1994).

Pain is the ‘fifth vital sign’ in the physiological assessment of patients, making it a core component of nursing practice (Chronic Pain Policy Coalition, 2008). The Joint Commission on Accreditation of Healthcare Organisations has made it mandatory for hospitals to assess pain in patients (Krebs, Carey, and Weinberger, 2007). Nurses are morally and ethically responsible for the accurate assessment of post-operative pain (Dimond, 2002), since this is vital for identifying the nature and severity of pain as well as for administering pain relief interventions and ascertaining the effectiveness of such interventions (Mackintosh, 2007). As an example, pain scores can be used alongside the WHO (1990) three-step analgesic ladder in the administration of pain relief.

The assessment of pain is complex and decisions are required as to the most accurate method of assessment within different clinical environments and with different patients. One such complex decision is whether to measure pain observationally or via self-reports and this decision is most likely to be led by conceptions of pain. If defined as a subjective experience, or as described by McCaffery and Beebe (1968, p. 95) as, “whatever the experiencing person says it is, existing whenever the experiencing person says it does,” then choice of assessment is most likely to be self-report.

Self-report is the ‘gold standard’ for measuring pain since subjective experiences can only be measured from the perspective of the patient (Wood, 2004). The importance of self-report pain assessment is highlighted in a study by Whipple et al. (1995) whereby, out of 17 trauma patients admitted to an intensive care unit, 95% of doctors and 81% of nurses felt that the patients had adequate pain relief; in contrast, 74% of patients rated their pain as moderate or severe. Many other studies confirm this inconsistency between the subjective pain reported by patients and the objective pain reported by healthcare professionals (Sjostrom et al., 2000; Marquie et al., 2003; Sloman et al., 2005).

There are a vast array of patient-reported outcome measures for assessing pain, including uni-dimensional scales that measure one element of pain (such as intensity) and multidimensional scales that measure more characteristics of pain and its impact (Macintyre et al., 2010). Whilst multidimensional tools might be better for chronic long-term conditions, uni-dimensional scales have been reported to be effective for acute pain, which can be experienced in the cardiothoracic surgery setting (Wood, 2008). Multi-dimensional measures of pain are rarely used post-surgery as they are more complex and time-consuming (Coll et al., 2004). Therefore, this assignment evaluates selected literature on uni-dimensional outcome measures within this context, with particular focus on the measure recommended by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine in their guidance on ‘Acute Pain Management: Scientific Evidence’ (Macintyre et al., 2010): The Numerical Rating Scale for Pain.

Methodology

Literature pertaining to the Numerical Rating Scale (NRS) for pain was searched in order to identify articles on the NRS and comparative pain assessment tools. The following keywords were used within the search strategy: “pain” AND “numerical rating scale” OR “NRS” AND “surgery.” The search was limited to articles comprising adult participants. The search was also limited to records no earlier than 2005 in an effort to obtain the most recent evidence examining the NRS. Nevertheless, where these records have cited earlier research assessed as being applicable to this assignment, these records have also been obtained and used as evidence.

Results

A total of 88 records were retrieved from the pre-defined search criteria, 28 of which were not relevant to this assignment. A total of 60 records were evaluated for evidence to be included within this assignment. In synthesising the evidence within these records and the utilised pain assessment tools, a framework created by Fitzpatrick et al. (1998) was adopted. This framework, designed to facilitate the selection of the most appropriate patient-reported outcome measures, promotes a consideration of the following psychometric properties and operational characteristics: appropriateness of the instrument to the purpose and setting; reliability; validity; responsiveness; precision; interpretability; acceptability; and feasibility.

Examples of three of the most frequently utilised uni-dimensional pain assessment measures, as discussed within the following appraisal of the literature, can be found in appendix 1.

Literature Appraisal

The reviewed evidence suggests that the four most commonly utilised uni-dimensional pain assessment tools are the verbal rating scales (VRS), numerical rating scale (NRS), visual analogue scale (VAS), and pictorial rating scale (PRS). Such tools were developed due to the lack of feasibility associated with using multidimensional outcome measures within the clinical environment (Wood, 2004). Uni-dimensional tools such as the VRS, NRS, VAS and PRS enable health professionals to quantify pain intensity from a subjective perspective without being too time-consuming and without creating a burden for patients.

Verbal rating scales are descriptive in nature, allowing patients to rate their pain intensity on a scale of ‘no pain,’ ‘mild pain,’ ‘moderate pain,’ or ‘severe pain’ (Wood 2004; Williamson and Hoggart, 2005). They have been reported as being one of the easiest tools to understand and use, whilst also offering the option of being completed verbally or in written format. The VRS has been adopted and integrated into acute settings, with numbers to rate pain being used in observation charts (e.g. 1=mild pain; 2=moderate pain, etc.). Such integration into standard practice increases the feasibility of the scale, whilst using numbers to document pain provides ease of interpretability. Of caution, however, is that although verbal rating scales are easy to use, the adjectives do not necessarily represent equal intervals of pain. Indeed, patients may wish to express their pain in via a word not appearing within the list of adjectives they have been presented with (Schofield, 1995). Due to the use of words to describe pain, the VRS is dependent on both the respondent’s interpretation and understanding of the terms, as well as the health professionals’ interpretation. It has, therefore, been suggested that this scale lacks the sensitivity and accuracy of other pain rating scales (Baillie 1993). Jensen et al. (1994) suggested that the lack of sensitivity of the VRS could lead to an over or underestimation of changes in pain being experienced and, as such, could make it difficult to manage pain appropriately and effectively.

In contrast to the VRS, the visual analogue scale (VAS) uses a 100mm horizontal or vertical line with extremes of pain placed at either end of the line so that the patient marks their pain intensity along the continuum. The distance to the line can then be measured and documented. A VAS rating of greater than 70mm is usually the threshold indicative of severe pain (Aubrun et al., 2008). However, the VAS poses a number of limitations within the clinical setting. It requires a greater degree of cognitive functioning, physical dexterity, and concentration than other measures of pain, and thus it is not suitable for some patients, including older patients and those with visual difficulties (Krulewitch et al., 2000). Indeed, Chapman and Syrjala (1990) estimated that 7-11% of adults would have difficulty using the VAS, whilst Wood (2004) went on to find that about 20% of patients are either unable to complete the VAS or find it confusing. Also, because it is administered verbally, it might be difficult to use after general anaesthesia or administration of some analgesics. In addition, the VAS has been found to be highly sensitive to changes in levels of pain, which can make it difficult to use (Bird and Dickson, 2001). Overall, the VAS has been found to be the least suitable uni-dimensional pain assessment measure, especially if administered after cardiac surgery (Pesonen et al., 2008).

Numerical rating scales (NRS) offer an alternative to descriptive measures of pain by assessing pain intensity numerically, on a scale of 0 (no pain) to 10 (worst pain imaginable). A value of four or more is most often used as a threshold to guide clinical intervention (Mularski, 2006). On the other hand, the most recent guidance from the World Union of Wound Healing Societies (WUWHS, 2007) makes no reference to pain score thresholds, merely offering that change in pain level may indicate a need to reassess the patient.

The NRS has been found to be highly acceptable to patients when compared to other pain scales (WUWHS, 2007) and, like the VRS, it has the advantage of being validated for verbal or written administration, which makes it feasible for use with patients who have differing levels of ability to complete such assessments (Paice and Cohen, 1997). It has been shown that older patients, post-operative patients, and patients with poor motor coordination are able to use the NRS (Rodriguez, 2001; Aubrun et al., 2003). It is not recommended, however, for patients with post-operative confusion (Ferrell et al., 1995). The NRS is more sensitive than the VRS, although some patients might find it difficult to describe their pain numerically (Carpenter and Brockopp, 1995).

The NRS for pain is recommended by the The Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine developed guidance on ‘Acute Pain Management: Scientific Evidence’ (Macintyre et al., 2010), which is endorsed by the Faculty of Pain Medicine, Royal College of Anaesthetists in the UK as well the International Association for the Study of Pain. The guidance aims to combine a review of the best available evidence for acute pain management with current clinical practice and was designed to provide information based on best evidence. The support cited within the document shows a good correlation between the VAS and NRS, indicating good levels if convergent validity with a measure purporting to assess the same construct. However, this correlation is not as strong in cardiothoracic patients compared to non-cardiothoracic patients (Ahlers et al., 2008).

The document also highlights that the NRS is usually preferable, most certainly among patients (Herr et al., 2004). This is likely due to its feasibility in terms of burden to patients and staff since it only takes 30 seconds to complete (Downie et al., 1978). Importantly, the NRS has been found to be responsive to interventions such as patient-controlled analgesia (Li, Liu and Herr 2009), making it an effective instrument for monitoring pain management. The scale is also highly Downie et al. (1978) also found the NRS to have superior accuracy when compared to the VAS and simple descriptive measures of pain such as the VRS. It could be argued that the NRS provides a compromise between the VRS, which offers only a few descriptors for patients to choose from, and the VAS, which has been reported to offer too much choice and to be confusing.

In terms of comparability against observer-based measures of pain, the NRS has been found to be more sensitive to detecting pain than the Behavioural Pain Scale (BPS) in both cardiothoracic and non-cardiothoracic patients (Ahlers et al., 2008). The authors rationalise that when using the NRS, health professionals tend to gather more background information on the patient, taking into consideration pain over time. In contrast, the BPS measures pain at one point in time, is objective, and lacks a contextual basis for interpretation. Therefore, the authors recommend that the BPS is only used alongside the NRS (Ahlers et al., 2008). This again supports self-reported pain as being the ‘gold-standard’ for pain assessment and management.

Importantly, studies have demonstrated that improvements in pain assessment and documentation frequently lead to more effective pain management (Erdek and Pronovost, 2004). In terms of the NRS, the evidence suggests that using this scale frequently results in favourable clinical outcomes such as decreased incidence of pain and agitation, as well as a decrease in the duration of mechanical ventilation (Chanques et al., 2006). It also enhances the nurse-patient relationship by providing acknowledgment of pain (Briggs, 2003). These positive outcomes are likely related to the fact that healthcare professionals are less liable to underestimate a patient’s level of pain when using the NRS than when compared to not using it. One study showed that of patients experiencing pain, where a discrepancy was reported between patient and nurse ratings, the NRS had not been used in 45% of such cases (Lorenz et al., 2009). This problem is especially apparent when patients rate their pain as being unacceptable; nurses tend to underestimate the level of pain if not collecting pain ratings from patients using the NRS (Ahlers et al., 2008). In this sense, the NRS and, indeed, other pain measures are invaluable for facilitating patient communication of pain and expression of pain (Wood, 2004). The NRS also offers a number of practical advantages in that it is easy to teach to all staff and patients, as well as being easy to score and document. The documentation of all measures of pain is fundamental for the delivery of effective care, and it also facilitates communication between multidisciplinary team members (American Pain Society, 1995).

The NRS is a valid and reliable measure of pain, but does still need to be used with caution and professional judgment as some studies have found a lack of consistency between ratings of pain. For example, one study found that whilst a patient might express a reduction in pain after an intervention, their score on the NRS remains the same (Mackintosh, 2005). Furthermore, a rating of, for example, seven by one patient might have a different meaning to another patient (Sloman et al., 2000). However, provided that such limitations are taken into consideration and efforts made to supplement the information gathered from the NRS, the instrument can be a highly effective tool for the assessment and management of pain (Mackintosh, 2005). Such supplementary enquiry might include observation and history taking, as recommended by McCaffery and Pasero (1999).

Implications for Practice

Despite the many benefits to uni-dimensional outcome measures of pain, such tools need to be used with caution as they only focus on limited aspects of the pain experience, arguable oversimplifying the complexity of the experience (Wood, 2004). They also pose the risk of being misinterpreted, a risk that cannot be rectified via descriptive tools since interpretation difficulties are also present when using the VRS. For example, what constitutes ‘moderate pain’ might vary across patients and health professionals, as well as be dependent on factors such as personality, culture, and experience (Closs et al., 2004).

The validity and reliability of all pain assessment tools, including the NRS, can be enhanced by familiarising the patient with the assessment tool and explaining the reasons for its use. Indeed, Giordano, Abramson and Boswell (2010) have emphasised the importance of listening to the patient’s subjective descriptions of pain and being consistent in the documentation of any pain assessment. At the same time, it is imperative to acknowledge that a pain assessment tool is only one aspect of the overall assessment of the patient’s pain (Duke, 2006). In the cardiothoracic setting, pain assessment should include static (rest) and dynamic (sitting, coughing, etc.) pain assessment and management (Macintyre et al., 2010).

Although the assessment process should not be rushed, it does need to commence soon after surgery since studies have shown that high levels of pain immediately after surgery are associated with increased risk of developing chronic pain (Katz et al., 1996). In the clinical environment, it is not always feasible to carry out extensive assessments of pain, but the benefit of utilising a tool such as the NRS is that it provides an initial brief assessment of pain intensity. This, in turn, provides vital information on whether pain relief is required or whether a previously administered intervention has been effective. It is understood, however, that awareness of other pain measures is essential for the purpose of providing equal care to patients who might not be able to complete the NRS. For example, patients with cognitive impairments might find the Abbey Pain Scale easier to complete (Abbey et al., 2004), whilst patients with learning disabilities might prefer Zwakhalen et al.’s (2004) scale of non-verbal indicators.

Conclusions

Effective pain management needs to commence with effective pain assessment, as well as the identification of factors requiring urgent intervention (Fear, 2010). The Numerical Rating Scale for pain provides a psychometrically robust method of assessing pain intensity and monitoring pain reduction interventions. As well as being psychometrically robust, the scale is acceptable to patients and feasible within busy clinical environments such as the cardiothoracic surgery setting. The best available evidence suggests the Numerical Rating Scale for pain is a suitable tool for the assessment and management of post-surgery pain and using this tool thus adheres to the Nursing and Midwifery (NMC, 2008) Code of Practice for providing a high standard of evidence-based practice at all times. Not only does this scale provide improved patient outcomes, but it also promotes communication between the patient, nurse, and multidisciplinary team (de Rond et al., 2001). More research is needed on the accuracy and effectiveness of the NRS, as well as exploration as to any potential improvements to the instrument (Krebs, Carey, and Weinberger, 2007); however, until then, the evidence suggests that the NRS is an acceptable and efficacious screening tool for measuring pain in patients.

Appendix 1: Pain Rating Scales

Visual Analogue Scale (VAS)

Numerical Rating Scale (NRS)

Faces Rating Scale (FRS)

The lungs are one of the most important organs in the human body. Without the lungs a person is unable to intake oxygen that is need to life. There are many problems that can develop within the lungs. Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases. This paper will discuss the epidemiology and pathophysiology of COPD. The pre-hospital treatment of COPD will also be covered. A detailed example of a field impression and treatment plan will also be illustrated.

Chronic obstructive pulmonary disease causes a person to have difficulty in breathing. There are to main forms of COPD; chronic bronchitis and emphysema. Chronic bronchitis is a long-term cough that produces mucus. Emphysema is the destruction of the lungs of a period of time. Most people that have COPD have a combination of chronic bronchitis and emphysema. There are several causes of COPD, with smoking being the most prevalent. The more a person smokes, the more likely they are to develop COPD. There are also several causes of COPD in non-smokers. Patients who lack the protein alpha-1 antitrypsin can develop emphysema. Other airway irritants such as, exposure to gases and fumes in the workplace, second-hand smoke, and frequent use of cooking gases without ventilation are other potential risk factors. Again, smoking is the primary cause of COPD; however someone can be a lifelong smoker and not develop COPD.

All diseases have a pathophysiologic reason as to how and why it affects the body. However, according to the American Academy of Family Physicians, COPD does not have a clear pathophysiology. What is known about COPD is that the cells of the bronchial tree have been subjected to chronic inflammation. This inflammation is caused by smoking and other irritants that mentioned previously. When the cells of the bronchial tree are inflamed it causes the smooth muscles of the airway to constriction excessively. This hyperactivity causes the airway to become swollen, production of excess amounts of mucus, and decreased effectiveness of the cilia. As COPD progress, patients begin to have difficulty clearing secretions, which causes a chronic productive cough, wheezing and difficulty breathing. Due to the inability for the patient to clear the productive cough, mucus begins to collect in the airway. The collection of mucus is an issue because it collects bacteria and cause causes infections. Both chronic bronchitis and emphysema caused airway obstruction. In cases of chronic bronchitis the airway is obstruction caused by the build-up of mucus describe previously. In cases of emphysema, the alveoli become enlarged an eventually destroy. This hinders the necessary exchange of oxygen and carbon dioxide. Chronic obstructive pulmonary disease has many negative effects on the body that impedes the body from respiring efficiently.

Just like every condition chronic obstructive pulmonary disease has signs and symptoms that all providers the ability to both diagnosis and treat their patients. The classic signs of COPD include an ongoing productive cough, shortness of breath, wheezing, and tightness in the chest. These symptoms can appear both early and late in the disease process. If a patients presents with these symptoms early, then it is possible that they have not lost the ability effectively move air. COPD patients may also present with the following symptoms: difficulty catching breath, signs of cyanosis such as blue or gray lips and nail beds, alerted mental status, and tachycardia. It is important for the provider to have good assessment skills so that he/she picks up on these signs and symptoms. Most COPD patients that an EMS provider will come in contact with will already be diagnosed with the disease, thus making it important for the provider to obtain SAMPLE and OPQRST history. After the provider has concluded that this patient is suffering from chronic obstructive pulmonary disease it is time for treatment to begin.

The treatment of chronic obstructive pulmonary disease is pretty straight forward in the pre-hospital arena. Due to difficulty breathing, the patient should be placed on high-flow oxygen via non-rebreather. The provider should keep a constant monitor on the patients pulse oximetry to issue adequate oxygen levels in the blood. If the patient is wheezing then a nebulized albuterol treatment is indicated. Albuterol dilates the airway, thus increasing air movement. The next step in the treatment plan should be obtaining intravenous access for medicine administration. A blood draw should also be performed at this time. The provider should monitor the patient’s ECG. If accessible the provider should also obtain a 12-lead ECG and monitor Capnography. If the patient continues wheezing after the initial albuterol treatment, a second dosage should be administered after ten minutes. If wheezing still continues, the provider should consider administering Solu-Medrol intravenously. Solu-Medrol is a parenteral steroid that attempts to lower the inflammation of the cells in the bronchial tree. If the patient’s pulse oximetry is below 90 percent on high flow oxygen via non-rebreather, the provider should consider use of positive-pressure ventilation. There are two types of positive-pressure ventilation, bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP). Since local protocols allow the use of CPAP, it will be used for the purposes of this paper. CPAP decreases the workload of the patient on inspiration. CPAP also keeps the alveoli open allowing better gas exchange. Fluid build-up in the lungs is another indication for CPAP. The positive pressure supplied by a CPAP device will push the fluid from the lungs back into the vascular space. CPAP is contraindication on patients with altered mental status and systolic blood pressure of less than 100. With the treatment plan listed above, the pre-hospital provider should be able to effective treat a symptomatic chronic obstructive pulmonary disease patient.

Chronic obstructive pulmonary disease is disease that Emergency Medical Services provider will have to deal with on a daily basis in a busy locality. This is caused mainly by the high popularity of tobacco smoking in the United States over the last century. COPD can by a gateway to other medical issues in the body, such as congestive heart failure and infection. The effects on the body in COPD patients works like a chain reaction, inflammation causes fluid build-up, which causes airway compromise and possibly infection. Patients suffering from COPD should immediate stop smoking. The treatment plan describe above is straight forward and can provide short term relief in the pre-hospital setting. Like stated at the beginning of this paper Chronic obstructive pulmonary disease is a like changing disease that can destroy one of the body’s most important organs, the lungs, and if a patient is unable to breath, they will die!

But to you who fear my name, the sun of righteousness

Shall arise with healing in his wings. – Mal.4:2

Cancer is a disease that poses a threat to many aspects of life. Caring for clients with cancer is one of the most significant tasks perturbing health care professionals. One of the most debilitating complications of cancer is moderate to severe pain, calling for aggressive treatment.

Cancer pain management starts with the assessment of physical and psychological components of pain by measurement tools. A lot of empathy and a holistic approach including physical therapy, psychological interventions, neurologic techniques, nerve blocks, counter stimulation techniques and ongoing support are essentially required for effective management of these difficult pain situations, (Chec.et. al ,1994).

As of 2004, world wide the death’s caused by cancer was (7.4 million). The main causes were lung cancer (1.3 million death / year), stomach cancer (803,000 deaths), colorectal cancer (639,000 deaths), liver cancer (610,000), and breast cancer (519,000 deaths).

In the US, about 25% of deaths were caused by cancer and among the lung cancer is the leading (30%). The most commonly occurring cancer in men is prostate cancer and in women is breast cancer (about 25% new cases were reported). But in total figures cancer is s frequent with women as with men. Cancer can occur in children and adolescents, leukemia is the common cancer seen in these age group with the statistics of150 cases per million in US. In the first decades of life the neuroblastoma is the commonly occurring cancer. New cases were found to be 1,529,560 and deaths 569,490.

The magnitude of the problem of cancer in the Indian subcontinent in terms of sheer number is the most alarming. From the population census data for India in 1991, 609,000 new cancer cases were estimated to have been diagnosed in the country. This figure had increased to 806,000 by the turn of the century. The estimated age standardized rates per 100,000 were 96.4 for males and 88.2 for females. The most common cancers found in males were cancers of the lung, pharynx, esophagus, tongue and stomach while among female, cancers of the cervix, breast ovary, esophagus and mouth were common. In 2010 Pernilla reveals in her study that the incidence of esophageal adenocarcinoma has been increasing rapidly than any other caners in many countries since 1970’s.

Cancer

Cancer is a term used for group of symptoms when the cells in a part of a body starts to grow beyond the control. (American Cancer Society, 2010)

Categories of cancer

Carcinoma – that is seen in layers that protect the internal organs

Sarcoma – seen connective tissue and vascular system

Leukemia – cancer in precursor cells of the blood

Lymphoma and myeloma – cancer in the white blood cells.

Central nervous system cancers – cancer in the central nervous system

Cancer and Pain

The most alarming concept of cancer is not the risk of dying as much as the anticipation of continuous and existing pain. The pain is a combination of both physical and biopsychosocial phenomenon.

Pain and cancer are not synonymous

¾ of patients experience pain.

¼ of patients do not experience pain.

Pain in cancer is due to cancer, treatment, cancer / debility, concurrent disorder

Cancer pain and its management

Nursing is a compassionate concern for human beings. It is the heart that understands and the hand that soothes. In 2007 Carcy and Turpin stated that nurses, who accepted the challenges of cancer pain as a clinical problem were studied, are low communicating.

“By Mouth”, the oral route is the preferred route for analgesics, including morphine.

“By clock”, persistent pain requires preventive therapy. This means that analgesics should be given regularly and prophylactic ally.

“By ladder”, use a three step WHO analgesic ladder.

Step 1: Non-narcotics NSAIDS

Step 2: Mild opioids

Step 3: Strong opioids (Morphine)

Use of adjuvant drugs

Alternative and complementary therapies

Alternative and complementary therapies

During the last few decade, patients with cancer have increasingly turned to complementary and alternative medicine (CAM) resources in an attempt to cure cancer, to provide relief from cancer related symptoms , or to improve overall well being and quality of life. The National Centre For Alternative and Complementary Medicine defines “It as a group of diverse medical and health care system, practices and products considered to be part of conventional medicine.

Foot massage

Foot massage is a simple, non-invasive method to help balance the body; it has been described as a natural therapy that requires the application of a specific type of pressure on particular areas of the feet. It is based on the principle that there are reflexes in the feet which correspond to every part of the body. Foot massage serves to relax, improve circulation and promote a general feeling of wellness. (Carlson, 2006)

Foot massage has a positive effect on relieving pain of cancer patients, and also it is one of the caring interventions which has greater benefit to cancer patients not only relieving the distressing symptoms of their disease but also fulfills the basic nedsic need of human touch, one of the five senses (Vora, 1982).

SIGNIFICANCE AND NEED FOR THE STUDY

Pain is one of the most feared consequences of cancer. Estimates indicate that pain is experienced by 25% newly diagnosed cancer patients and by 60% to 90% of patients with advanced cancer by patients. (Bernard et.al.,2007). Much of the suffering due to serious pain including cancer pain can be reduced or eliminated by properly implemented technologies for relief.

The American Cancer Society Projects treat over 15,000 new cancer cases each year and pain is most common in patients with far advanced disease. The pain occurs when tumor infiltrates or compresses normal tissue and is most common in patients with advanced malignancies.( Burton,2006)

The future of nursing promises to convey feelings of caring and comfort through the aspect of evidence based practice. Pain assessment is a critical component in managing pain. Pain is multi-factorial and includes sensory, affective behavioural, cognitive, socio-cultural and physiologic components. In 1999 The American Pain Society created the phase “Pain: The fifth vital sign” to increase awareness of pain assessment among health care professionals.

The relief of pain is always a priority for nursing action. The pain relieving measure in nursing care includes maintaining a comfortable position, providing comfort device, administering complementary therapies such as relaxation, aroma therapy, music therapy, guided imagery, etc., among these therapies, foot massage has got greater potential to be used by all nurses in the multidisciplinary pain management programme. Foot massage is one among the few natural therapies which has got its evidence in patient care and is implemented by all health professionals in order to attain a holistic approach in patient care.

Caring is nursing and nursing is caring.(Leiniger,1984).it is every nurses prime responsibility to render care to the chronically ill patients suffering from pain. The nurse should look for the promotion of health, prevention, management and rehabilitation.

An empirical study was conducted by the nurses at the school, from the School of Nursing, Division of Science and Design, University of Canberra, Australia on the use of foot massage as a part of nursing care in patients hospitalized with cancer. 87 patients participated in the study and each received a ten minutes foot massage (5 minutes per foot). The patient’s perception of pain was measured using visual analog scale. The results revealed that the intervention produced a significant and immediate effect and is a simple nursing intervention for patients experiencing nausea or pain related to the cancer experience. (Grealish,et. al. 2000).

A study was conducted in East Carolina by the nurses in the school of Nursing, Green Ville USA to measure the effect of foot reflexology on pain in patients with metastatic cancer. 36 oncology inpatients participated in the study and each received a foot massage. The foot massage was found to have a positive immediate effect for patients with metastatic cancer, who reports pain. (Stephenson et.al,2003).

The complementary therapies such as massage, reflexology, acupressure, herbal remedies, and aromatherapy are rising in popularity among patients and health care professionals and increasingly being used in palliative care to improve the quality of life of patients.

Considering the above facts the investigator implements this complementary intervention as a non-pharmacological measure and also as a means for increasing human touch, a basic human need. It also renders an opportunity to convey a feeling of caring to alleviate the pain and providing a sootiness to enhance the relaxation effect as well as provide a sense of satisfaction among clients with advanced cancer.

STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of foot massage in minimizing pain perception and selected associated symptoms among clients with advanced cancer in selected hospital, Trivandrum.

OBJECTIVES

To assess the level of pain perception and selected associated symptoms among the experimental group and control group before giving the foot massage.

To assess the level of pain perception and selected associated symptoms among the experimental group and control group after giving the foot massage.

To find out the difference between the level of pain perception and selected associated symptoms among the experimental group and control group after the foot massage.

RESEARCH HYPOTHESIS

H1There is no association between the foot massage in minimizing pain perception and selected associated symptoms among clients with advanced cancer.

OPERATIONAL DEFINITIONS

Effectiveness

In this study, effectiveness refers to the outcome of foot massage in terms of minimization of pain perception and selected associated symptoms among clients with advanced cancer

Foot massage

In this study, foot massage refers to the complementary technique by which both feet of the clients with advanced cancer are held at comfortable position, given massage to the dorsum and plantar surface of the feet following a sequence of 15 steps to attain a relaxation response for 25-30minutes.

Pain Perception

In this study, pain perception refers to an unpleasant sensation perceived by the client with advanced cancer which is measured by the numerical pain intensity scale.

Selected Associated Symptoms

In this study selected associated symptoms refers that changes in physical and psychological parameters due to pain which is measured by the symptom assessment scale.

Clients with advanced cancer

In this study, it refers that the clients who have been diagnosed with III and IV stage of advanced cancer receiving palliative care.

ASSUMPTIONS

There will be a significant minimization of pain perception and selected associated symptoms among clients with advanced cancer after foot massage.

The pain perception will be different from each individual.

The prevalence of symptoms will be associated with the intensity of pain.

DELIMITATIONS

The study was limited only to clients who are in III and IV stage of cancer.

The study was conducted on less number of subjects in one setting which limits the generalization.

PROJECTED OUTCOME

Application of foot massage among clients with advanced cancer will help to bring about a significant physical and physiological effect that enhances support, comfort and relaxation.