Critically discuss the case study in relation to Rosemary’s post-operative pain management.

Case Study 2: September 2017

Critically discuss the case study in relation to Rosemary’s post-operative pain management. Your assignment should focus on: pharmacological processes, medicines management issues, nursing care and safe practice and the nurse’s role.

Rosemary Reynolds is 76 years old with a past medical history of rheumatoid arthritis. She has experienced increasingly severe pain, swelling and stiffness in her right knee for the past two years. Treatment with physiotherapy and exercises and regular steroid injections has not been effective and Rosemary has now decided to undergo a right total knee replacement. Rosemary’s symptoms affect her quality of life and prevent her from leading an active social life and disrupt her sleep pattern. Rosemary is otherwise fit and well and has no other relevant past medical history and lives alone in a ground floor flat with regular visits from her daughter.

Rosemary underwent a right total knee (arthroplasty) replacement 3 day ago and is now back on the orthopaedic ward. Her surgery was uneventful and there were no complications during the surgical procedure.

Rosemary is only managing very small amounts of food and fluids due to persistent nausea, frequent vomiting and mild dyspepsia. She has not had her bowels open since before the surgery (5 day post operatively) and is experiencing mild pruritus to her trunk and back. She has a small dressing on her knee wound, which is showing no signs of infection and is wearing anti embolism stockings (AES).

Rosemary has a morphine patient controlled analgesia pump (PCA) in progress and is managing to gently mobilise the short distance to the toilet and back with the assistance of a walking frame and one nurse. She is finding her physiotherapy exercises difficult to manage due to persistent nausea, pain and fatigue.

The nurse caring for Rosemary today has just completed a pain assessment using the numerical rating scale tool (NRS). Where 1-3 is calculated as mild pain and 7-10 as severe pain (Figure 1). Rosemary has stated that she is experiencing moderate to severe pain which she rates as 6-7 when mobilising and mild to moderate pain: 3-4 when resting in her chair. Her current sedation score according to the Alert, Confusion, Verbal, Pain and Unresponsive tool (ACVPU) (NEWS2 2017) is recorded as alert. All clinical observations are within normal parameters. She continues to experience persistent nausea and vomited once after breakfast this morning, her back and chest remain itchy with no visible rash present.

Figure 1: numerical rating scale tool.

Rosemary’s current medication regime:

Paracetamol (acetaminophen)

Enoxaparin sodium Ondansetron Diclofenac Lactulose 15ml

1 gram every 6 hours: maximum daily amount 4 grams (PO)
40mg once a day, subcutaneous (S/C)
8mg twice a day (PO)

50mg three times a day (PO), when required Twice a day (PO)

Drug	Dose
Intravenous (IV) morphine PCA	50mg/50ml (concentration of 1mg/ml). There is no continuous or background infusion 1mg (1ml) bolus with a lock out period of 5 minutes. Total dose: 12mg/hr