September 2018: Case Study A: Post-operative Pain Management Tom Bing is 84 years old with a past medical history of severe osteoarthritis. He has experienced persistent hip and joint pain for the...

September 2018: Case Study A: Post-operative Pain Management


Tom Bing is 84 years old with a past medical history of severe osteoarthritis. He has experienced
persistent hip and joint pain for the past 7 years and is now only able to walk short distances with the
aid of his walking (Zimmer) frame. Tom is otherwise fit and well and has no other relevant past
medical history. He lives with his daughter and one teenage grandson in a bungalow.
Tom underwent a total hip replacement (THR) for his osteoarthritis 3 days ago and is now back on the
orthopaedic ward. His surgery was uneventful and there were no complications during the surgical
procedure.
Tom is managing small amounts of diet and fluids due to persistent nausea, frequent vomiting, and
mild dyspepsia. He has not had his bowels open since the day before the surgery (4 days) and is
experiencing mild pruritus to his trunk and back with no visible rash present. He has a small dressing
on his wound, which is showing no signs of infection and is wearing anti-embolism stockings (AES).
Tom has a morphine patient-controlled analgesia pump (PCA) in progress and is managing to gently
mobilise short distances to the toilet and back with the assistance of his walking (Zimmer) frame and
one nurse. He is finding his physiotherapy exercises challenging due to persistent nausea, pain, and
fatigue.
The nurse caring for Tom today had completed a pain assessment using the numerical rating scale
tool (NRS). Where 1-3 is calculated as mild pain, 4-6 moderate pain and 7-10 severe pain (Figure 1).
Tom has stated he is experiencing moderate pain which he scores as 5-6 when mobilising and mild
pain, rated 2-3 when resting in his chair. His cu
ent sedation score according to the Alert, Confusion,
Ve
al, pain, and Unresponsive tool (ACVPU) (NEWS XXXXXXXXXXis recorded as alert but he is feeling
drowsy. All clinical observations are within normal parameters. He continues to experience persistent
nausea with no vomiting recorded today and his back and chest remain itchy with no visible rash
present.
Figure 1: Numerical Rating Scale Tool (NRS)
Tom’s cu
ent medication regime:
Intravenous (IV) morphine PCA 50mg/50ml (concentration 1mg/1ml). No
continuous or background infusion.
1mg(1ml) bolus with a lockout period of 5
minutes: total dose 12mg/hr.
Paracetamol (acetaminophen): PO 1 gram: 6 hourly: maximum daily dose: 4
grams
Enoxaparin Sodium (S/C) 40mg once a day
Diclofenac (PO) 50mg, three times a day, when required
Ondansetron (PO) 8mg, twice a day
Lactulose (PO) 15ml, twice a day

S18: Case Study A (Post-operative Pain): Student Essay Guidelines
 This information is guidance only, you may not be able to add all of the topic
areas presented here.
 Critical writing at level 6 involves making decisions regarding the information
you decide to present to fully answer the 4 questions in the essay title.
 Use the information presented here to carefully structure you assignment.
Introduction 5-15%

 Provides structure to the essay

 Provides the reader with an
outline of the essay and what to
expect


 Present the topics logically and
follow this sequence in main
ody of the essay

 Third person only: no ‘I’ or ‘ME’
 Outline the topics you are going to present in
the essay (logically and sequentially), but
succinctly
 Make it clear but short and succinct: 1
paragraph max.
 Refer to the case study: do not reproduce
the case study in full but make it clear this is
a case study: introduce the patient name.
 Introduce your topic with some relevant
ackground information on the topic: make it
short, snappy, and interesting: grab the
eader’s attention right at the beginning of
your essay.
 This assignment will critically examine,
explore, discuss, highlight or
address…………
 Main Body 70-80%

 Use the information presented in
the case study to illustrate and
critically discuss the 4 required
areas of the essay:

1. Pharmacological processes
2. Medicines management
3. Nursing care
4. Safe practice and the nurse’s
ole

 Use clearly defined (short)
paragraphs
 Only present one topic or
subject area per paragraph
 Logical approach: sequence
your paragraphs to aid structure
and flow of your topics: helps
the reader to understand your
essay: do not mix and match
topics in a paragraph.

 Avoid repetition of topic areas in
different sections of the essay.
 Include the case study (patient
name) throughout: refer back to
the case study and use the
1. Pharmacological processes:
 PK: ADME, bioavailability, plasma half-life,
peak plasma concentration, synergism, and
additive effects in relation to case study
information
 PD: mechanism of action, side effects,
selectivity, affinity, and efficacy in relation to the
case study information
 Adverse effects/interactions in relation to the
case study information
2. Medicines Management:
 Nurses role and responsibilities and drug
administration: 6Rs (do not list/describe the 6Rs)
and the importance of pharmacology knowledge
and understanding and nurses
 Professional issues: consent, accountability
and appropriate knowledge and understanding
 Nurses roles and responsibilities in
assessment before, during and after drug
administration
 Nurse roles and responsibilities in the
evaluation of effectiveness of the medication and
side effects: ADRs
 Education, training, and concordance issues:
patient and staff
 Mode
oute of delivery: pharmacological and
patient factors in relation to the information in the
case study
3. Nursing care:
information to illustrate (critically
discuss) your points/subjects
 Do not provide long explanations
of the pharmacology principles/
processes: use them to critically
discuss and illustrate the drugs
in the case study

 Avoid listing and bullet points:
this is not critical writing level 6

 Avoid long descriptions of the
PK/PD of each individual drug in
the case study: use the drugs to
critically discuss your topic
areas in relation to the case
study information
 Focus on pain management and assessment
and the nurses role and responsibilities and the
information presented in the case study
 Type of pain the patient is experiencing and
why?
 Pain assessment: critique do not describe pain
assessment: relate to the case study information
 Pain tools: critique do not describe different
pain tools: relate to patient scenario
 Complications of poorly controlled pain for this
patient with reference to the information in case
study: critique do not list all of the potential
complications: apply the information to the
scenario
 Identification and management of side effects:
nurses roles and responsibilities
4. Safe practice and the nurses role:
 To some extent this may be incorporated in
the other areas of the essay
 Accountability, consent, knowledge and
understanding and the 6Rs
 Critical thinking and decision-making skills:
would you offer any alternatives or changes to
the care and cu
ent medication regime?:
objectively critically discuss, with relevant
supporting literature: relate to professional, legal,
and moral/ ethical responsibilities and
accountability of the nurse
 Professional issues: NMC XXXXXXXXXXThe Code
and RPS (2018 and 2019)
Conclusion 5-15%

 Succinctly summarise the key
points in your essay: ‘che
y
pick’ the important points you
have presented
 Make it short and snappy: 1
paragraph at the very most
 No reflection
 Aim to make it clear you have begun your
conclusion, I.E. ‘to conclude’ or ‘to
summarise’
 Reference where appropriate
 Do not add any new information
 Use the third person only
 No reflection on what you have learnt writing
this essay: factual only based on your essay
contents
 Avoid biased subjective opinions in relation
to the case study
References
 Must demonstrate you have read
widely and appropriately around
your topic areas
 Use the Harvard Referencing System
accurately and co
ectly
 All references in the main text should be
present and accurate in your terminal
eference list
 Author name and date only in the main text:
no journal names or website details
 Strictly alphabetical
 Do not use numbers or bullet points in your
terminal reference list
 Do no use non-academic sources to support
your points/topics
 Contemporary and up-to-date sources
should be used
Your essay: A Quick Checklist
 Have I read the marking grid?
 Am I writing at the appropriate level?
Introduction
 Am I writing in the third person only?
 Is my introduction short and succinct?
 Have I logically and succinctly set out my topic areas?
Main body
 Am I using short, clearly defined paragraphs?
 Do the paragraphs link well together or are the topics/subjects disjointed throughout
 the essay?
 Is there logical sequence and flow to my work that makes sense to the reader?
 Have I carefully proof-read my essay? Does it make sense?
 Is my grammar, punctuation, spelling, and sentence construction co
ect throughout
 my essay? Does it make sense?
 Am I presenting and refe
ing to the case study contents throughout my
 essay? The name of the patient and details should appear from beginning to the end
 of the essay
 Am I supporting my points with relevant up-to-date literature linked to the case study
information?
 Am I comparing /contrasting my topics/points with relevant up-to-date literature and linking
this to the case study information?
 Am I repeating topics in different sections of the essay: avoid repetition of topic areas in
different sections of the essay.
Conclusion
 Is it clear I have begun to conclude or sum up my essay?
 Have I included the key points from my essay related to my topics?
 Have I appropriately referenced my conclusion?
 Is my conclusion short: one paragraph?
 Am I writing in the third person only?
 There is no reflection of what I have learnt in my conclusion.
 Have I avoided biased and subjective comments regarding the case study and patient in my
conclusion
Referencing