Managing Pain

This chapter aims to provide you with the knowledge to be able to take an evidence-based approach to the nursing management of people who are experiencing pain. As a practising nurse, pain will be something that many of your patients will experience; however, one individual’s pain may be very different from another person’s. Pain can vary depending on the circumstances in which it is experienced and the individual characteristics of the person experiencing it. Understanding someone’s pain experience is therefore challenging because you cannot see someone’s pain or easily judge how bad it is, what it feels like, or how it affects him or her. This chapter provides you with knowledge and skills to recognize, assess, and manage the patient’s experience of pain effectively with evidence-based strategies. The variability of the experience of pain makes defining pain difficult. Pain is something that we have all experienced at some point in our lives and therefore, through these experiences, we have developed an understanding of what we consider to be pain. One of the most widely accepted definitions is that of the International Association for the Study of Pain (IASP), which defines pain as:…An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (Merskey and Bogduk,1994)…Although this definition is often quoted, the difficulty in defining pain is illustrated by the fact that the IASP added a note (go to http://www.iasp-pain.org/ and search for ‘pain definitions’) to highlight the individual nature of pain and the fact that pain is a sensory experience with an emotional component. The individual nature of pain is also highlighted by another commonly used definition:…Pain is whatever the experiencing person says it is and happens whenever he/she says it does. (McCaffery, 1972)…This definition highlights the fact that pain is an individual experience and that measuring pain objectively is difficult. Therefore asking the person and actively listening to the self-report of the experience is the best way in which to understand another person’s pain. A common criticism of McCaffery’s definition is that some people cannot say what they are experiencing.

Managing Nutrition

This chapter addresses the essential nursing responsibility to ensure that adequate nutritional care is offered to all patients, whether in hospital or community-based settings. To provide appropriate nutritional care to patients or clients, nurses must have a good knowledge and understanding of the principles of human nutrition, and be able to deliver nutritional support that is informed by current clinical guidelines and up-to-date evidence, as well as to evaluate that care. Healthcare organizations have a duty to ensure that patients and clients receive high-quality nutritional care. The Council of Europe (2003) has published guidelines on food and nutritional care in hospitals, and a recent Europe-wide campaign has been launched to improve nutritional care in all types of care facility (Ljungqvist et al., 2010). A European strategy to address obesity has also been launched (Commission of the European Communities, 2007). In England, the Care Quality Commission (CQC, 2010), which regulates care settings, has set national standards concerning nutrition. The provision of high-quality nutritional care involves a range of services and requires a multidisciplinary team approach. As a nurse, your role within the multidisciplinary team is fundamental in ensuring the delivery of appropriate nutritional care. In the UK, this is clearly identified by the incorporation of ‘Nutrition and Fluid Management’ within the Essential Skills Clusters for pre-registration nursing education (Nursing and Midwifery Council, 2010). Human nutrition is the study of nutrients and their effect on health, and the processes by which individuals obtain nutrients and use them for growth, metabolism, and repair. The term ‘human nutrition’ therefore incorporates many aspects of behaviour and physiology. The way in which the body obtains, ingests, digests, absorbs, and metabolizes nutrients is described in core anatomy and physiology textbooks (for example, Marieb and Hoehn, 2010), and it is important that a good knowledge and understanding of these processes is gained before considering the nursing management of nutritional care. This chapter considers the principles of human nutrition that underpin the nursing management of nutritional care and focuses on the key nursing interventions that you should be able to provide with confidence. The amount and type of nutrients that a person obtains influences his or her ‘nutritional status’.

Managing End-of-Life Care

This chapter addresses the fundamental nursing role of managing end-of-life care. Death is as fundamental a part of life as living, and while caring for a dying patient and their family is demanding, complex, and emotionally exhausting, it can also be a gratifying and privileged experience for nurses. Specifically, nurses have a centre-stage role in leading and informing care delivery at the end of life. Care will typically embrace assessing the needs of the patient and family, providing symptom relief and comfort care, and providing cultural and spiritual support. Additionally, caring functions should also extend following death to caring for the deceased in a dignified manner and supporting the newly bereaved, demonstrating genuine concern, compassion, and effective communication skills (Hills and Albarran, 2010a; Maben et al., 2010). To examine the key themes and challenges of practice, it is important to understand the political, professional and societal influences, and contextual nature of death and dying in the UK. At present, there is neither a clear nor universally accepted definition of end-of-life care, but it is generally understood to be the care of a person who is identified as having failing health and who is in a progressive state of decline (Shipman et al., 2008). Establishing the last phase of a patient’s life can be a difficult and complex process, and this might occur:…● after the diagnosis of a life-limiting condition; ● during the transition or deterioration of a chronic disease illness; ● when there is an increasing frailty combined with greater dependence on care provision, particularly in the older adult; ● following a sudden infective episode, cardiac event, or a life-threatening accident….The last phase of end-of-life care is referred to as the dying phase. Consideration of the end-of-life care needs of people with chronic terminal conditions should begin at diagnosis, and must embrace after-death care and family support. Over the past century, progress and advancement in disease management, together with improvements in living standards, have resulted in changes to the national death profile, with currently two-thirds of the 0.5 million annual deaths in the UK occurring in people over 75 years of age.

Managing Delirium and Confusion

This chapter focuses on the assessment, management, and diagnosis of delirium, one form of confusion that commonly presents in healthcare settings. It will equip you with the skills required to differentiate between dementia, delirium, and depression through comprehensive assessment, and will improve the confidence of practising nurses in the management of this debilitating condition. This chapter will help you to select and implement evidence-based strategies to manage patients presenting with confusion regardless of the cause of confusion, such as dementia (see Chapter 7 Understanding Dementia). Confusion is derived from the Latin verb confundere, meaning ‘to mingle’. It is a descriptive term that has a variety of different definitions. It has been defined as a disturbance of consciousness characterized by impaired capacity to think clearly and with customary rapidity, and to perceive, respond, to, and remember current stimuli, and some degree of disorientation (Faber and Faber, 1953). Disorders causing confusion can be categorized into three groups:…● acute disorders usually associated with acute illness, drugs, and environmental factors; ● more slowly progressive impairment of cognitive function, such as that seen in dementia syndromes; ● impaired cognitive function associated with affective disorders and psychoses such as depression….Regardless of aetiology, confusion can be very distressing for the person exhibiting these symptoms, his or her relatives and carers, and for health and social care practitioners. It is important to differentiate between different causes of confusion for appropriate treatment plans to be developed. The word delirium is derived from Latin, meaning ‘off the track’, and is often referred to as acute confusional state. Delirium is a common and distressing disorder associated with increases in physical morbidity, length of hospital stay, and entry to long-term care, and therefore increases in cost to health services. However, it can be prevented and treated if dealt with urgently (National Institute for Health and Clinical Excellence (NICE), 2010a). The Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV TR), is used by clinicians and psychiatrists to diagnose psychiatric illnesses.

Managing Breathlessness

This chapter addresses the fundamental nursing in managing breathlessness. Every nurse should possess the knowledge and skills to assess patients holistically, to select and implement evidence-based strategies, to manage breathlessness, and to review the effectiveness of these to inform any necessary changes in care. The nurse has a key role in managing this often frightening symptom, which may be caused by many disorders, including certain heart and respiratory conditions, strenuous exercise, or anxiety. Breathlessness is described as a distressing subjective sensation of uncomfortable breathing (Mosby, 2009) and can be expressed as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990). The term dyspnoea, also meaning breathlessness, is derived from the Greek word for difficulty in breathing. Whilst it is difficult to estimate the prevalence of dyspnoea, it is apparent when we exercise beyond our normal tolerance levels; pathologically, dyspnoea occurs with little or no exertion and is a symptom response to different aetiologies (causes of illness). Breathlessness is a common symptom in patients with both cardiac (McCarthy et al., 1996) and respiratory disease (Dean, 2008), and also in people with neuromuscular diseases approaching the end of life; this can prove difficult and distressing to manage (see Chapter 18 Managing End-of-Life Care). There is a peak incidence of chronic dyspnoea in the 55–69 age group (Karnani, 2005), and the prevalence and severity of dyspnoea increases with age. This is associated with an increase in mortality and reduction in quality of life (Huijnen et al., 2006). It is estimated that 70% of all terminal cancer patients experience breathlessness in their last 6 weeks of life (Davis, 1997). Both physiological and psychological responses (including pain, emotion, and anxiety) can lead to an increase in respiratory rate. Breathing is controlled by the respiratory centre in the medulla of the brain. Higher centres in the cerebral hemispheres can voluntarily control respiratory rate so that breathing can be temporarily stopped, slowed, or increased. The respiratory centre generates the basic rhythm of breathing, with the depth and rate being altered in response to the body’s requirements, mainly by nervous and chemical control (Ward and Linden, 2008).

Understanding Dementia

This chapter presents a comprehensive understanding of dementia as a commonly encountered condition/syndrome in the nursing care of older adults and offers insights into the health challenges faced by people living with dementia. It will provide nurses with the knowledge to be able to assess, manage, and care for people with dementia in an evidence-based and person-centred way. After a comprehensive overview of the causes, risk factors, and impact of dementia, it will outline best practice to deliver care, as well as to prevent or minimize further ill-health. Nursing assessments and priorities are highlighted throughout, and the nursing management of the symptoms and common health problems associated with dementia can be found in Chapters 14 and 17, respectively. In the past, dementia was most often described in terms of mental disability. However, it is now more often described in terms of neurological disability (i.e. changes in the brain). For example, the Mental Health Foundation describes dementia as:…A decline in mental ability which affects memory, thinking, problem-solving, concentration and perception….The NHS Choices website states:…Dementia describes the effects of certain conditions and diseases on a person’s mental ability, personality and behaviour….Dementia is generally classified according to two international classification systems: the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV); and the International Classification of Diseases tenth edition (ICD-10). Dementia can be defined as a syndrome whereby there is gradual death of brain cells, resulting in a loss of brain ability that is severe enough to interfere with normal activities of living for more than 6 months. Problems with brain function should not have been present at birth and it is not associated with a loss or alteration of consciousness. This latter point distinguishes dementia from delirium, which is a state of mental disorientation that can happen if you become medically unwell, also known as an ‘acute confusional state’ (Royal College of Psychiatrists, 2009). (See Chapter 11). It is vital that nurses hold central what dementia means for people living with it. For example, people will commonly experience changes to their perception, senses, memory, and the range of skills they need to carry out everyday activities.

Understanding Cancer

The aim of this chapter is provide an overview of cancer, a biologically similar, but diverse, group of diseases. Understanding the disease process will help the practising nurse to plan nursing care and to seek appropriate specialist advice. Cancer can affect almost any part of the body and has significance for different age groups and within different cultures, so the effect on the individual, the prognosis, and the treatment will significantly differ depending upon cancer site and treatment setting. This chapter will outline symptoms in relation to the site of the body affected to illustrate the effect of cancer on an individual, and consideration will also be given to the wider impact of the disease. This chapter is underpinned by the principles of evidence-based patient-centred care and will focus on the concepts associated with promoting lifestyles that reduce the risk of developing cancer, screening to identify those at risk, detection of early disease, and the care and management of the individual with and beyond cancer. Cancer refers to a condition in which there is abnormal growth of cells. The characteristics of cancer cells are that they divide uncontrollably, do not require stimulation for growth as do normal cells, and are not restrained by the presence of neighbouring cells. Because cancer is concerned with a failure in the growth control mechanism of the cell at a gene or DNA level and because there are potentially as many different types of cancer as there are types of body cell, no two cancers are exactly alike (Cancer Research UK, 2009). The site at which a cancer first develops (primary cancer), such as lung or breast, is often used broadly to describe it; however, cancer is generally defined by the origin of the type of cell that has become cancerous. The most frequent sites and types of cancer are as follows….● Carcinomas—arise in epithelial cells in the skin, gastrointestinal tract, and other internal organs, and make up about 85% of all cancers (Cancer Research UK, 2010a) ● Haematological (blood and lymphatic system) cancers—arise from blood or bone marrow cells; include leukaemia, lymphoma, and myeloma, and make up about 7% of all cancers, but leukaemia is the commonest cancer in children (Cancer Research UK, 2010b)…

Understanding Bone Conditions

The aim of this chapter is to provide nurses with the knowledge to be able to assess, manage, and care for people with bone conditions in an evidence-based and person-centred way. Bone conditions (a major category of musculoskeletal conditions) cover a wide spectrum of diseases, some of which may be considered mild and self-limiting, while others may have a significant impact upon the individual’s quality of life and ability to function. It is estimated that up to 30% of all GP consultations are about musculoskeletal complaints; many are age-associated, and population ageing will continue to increase this demand (Oliver, 2009). The chapter will focus on osteoporosis, hip fracture (perhaps the most serious and costly consequence of osteoporosis or osteopaenia), Paget’s disease, and osteoarthritis, respectively. The chapter will provide a broad overview of these common conditions, enabling a proactive approach to patient care within a multidisciplinary context, whether in the primary or secondary care setting. The nursing management of the symptoms and common health problems associated with bone conditions can be found in several Part 2 chapters, and these are highlighted throughout the chapter. Osteoporosis has been defined as:...A progressive systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. (WHO, 1994)…The World Health Organization (WHO) has recommended a clinical definition of osteoporosis based on a bone mineral density (BMD) measurement of the spine or hip, expressed in standard deviation (SD) units called T scores. Using this definition, an individual is classified as having osteoporosis if his or her T score is ≤–2.5 SD at the spine or hip (WHO, 1994). It is estimated that osteoporosis occurs in approximately 3 million people in the UK, resulting in more than 230,000 fractures per annum, the most frequent being hip, vertebral body, and forearm fractures. In total, 75,000 hip fractures occur annually (British Orthopaedic Association, 2007), with the average age of incidence being 84 and 83 in men and women, respectively (National Hip Fracture Database, 2010).

Managing Continence

This chapter addresses the fundamental role of continence management as a core nursing activity. Every nurse should possess the knowledge and skills to carry out an essential, but simple, continence assessment, as well as to select and implement evidence-based strategies to manage continence in all care settings (including hospital and community), and to review the effectiveness of these to inform any necessary changes in care. Despite being essential for dignity and compassionate care, continence needs are often not prioritized as highly by nurses as they are by patients and their relatives. For adults, the ability to control bladder and bowel emptying is very important to self-esteem and dignity. Continence is a complex specialty involving a number of disciplines, including specialist nurses, specialists in urology, gynaecology, physiotherapy, and elderly care, yet the prevalence of continence problems means that much depends on you as a registered nurse taking responsibility for initiating assessment and management. Continence issues frequently arise as a result of other healthcare problems, and you should remain constantly aware of this, identifying patients who are at risk of incontinence and helping embarrassed patients to seek help. Bladder and bowel control are taken for granted by most of us. Once continence is achieved during childhood, we expect to remain in charge of these bodily functions for the rest of our life. Temporary loss of continence commonly accompanies acute illness or hospitalization, particularly if mobility and/or cognition become impaired (Resnick et al., 1989), or if the disease or injury impacts directly on bladder or bowel function. If the bladder fails to function normally (such as an overactive bladder), lower urinary tract symptoms may be experienced, and these may include incontinence. If bowel habits are disrupted, this may result in faecal incontinence (FI), constipation, or both. Incontinence is also associated with long-term conditions, in particular those affecting the neurological system (Fowler et al., 2010). Dealing with incontinence is a very common activity for nurses, and it is easy to become inured to this, forgetting that, for the patient, the experience can be devastating. It is noteworthy that the International Continence Society defines urinary incontinence (UI) as being any involuntary leakage of urine (Abrams et al., 2002), and it is therefore a symptom (however slight) that you should never ignore.

Understanding Stroke

The aim of this chapter is to provide nurses with the knowledge to be able to assess, manage, and care for people with stroke in an evidence-based and person-centred way. The chapter will provide a comprehensive overview of the seven stages of stroke, exploring best practice to deliver care, as well as to prevent or minimize further ill-health. Nursing assessments and priorities are highlighted throughout, and the nursing management of the symptoms and common health problems associated with stroke can be found in Chapters 23, 24, and 27, respectively. Stroke is defined as the rapid onset of focal neurological deficit lasting more than 24 hours (in which the patient survives the initial event), with no apparent cause other than disruption of blood supply to the brain (World Health Organization, 1978). As well as being the third commonest cause of death only in middle- and high-income countries (WHO, 1978) (along with cancer and heart disease), stroke is the largest cause of adult physical disability in the world (Bath and Lees, 2000). However, owing to advances in research and evidence synthesis, stroke is now a preventable and treatable disease (National Collaborating Centre for Chronic Conditions (NCCC), 2008). Despite its relative small weight (approximately 2% of body weight), the brain requires 750 ml of bloodflow every minute, and consumes nearly 45% of arterial oxygen (Alexandrov, 2003). Bloodflow to the brain is assured through two circulatory systems (anterior and posterior), which are connected by the circle of Willis, and supplied by the internal carotid and vertebral arteries. Disruption of this bloodflow can be either in the form of a bleed (haemorrhagic stroke) or clot (ischaemic stroke), and the clinical presentation will vary depending on the location of the disruption in the brain. Ischaemic strokes are more common and account for almost 70% of all events (Wolfe et al., 2002). Whilst thorough clinical examination is essential, the only clear tool to identify the type of stroke is to perform a brain scan using either magnetic resonance imaging (MRI) or computed tomography (CT) technology. It is important to note that, often, when a CT brain scan is performed within the first few hours of an event, the scan may not show any significant tissue damage because the changes that occur may take several days to be clearly visible.