University of Tasmania Nursing Report: Pain Management in ACS

This report focuses on the pain management of an 88-year-old patient admitted to a cardiovascular ward with acute compartment syndrome following a lower limb fracture. The report details the patient's initial presentation, including vital signs and physical examination findings, and discusses the pathophysiology of compartment syndrome. The chosen aspect of care is the use of morphine for pain management, with a rationale provided for its selection based on the patient's severe pain levels and the ineffectiveness of alternative analgesics. The report explores the effectiveness of morphine, its mechanism of action, and potential adverse effects, including respiratory depression. It also includes a reflection on the administration of medication, the importance of evidence-based practice, and the challenges encountered in the patient's care. The report references relevant literature to support the chosen interventions and reflects on the nurse's role and responsibilities in medication administration, clinical reasoning, and patient-centered care. The Harvard referencing style is used throughout the report.

Running head: WRITTEN REPORT
WRITTEN REPORT
Name of the Student
Name of the university
Author’s note

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WRITTEN REPORT
Brief outline of the case
My placement was in the cardiovascular ward, where a patient has been admitted with a
compartment syndrome following a lower limb fracture. Mr X is an 88 years old man who lives
in a home on his own. While using the toilet she had suffered from a fall and was admitted in to
the emergency department with acute pain in the lower limb. Further examination revealed a
fracture in the lower leg. Mr. X denied the use of alcohol or drugs, his initial vital signs were
pulse of 76 beats per minute, oral temperature of 36.8 degree , blood pressure of 144/96 mmHg,
room air pulse oximetry of 100%, respiratory rate of 16 breaths per minute. Right leg revealed it
to be firm and tender to palpation and measured 4 cm larger in the circumference than the left
leg. The radial pulse was palpable and the fingertip capillary refill was less than two seconds.
The skin was reddish and swollen with no overlying erythema.
Compartment syndrome after lower limb fracture
A compartment is a group of muscles, blood vessels and the nerve fibers. Fascia is a
connective tissue that holds the walls of the compartments. ACS occurs when pressure and fluid
builds up in the muscles due to a limb fracture (Oprel et al. 2010). This pressure can decrease the
flow of the blood to and from the nerve and the muscle cells decreasing the access and the
nutrients to the affected tissue. The acute compartment syndrome (ACS) right after the fracture
of the lower leg can be a serious complication. ACS of the lower leg if not recognized and kept
undiagnosed can result in life threatening condition (Oprel et al. 2010). Prognosis for the full
recovery is dependent on the early diagnosis and treatment of the condition. The acute
intervention for tis is the fasciotomy because ACS can induce nerve and muscle damage

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(Tosounidis 2015). A late diagnosis of the ACS of the lower leg and the failure to perform an
emergency facsiotomy can lead to the loss of the extremity. Early facsiotomy can be helpful in
preventing the neuromuscular damage. Prevention should be considered as the first step in the
treatment of the compartment syndrome. The classic sign of an acute compartment syndrome is
pain, especially when the muscle within the compartment is stretched. Using and the stretching
of the involved muscle induces pain.
Chosen aspect of care
Using morphine (opoids) for pain management
An approach the patients with acute pain begins with the assessment of the underlying
cause of the pain. Right after the fracture a patient experiences acute pain that has to be managed
by pharmacological interventions (Ahmadi et al. 2016). It is the pain status of the patient that
determines the time of the surgery. Hence he chosen aspect of care for this report is the pain
management. The scope of a registered nurse lies within the provision of medicines specifically
for relieving the pain. Many recent and emerging studies have clearly documented that persistent
pain exerts profound effect of the endocrine system, cardiovascular, neurologic, and immune and
the musculo-skeletal system of the body (Ahmadi et al. 2016). This provides the rationale for
choosing this aspect of care. Analgesics can be warranted in patient suffering from ACS.
Acetaminophen and non-steroidal anti-inflammatory drugs are also used for the management of
the pain. But if the pain is severe then opoids can be used.

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Rationale for choosing morphine as the pain management
Patients that commonly present to the emergency department with suspected long bone
fractures require early and effective analgesia (Ahmadi et al. 2016). The in-hospital management
of the pain is considered as suboptimal and most of the patients are dissatisfied with the
treatment. Intravenous morphine has always been the main treatment for the management of pain
in patient having acute to moderate limb trauma (Oprel et al. 2010). In my scope of practice,
while I was attending patient X, at first non-opoid oral medications were applied, which could
not manage the pain to greater extent. Previously, we thought of applying Tylenol in
combination with Ibuprofen but this could not manage pain in the patient and the patient was
found to be allergic Acetaminophen. The rating of the patient in the numeric rating scale was
measured in between 7-8, which indicated severe pain. Finally with the application of Morphine,
the pain started to neutralize. Mr X’s tolerance towards Morphine and its effectiveness in
reducing the pain, provided the rationale for using Morphine. According Smith & Wolford
(2015), opoids have been found to be effective in managing pain than the NSAIDs. Intravenous
paracetamol supplemented with intravenous morphine has been found to be useful. The
morphine binds to the opoid receptors and the molecular signaling activates the receptors or
mediating certain actions. Morphine works as a powerful μ agonist. The active metabolite of
morphine is Morphine-6-glucuronide (M6G) that produces an analgesic effect and is the first
choice of treatment for intense non-iceptive pain (Mann & Carr 2018). However Von Keudell et
al.(2016) has argued that once used in high doses morphine can increase the pain, but this can be
linked to the fact that abnormal metabolism of morphine can produce M3G as opposed to M6G.
In such case morphine should be titrated to appropriate dosages (National Clinical Guideline

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Centre. 2016). However it was found that Morphine if applied in a 6-8 interval or longer and
produce desired effects.
One thing that has to be considered about the application of morphine is the respiratory
depressant effect of morphine. It has been found that it may cause an increase in the arterial
PCO2 that can cause intracranial pressure (Boyer 2012). Since the patient is an elderly patient
hence one has to be careful about the dosages. Although opoids have been considered as an
appropriate alternatives for the management of acute pain, opoid related adverse effects can act
as a barrier to analgesia. As stated by Pechar & Lyons (2016) the side effects associated to opoid
therapy involves nausea, vomiting, diarrhea (Mollaei et al. 2016). And side effects have been
found to be occurring in a large group of patients. Initially the patient, Mr X was having
delirium, when we thought of using naxolone hydrochloride for reducing the respiratory
depression and the sedation. But as the patient started to develop tolerance to the drug he started
responding well (Pechar & Lyons 2016).
Reflection
Administration of medicines are an integral part of the role of an RN. Medications are
generally prescribed by the doctors and are dispensed off by the pharmacist but the
accountability and the responsibility of the medication administration lies with the nurses. As a
registered nurse I am accountable for the checking, updating the knowledge of the medications,
preparing and administering the medication, to keep a check on any adverse reactions. Owing to
the adverse effects of the opioids, I was a bit mindful and nervous about the dosages.
While brainstorming through the databases regarding the effectiveness of morphine. It
was found that the several literatures were in support of the NSAIDs instead of opoid

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medications, but only in case of mild to moderate pain. Hence the treatment might not appear to
go in congruency with the evidences but the application of morphine to the concerned patient has
been useful. The dosages were accurate and the patient did not have any adverse reaction. This
experience of administrating an intravenous drug and self-reflecting on this case will help me in
my future scope of practice. This quality of evidence based practice in nursing would help in the
provision of a patient centered care by improving the ability of critical thinking and clinical
reasoning.

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References
Ahmadi, A., Bazargan-Hejazi, S., Heidari Zadie, Z., Euasobhon, P., Ketumarn, P.,
Karbasfrushan, A., … Mohammadi, R. 2016. Pain management in trauma: A review study.
Journal of Injury and Violence Research, vol 8, no. 2.pp. 89–98
Boyer, E.W., 2012. Management of opioid analgesic overdose. New England Journal of
Medicine, vol.367, no.2, pp.146-155.
Mann, E. & Carr, E., 2018. Pain management. Foundation Studies for Caring: Using Student-
Centred Learning, p.259.
Mollaei, M., Esmailian, M. & Heydari, F., 2016. Comparing the effect of intravenous
acetaminophen (Apotelï¿ ½) and intravenous morphine in controlling the pain of forearm and leg
fractures in adults. Journal of Isfahan Medical School, vol.34, no.376, pp.293-298.
National Clinical Guideline Centre (UK). Fractures (Non-Complex): Assessment and
Management. London: National Institute for Health and Care Excellence (UK); 2016 Feb. (NICE
Guideline, No. 38.) 6, Initial pain management. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK368141/
Oprel, P. P., Eversdijk, M. G., Vlot, J., Tuinebreijer, W. E., & den Hartog, D. 2010. The Acute
Compartment Syndrome of the Lower Leg: A Difficult Diagnosis? The Open Orthopaedics
Journal, vol.4, pp. 115–119.
Pechar, J., & Lyons, M. M. (2016). Acute Compartment Syndrome of the Lower Leg: A Review.
The Journal for Nurse Practitioners : JNP, vol. 12, no.4, pp.265–270.

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Smith, K., & Wolford, R. W. 2015. Acute Idiopathic Compartment Syndrome of the Forearm in
an Adolescent. Western Journal of Emergency Medicine, vol. 16, no.1, PP.158–160.
Tosounidis, T.H., Sheikh, H., Stone, M.H. & Giannoudis, P.V., 2015. Pain relief management
following proximal femoral fractures: Options, issues and controversies. Injury, vol.46, pp.S52-
S58.
Von Keudell, A.G., Weaver, M.J., Appleton, P.T., Bae, D.S., Dyer, G.S., Heng, M., Jupiter, J.B.
& Vrahas, M.S., 2015. Diagnosis and treatment of acute extremity compartment syndrome. The
Lancet, vol.386, no.10000, pp.1299-1310.