Case Study Analysis: Post-Operative Pain Management for Mr. Hemsley

This case study analyzes the post-operative care of Mr. Hemsley, focusing on pain management and wound assessment following a sigmoid colostomy. The study examines the administration of morphine for pain, highlighting the potential for Central Nervous System (CNS) toxicity and the importance of careful dosage adjustments and monitoring by nurses. It also explores non-pharmacological interventions, specifically mindfulness meditation, as a method to manage post-operative pain and promote healing. Furthermore, the case study emphasizes the crucial nursing considerations for wound assessment, including monitoring for infection, assessing stoma and peristomal skin, and implementing appropriate interventions to promote healing and prevent complications. The case study utilizes various research articles to support the nursing interventions and considerations.

Case Study

Table of Contents
Question 1....................................................................................................................................1
Question 2....................................................................................................................................2
Question 3....................................................................................................................................3
REFERENCES................................................................................................................................4

Question 1
After the surgery, Mr. Hemsly has been ordered PRN I.V. 2.5 to 5 mg morphine for
management of pain. During this, nursing consideration related to Central Nervous System
(CNS) toxicity can be taken into account which requires the nurses to avoid giving high doses of
Morphine. According to Bounes and et.al., (2017), opioids are considered to be broad spectrum
analgesics which provide relief from pain. However, these medications have been found to be
associated with a wide range of side effects. Dahan and et.al., (2020) found that CNS toxicity is
one of the side effects of Morphine which are caused due to high doses. This includes excitation
of the central nervous systems which further results in convulsion. Deer and et.al., (2019) found
that high doses of morphine if administered intravenously may be accompanied by CNS toxicity.
There may also be presence of dysphoric reactions after any size dose.
According to Mahshidfar and et.al. (2017), the usual starting dose for intra venous
injection of morphine in adults is 0.1 mg to0.2 mg per kg every 4 hours. While caring for Mr.
Hemsley, the nurses are required to take care that this dosage needs to be adjusted according to
the pain severity. It also needs to be adjusted based upon the occurrence of adverse events.
Morad and Farrokh (2018) state that the dosage of morphine should take into account the
underlying disease of the patient as well as his age. Li and et.al., (2017) found morphine to be a
lethal medication associated with various symptoms related to depression of the CNS. CNS
toxicity can be manifested in the form of lightheadedness and visual and auditory disturbances.
This may be accompanied by muscle twitching, shivering and tremors that generally involve
muscles of face as well as extremities. According to Bounes and et.al., (2017), when morphine is
administered in sufficiently large dose the initial symptoms of CNS toxicity may be followed by
generalized state of CNS depression.
Telford (2020) found that CNS toxicity occurs due to excitation of the CNS which may
be caused when inhibitory pathways in the cerebral cortex are initially blocked. It can also be
caused due to net stimulation of release of glutamate which is an excitatory amino acid
neurotransmitter. Which inhibitory pathways are blocked, the facilitatory neuron are allowed to
function in an unopposed fashion. As a result of this there is an increase in the excitatory activity
which further causes convulsions. If the dosage is further increased, it can lead to inhibition of
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the activity of facilitatory as well as inhibitory circuits. Following it, a generalized state of
depression of the CNS is resulted. Therefore, it is important for the nurses to administer suitable
dose of Morphine to Mr. Hemsley and assess the signs of CNS toxicity.
Question 2
In order to help Mr. Hemsley manage post -operative pain, mindfulness meditation is a
non- pharmacological method that could be implemented. dos Santos Felix and et.al., (2019)
found that mindfulness meditation is a type of mental training practice which involves slowing
down the racing thoughts and calming both mind as well as body. This technique comprises of a
combination of meditation with the practice of mindfulness. Tola, Chow and Liang (2021) stated
that mindfulness is a mental state in which an individual is fully focused upon present. It
involves acceprti8ng thoughts, sensations and feelings without any judgement. Nascimento,
Oliveira and DeSantana (2018) asserted that the technique of mindfulness meditation comprises
of deep breathing and helps to make an individual aware of body and mind.
According to Jinich-Diamant and et.al. (2020), relaxation techniques such as mindfulness
meditation are effective in reducing post operative pain. It helps in reducing the intensity and
unpleasantness of pain. This is because various regions of the brain are impacted due to
mindfulness meditation technique. These include high level executive functioning, sensory
processing, and contextual evaluations. Due to this, mindfulness relies upon various neural
mechanisms for pain management. Deng (2019) found that by observing and accepting the
discomfort, an individual’s tolerance for pain increases. This is because, during meditation, an
individual is able to relax his mind and body. In this way, mindful meditation is an effective non-
pharmacological method for post- operative pain. This helps in releasing endorphins which are
also called as the ‘feel good’ hormones.
According to dos Santos Felix and et.al., (2019), meditation is effective and enables an
individual to calm down and observe sensations in the body. This relaxes the body and helps in
accepting the pain and discomfort. Therefore, in Mr. Hemsley case various sessions of
mindfulness meditation will assist him in accepting the pain and discomfort and observing it
precisely. Mindfulness will assist in feeling the sensations of pain leading to its acceptance. By
accepting the pain, an individual will be able to cope with it in a better manner. Smaller sessions
of the mindfulness meditation can be started moving towards longer sessions. Gumus and et.al.
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(2020) argued that mindfulness meditation also assists in speedy healing after surgery. This
healing process also helps in better management of post -operative pain. Jinich-Diamant and
et.al. (2020) found that meditation plays a significant role in healing process post- surgery as it
provides strength to the immune system. Meditation also helps in changing the perspective of
the patient about the surgery or circumstance. It calms the nervous system which assists in
speedy recovery by stopping both the fight or flight mechanisms.
Question 3
Mr. Hemsley has undergone sigmoid colostomy. Assessment of wound is an important
nursing consideration when taking care of a patient with colostomy during post- operative
period. According to Sun and et.al., (2017), nurses need to observe wound and note
characteristics of draining. This is required for avoiding complications such as post- operative
hemorrhage. As per the views of Suwanabol and Hardiman (2018), in the first 48 hours of
surgery, infection may develop any time. This makes it important for the nurses to consider
wound assessment at regular intervals to check for any signs of infection. Wound assessment
helps in identifying early signs and symptoms of infections and other complications which may
occur post colostomy. Following it, the nurses are required to adopt suitable pharmacological
and non- pharmacological interventions for treating the complications. Negri and et.al. (2019)
asserted that wound assessment post colostomy is also essential to check for the recovery and
healing process.
According to Zelga (2021) The nursing consideration of wound assessment requires the
nurse to assess the stoma and peristomal skin. The color of the stoma should be red and it should
be raised above the level of the skin. The nurses also and to assess the skin around stoma which
should ideally be intact and free from rashes or breakdown. Huang and et.al. (2021) found that
there is need for wound assessment post colostomy to check for signs of infection or skin
integrity. This helps in adopting early intervention thus reducing the chances of complications
such as infection. According to Berti-Hearn and Elliott (2019), wound assessment is important as
it helps in defining the status of a wound. With this, the nurses are able to identify impediments
to the healing process. Wound assessment after colostomy is also important as it helps in
adopting appropriate skin protection regime (Sujianto, Billy and Margawati, 2020). Wound
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assessment helps in identifying the stage of the healing process and helps in making decisions
regarding adoption of appropriate interventions for keeping the skin healthy.
REFERENCES
Journals and Books
Berti-Hearn, L., & Elliott, B. (2019). Colostomy care: a guide for home care clinicians. Home
healthcare now, 37(2), 68-78.
Bounes, V., Charriton-Dadone, B., Levraut, J., Delangue, C., Carpentier, F., Mary-Chalon, S., ...
& Ganetsky, M. (2017). Predicting morphine related side effects in the ED: An
international cohort study. The American Journal of Emergency Medicine, 35(4), 531-
535.
Dahan, A., van Dam, C. J., Niesters, M., van Velzen, M., Fossler, M. J., Demitrack, M. A., &
Olofsen, E. (2020). Benefit and risk evaluation of biased μ-receptor agonist oliceridine
versus morphine. Anesthesiology, 133(3), 559-568.
Deer, T. R., Pope, J. E., Hanes, M. C., & McDowell, G. C. (2019). Intrathecal therapy for
chronic pain: a review of morphine and ziconotide as firstline options. Pain
Medicine, 20(4), 784-798.
Deng, G. (2019). Integrative medicine therapies for pain management in cancer patients. Cancer
Journal (Sudbury, Mass.), 25(5), 343.
dos Santos Felix, M. M., Ferreira, M. B. G., da Cruz, L. F., & Barbosa, M. H. (2019). Relaxation
therapy with guided imagery for postoperative pain management: an integrative
review. Pain Management Nursing, 20(1), 3-9.
Gumus,K., Musuroglu, S., Ozlu, Z.K., & Tasci, O. (2020). Determining the Use of
Nonpharmacologic Methods by Surgical Nurses for Postoperative Pain
Management and the Influencing Professional Factors: A Multicenter Study. Journal of
PeriAnesthesia Nursing, 35, 75-
79. https://doi.org/10.1016/j.jopan.2019.04.011
Huang, Q., Zhuang, Y., Ye, X., Li, M., Liu, Z., Li, J., & Pan, Z. (2021). The effect of online
training-based continuous nursing care for rectal cancer-patients undergoing permanent
colostomy. American Journal of Translational Research, 13(4), 3084.
Jinich-Diamant, A., Garland, E., Baumgartner, J., Gonzalez, N., Riegner, G., Birenbaum, J., ... &
Zeidan, F. (2020). Neurophysiological Mechanisms Supporting Mindfulness Meditation–
Based Pain Relief: an Updated Review. Current pain and headache reports, 24(10), 1-10.
Li, H., Yang, L., Guo, Z., Tang, Y., Chen, N., Lu, Y., & Ni, J. (2017). Successful treatment of
refractory cancer pain with morphine and ropivacaine: A case report. Medicine, 96(22).
Mahshidfar, B., Mofidi, M., Fattahi, M., Farsi, D., Moghadam, P. H., Abbasi, S., & Rezai, M.
(2017). Acute pain management in emergency department, low dose ketamine versus
morphine, a randomized clinical trial. Anesthesiology and pain medicine, 7(6).
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Morad, A., & Farrokh, S. (2018). Pain management. In Essentials of Anesthesia for
Neurotrauma (pp. 447-460). CRC Press.
Nascimento, S. S., Oliveira, L. R., & DeSantana, J. M. (2018). Correlations between brain
changes and pain management after cognitive and meditative therapies: a systematic
review of neuroimaging studies. Complementary therapies in medicine, 39, 137-145.
Negri, E. C., Pereira, G. A., Cotta, C. K., Franzon, J. C., & Mazzo, A. (2019). Construction and
validation of simulated scenario for nursing care to colostomy patients. Texto &
Contexto-Enfermagem, 28.
Sujianto, U., Billy, R., & Margawati, A. (2020). Family’s Experience: Nursing Care for
Colorectal Cancer Patients with Colostomy. Nurse Media Journal of Nursing, 10(1), 96-
107.
Sun, X., Wu, S., Xie, T., & Zhang, J. (2017). Combing a novel device and negative pressure
wound therapy for managing the wound around a colostomy in the open abdomen: a case
report. Medicine, 96(52).
Suwanabol, P. A., & Hardiman, K. M. (2018). Prevention and management of colostomy
complications: retraction and stenosis. Diseases of the Colon & Rectum, 61(12), 1344-
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Telford, A. (2020). Role of the nurse in supporting the safe use of opioids. Nursing Standard,
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Tola, Y. O., Chow, K. M., & Liang, W. (2021). Effects of non‐pharmacological interventions on
preoperative anxiety and postoperative pain in patients undergoing breast cancer surgery:
A systematic review. Journal of Clinical Nursing, 30(23-24), 3369-3384.
Zelga, P., Kluska, P., Zelga, M., Piasecka-Zelga, J., & Dziki, A. (2021). Patient-Related Factors
Associated With Stoma and Peristomal Complications Following Fecal Ostomy
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