Biomedical subjects
Publications and source records attributed to E C Carr.
The impact of postoperative pain can be a devastating experience. While there has been a wealth of research to evaluate the effectiveness of pain relief, relatively few studies have considered how pain affects people. A study was therefore undertaken to explore the effect of postoperative pain on patient outcomes following major gynaecological surgery.
The adequacy of postoperative pain management in British hospitals appears insufficient to improve patient care, and much of the research and clinical audit in postoperative pain has failed to seek the patient's perspective. This paper reports on the findings from a semi-structured telephone interview survey which formed part of a hospital-wide audit on postoperative pain at a district general hospital in the south of England. Of a total of 360 completed audit questionnaires, 114 patients left their telephone number and 29 were interviewed. Content analysis revealed five main themes: inadequate information, pain at home, staff attitudes, expectations of pain, and ward atmosphere. Several patients identified insightful strategies that potentially could improve pain management. The telephone interview generated a richness of data that had not been reported before in this important area. Some authors view clinical audit and research as having different characteristics but this work raises important questions for both approaches when using the semi-structured telephone interview. The ethical issues pertaining to collection of audit data using the telephone interview are discussed.
One hundred female patients undergoing major reconstructive plastic or gynaecological surgery were randomized to either receive subcutaneous patient-controlled analgesia (PCA) (bolus dose 2.5 mg diamorphine in 1 ml with a 20-minute lockout) or intravenous PCA (bolus dose 0.5 mg diamorphine in 1 ml with a 5-minute lockout). Data were collected by questionnaire and interview to evaluate the intervention on pain scores, quality of sleep on the first postoperative night, postoperative nausea and vomiting (PONV) and overall patient acceptability. The subcutaneous PCA group experienced less 'worse pain' (P < 0.01) and less sleep disturbance due to pain (P < 0.001). Subcutaneous PCA would appear to offer patients a safe and effective means of analgesia and may offer significant advantages over the intravenous route of administration.
Pain control in hospital has long been documented as ineffective and problematic. A multi-professional group of clinicians formed to consider how they might continue to improve pain management at a district general hospital. Following a pain audit, in general wards, it became apparent that pain assessment tools were not being used. The group devised a draft pilot assessment tool and care plan which was piloted over a 2-week period on a rehabilitation ward for elderly people. A review of these documents revealed that pain assessment using the body map ascertained considerable detail about the pain location, and the pain ruler elicited pain intensity and associated descriptors. None of the documented goals for pain were measurable, and interventions focused on analgesia and actions to relieve the physical cause of the pain. No psychosocial interventions were mentioned. All care plans were evaluated at least once but 44% of evaluations did not refer to the pain. On this ward, these outcomes suggest the pain assessment tool has the potential to improve communication of pain between the patient and the nurse but there is an urgent need for education to enable this information to be used effectively and develop pain management strategies which reflect the multidimensional nature of pain.
This study uses a qualitative approach to explore patients' expectations and experiences of pain, factors contributing to the effective/ineffective management of their pain and strategies patients reported as helpful when experiencing pain. Ten patients on a mixed surgical ward at a District General Hospital in the south of England participated in the study. Pain scores, using a visual analogue scale, were obtained for 'expected' pain preoperatively and 'worst pain experienced'. A taped in-depth interview exploring patients' experience of pain after surgery took place on the fifth post-operative day. Details of analgesia were also collected for the 5 days following surgery. Patients expected pain after surgery but the intensity of the pain they experienced was often significantly greater than anticipated. Lack of information, inadequate pain assessment and ineffective pain control contributed to this finding. It is suggested that new pain technology, such as epidural and patient-controlled analgesia, may not change the prevalence and incidence of pain unless the systems these technologies are placed within also change.
Reflection can be seen as a useful tool to enable the practitioner to explore the everyday world of clinical practice. This paper reviews the background to reflection and its relevance to nursing in reducing the theory--practice gap and its role in generating theory from practice. Exemplars from clinical practice are reflected upon and Carper's (1978) 'Patterns of Knowing' are used as a framework to identify nursing knowledge embedded in practice. The process of reflection is critically discussed in the light of the author's experience.
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Carbamylated haemoglobin arises from the non-enzymic modification of haemoglobin monomers by isocyanate derived from the spontaneous dissociation of urea. We measured carbamylated haemoglobin by high performance liquid chromatography in healthy subjects, non-uraemic hospital patients, diabetics, and different groups of uraemic patients. Carbamylated haemoglobin levels were found to be raised in uraemic subjects, but were independent of age, sex, glycaemic state and haemodialysis procedure. There was no significant difference in carbamylated haemoglobin levels between two groups of patients having different modes of dialysis treatment, probably indicating a similar degree of uraemic exposure in these patients.
Urea kinetic modelling (UKM) has increasingly been used for assessing adequacy of dialysis and protein nutritional status of dialysis patients. Using a precise HPLC method we developed, we measured carbamylated haemoglobin (CarHb) values in 20 stable twice-weekly dialysed patients and attempted to correlate their CarHb values with their UKM-derived indices. Based on these indices, 11 patients were found to have been adequately dialysed with sufficient protein intake, three patients were adequately dialysed but malnourished and six patients were under-dialysed. Estimated dietary protein intake correlated poorly with calculated daily protein catabolic rate in our patients. CarHb values were found to correlate strongly with the time-averaged urea concentrations, suggesting that CarHb might be a time-integrated urea-derived index. Those adequately dialysed patients have a mean (SD) CarHb value of 142 (29) micrograms CV/gHb against the underdialysed patients, 197 (30) micrograms CV/gHb (t-test, P = 0.002). We suggest that a CarHb value less than 175 micrograms CV/gHb may represent satisfactory uraemic exposure, whereas CarHb value greater than 175 micrograms CV/gHb is undesirable.
Recent evidence suggests that postoperative pain is poorly controlled and it is reported that nearly 75% of hospitalized patients failed to receive adequate pain relief. It was hypothesized that there was no difference between expected and experienced pain and that pain scores on the first postoperative day would be 'low'. Factors affecting the management of pain were identified using a patient questionnaire. A Visual Analogue Scale was used to measure patients' pain, pre- and post-operatively. A patient questionnaire explored pain experience and identified contributing factors. A review of all analgesia prescribed and given to the patients was undertaken. Twenty-one surgical patients participated in the study. There was a significant difference between preoperative expectations and postoperative experience of pain. No relationship was found between the doses of analgesia and pain scores on the first day postoperatively and pain scores on the first day postoperatively were not 'low'. The nurse did not play a key role in the preoperative information given to the patient. Patients experienced 'worsened' pain in the morning and evening. Nurses questioning patients about their pain often failed to identify those in pain.
We have developed an HPLC method for measuring carbamylated hemoglobin (CarHb), based on the quantification of valine hydantoin formed from the released NH2-terminal carbamyl valine residue after acid hydrolysis of hemoglobin. In uremia, CarHb is produced by nonenzymatic post-translational modification of the terminal amino group of hemoglobin monomers by isocyanic acid, derived from the spontaneous dissociation of urea. We measured CarHb in 25 nonuremic control subjects, 24 nonuremic diabetic subjects, and 30 patients with stable chronic renal failure. There was no significant difference between the controls and diabetic patients, their mean (SD) CarHb values being 41 (11.5) and 38 (10.8) micrograms of carbamyl valine per gram of hemoglobin (microgram CV/gHb), respectively. Mean (SD) CarHb values in the uremic patients were much greater, 164 (87.7) microgram CV/gHb. There was significant correlation between the concentrations of CarHb and plasma urea in the uremic subjects. Thus CarHb provides a urea-derived index of chronic uremia.
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