The Acute Pain Service Nurse Practitioner: A Case Study in the Postoperative Care of the Child With Bladder Exstrophy

Lori J.Kozlowski, MS, RN, CPNP

Disclosures

J Pediatr Health Care. 2008;22(6):351-359. 

In This Article

Role of the PNP

Day-to-day management of this complex patient population is a shared task among several clinicians. The PNPs complete the pain assessment using valid and reliable tools. Pain and sedation goals are set and plans of care initiated. Pharmacologic interventions and nonpharmacologic therapies are recommended. The NPs of the Pain Service are involved immediately after surgery in the initiation of epidural or intravenous PCA for analgesia. Vigilant monitoring is necessary, especially with epidural therapy, because of the potential for drug toxicity as well as technical difficulties. Care of the catheter requires repeated physical assessments of the child and catheter site and strict attention to the prevention of infection. With careful nursing care and supervision by the Pain Service, prolonged analgesia with an epidural is feasible and safe.

Adjuvant medications to achieve appropriate immobilization may not be necessary in the immediate postoperative period while the effects of anesthesia are still present, but orders need to be present so that the bedside nurses can quickly deal with movement of the pelvis or lower extremities. The first 24 to 72 hours following surgery typically gives the practitioner some idea of the child's medication requirements. The child usually is admitted to the ICU during the initial postoperative period so his or her medication needs and response to these medications can be monitored. If he or she is stable on a regimen that can be safely administered on the general care unit, the child is transferred. The efficacy of treatment must be assessed and reassessed continuously and measured against the planned goals. Often several visits a day are needed to monitor analgesia and sedation. There is ongoing staff education and assistance with assessment, titration of opioids and benzodiazepines, and decision making as staff determine whether a moving child needs more analgesia or sedation. The staff also has frequent contact with the urology service to assess effectiveness of the regimen. Sometimes a child may need to be transferred back to the ICU if his or her medication requirements cannot be safely administered in the floor setting.

Keeping these children content while immobilized takes a multidisciplinary effort. The Child Life staff and their volunteer corps are an invaluable resource to children, their families, and to the Pain Service. Using nonpharmacologic strategies to assist with immobilization is as important as pharmacologic support and may even allow decreased use of medications. Child Life staff provide developmental play such as creatively dangling toys from the traction bed and providing special desks for children to use for coloring and other activities while flat in bed. They provide medical play and use visual imagery techniques during painful procedures such as cleaning of the fixator pins. They can help older children have some control over their day by establishing daily schedules with their input. Humor is provided by visits from the Big Apple Circus clown corps. Supportive listening and spiritual support for the children and their families is provided by the chaplaincy service. The NPs communicate daily with these colleagues to discuss goals of care.

Families have their own set of concerns and fears while their child is hospitalized. They have shared that they are most concerned about several things, including surgical success, keeping their child content and pain free, long-term effects of pain and sedation medications, and finding "escapes" for themselves. Parental bonding, especially with a newborn infant in traction, can be another area of concern with our families. When possible, children are placed in a bed that can accommodate a parent/caregiver to provide valuable "snuggle time." Breastfeeding is encouraged and supported. The Pain Service NPs provide ongoing education and guidance to families as they help address these concerns. Information on the rationale for specific treatment modalities and potential adverse effects is discussed daily and often multiple times throughout the day as plans of care change.

Once it is determined that pins and/or traction can be removed, at which time the child's movements can be liberalized, the Pain Service can begin weaning medications. As previously discussed, methadone often is used as an oral agent for weaning. In most cases, weaning of benzodiazepines and opioids is not complete by the time of discharge. The Pain Service NP is responsible for developing a schedule for further weaning as an outpatient and reviewing this schedule with the family. At our institution, many families are from outside the United States, so international services are needed to assist in the interpretation of these schedules. The Pain Service remains available at all times to the families to provide assistance with the weaning process and to community physicians continuing the care of these children once they return home. Because these children return to the Children's Center for further stages of their reconstruction, the Pain Service NPs provide continuity of care for their ongoing analgesic and sedation needs.

The bedside nurse must be informed and confident in the analgesic and sedation techniques used. It is not the aim of the Pain Service NPs to restrict the bedside nurse role in pain management, but rather to expand and support it. The NPs have a collegial relationship with the nursing staff, allowing for consultation in a supportive environment. Appropriate nursing education is essential so that analgesic and sedative modalities can be administered safely. The Pain Service NPs provide ongoing formal education to the nursing staff, including orientation classes for new nurses and advanced education for experienced nurses, as well as ongoing monthly programs. Informal education at the bedside occurs daily. Preceptorships are offered to bedside nurses as an opportunity to observe pain management role models in action. A pain management curriculum is offered to various undergraduate and graduate nursing programs in the area. Nursing students participate in clinical rotations with the Pain Service practitioners. Pain protocols, standards, and policies are developed in conjunction with nursing colleagues from the various hospital units. They are used to direct safe use of therapies such as epidurals and intravenous PCA. Particular attention is directed to the development of educational materials for families so that they can safely use parent-controlled analgesia. The NPs participate in development of standardized order sets, which include adverse effect management so there is a consistency in drugs used and dosages and prompt treatment of adverse effects. Standards for pain assessment and documentation are defined and implemented with direct input from the Pain Service practitioners. Physicians and Child Life colleagues also are exposed to ongoing pain education opportunities. The NPs present at various physician educational forums, participate in anesthesiology fellow orientation programs, and provide pain education during Child Life orientation. Educational materials such as "quick reference" cards for new residents and educational posters during Pain Awareness Month are made available.

Continuous quality improvement and involvement in research is essential to delivery of quality care, reducing risk, and improving outcomes in this patient population. The Pain Service NPs monitor epidural complications such as unintentional loss of catheters as well as naloxone administration for respiratory depression in children receiving epidural or intravenous analgesia. Compliance with standards and competencies in pain assessment and management is monitored. The NPs review current literature and research pertaining to epidural and intravenous PCA adjuvants, new sedation medications and protocols, and opioid conversion recommendations and weaning guidelines and apply these findings to the exstrophy population. The NPs are involved in various research initiatives that address these and other care improvement topics.

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