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Chronic Pain Using The Levett-Jones Clinical Reasoning Cycle

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Question:

Discuss about the Chronic Pain Using the Levett-Jones Clinical Reasoning Cycle.

 

Answer:

Introduction:

Chronic pain is an insidious health problem that affects almost all aspects of a patient’s life. Chronic pain has adverse implications on a patient’s physical and psycho-social functioning. Consequently, a health care professional, who in this case has the significant responsibility in the management of chronic pain, must be able to identify the effect of pain on the patient as well as the family of the patient and come up with ways of assessing the situation. Levett-Jones et al. (2015) argue that an efficient nurse-patient relationship is one of the most fundamental elements which should be incorporated in the chronic pain management process. The purpose of this paper therefore is to assess John Ryan’s case of chronic pain using Levett-Jones clinical reasoning cycle.

 

Depending on Ryan’s case and considering that it is the first encounter with him a number of activities during this initial visit would be necessary. These activities and priorities will be essential in the management of the Ryan’s recurring pain and will also be of assistance in decision-making and ensuring provision of high health care to the patient. Ryan’s case would be developed within the eight stages involved in clinical reasoning which include; consideration of the patient’s situation, gathering of information, identification of the problems, identification of goals, taking an action, assessment of the outcomes and reflection (Levette-Jones & Bourgeois , 2010). Therefore, the first activity would involve familiarizing with the patient. That is, the activity will involve gathering of personal information about the patient which includes; the patient’s age, family background, occupation and lifestyle. Such information is vital in establishing whether they could be the predisposing factor to the patient’s ailment. For instance, it is estimated that chronic pain has the prevalence rate of between 27 percent and 51 percent among people aged 65 years and above (Makic, Martin, Burns, Philbrick & Rauen,).  Similarly, information about a patient’s family background could be used to determine whether the illness is as a result of inheritance or not. Occupation on the other hand is vital in establishing whether the patient’s situation could be aggravated by the daily activities he engages in. It could also determine the support that the patient gets from the family as well as the impact of the patient’s illness to the family members (Williams, Eccleston & Morley, 2012).

The second activity would involve review of the current information as well as gathering of new information. The current information includes reviews on the patient’s health history and the previous medical assessment. Ryan’s current information is such as his diagnosis with spinal stenosis at the age of forty, his current treatment with ibuprofen, baclofen and diazepam. It also includes the exercise therapy. It is also essential to review how Ryan copes with his situation and the mode of treatment. The new information may include determination of his current bpm and weight. In addition, other vital information includes determining how Ryan relates with people who are close to him. In essence, the review of current information and gathering of new information helps in the collection of data and helps in making the right judgment. For example, reviewing of Ryan’s case’s information will aim in determining the extent to which his condition has interfered with his ability to perform some activities as well as how it has affected him psychologically and socially.

 


Another activity would entail the processing of the information gathered. Information processing involves a comparison of the newly obtained information and the already known information. Interpretation of data helps in determining whether a patient’s condition has improved or whether it is deteriorating. It is also vital in deciding on the intervention strategy to adopt. For example, a comparison of Ryan’s blood pressure from the previous recording and the current recording will assist in determining the variation. The case study has also reported that Ryan is not comfortable with the physical exercises, the medications and event the recurring pain that keeps him awake. He is discontented by the fact that he can no longer do some of the activities that he enjoyed doing such as hiking. Similarly, he has stopped attending regular checkups by his physiotherapist because none of the mentioned attempts helped in reducing his pain. Such information can be interpreted that the patient’s attitude towards the modes of treatment is affected significantly and may affect his condition further. MacNeela et al. (2012) have argued that factors such as fears about medication, stoic attitude and fears about pain may interfere with the process of pain management.  Therefore, data processing and interpretation is essential in making predictions about the outcome.

Determining the patient’s problems is also another vital activity. From Ryan’s health history, it can be deduced that his major problem is the chronic back pain which is as a result of spinal stenosis. Other problems include hip pain, weakness in his left leg and loss of sensation in both legs. Ryan can also be considered to under stress due to his deteriorating health and the excruciating pain. According to Levett-Jones and Bourgeois (2010) patients with chronic pain are likely to suffer depression or stress. After the determination of problem, the other activity would include setting out of goals. It involves prioritization of intervention strategies. In Ryan’s case, goal setting on intervention strategy would largely depend on the extent of pain and the urgency of treatment. Levette-Jones and Bourgeois (2010) suggest that the setting of goal should be SMART. That is, a goal should be specific, measurable, attainable, and realistic and time based.

 

Priorities for the Follow-up Visit

The first priority in this case is to provide pain assessment and management of the chronic back pain. Pain assessment is an important approach towards pain management (Rush, Polatin, & Gatchel, 2015). Indeed, Christianson (2016) contends that inadequate assessment of pain is one of the most challenging problems that interfere with pain control strategies. Therefore, pain assessment in Ryan’s case would include the assessment of when he experiences a lot of back pain as in when he is resting, sleeping or exercising. This is helpful in determining what factors could lead to pain aggravation and what intervention measures to use. For example, according to Ryan, he experiences much pain after sitting for a longer period of time or even when he walks or rides for long. Following this observation, it would be necessary to ensure the monitoring of the exercises Ryan engages in. He should minimize sitting hours, reduce the duration of walking and riding by doing it sparingly. Another pain nondrug pain management strategy such as massage could also be introduced. Massage helps in the stimulation of fibers which are known to minimize central pain transmission and also reduces muscle tension (Newton et al. 2013).

 


The second priority is pain assessment and management of the degeneration of the left hip. Firstly, it would be important to establish the causes of the hip pain, the weakness of his left leg and loss of feet sensation. It is essential to determine whether these problems could be linked to spinal stenosis. Spinal stenosis causes the narrowing of the spine which in turn exerts pressure on the nerves and the spinal cord thereby causing pain. Spinal stenosis causes the compression of nerves in the lumbar spine as in the case of Ryan. The effects of spinal stenosis are such as pain, muscle weakness and numbness. It particularly causes cramping of legs when one stands, sits, or walks for long (Ackerman, Buchbinder & Osborne, 2012). During this stage, it would be considered viable to alter the previous medications as well as introduce new exercises and guide Ryan on how to do physical exercises. Thus, it would be necessary to prescribe the use of nonsteroidal anti-inflammatory drugs, antidepressants, opioids, muscle relaxants and anti seizure drugs in order to ease the pain (Jimmy & Jose, 2011).

The third priority will entail the determination of the history of pain since the inception of home-based pain management and assessment. The pain history provides information such as; the patient’s family expectations and beliefs about pain and stress management, the previous and the current pain experienced by the patient and its effects on him, the knowledge, preferences and expectations of the patient concerning the methods employed in pain management process and his description of pain. Additionally, pain history shows the patient’s response towards pain and how he is coping with the pain, the patient’s assessment of the pervious pain control methods in comparison to the new ones and which ones he finds helpful than the other and his attitude towards the use of medication.

Finally, is to ensure that both patient and the family receive adequate education on chronic pain management. Patient and family education is recommended for chronic pain management (Dworkin et al. 2008). Both patient and the family ought to understand the essence of preventing and controlling pain as well as the importance of working closely with a health care provider. The patient should also report when he experiencing pain or when the nature of the pain changes. Similarly, both parties should be made aware of the various available interventions of chronic pain management (Lam & Fresco, 2015).

 

References

Ackerman, I. N., Buchbinder, R., & Osborne, R. H. (2012). Challenges in evaluating an Arthritis

Self-Management Program for people with hip and knee osteoarthritis in real-world clinical settings. The Journal of rheumatology, 39(5), 1047-1055.

Christianson, H. (2016). Alaska Nurse Practitioners Barriers to Use of Prescription Drug

Monitoring Program. SAGE Publications.

Dworkin, R. H., Turk, D. C., Wyrwich, K. W., Beaton, D., Cleeland, C. S., Farrar, J. T., &

Brandenburg, N. (2008). Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. The Journal of Pain, 9(2), 105-121.

Jimmy, B., & Jose, J. (2011). Patient medication adherence: measures in daily practice. Oman

Med J, 26(3), 155-159.

Lam, W. Y., & Fresco, P. (2015). Medication adherence measures: an overview. BioMed Res Int.

Levett-Jones, T., & Bourgeois, S. (2010). The clinical placement: An essential guide for nursing

students. Elsevier Health Sciences.

Levett-Jones, T., Pitt, V., Courtney-Pratt, H., Harbrow, G., & Rossiter, R. (2015). What are the

primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience?. Nurse education in practice, 15(4), 304-309.

MacNeela, P., Doyle, C., O'Gorman, D., Ruane, N., & McGuire, B. E. (2015). Experiences of

chronic low back pain: a meta-ethnography of qualitative research. Health psychology review, 9(1), 63-82. 

Makic, M. B. F., Martin, S. A., Burns, S., Philbrick, D., & Rauen, C. (2013). Putting evidence

into nursing practice: four traditional practices not supported by the evidence. Critical care nurse, 33(2), 28-42.

Newton, B. J., Southall, J. L., Raphael, J. H., Ashford, R. L., & LeMarchand, K. (2013). A

narrative review of the impact of disbelief in chronic pain. Pain management nursing, 14(3), 161-171.

Rush, A. J., Polatin, P., & Gatchel, R. J. (2015). Depression and chronic low back pain:

establishing priorities in treatment. Spine, 25(20), 2566-2571.

Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the

management of chronic pain (excluding headache) in adults. The cochrane library.

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