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A learning contract to consider the management of pain in chronic venous leg ulcers

A learning contract to consider the management of pain in chronic venous leg ulcers

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An essay for the 2011 Undergraduate Awards (Lecturer Nomination) Competition by Elizabeth Browne. It is nominated by Lecturer Maria Bailey of University of Limerick in the category of Nursing & Midwifery
An essay for the 2011 Undergraduate Awards (Lecturer Nomination) Competition by Elizabeth Browne. It is nominated by Lecturer Maria Bailey of University of Limerick in the category of Nursing & Midwifery

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Published by: Undergraduate Awards on Sep 01, 2012
Copyright:Attribution Non-commercial

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10/27/2013

 
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A learning contract to considerthe management of pain in chronic venous leg ulcersAbstract
On average 80% of patients with venous leg ulcers experience (Van Hecke et al2008; Hareendran et al 2005) and leg ulcers have a major impact on healthcare costand patient quality of life (Van Hecke et al 2008). The role of the nurse involes painassessment, pharmacological and non pharmacological interventions (Briggs 2010;Alexander et al 2006) as well as communicating with and educating the patient (Fear2010; Woo et al 2008). A barrier in managing this pain effectively includes a lack of nursing education (Bell and McCarthy 2010).This paper presents a learning contractwhich was used as a framework to assist in the development of knowledge inrelation to the management of pain in venous leg ulcers.
Introduction
A learning contract is a tool that allows students to take part in self directed learningand enables them to learn what is specific to their own needs (McAllister 1996).Learning contracts allow students to focus their learning on one specific area and inaddition as Timmins (2002) notes, students can learn independently and have thefreedom to choose what they learn. Students have reported increased freedomm,enjoyment and motivation to learn with the use of a learning contract and in additionhave benefited from the process of self-assessment (McAllister 1996). In thislearning contract I aim to learn more about the nurses role in managing painassociated with chronic venous leg ulcers. I am particularly interested in this subjectbecause of the prevalence of venous leg ulcers among the elderly and the painassociated with them. On average 80% of patients with venous leg ulcers have pain(Van Hecke et al 2008; Hareendran et al 2005) and leg ulcers have a major impact onhealthcare cost and patient quality of life (Van Hecke et al 2008).My learning objectives are to learn how pain is defined and to understand the
 
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physiology of pain. Nurses need to have an understanding of the physiology of painand the different types of pain so they can give optimum care to patients with venousleg ulcers (Helms and Barone 2008). I will learn about the
nurses‟
role in assessingpain and pain assessment tools for patients with chronic venous leg ulcers becausepain requires structured assessment to find out the cause of pain and what triggers it(Cox 2010). I will learn about the pharmacological and non-pharmacologicalmethods of pain management and the barriers to effective pain management.The resources that I used to assist me with this learning contract were current and relevant journalarticles, books and websites. In particular I found Briggs
, M. and Closs S.J. (2006) „Patients‟ perceptions of the impact of treatments and products on their experience of leg ulcer pain‟,
 Journal of Wound Care,
15(8), to be very helpful and interesting from a patient perspective. Ialso contacted and spoke to a tissue viability nurse and a public health nurse about theirexperiences of managing chronic venous leg ulcer pain and I attended a talk on pain presented bya pain specialist in the local acute hospital.
Evidence of accomplishment
Pain is subjective so the preferred definition for use in clinical setting is “Pain is
whatever the experiencing person says it is, existing whenever the experiencing
 person says it does”
(McCaffery, cited in Dougherty and Lister 2006, p. 496). TheInternational Association for the Study of Pain gives a more comprehensive
definition of pain “an unpleasant sensory and emotional experience associated with
actual or potent
ial tissue damage, or described in terms of such damage” (Merskey
and Bogduk, cited in International Association for the Study of Pain 2010).Nurses must understand the physiology of pain. This will help increase theirknowledge of pain processes and subsequently will help them understand painmanagement (Wood 2008). The nociception process depicts the usual processing of pain and the reactions to noxious stimuli that damage or could potentially damagenormal tissue (Wood 2008). There are three types of noxious stimuli and these are
 
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thermal, for example scalding or burning, chemical, for example infection orischemia and mechanical, for example pressure, tumor growth or swelling.Stimulation may be external where somebody might burn themselves or internalwhere someone might have a tumor that is exerting pressure. Chemical mediators arereleased as a result of the noxious stimulation from the damaged cell. These chemicalmediators include potassium, serotonin, substance P, histamine and bradykinin. Thenociceptors are activated or sensitized to the noxious stimuli by the chemicalmediators. A pain impulse is generated when there is an exchange of potassium ionsand sodium in the cell membrane. This produces an action potential and a painimpulse is generated (Wood 2008).Nociceptors, also known as pain receptors are free sensory nerve endings thatrespond to painful stimuli (Tortora and Derrickson 2006). When nociceptors C fibresand A-delta fibres of primary afferent neurons react to noxious stimuli, transductionbegins (Wood 2008). A delta fibres and C fibres are involved in pain transmission.Stimulation of A delta fibres produces a sharp fast first action of pain. A delta fibrestransmit pain very fast, so fast, that that the body is able to respond quicker than thepain stimulus, resulting in the person moving away the body part that has beenaffected even before the person feels the pain (Helms and Barone 2008). The C fibresproduce a slower more chronic, aching, burning and throbbing pain (Tortora andDerrickson 2006).The transmission of pain starts from where transduction occurred, along the A deltaand C fibres and to the dorsal horn in the spinal cord. Then it goes from the spinalcord to the brain stem via links between the thalamus, cerebral cortex and upperlevels of the brain. The A delta and C fibres end in the dorsal horn of the spinal cord.Between the terminal ends of the C fibres and A delta fibres and the nociceptivedorsal horn neurons (NDHN), there is a synaptic cleft. Excitatory neurotransmittersare released so that pain impulses can be sent across the synaptic cleft and these bindwith specific receptors in the NDHN. These neurotransmitters include adenosine

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