A review of postoperative pain assessment records of nurses

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Applied Nursing Research

journal homepage:www.elsevier.com/locate/apnr

Original article

A review of postoperative pain assessment records of nurses

☆

Sevilay Erden, PhD Assistant Professor

a,⁎

, Sevban Arslan, PhD Associate Professor

a

,

Sevgi Deniz Research Assistant

a

, P

ınar Kaya

b

, Derya Gezer, MSc

c

a_{Çukurova University, Faculty of Health Sciences, Surgical Nursing Department, Adana, Turkey} b_{Departments of General Surgery, Numune Training and Research Hospital, Adana, Turkey} c_{Departments of General Surgery, Cukurova University, School of Medicine, Adana, Turkey}

1. Introduction

Pain, one of the most common postoperative symptoms, develops at moderate and severe levels in approximately 30 to 80% of the patients. (Ay & Alpar, 2010; Rizalar & Özbaş, 2016; Sommer et al., 2008;

Wu & Raja, 2011). Pain disturbs organ functions and leads to delayed recovery, thus it may extend the length of hospital stay (Coluzzi et al., 2015). Theﬁrst step to take the pain under control is an appropriate pain assessment (Ayasrah, O'Neill, Abdalrahim, Sutary, & Kharabsheh, 2014). The main goals of pain assessment are to determine pain in-tensity, to decide the dose and type of analgesic drug, and to assess the eﬃcacy of the administered drug. Surgical nurses have important tasks to achieve the stated goals (Yüceer, 2011).

The patient should be actively involved in the pain assessment, a valid and reliable pain assessment scale should be used, the severity, quality and location of pain should be questioned periodically (i.e. once every 2 h). Also, appropriate analgesia should be determined according to the type, severity of pain and medical condition of the patient and pain assessment should be repeated after every analgesic administra-tion. Pain should be assessed during rest and movement, and reassessed after analgesic interventions (pharmacological and non-pharmacolo-gical). Then, all of the obtained data should be recorded in the ob-servation forms of nurses and shared with the medical team (Anesthesia Practice Guidelines, 2006; Joint Commission Requirements, 2007). These data also provide important information for the medical team about the eﬃcacy of analgesia and the cause of pain (Yüceer, 2011). However in Turkey, recording pain assessment and treatment are not considered as the main steps of postoperative pain management nursing intervention (Yüceer, 2011;Bas Gürarslan et al., 2016).Therefore, we consider that pain management records are insuﬃcient to provide in-formation to health care professionals to control the pain and analgesia. The International Pain Committee recommend recording pain as-sessment, since it enables pain control and facilitates follow-up (Gordon et al., 2008; Gordon et al., 2016; Joint Commission Requirements, 2007). However, several studies have shown that the nursing records about pain assessment are inadequate (Ayasrah et al., 2014; Dalton

et al., 2001; Gordon et al., 2008; Idvall & Ehrenberg, 2002; Liu et al., 2016; Mędrzycka-Dąbrowska, Dąbrowski, Basiński, & Małecka-Dubiela, 2016). Ayasrah et al. reported that pain assessment was recorded only in 35% of 301 medical records and re-assessment after analgesia was performed only in 37% (Ayasrah et al., 2014). In a study by Idvalland Ehrenberg examining the medical records of 172 patients, although 73% of the nurses registered the records in accordance with the guidelines, 50% reports (n = 86) did not contain location of pain, ap-proximately 88% lacked the quality of pain, while a pain scale was not used in 40% (Idvall & Ehrenberg, 2002). In a study by Rafati et al. only 6% of the records included the quality of pain and no pain scale was used in the assessment (Rafati, Soltaninejad, Aﬂatoonian, & Mashayekhi, 2016).

Previous ﬁndings have suggested that why ineﬀective pain man-agement and inadequate pain records are still the topics to be worked on. They have also indicated that hospital administration and nurses do not pay enough attention to the records of pain assessment (Abdalrahim, Majali, & Bergbom, 2008; Gordon et al., 2008; Gunningberg & Idvall, 2007; Liu et al., 2016; Mackintosh-Franklin, 2017) The protocols of pain assessment and management to be used in hospitals are needed, since no standard guide for assessing post-operative pain is developed in Turkey. Since the missing pain records are considered as obstacles in front of pain management, awareness related to the topic should be increased in nurses and the current si-tuation should be revealed. In our study, we aimed to examine the postoperative pain assessment records of nurses.

2. Materials and methods 2.1. Type of study

The aim of this retrospective and descriptive study is to examine postoperative pain assessment records of nurses.

http://dx.doi.org/10.1016/j.apnr.2017.08.003

Received 21 February 2017; Received in revised form 25 April 2017; Accepted 23 August 2017 ☆_{Acknowledgments: We acknowledge all the patients accepted to participate this study.}

⁎_{Corresponding author at: Çukurova University, Faculty of Health Sciences, Nursing Department, Adana, Turkey.} E-mail address:sevilaygil@gmail.com(S. Erden).

Applied Nursing Research 38 (2017) 1–4

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2.2. Location of study

The study was conducted in Cukurova University, Faculty of Medicine, Balcali Hospital with a total capacity of 1200 beds, Health Application and Research Center, General Surgery clinic. This clinic where patients are followed postoperatively has 74 beds and 24 nurses. Eight nurses work in the day shift and four work in the evening and nightshifts.

2.3. Study population and sample

The study population included the nurse observation forms of 956 patients who were hospitalized for surgery between January 2014 and January 2015 in Cukurova University Faculty of Medicine, Balcali Hospital, Health Application and Research Center, General Surgery clinic. Of theseﬁles, 511 were unable to be reached and 24 was not included in the sample group, as it was either torn or unreadable (Fig. 1). As a result, the sample of the study consisted of the nurse observation forms of a total of 421 patients older than 18 years of age who underwent surgery under general anesthesia and who were hos-pitalized at least 48 h postoperatively.

2.4. Data collection instruments

The questionnaires and nurse observation forms were used to collect data in the study. The questionnaire was developed by the researchers after literature review (Anesthesia Practice Guidelines, 2006; Gordon et al., 2008; Idvall & Ehrenberg, 2002; Joint Commission Requirements, 2007; Yüceer, 2011) The questionnaire consisted of two parts including the data about patient(i.e., age, sex, comorbidities)and the data re-garding pain assessment. The section contained the data for pain as-sessment included, the characteristics of pain, the pain scale used, the type of analgesia (pharmacological/non-pharmacological analgesia), the route of administration and the frequency of pain assessment after analgesia were also questioned. The other form which was the nurse observation form included the recorded patient data(diagnosis, chronic diseases, vital ﬁndings, or treatment applied) and the nursing inter-ventions for diagnosis and treatment.

2.5. Data collection

The data were collected by two researchers who did not work as nurse at the hospital. There searchers examined the nursing observation forms of the patients with in the sample group in the room of the ar-chive section of the hospital. They were supposed to evaluate 30 re-cords per week. Depending on the type of surgery, some patients were discharged after 48 h after surgery (i.e., laparoscopic cholecystectomy, inguinal hernia repair, breast mass excision, and thyroidectomy). In these cases, the nurse observation forms including thefirst 48 h were evaluated. The evaluation of each file that met the inclusion criteria took about 10 min. The files and forms that did not meet the study criteria (unread, faded, or lost,) were excluded from the study. The data

of our study were based on the hospital statistics and the documenta-tion of data base department.

2.6. Evaluation of data

Statistical analysis was performed using SPSS version 20.0 software (IBM Corp., Armonk, NY, USA). The descriptive data were expressed in numbers and percent distributions.

2.7. Ethical aspect of study

The ethical approval was obtained from Cukurova University, Faculty of Medicine, Non-Interventional Ethics Board (Decisionno:16; Date:05.06.2015)and a written permission was received from the chief physician of Cukurova University, Faculty of Medicine, Balcali Hospital (27/04/2015-5054/18649120-302.08.01).

3. Results

Demographic data of nurses working in clinics was obtained from staﬀ records in the clinic and the number of nurses was found to be 24. The mean age of the nurses was 27,8 ± 6,8 years, 83.3% of them were female, 54,1% of them were under graduate/graduate and their mean of working period was 6.5 ± 4.5 years.

The mean age of the patients was 46.03 ± 15.4 and there was a chronic disease in 33% of them. The most frequently performed surgery was colorectal surgery (63.7%) (Table 1).

The nursing observation forms of in total 421 patientﬁles were examined in the study. When theﬁrst 48-hour postoperative records were reviewed, it was detected that no information regarding pain as-sessment (severity, location, type, duration, and pain asas-sessment scale) was recorded in any patient (Table 2).

The highest rates (70.8%) of pain therapy-related records (phar-macological and non-phar(phar-macological) were registered with in theﬁrst 2 h in the postoperative period. The analgesia record rate was detected to be below 42% after 24 h. It was determined that the most commonly administered and recorded analgesic was diclofenac sodium, the least administered analgesic was pethidine HCl and the most frequently used and recorded route of administration was intramuscular route. Also, there was not any record related to non-pharmacological pain therapy (massage, hot-cold application, and positioning) in the nurse observa-tion forms (Table 3).

4. Discussion

Pain assessment records, including the characteristics of pain and the patient's analgesic response, guide the medical team for providing eﬀective pain management. In our study there was no record related to Fig. 1. The population and sample of study.

Table 1

The demographic and surgery-related data of the patients (n = 421).

n % Meant ± SD (min-max) Age – – 46.03 ± 15.4 (15–87) Gender Male 196 46.6 – Female 225 53.4 Chronic Disease (DM, HT etc) Yes 139 33.0 – No 282 67.0

Surgery type Colorectal surgery 268 63.7 Breast-thyroid surgery 61 14.5

Hernia surgery 45 10.6

Upper GIS surgery 34 8.1 Others (splenectomy,

drainage of abscess etc.)

13 3.1

Total 421 100

S. Erden et al. Applied Nursing Research 38 (2017) 1–4

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pain assessment in any of the patient ﬁles with the ﬁrst 48 h which should be followed most closely. Also, there was no pain assessment scale recorded in the nurse observation forms (Table 2). According to this results, our observations and other researches on and other studies of the researchers Among the reasons, there may be unawareness of the nurses about the importance of pain records, the hospital adminis-tration's lack of interest, and non-compliance with the pain guidelines (Yüceer, 2011; Erden, Akçalı, Bulut, & Babacan, 2015; Erden, Akçalı,

Çizmeci, İnan, & Babacan, 2015; Erden, Demir, Kanatlı,

Danacı, & Carboğa, 2017). Moreover, no formal standards of care for the assessment and management of pain are available at Balcali Hos-pital. Therefore, not only the hospital managers, but also the health care professionals, even the patients, do not consider pain management important. Ourﬁndings as well as the studies in Turkey (Erden et al., 2015; Sü & Sahin, 2014; Yılmaz & Gürler, 2011) and aboard (Idvall & Ehrenberg, 2002; Rafati et al., 2016) indicate that pain as-sessment scales are used less or not at all in the hospitals, no routine pain assessment is performed, the gathered data is not recorded or there are missing data. Thus, the researchers In a study conducted in Turkey with 360 surgical patients, the nurses did not use pain assessment scale and the patients expected more frequent pain assessment from the nurses (Yılmaz & Gürler, 2011).In the study of Idvall and Ehrenberg, they found that systematic pain assessment was not performed in about 90% of the records, there was no data related to the location of pain in the half of the records and no data related to the quality of pain in 88% of the records (Idvall & Ehrenberg, 2002). Rafati et al. (Rafati et al., 2016) reported that nurses did not use a standard scale while assessing pain, and of the records only 6% included the intensity of pain, while 5.2% included the characteristic of pain.

Ourfindings showed that the analgesia record, which was 70.8% within thefirst 2 h postoperatively, decreased to 42% after 24 h. The most commonly administered and recorded analgesic was diclofenac sodium, and pethidine HCl was found to be the least administered and recorded analgesic (Table 3). The decrease of the records after thefirst 2 h indicated that the administration of as needed (Pro Re Nata: PRN) analgesia was preferred rather than the around the clock analgesia (ATC) postoperatively, or analgesia was administered, but not recorded. Similarly, in the studies conducted on surgery patients, Rizalar and Ozbas found the percentage of non steroidal anti-inflammatory drugs (NSAIDS) use as 73% and that of the opioids as 8.7% (Rizalar & Özbaş,

2016); whereas Lorenzte et al. found the percentage of NSAIDS ad-ministration as 100% (Lorentzen, Hermansen, & Botti, 2012). As one can see, unlike acute pain guidelines, NSAIDS is thefirst choice in the postoperative analgesia. However, the opioids should be thefirst choice in severe pain postoperatively and multi modal combinations should be performed by adding nonopioids to opioids (Erden et al., 2017; Garimella & Cellini, 2013; Gordon et al., 2016). The stated results in-dicate that there commendations of acute pain guidelines are not fol-lowed. In a study which evaluated the pain records in Iran, it was stated that there was no official document of postoperative pain record, on the contrary to the procedure of Iran Health and Medical Education Min-istry, opioids were the most commonly used postoperative analgesics (Rafati et al., 2016). Although cultural differences affect drug

admin-istrations, hospital policies and procedures should be organized in ac-cordance with pain guidelines based on international evidence-based studies. Anotherﬁnding in our study is that IM route is preferred as the route of administration in analgesia (Table 3). However, it is suggested that intravenous route should be preferred in terms of both eﬃcacy Table 2

Records of nurses regarding postoperative pain assessment.

2 h 4 h 8 h 12 h 24 h 36 h 48 h n % N % N % n % N % n % n % No 421 100 421 100 421 100 421 100 421 100 421 100 421 100 Yes – – – – – – – – – – – – – – Total 421 100 421 100 421 100 421 100 421 100 421 100 421 100 Table 3

Records of nurses regarding postoperative pain management.

2 h 4 h 8 h 12 h 24 h 36 h 48 h

n % N % N % N % n % N % n %

Recording the pain treatment

No 123 29.2 421 100 258 61.3 222 52.7 183 43.5 245 58.2 274 65.1

Yes 298 70.8 – – 163 38.7 199 47.3 238 56.5 176 41.8 147 34.9

The recorded analgesics Opioids Tramadol Hcl 22 5.2 – – 3 0.7 9 2.1 8 1.9 7 1.7 6 1.4 Pethidine HCL 2 0.5 – – 2 0.5 2 0.5 3 0.7 1 0.2 2 0.5 NSAIDa Diclophenac sodium 270 64.1 – – 155 36.8 185 43.9 165 39.2 123 29.2 97 23.0 Paracetamol 4 1.0 – – 3 0.7 3 0.7 62 14.7 45 10.7 42 10.0

Recording of the route of the analgesics

No 122 29.0 420 99.8 256 60.8 223 53 183 43.5 245 58.2 274 65.1

Yes 299 71.0 1 0.2 165 39.2 198 47 238 56.5 176 41.8 147 34.9

The recorded the route of the analgesics

IM 269 63.9 1 0.2 156 37.1 183 43.5 167 39.7 123 29.2 96 22.8

IV 30 7.1 – – 8 1.9 13 3.1 17 4.0 13 3.1 12 2.9

Oral – – – – 1 0.2 2 0.5 54 12.8 40 9.5 39 9.3

Recording of the nonpharmacological methods

No 421 100 421 100 421 100 421 100 421 100 421 100 421 100

Yes – – – – – – – – – – – – – –

Total 421 100 421 100 421 100 421 100 421 100 421 100 421 100

a_{NSAID: Non-steroidal anti-inﬂammatory drug.}

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time and tissue perfusion in the postoperative pain guidelines (Anesthesia Practice Guidelines, 2006; Gordon et al., 2016).

According to the records, for pain control only analgesics were ap-plied, no record related to non-pharmacological pain therapy (massage, hot-cold application and positioning) was encountered in the nurse observation forms (Table 3). However, pain guidelines and literature information suggest that non-pharmacological methods decrease the use of analgesic drugs (Erden & Senol Çelik, 2015; Gordon et al., 2016; Yüceer, 2011). In the studies conducted on general surgery patients in Turkey, nurses reported that they applied analgesic medication pre-ferentially and most frequently to the patients with severe pain and applied very little of non-pharmacological methods (Yılmaz & Gürler, 2011; Sü & Sahin, 2014; Çelik, 2014) Similarly, in a study which eval-uated the pain records of 385 surgical patients, no record regarding the application of non-pharmacological methods was observed in the nurse observation forms(Rafati et al., 2016).

Although postoperative pain guidelines and studies suggest that pain should be reassessed periodically after analgesia for effective pain management (Joint Commission Requirements, 2007; Yüceer, 2011; Gordon et al., 2016; Erden et al., 2017), it is observed that this sug-gestion is not followed. Ayasrahet al. reported that only in 37% of the medical records, pain was reassessed after analgesia (Ayasrah et al., 2014). Gunninberg and Idwall found that despite the hospital proce-dures, the quality of pain in about 60–93% of patients in the post-op-erative period were not assessed to the quality goals of hospital. In our study, were commend electronic patient registries to support the use of clinical pain guidelines. In Turkey, JCI accredited hospitals have elec-tronic patient records which provide healthcare staff with the in-formation to support effective pain management. However Balcali isn't an accredited hospital and do not use any electronic records on pain management. In this context, both the hospital management should provide the necessary feedback to health personnel on the importance of records in pain management and pain management should be sup-ported with electronic patient record information.

5. Conclusion

In conclusion, our study results showed that pain assessment was not carried out in accordance with the pain guidelines and pain as-sessment and analgesia records were missing. What is desired and ex-pected is that pain which should be paid attention and followed as much as vital signs should be evaluated ideally and recorded. Although the education level of more than half of the nurses in the study was graduate or undergraduate, they were not aware of the importance of pain records. In this context, hospital policies and procedures should be formed and patient record should be made apparent with electronic patient recording system. Online pain management courses should be prepared, bed side visits per day should be performed in the supervision of pain nurse, awareness should be provided by giving training and feedback to the other nurses along with the clinical head nurses. The pivotal role of pain assessment records in the eﬀective pain manage-ment therapy should be emphasized in the training.

No conﬂict of interest

None of the authors of the above manuscript has declared any conﬂict of interest.

Acknowledgment

We would like to thank Research Project Unit of Cukurova University for supporting this work within the scope of TSA-2016-5206 project. We would like to thank also the staﬀ who provided the ﬁles in the archive section of Balcali Hospital, Health Practice and Research Center of Cukurova University, Faculty of Medicine.

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