The effect of standard pain assessment on pain and analgesic consumption amount in patients undergoing arthroscopic shoulder surgery

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The effect of standard pain assessment on pain and analgesic

consumption amount in patients undergoing arthroscopic

shoulder surgery

Sevilay Erden, RN, PhD, Assistant Professor

a,

⁎

, Sevil Güler Demir, RN, PhD, Instructor

b

,

Ulunay Kanatl

ı, MD, Professor

c

, Fatma Danac

ı, RN, Staff Nurse

d

, Banu Carbo

ğa, RN, Staff Nurse

d

a

Department of Nursing, Faculty of Health Sciences, Çukurova University, Adana, Turkey

b

Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey

c

Gazi University Faculty of Medicine, Department of Orthopaedics and Traumatology, Besevler, Ankara, Turkey

d_{Gazi University Health Research and Practice Center, Orthopaedic and Traumatology Clinic, Ankara, Turkey}

a b s t r a c t

a r t i c l e i n f o

Article history: Received 9 August 2016 Accepted 12 November 2016

Pain assessment has a key role in relief of the postoperative pain. In this study, we aimed to examine the effect of the Standard Pain Assessment Protocol (SPAP), which we developed based on acute pain guidelines, on pain level, and analgesic consumption. The study population consisted of a total of 101 patients who had arthroscopic shoulder surgery. The routine pain assessment was administered to the control group, while the SPAP was ad-ministered to the study group. The routine pain therapy of the clinic was adad-ministered to the subjects from both groups based on the pain assessment. Throughout the study, pain was assessed nearly two times more in the study group (pb 0.001) and the mean pain levels were lower at 8th–11th hours in the study group (pb 0.001). Pain assessment was not performed after 12th hour despite the severe pain in the control group, and, therefore, analgesia was administered at irregular intervals or was not administered at all. However, the hours of analgesic administration were found to be more regular according to the pain levels of the patients in the study group. In conclusion, the SPAP reduced the pain level by providing regular analgesia when used in com-bination with regular pain assessment.

Perspective: This article highlights the appropriate assessment for patients with surgical pain. In majority of liter-ature on the subject, the authors emphasize the importance of Standard Pain Assessment Protocol to provide ad-equate pain relief.

Keywords: Postoperative pain Pain assessment protocol Analgesic consumption Pain management Orthopedic nursing

1. Introduction

Upper extremity surgeries are among major surgical interventions which may cause severe pain in the postoperative period (Beecroft & Coventry, 2008; Fredrickson, Krishnan, & Chen, 2010; Sommer et al., 2008). They are also associated with increased severe pain-related com-plications (atelectasis, hypertension, deep vein thrombosis, etc.), opioid requirement and opioid-related side effects (respiratory depression, nausea, vomiting, constipation, etc.), and hospital admission after dis-charge (Fredrickson et al., 2010; Fortier, Chung, & Su, 1998). A study in-vestigating the postoperative pain experiences of patients showed that 96.4% of the patients had difﬁculties in cough, 78.3% in movement, and 46.7% in breathing due to postoperative pain (Yılmaz & Gürler, 2011).

Another study, which was conducted with 15.172 ambulatory surgery patients, reported that 12% of the patients were re-admitted to the hos-pital due to pain, 60% of these presenting patients were orthopedic sur-gery patients, and this resulted from postoperative insufﬁcient pain management (Fortier et al., 1998).

A cohort study with 50.523 patients in 105 German hospitals dem-onstrated that the highest pain score was in orthopedic surgery clinics and the pain expected to be in mild to moderate levels were expressed as severe pain by the patients (Gerbershagen et al., 2013). The study highlighted that regardless of the surgery type and analgesia, the pain could be more severe than expected, and, therefore, it should be fre-quently and periodically assessed for the management (Gerbershagen et al., 2013). A meta-analysis (2011) investigating the frequency of pain assessment during postoperative movement established that the pain was assessed only in 39% of the studies and the assessment time was not clear in certain studies. Pain would be more severe during movement than it is at rest, and this would create differences in pain re-sults. Researchers have recommended to specify and standardize the

⁎ Corresponding author.

E-mail addresses:sevilaygil@gmail.com(S. Erden),sevilgulerdemir@yahoo.com,

sevil.guler@gazi.edu.tr(S.G. Demir),ulunayk@hotmail.com(U. Kanatlı),

d_fatos5@hotmail.com(F. Danacı),bn.car@outlook.com(B. Carboğa).

http://dx.doi.org/10.1016/j.apnr.2016.11.009

Contents lists available atScienceDirect

Applied Nursing Research

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pain assessment times (movement and/or rest) to remove such differ-ences (Srikandarajah & Gilron, 2011).

The assessment of pain is a critical step for providing good pain man-agement. In the April 2016 report, JCAHO emphasizes that comprehen-sive pain assessment and reassessment of the pain (Joint Commission Statement on Pain Management, 2016). In the literature, randomized-controlled studies report that pain should be properly assessed for an ef-ﬁcient pain management (Dewar, 2006; Schoﬁeld, O'Mahony, Collett, & Potter, 2008; Silva, Pimenta, & Cruz Dde, 2013).Wells, Pasero, and McCaffery (2008)found that the lack of pain assessment was one of the most problematic barriers to achieve improved pain control (Wells et al., 2008). Pain management guidelines have been developed for an effective pain management in the postoperative period (Agency for Health Care Policy and Research (AHCPR), 1992;American Society of Perianesthesia Nurses (ASPAN), 2003;Clinical Practice Guideline for the Management of Postoperative Pain, 2002; JCAHO, 2001). Such guidelines include recommendations for standard pain assessment and treatment which cover pre- and postoperative periods, and high-light that each hospital should formulate its own protocol based on these recommendations (Agency for Health Care Policy and Research (AHCPR), 1992;American Society of Perianesthesia Nurses (ASPAN), 2003;Clinical Practice Guideline for the Management of Postoperative Pain, 2002; Joint Commission Statement on Pain Management, 2016). Recently, the American Pain Society using the data of the American So-ciety of Anesthesiologists commissioned an interdisciplinary expert panel and developed a clinical practice guideline to promote an evi-dence-based, effective, and a safer postoperative pain management in children and adults (Chou et al., 2016).

There is a few number of studies examining the effect of standard pain assessment on pain and analgesic consumption in the literature (Silva et al., 2013; Harmer & Davies, 1998). In addition, the number of studies on pain of shoulder surgery patients is also limited (Brown, 2008). A study evaluating the efﬁcacy of treatment-based on acute pain protocol found decreased rates of patients with moderate to severe pain, when the protocol was applied (Sommer et al., 2008). In another study, the authors reported signiﬁcantly reduced postoperative pain and morphine consumption in patients for whom standard and routine pain assessments were performed by nurses (Silva et al., 2013). Al-though the protocols emphasize the importance of standard pain as-sessment, our observations and the literature data suggest that pain assessment scales are not effectively used in clinical practice, and there is no periodical assessment and there is no adequate recording system for pain assessment at hospitals (Erden, Akcali, Bulut, & Babacan, 2015; Yılmaz & Gürler, 2011; Yuceer, 2011). In a study which was conducted in Turkey with 360 surgical patients in 2011, all patients reported that nurses did not use any form to measure the pain level, only 11.4% of the patients had expectations from the nurses toward pain relief, and 36.6% of these patients asked nurses to check the pain more frequently after the operation (Yılmaz & Gürler, 2011).

Pain assessment is also guiding in determining the optimum analge-sic dose and administration frequency (Faydalı, 2010). For an effective postoperative pain management, a routine and standard pain assess-ment which guides the option of analgesia and also measures the ef ﬁca-cy of analgesia should be performed (Gerbershagen et al., 2013; Yuceer, 2011). Previous studies have shown that pain assessment based on acute pain protocols enhances pain awareness and pain management (Karlsten, Ström, & Gunningberg, 2005; Silva et al., 2013; Sommer et al., 2008). The clinical practice guideline of the Agency for Health Care Policy and Research and the Joint Commission on Accreditation for Healthcare Organizations publish the following suggestions for postop-erative pain assessment: (Agency for Health Care Policy and Research

(AHCPR), 1992;Joint Commission Statement on Pain Management,

2016; JCAHO, 2001)

• Informing the patient and his/her family on the pain assessment (pain scale, pain assessment frequency, etc.),

• Selecting a valid, reliable, and a commonly used pain scale (Verbal or Numerical Pain Scale, Visual Analogue Scale, etc.) prior to the opera-tion and using this scale after the operaopera-tion,

• Determining the pain level only by a self-rated scale ﬁlled by the pa-tient,

• Allowing patient to express his/her pain, determining the pain-reduc-ing and increaspain-reduc-ing factors,

• Measuring the pain level routinely (within the ﬁrst 24 h, once in 2 h, once in four to 8 h, once in shift, etc.) after the operation as a vital sign, • Measuring the pain both at rest and during activity (cough,

mobiliza-tion, etc.),

• Assessing the pain after every analgesic administration (30 min after parenteral analgesia, 1 h after oral analgesia/non-pharmacological an-algesia), and

• Recording the pain level and analgesic practices performed. In accordance with the speciﬁed recommendations, each hospital should formulate its own pain protocols and properly assess the pain. In this study, Standard Pain Assessment Protocol (SPAP) was developed by the researchers considering the recommendations of available guide-lines. This protocol involves organized and standard practices in several aspects from pain scale to the assessment frequency.

In this study, we aimed to examine the effect of the SPAP on pain and analgesic consumption amount in patients undergoing arthroscopic shoulder surgery.

2. Methods

2.1. Study design and participants

This study was conducted as an interventional research on patients who had arthroscopic shoulder surgery at Gazi University Health Prac-tice and Research Center Orthopedics and Traumatology Clinic.

The study population consisted of patients who had arthroscopic shoulder surgery in the Orthopedics and Traumatology Clinic of the hos-pital. The mean number of shoulder surgery performed at the hospital is 250. Of these 250 patients, 101 patients met the inclusion criteria. The study population consisted of a total of 101 underwent arthroscopic shoulder surgery patients (study group, n = 51; control group, n = 50) aged above 18, who had no operations within the past six months, no orthopedic surgery within the past one year for any reason, had theﬁrst shoulder surgery, and gave a consent to participate in the study. Patients who did not meet these criteria were excluded. The pa-tients were randomly selected for the study and control groups. Ran-domization was performed according to the surgery date to prevent any interaction among the patients. The patients with an odd number of surgery date were included in the control group, while those with even numbers were included in the study group.

2.2. Procedures

There is not any pain assessment protocol applied to orthopedics and traumatology patients in the clinic where the study was conducted. The patients undergoing arthroscopic shoulder surgery are admitted to the clinic on the surgery day and discharged on postoperative day one. The pain of the patient is assessed at varying intervals on the surgery day and in the subsequent periods. The analgesic treatment of the pa-tients following arthroscopic shoulder surgery includes tenoxicam (20 mg, bid, intravenous), diclofenac sodium (as needed, intramuscu-lar), and Pethidine hydrochloride (as needed, intramuscular).

In our study, the operations of the control and study group patients were performed by the same team (orthopedist and anesthesia). Fol-lowing the operation, the routine pain assessment and analgesic treat-ment of the clinic were administered to the control group patients. To the study group patients, SPAP which was developed by the researchers

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in accordance with the international clinical guidelines was adminis-tered (Table 1). The routine pain therapy (pharmacological and non-pharmacological) was administered to both group patients based on the pain assessmentﬁndings.

2.3. Data collection

Data were collected using a questionnaire form, which was prepared based on the related literature and observations, and consisted of three sections. Theﬁrst section of the form included eight items on the intro-ductory information of the patients and the second section included seven items on the preoperative status and the operation of the patient. The third section included items regarding the pain level at rest and dur-ing cough within theﬁrst 24 h, the analgesics administered and their amounts, as well as the non-pharmacological analgesic methods.

The questionnaire form was completed by nurses through one-on-one interviews and by using patientﬁles. The interviews took about 15 to 20 min. Pain assessment was repeated at pre-speciﬁed intervals in the study group and according to the routine practice of the clinic in the control group, and then, analgesia suited for pain level was ad-ministered for both groups. All pain assessments were recorded into the form by the nurses according to the analgesic treatments and amounts.

2.4. Statistical analysis

Demographic information and operation information was analyzed with descriptive statistics including Chi-square, t-test and Fisher's exact tests. The pain levels and analgesic consumption at different times in both groups was analyzed and compared by repeated measures Mann-Whitney test. Statistical analysis was performed using the Statis-tical Package for Social Science, version 16.0 software (SPSS Inc., Chicago, IL, USA). Data were expressed in numbers, mean, and percent-age. A p value ofb0.05 was considered statistically signiﬁcant. 2.5. Ethical considerations

Ofﬁcial permission for the study was taken from the Ethical Commit-tee of the University (77082166-604.01.02). All participants were in-formed of the nature and purpose of the study and it was based on the voluntary participation. Prior to the initiation of the study, a written consent was obtained from each participant (Date: 29/05/2015, Num-ber: 54088). The study was conducted in accordance with the principles of the Declaration of Helsinki.

3. Results

The study population consisted of a total of 101 patients (study group, n = 51; control group, n = 50). (Fig. 1). Age, education status, chronic diseases, the presence of severe pain, and previous surgery

were similar between the study and control groups (p N 0.05)

(Table 2). In both groups, nearly 60% of the patients had previous sur-gery and severe pain experiences (Table 2). None of the patients were administered analgesia before or during surgery (Table 3). Almost half of the patients had axillary block (study: 54.9%, control: 56.0%) and the operation took more than 3 h. In both groups, the majority of the pa-tients underwent rotator cuff surgery (study: 72.5%, control: 84.8%). The groups were also similar in terms of surgery-related characteristics (pN 0.05) (Table 3).

The mean number of pain assessment within the postoperativefirst 24 h was 9 ± 2.03 and 4 ± 1.97 in the study and control groups, respec-tively, indicating statistical significance (p b 0.001). Despite the pres-ence of severe pain in the control group (resting: 6.6 ± 1.99–5.2 ± 2.80; cough: 7.01 ± 2.18–5.5 ± 2.91), the pain assessment was per-formed only between the 4th and 11th hours (Table 4). The difference in the pain levels of the patients at these time points was signi_{ficant in} favor of the study group (pb 0.001) (Table 4).

Furthermore, analgesia was administered at irregular intervals or was not administered at all after postoperative 12th hour in the control group; however, there was no signiﬁcant difference in the amount of opioid and non-opioid consumption between the groups at the time of analgesia (pN 0.05) (Table 5). In the study group, non-pharmacolog-ical methods were applied to almost all patients, while the most com-monly used ones were proper positioning, supporting the shoulder, informing the patient about pain, and encouraging the patient toward expressing his/her pain (Table 6). In the control group, however, these methods were applied only to the one quarter of the patients, indicating a statistically signiﬁcant difference between the groups (p b 0.001) (Table 6).

4. Discussion

Pain assessment and re-assessment are required to provide optimal postoperative pain care. Pain assessment helps to determine whether pain management is adequate, whether analgesic or analgesic dose modiﬁcations are required, whether changes in the postoperative pain management plan or additional interventions are warranted, and, in case of difﬁcult to manage pain, whether specialty consultation or other measures are needed (Chou et al., 2016). Our study investigated the effect of a pain assessment protocol, which was developed based on acute pain guidelines, on postoperative pain level and analgesic con-sumption. The study and control group patients were similar in terms of sociodemographic and surgical characteristics (pN 0.05).

4.1. Pain levels

Pain was measured both at rest and during activity at a mean of four times in the control group, compared to nine times in the study group within thefirst 24 h. Despite the severe pain in the control group (rest: 6.6 ± 1.99–5.2 ± 2.80; cough: 7.01 ± 2.18–5.5 ± 2.91), pain as-sessment was performed only between the 4th and 11th hours, and the difference in pain levels was significant in favor of the study group (pb 0.001) (Table 4). It was considered that SPAP, which was adminis-tered to the study group, prevented the exacerbation of pain due to the close follow-up of the pain and the patient's response to analgesia. In-deed, the pain level between thefirst 8th and 11th hours was 2.4 ± 2.1 in the study group patients, compared to 5.2 ± 2.8 in the control group (pb 0.001). Previous studies have shown that pain assessment based on acute pain protocols improves pain management (Karlsten et al., 2005; Silva et al., 2013; Sommer et al., 2008). Another study ob-served the effects of a continued educational program for the nursing team and physicians on the assessment of post-operative pain intensity at rest and on exertion, as well as on analgesic prescriptions (Karlsten et al., 2005). The assessment of pain according to the protocols increased from 71 to 91% in the surgical wards and from 60 to 88% in the orthope-dic wards, which led to increased awareness of pain and improved pain

Table 1

Standard Pain Assessment Protocol (SPAP). Standard Pain Assessment Protocol

– Inform the patient and his/her family about pain assessment prior to the operation.

– Select the pain scale (numerical, VAS) together with the patient prior to the operation, and use that scale after the operation.

– Determine the pain level only by a self-rated scale ﬁlled by the patient. – Determine the pain-reducing and increasing factors during the assessment. – Assess the patient's pain once in 2 h during the ﬁrst 8 h, and, then, once in 4 h

until 24 h.

– Re-assess the pain 30 min after parenteral analgesia and 1 h after oral analgesia/non-pharmacological analgesia.

– Measure the patient's pain both at rest and during cough.

– Record the patient's pain level and analgesics administered into the nurse observation form.

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assessment (Karlsten et al., 2005). The study bySommer et al. (2008) with 1490 surgical patients reported that the rate of patients with mod-erate to severe pain reduced from 41 to 16%, when the acute pain

protocols were applied (Sommer et al., 2008). In a study ofSilva et al. (2013), it was shown that the use of the Systematized Assessment Form for Pain consulted a better strategy toward the postoperative pain management among cardiac surgery patients, as the interventions increased the employment of supplementary morphine and resulted in lower pain intensity, as reported by the patients (Silva et al., 2013).

Since pain assessment was not performed as of the 12th hour in con-trol group patients in our study, we have no information on the pain level andﬂuctuation in pain. The results of our study suggested that the pain level statistically signiﬁcantly reduced, when the pain assess-ment was performed in a standard manner.

4.2. Amount of analgesic consumption

Analgesics are administered in case of necessity at the clinic where the study was conducted. Since pain assessment was not performed as of the 12th hour in the control group despite severe pain, analgesia was administered at irregular intervals or was not administered at all. This may result both from the work load of the orthopedic nurses and from their discretion to administer lower amounts of drugs to the pa-tients. Several studies conducted with surgical nurses in Turkey report that a considerable part of the nurses (67.2%) do not implement the an-algesic request in case of necessity unless needed, and their main goal is to administer fewer drugs (Dikmen, Usta,İnce, Gel, & Kaya, 2012; Sü & Sahin, 2014).

Our study found a lower amount of analgesic consumption for both opioids and non-opioids in the study group based on the time of

Fig. 1. The participantﬂow diagram.

Table 2

The socio-demographic features of the patients.

Features Study Control Statistical analysis n (%) n (%) Age mean ± SD 45.8 ± 14.51 50.38 ± 14.24 p = 0.135a Min-Max 18–80 21–76 Gender Female 33 (64.7) 34 (68.0) p = 0.726b Male 18 (35.3) 16 (32.0) Education Non literate 7 (13.7) 5 (10.0) p = 0.826b Primary school 22 (43.14) 22 (44.0) High school 12 (23.5) 10 (20.0) University 10 (19.6) 13 (26.0) Chronic disease p = 0.129b Yes 25 (49.0) 32 (64.0) No 26 (51.0) 18 (36.0)

Having surgery before p = 0.744b

Yes 30 (58.80) 31 (62.0) No 21 (41.2) 19 (38.0)

Having severe pain Before p = 0.936b

Yes 31 (60.8) 30 (60.0) No 20 (39.2) 20 (40.0) a T test. b Chi-square test.

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analgesia within the postoperativefirst 24 h (p N 0.05) (Table 5). In the literature, regular analgesic administration has been reported to reduce thefluctuations in the blood analgesic levels during the first 48 h, in par-ticular, and, thereby to facilitate the pain management (Pasero, 2010; Pillai Riddell & Craig, 2003). In a study which investigated the effect of regular analgesic administration on the outcomes of hip surgery, the au-thors found that a scheduled analgesic intake could improve the func-tional outcomes of patients with hip fractures after surgery (Chin, Ho, & Cheung, 2013). In our study, a periodical and more frequent pain as-sessment provided pain management, and, thus, reduced both analgesic consumption and pain level. Similarly,Silva et al. (2013)demonstrated that postoperative opioid consumption was significantly reduced in pa-tients for whom standard and routine pain assessments were per-formed by nurses compared to the other groups (Silva et al., 2013). Acute pain protocols also recommend a pain-preventive approach through the analgesic administration before the start or exacerbation of the pain (Pasero & McCaffery, 2011). The Joint Commission states

that a systematic and periodical assessment of the pain enables an effec-tive pain management (Pasero & McCaffery, 2011; Wells et al., 2008). Therefore, the nurse, who has the key role in pain management, should assess the pain periodically without any exacerbation of the pain and administer analgesics on a regular basis.

4.3. Non-pharmacological applications

Pain assessment protocols question pain-increasing (operated shoulder being under pressure, not informing about pain, etc.) and pain-reducing (expressing pain, supporting the shoulder, etc.) factors, as well as encouraging the patient toward expressing his/her pain. Non-pharmacological methods were used in almost all of the patients in the study group and one quarter of the patients in the control group; it indicated a statistically signiﬁcant difference between the groups (pb 0.001) (Table 6). Since the frequency of pain assessment was higher in the study group, the frequency of one-on-one interview with the patient was higher, too. During each inquiry of pain, the patient was encouraged to express his/her pain, informed about pain and, the position-related discomfort wads corrected, if available. In this study, both groups of patients were allowed to express their pain during the pain assessment, and non-pharmacological methods, such as proper pa-tient positioning and supporting the shoulder, were applied during the pain assessment with the direction of the patient.

4.4. Limitations

Nonetheless, this study has some limitations. First, the pain levels of the patients were not regularly assessed within the postoperativeﬁrst 24 h in the control group. Routine pain assessment hours were not added to the control group, since it was considered at the beginning of our study that the clinical nurses frequently followed the vital signs of

Table 3

The operational features of the patients.

Features

Study Control Statistical Analysis n (%) n(%)

Analgesia in the preoperative period

Yes – – – No 51 (100.0) 50 (100.0) Anesthesia General 4 (7.8) 8 (16.0) p = 0.353a Axillary block 28 (54.9) 28 (56.0) General and axillary block 19 (37.2) 14 (28.0)

Surgery p =

0.322b

Subacromial decompression 3 (5.9) 1 (2.0) Labrum lesion repairs 8 (15.7) 3 (6.0) Rotator cuff surgery 37 (72.5) 43 (86.0) Superior labrum anterior posterior lesion

repairs 3 (5.9) 3 (6.0) Surgery position – Lateral decubitus 51 (100.0) 50 (100.0) Surgery time (hr) p = 0.842a b3 st 24 (47.1) 22 (44.0) ≥3 st 27 (52.9) 28 (56.0) Analgesia in the intraoperative period –

Yes – –

No 51

(100.0) 50 (100.0) Analgesia in the postanesthesia care unit p =

0.836a

Yes 10 (19.6) 9 (18.0) No 41 (80.4) 41 (82.0)

a_{Chi-square test.} b _{Fisher's exact test.}

Table 4

The mean pain levels of the patients.

Time Pain levels Statistical analysisa Study Control n(%) n(%) 0.–3. h Resting 2.2 ± 3.13 – – Coughing 2.3 ± 3.27 – – 4.–7. h Resting 1.8 ± 2.40 6.6 ± 1.99 pb 0.001 Coughing 1.9 ± 2.54 7.01 ± 2.18 pb 0.001 8.–11. h Resting 2.41 ± 2.10 5.2 ± 2.80 pb 0.001 Coughing 2.60 ± 2.26 5.5 ± 2.91 pb 0.001 12.–15.h Resting 4.15 ± 2.02 – – Coughing 4.39 ± 2.11 – – 16.–19. h Resting 3.4 ± 2.28 – – Coughing 3.5 ± 2.36 – – 20.–24. h Resting 3.1 ± 2.09 – – Coughing 3.3 ± 2.30 – – a

Mann Whitney U test.

Table 5

The consumption of the analgesics in the postoperativeﬁrst 24 h.

Analgesia time Analgesia

Amount of the analgesic (mg)

Statistical analysisa Study Control n(%) n(%) 0.–3. h Opioid 95.0 ± 15.81 100.0 ± 0.0 p = 0.584 Non-opioid 361.1 ± 484.72 554.7 ± 488.75 p = 0.124 4.–7. h Opioid – 100.0 ± 0.0 – Non-opioid 532.9 ± 488.09 607.08 ± 499.588 p = 0.875 8.–11. h Opioid 100.0 ± 0.0 100.0 ± 0.0 p = 1.000 Non-opioid 318.9 ± 435.44 393.6 ± 469.56 p = 0.779 12.–15. h Opioid 92.9 ± 18.90 – – Non-opioid 316.5 ± 431.19 390.0 ± 528.37 p = 0.357 16.–19. h Opioid 100.0 ± 0.0 100.0 ± 0.0 p = 1.000 Non-opioid 445.0 ± 477.67 – – 20.–24. h Opioid 100.0 ± 0.0 – – Non-opioid 408.1 ± 490.65 – – a

Mann Whitney U test.

Table 6

Details on Non-pharmacological pain methods applied to patients. Details of non-pharmacological pain methods Study Control pa n (%) n (%) Administration of non-pharmacological analgesia Yes 50 (98.0) 13 (26.0) pb 0.001 No 1 (2.0) 37 (74.0)

Non-pharmacological pain methods used

Proper positioning 46 (90.2) 11 (84.6) pb 0.001 Supporting the shoulder 47 (92.2) 13 (100.0) pb 0.001 Informing the patient about pain 36 (70.6) 4 (30.8) pb 0.001 Encouraging the patient toward

expressing his/her feelings about pain

31 (60.8) 1 (7.7) pb 0.001 Distracting 24 (47.1) 3 (23.1) pb 0.001

a

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patients within the postoperativefirst 24 h and pain would be evaluated as thefifth vital sign. Since the pain of the control group patients was not regularly assessed, both the pain levels and the amount of analgesic consumption were unable to be compared between the groups for each hour. The second limitation of the study was the study population and relatively small sample size. The research was conducted on patients undergoing arthroscopic shoulder surgery. Thus, the study results can-not be generalized to the overall population. Therefore, further large-scale studies are needed in different surgicalfields to establish a conclusion.

5. Conclusions

In conclusion, pain assessment alone does not provide an effective pain management; however, it is effective in reducing pain and analge-sic consumption when applied in accordance with the pain protocols. The following suggestions were made based on the results from our study:

• Based on the recommendations involved in acute pain guidelines, each hospital should standardize pain assessments by formulating its own pain protocols, and analgesics should be administered at reg-ular intervals, not in case of necessity.

• With an effective role in pain management, nurses should undertake the key role in formulating, administering, and supervising the protocols.

Sources of support

This research did not receive any speciﬁc grant from funding agen-cies in the public, commercial, or not-for-proﬁt sectors.

Conﬂict of interest

The authors declare that they have no conﬂicts of interest. Acknowledgment

We would like to thank to the nurses and surgeons of the orthopedic surgery clinic for their devoted work.

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