Documentation of postoperative pain by nurses in surgical wards

Summary 

Purpose

To describe nursing documentation of pain assessment and management in the first 72h postoperatively in surgical wards.

Methods

A retrospective approach was used to collect data on nurses’ documentation from patients’ records. A total sample size of 322 records at six hospitals in Jordan were audited using three audit instruments; Pain and Anxiety Audit Tool, the North American Nursing Diagnosis Association (NANDA) form for characteristics of acute pain, and comprehensiveness assessment tool.

Results

There was no evidence of pain assessment documentation on the first day of surgery in 113 (35%) of patient's records. Pain location was the most recorded information for pain assessment in 197 (61%) notes, and only 14 (4.3%) nurses used a pain scale. More than 53% of the records lacked information about medication for pain management. There was a significant difference (p<0.05) in all the categories of pain documentation between the first day and the subsequent days. Nurses documented patients’ self-report of pain [297 (92.3%)], and patients’ crying [200 (62.1%)]. More than 80% (273) of the records were ranked below the minimum score for a satisfactory documentation.

Conclusion

The results indicate the need to improve postoperative pain assessment and documentation, and the establishment of acute pain service.

Keywords: Postoperative pain, Audit, Nursing documentation, Pain assessment, Pain management