Documentation of postoperative pain by nurses in surgical wards

Abstract

Purpose: To describe nursing documentation of pain assessment and management in the first 72 h 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. © 2008 Elsevier B.V. All rights reserved.