Pain Score Recording as the Fifth Vital Sign Experience at Orthopedic Surgical Wards, Srinagarind Hospital

Abstract

Abstract

Background: Nursing care in the orthopedic surgical wards have in place a policy for quality improvement, which is emphasized by use of pain score recording.

Objective: To audit pain score records for the first 72 hours after surgery

Design: Descriptive study with retrospective data collection

Setting: Orthopedic Surgical Wards at Srinagarind Hospital, Khon Kaen University, Thailand

Methods: Between March and April 2005, we extracted data from the Graphic Sheets for patients ³ 10 years of age.

Outcome Measures:  1) All records were audited and the values for pain scores recorded each day including the operative day (Day 0 – assessed by a nurse every 4 hours) and two days post-op (Days 1 and 2 – assessed every 8 hours). Good quality records had regularly recorded pain scores. An improvement in quality was acknowledged if the proportion of quality records was ³80%.  2) The percentage of patients having two-consecutive severe pain recordings (i.e. score ³ 7) on each Day.  3) Mean pain score each time.  4) Patient-satisfaction before discharge.

Results: A total of 94 patients were included.  On Day 0, 98% of the assessment and recording of pain scores occurred, on Day 1 it was 95% and on Day 2 it was 89%. The highest post-operative pain was 5.5 ± 2.5, 4.0 ± 2.5 and 3.1 ± 2.7 on Day 0, 1 and 2; while the lowest pain score was 4.2 ± 2.8, 2.9 ± 2.7 and 2.1 ± 2.1 on Day 0, 1 and 2, respectively.  Percentages of the patients having two-consecutive severe pain were 19%, 5% and 1%, respectively. All of the patients were satisfied with the pain relief offered.

Conclusion: Completion of the assessment and pain score records at the orthopedic surgical wards were high and all of the patients indicated that they were satisfied with the pain service.

Keywords: Audit Recording, Orthopedic Wards, Pain Scores, Postoperative