Pain assessment is an essential part of postoperative care. Both analgesic and non-analgesic strategies should be developed with patients to manage their pain
Sharon Wood MSc, Dip healthcare research studies, IHBC body massage, RGN, is lecturer in nursing, University of Leeds.
Wood S (2010) Post operative pain 2: Patient education, assessment and management. Nursing Times; 106; 46, early online publication.
Postoperative pain is poorly managed with up to 67% of patients in the UK experiencing unnecessary moderate to severe pain. Part 1 of this two part series explored physiological mechanisms involved in the perception of pain and the role of psychological and environmental influences on how patients respond to it. This second part explores the principles of patient assessment and management of postoperative pain, and discusses acute pain analgesic guides.
Keywords Pain, Surgery, Measurement, Analgesia
- This article has been double-blind peer reviewed
- Assessment of POP should be incorporated as the fifth vital sign in secondary and primary care
- Accurate assessment of the causes of pain following surgery should be assessed and appropriate interventions implemented and evaluated
- Appropriate analgesia should be given promptly and evaluated. Consider using an acute pain analgesic guide.
- Early identification, management and referral for patient with suspected chronic post surgical pain is essential.
Preoperative patient education
Providing preoperative education about post operative pain (POP) can improve patients’ knowledge as well as encouraging a positive attitude towards it. It provides realistic expectations about POP and its management, reduces anxiety and increases patient satisfaction (ANZCA, 2010; Vickers et al, 2009). There is no consensus about whether educational interventions actually reduce the experience of pain.
Preoperative pain education may be delivered face-to-face with groups of patients or individuals, while written information or videos can also be used (Australian and New Zealand College of Anaesthetists, 2010; Vickers et al, 2009; American Society of Anaesthesiologists, 2004). Education should include:
The importance of treating POP;
- Goals of POP treatment;
- The degree/intensity/description of POP the patient can expect;
- Pain assessment tools and how often pain will be assessed on rest and movement;
- The importance of reporting pain and response to treatment;
- Pain management options including drug and non-drug therapy, their effectiveness and side effects.
A comprehensive assessment of POP, identifying physiological, psychological and environmental influences on patients’ experience is at the centre of achieving effective POP management (ANZCA, 2010; Department of Health, 2010; Vickers et al, 2009; Tissue Viability Nurses Assocation, 2004; Quality Improvement Scotland, 2004; Royal Marsden, 2003). This ensures patients’ pain is accurately identified in a timely manner and evaluated and managed appropriately. Pain assessment should be regularly and systematically conducted as part of pre-operative assessment, postoperative care, discharge processes and in primary care, until pain has subsided (Fig 1).
Preoperative pain assessment
Although not widely documented in the literature, it is recommended that the POP assessment should start in the preoperative phase (Box 1). Preoperative pain assessment could be carried out in primary care or in pre-assessment clinics (ANZCA, 2010; Vickers et al 2009, European Association of Urology, 2007; ASA, 2004). This initial assessment should include:
- An evaluation of any pre-existing pain(s);
- How this affects function;
- How it is managed (medication, non-drug strategies, coping strategies);
- Previous pain experiences;
- Expectations and beliefs about POP and its management.
Risk factors associated with the development of chronic post surgical pain (CPSP) should also be considered; these are outlined in part 1 (Wood, 2010). POP can then be anticipated, high risk patients can be identified - including those with pre-existing pain, past experience of pain management problems in hospital, significant anxiety about POP and those at high risk of developing neuropathic pain postoperatively (Vickers et al, 2009). Neuropathic pain is caused by a primary lesion or dysfunction in the nervous system (International Association for the Study of Pain, 1994).
This assessment will help in the development of a plan of care for POP. A pain management plan that includes analgesic and non-drug strategies should be developed with the patient, and be communicated to relevant healthcare professionals within the team (Vickers, 2010). This approach may require a strategic change in care processes so that pain assessment becomes a normal part of the primary care preoperative assessment or pre-assessment clinic.
Box 1 Components of pain assessment (Adapted from ANZCA, 2010)
- Site or expected site of POP or other pain.
- Circumstances associated with onset of POP or other pains.
- Character or expect character of POP or other pains (for example, sharp, dull, throbbing, aching, burning, shooting, tingling.
- Intensity or expected intensity of POP or other pains.
- At rest;
- On movement;
- Duration (continuous or intermittent);
- Aggravating or relieving factors.
- Associated symptoms, for example, nausea.
- Effect of POP and other pains on activities such as turning in bed, coughing and moving - a functional activity scale may be used.
- Treatment such as drugs and non-pharmacological strategies.
- Relevant past medical history.
- Factors influencing treatment of patients pain symptoms.
- Beliefs about POP and other pain;
- Knowledge, expectations and preference for POP management;
- Reduction in POP required to achieve patient satisfaction or resume normal activities;
- Typical coping response for pain/stress.
- Family expectations and beliefs about POP
Postoperative pain assessment
POP should be assessed regularly and systematically, at rest and during movement, by competent nurses (DH, 2010). It is recommended that pain is assessed along with other vital signs and it should be documented as the ‘fifth vital sign’ (Vickers et al, 2009). Assessments should consider:
- Intensity of pain;
- Description (Bϋyϋkyilmaz et al, 2010).
It is crucial to identify these aspects of pain as postoperative patients may experience no pain at rest, but moderate to severe pain on movement, which may contribute to reduced function and recovery. POP may result from a variety of sources and activitiesoutlined in Box 2 (ANZCA, 2010; Bϋyϋkyilmaz, 2010; Apfelbaum et al, 2003; Puntillo et al, 2001) and it is important to accurately identify these so pain is managed effectively.
Regular, systematic POP assessment and effective nurse-patient communication is crucial to ensure sudden severe pain or persistent unrelieved severe POP is recognised as soon, as possible as it may be associated with a medical emergency. Nurses are ideally placed to evaluate any changes in patients’ descriptions of pain that may indicate CPSP and/or neuropathic pain, for example; burning, shooting, stabbing, electric-shock-like, tingling, numbness.
Neuropathic pain may occur after any surgery, however, specific types of surgery are associated with high risk of nerve injury including; breast, amputations, thoracic or chest wall and hernia repairs (ANZCA, 2010). Prompt implementation of the National Institute for Health and Clinical Excellence (2010) guidelines on the pharmacological management of neuropathic pain in adults, and referral to a specialist pain service has beenlinked to a reduction in the development of CPSP.
POP is a subjective experience and patient experiencing it is the only person who can provide an accurate description of it (Quality Improvement Scotland, 2004). A patient self report of pain is therefore regarded as the ‘gold standard’ for pain assessment. Nurses should encourage patients to report and describe their POP experience, listen to and believe patients’ reports, act swiftly to implement appropriate POP management strategies/refer as necessary to specialist pain services, and return to patients to evaluate the effectiveness of these strategies (DH, 2010).
Box 2. Sources of postoperative pain
- Deep breathing
- Wound, wound dressings and dressing changes
- Wound drain
- Intravenous cannula
- Central line
- Sore throat and mouth ulcers following intubation
- Dry/cracked lips associated with oxygen therapy
- Nasal cannula
- Urethral catheter
- Chest drain
- Endotracheal suctioning
- Nasogastric tube
- Rectal tube
- Specific equipment associated with specialist surgery (eg passive movement machine, external fixator, traction)
- Blood tests
- Blood pressure cuff
- Back pain following length of time/position in surgery
- Uncomfortable position
- Tight bandages
- Anti-embolic stockings if inaccurately applied
- Orthopaedic casts
- X-rays and tests/examinations away from the ward
Pain assessment tools
It is difficult to fully assess and document the whole POP experience throughout the postoperative period, and pain assessment tools measuring the intensity of POP are used to supplement descriptive information gained from the patient. Tools should be explained to the patient during the preoperative education process.
To facilitate the systematic assessment of pain, a standard evidence based pain intensity tool that is valid and reliable and can be used for the majority of patients should be selected (DH, 2010; Vickers, 2010; Royal Marsden, 2003). There are numerous pain assessment tools that measure the intensity of POP, including verbal numerical rating scales (VNRS) and verbal descriptor scales (VDS); both these types have been shown to be sensitive and accurate in measuring the intensity of pain (Vickers, et al, 2009).
Verbal numerical rating scales
The VNRS measures the patient’s pain intensity on a scale from 0 to 10. It is often delivered verbally to a patient, for example: “On a scale from 0 to 10, with 0 being no pain at all and 10 being the worst pain you could imagine, where would you rate the pain you are experiencing right now?” (ANZCA, 2010). A value of 4 or more is usually used to guide implementation of POP management interventions (ANZCA, 2010). The VNRS is simple to explain and for patients to understand, it gives consistent results and patients are able to recall their previous ratings over a 24 hour period (ANZCA, 2010). Some patients, however, may find it difficult to capture the whole of their pain experience in a single number. The VNRS has been shown to be effective in older patients and those with a mild/moderate cognitive impairment (Royal College of Physicians, 2007). It is suitable for patients with visual impairment.
Verbal descriptor scales
VDS incorporate a numerical value and a description of pain intensity. The most frequently used tool for measuring POP in clinical practice is the 0-3 scale, where: 0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain. The numerical value can be recorded as the fifth vital sign on documentation. VDS scales are less sensitive to POP than the VNRS (ANZCA, 2010), but like the VNRS, they are easy and quick to teach, and easy for patients to understand. Older patients and those with a mild/moderate cognitive impairment are able to use the VDS effectively, as are patients with a visual impairment (ANZCA, 2010).
The POP intensity score reported by the patient can then be used to plan appropriate pharmacological and non pharmacological interventions. These scales may be difficult or inappropriate for some groups of patients, for example, unconscious/sedated patients, non-English speaking people, those with learning disabilities or moderate to severe cognitive impairment. There are validated tools available for some groups of patients, for example, behavioural and/or physiological observation tool for unconscious/sedated patients ?reference, Disability Distress Assessment Tool (Dis DAT) for patients with a learning disability (Regnard et al, 2007), and the Abbey Pain Scale for patients with a cognitive impairment (RCP, 2007).
Following implementation of pain management interventions, the intensity of pain should be assessed again using the same assessment tool, to evaluate the effectiveness of the interventions.
The World Health Organisation (WHO) analgesic ladder (tinyurl.com/WHO-pain-ladder-Palliative) is used in clinical practice to guide postoperative analgesic interventions. This, however, was originally developed to guide pain relief for patients with cancer, and as such, recommends that initial analgesic intervention should commence with mild analgesics progressing to stronger analgesics as the pain intensity increases (WHO, 2007)This differs from the aims of POP management, as POP is anticipated to be at its most severe immediately following surgery, and the intensity is expected to reduce over time as wound healing occurs (Bϋyϋkyilmaz, 2010). This means management is more likely to start with strong analgesics with a consequent reduction in the strength of analgesics until the pain has completely gone.
The WHO (2007) recommends that distinct guidelines need to be developed for acute pain. A useful analgesic guide for POP management is the ‘Descending ladder of acute pain’ (Bandolier, 2003), but it is not widely used in clinical practice (Fig 2).
Monitoring and management of side effects and complications following analgesic interventions is crucial. It must be acknowledged there will be individual patients who require a more comprehensive approach.
For effective POP management to occur nurses need the knowledge and skills to select and implement appropriate assessment strategies and interventions and be able to evaluate these accurately and identify any problems. If this does not happen patients will continue to experience unacceptable levels of POP and unidentified CPSP.
Apfelbaum JL et al (2003) Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anaesthesia and Analgesia; 97: 534-540.
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010) Acute PainManagement Scientific Evidence. Melbourne: ANZCA.
American Society of Anaesthesiologists (2004) Practice guidelines for acute pain management in the perioperative setting, an updated report by the American Society of Anaesthesiologists Task Force on acute pain management. Anaesthesiology; 100, 1573-1581.
Bandolier(2003) Acute Pain.
Bϋyϋkyilmaz FE et al (2010) Postoperative pain characteristics in Turkish orthopaedic patients. PainManagement Nursing; 11: 2, 76-84.
Department of Health (2010) Essence of Care: Benchmarks for the prevention and management of pain. tinyurl.com/benchmark-pain
Dolin SJ et al (2002) Effectiveness of acute postoperative pain management: evidence form published data. British Journal of Anaesthesia; 89: 3, 409-423.
European Association of Urologists (2007) Guidelines on Pain Management.
International Association for the Study of Pain (1994) IASP Pain Terminology.
Quality Improvement Scotland (2004) Post-Operative Pain Management Best Practice Statement. Edinburgh: QIS.
National Institute for Health and Clinical Excellence (2010) Neuropathic pain: the pharmacologicalmanagement of neuropathic pain in adults in non-specialist settings. London: NICE. guidance.nice.org.uk/CG96
Puntillo KA et al (2001) Are vital signs indicators for the assessment of pain in postoperative cardiac surgery ICU adults? Intensive and Critical Care Nursing; 26:83-90.
Regnard C et al (2007) Understanding distress in people with severe communication difficulties: developing and assessing the Disability distress assessment tool (DisDAT). Journal of Intellectual Disability Research; 51: 4, 277-292.
Royal College of Physicians (2007) The Assessment of Pain in Older People – Concise Guide to GoodPractice. Number 8, National Guidelines. London: RCP.
Royal Marsden (2003) Benchmarks for Pain Management. London: The Royal Marsden.
Tissue Viability Nurses Association (2004) Best Practice Statement: minimising trauma and pain in wound management. Aberdeen: Wounds UK.
Vickers A (2010) The management of acute pain. Surgery; 28: 4, 175-180.
Vickers A et al (2009) Consensus statement on the anticipation and prevention of acute postoperative pain: multidisciplinary RADAR approach. Current Medical Research and Opinion; 25: 10, 2557-2569.
World Health Organisation (2007) WHO normative guidelines on pain management. Geneva: WHO.
Wood S (2010) Postoperative pain 1: understanding the factors affecting patients’ experiences of pain. Nursing Times; 106, 10-13.