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Nurses need to improve post-op pain documentation

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Surgical nurses need to improve the documentation of post-operative pain assessment and management, suggests a new study.

Using three pain audit tools, nurse researchers reviewed a random sample of 322 patient records from six hospitals in Jordan in the Middle East.


They found the nursing documentation of patients’ pain in the first 72 hours post-op to be ‘unsatisfactory’ in more than 80% of cases.


On the first day of surgery, a third of the nursing notes had no documentation of a pain assessment, and this had risen to more than half by day two, said the researchers.


Less than 50% of the notes contained information about medication administered for pain management on day one, and less than a quarter had documentation relating to non-pharmacological interventions, such as coughing and deep breathing.


By the third post-operative day, nursing documentation was poor in most areas, particularly pharmacological interventions and outcomes, the researchers added.


‘The recording of post-operative pain interventions has major importance for the continuity of effective pain management,’ the authors said.


‘Our recommendation is to implement educational programmes through in-service training for improving pain management and documentation that can be evaluated by a proper mentor system.’


Acute Pain (2008) 10: 73-81

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