Recording acute pain in hospitalized patients

Abstract

BACKGROUND AND OBJECTIVES:Nurses are in a good position to carry out pain assessment and management, as well as to perform pharmacological and non-pharmacological interventions. The aim of this study was to compare hospital pain records in hospitalized patients with pain reports from a previous study and to analyze the presence of the "Acute Pain" Nursing Diagnosis and the Nursing Interventions prescribed for pain management. METHODS: Cross-sectional study with retrospective data collection. As a criteria for sample selection, the pain report referred to in a previous study interview was used. The medical records were analyzed in order to verify the registries of acute pain intensity, presence of the "Acute Pain" Nursing Diagnosis and nursing interventions prescribed for adult hospitalized patients. RESULTS:The sample of the present study consisted of 63 adult patients, with a mean hospital stay of 12 days. There was a disparity between medical records and pain data collected previously, indicating pain underreporting. The "Acute Pain" Nursing Diagnosis was identified in 60.3% of cases and Nursing Interventions were based on pharmacological pain relief (36.5%). CONCLUSION: The information in the hospital's medical records did not reflect the pain reports observed in a previous study. There was underreporting of pain and the Nursing Interventions listed by nurses privileged the assessment and pharmacological treatment of pain. These findings suggest the need for continuous training of the Nursing Team with an emphasis on non-pharmacological pain assessment and management.

Cultural Perspectives on Pain Assessment and Opioid Use: International Neuroscience Nursing Research Symposium Conference Proceedings

“…Even showing concern to identify treating pain, nurses face challenges in appropriate documenting and recording pain assessments and treatments. 38 Despite international and national guidelines for the use of opioids, in recent years, there has been an increase in prescriptions and use of opioids in the Brazilian population, especially in the out-of-hospital environment. 39,40 This scenario shows opportunities for nurses to act in the transition of the level of care and to provide awareness about pain and measures for its control, in addition to opioids.…”

“…Nurses look for valid tools for pain assessment in different populations with varied characteristics such as critical patients, cognitive decline, children, chronic patients, oncological pain, labor pain, and palliative care. Even showing concern to identify treating pain, nurses face challenges in appropriate documenting and recording pain assessments and treatments 38. Despite international and national guidelines for the use of opioids, in recent years, there has been an increase in prescriptions and use of opioids in the Brazilian population, especially in the out-of-hospital environment 39,40.…”

Functional capacity: association with risk for falls, fear of falling and pain in the elderly

“…Estes instrumentos foram traduzidos e validados no Brasil. Além disso, foi aplicado um questionário estruturado com informações sobre idade, sexo, cor da pele, escolaridade, estado civil, ocupação, dias de hospitalização, renda familiar, presença de cuidador e comorbidades (6)(7)(8)(9)(10)(11) .…”

“…A dor foi avaliada pela Escala Numérica, e sua intensidade foi classificada em: 0 ausência de dor; 1-4 (dor leve); 5-7 (dor moderada) e 8-10 (dor intensa) (11) . Diariamente, o pesquisador solicitava ao setor de internação a lista dos idosos internados em enfermarias clínicas e cirúrgicas que tinham idade a partir de 60 anos.…”

Dor orofacial e mecanismos de dor referida

“…Gimenes et al (2020) explica que ao examinar o local afetado pela dor, o paciente pode não ver nenhum sinal de lesão ou de inflamação. Embora não haja dano no local, é comum o paciente apresentar movimentos ativos restritos e sensibilidade à palpação.…”