Ayasrah Shahnaz Mohammad, O'Neill Teresa Mary, Abdalrahim Maysoon Saleem, Sutary Manal Mohammed, Kharabsheh Muna Suliman
Department of Applied Science/Nursing, Al-Balqa' Applied University (Ajloun University College), Al-Salt, Jordan.
Our Lady of Holy Cross College, 4123 Woodland Drive, New Orleans, LA 70131.
Int J Health Sci (Qassim). 2014 Jul;8(3):287-98. doi: 10.12816/0023981.
The purpose of this study was to describe: (1) pain indicators used by nurses and physicians to assess pain, (2) pain management interventions (pharmacological and non-pharmacological) used by nurses, and (3) indicators used by nurses to verify pain intervention effectiveness.
A total of 301 medical records of currently admitted patients from six different ICUs in Jordan were reviewed using a data collection instrument developed by Gélinas et al. (2004) Pain-related indicators were classified into non-observable (patient's self-reports of pain) and observable (physiological and behavioral) categories.
Only 105 (35%) of a total 301 reviewed medical records contained pain assessment data. From these medical records, 15 pain episodes were collected altogether. Observable indicators documented 98% of the 115 pain episodes. Patients' self-reports of pain were documented only 1.7% of the time. In 78% and 46% of the 115 pain episodes, pharmacological and nonpharmacological interventions for pain management were documented, respectively. Only 37% of the pain episodes were reassessed with self- report (1%) and observable indicators (36%) to determine the effectiveness of the interventions.
Pain documentation for assessment, management, and reassessment was lacking and needs improvement.
本研究的目的是描述:(1)护士和医生用于评估疼痛的疼痛指标,(2)护士使用的疼痛管理干预措施(药物和非药物),以及(3)护士用于验证疼痛干预效果的指标。
使用Gélinas等人(2004年)开发的数据收集工具,对约旦6个不同重症监护病房目前收治患者的301份病历进行了审查。与疼痛相关的指标分为不可观察(患者的疼痛自我报告)和可观察(生理和行为)类别。
在总共301份审查的病历中,只有105份(35%)包含疼痛评估数据。从这些病历中,共收集到15次疼痛发作。可观察指标记录了115次疼痛发作中的98%。患者的疼痛自我报告仅在1.7%的时间内有记录。在115次疼痛发作中,分别有78%和46%记录了疼痛管理的药物和非药物干预措施。只有37%的疼痛发作通过自我报告(1%)和可观察指标(36%)进行了重新评估,以确定干预措施的效果。
在疼痛评估、管理和重新评估方面的记录不足,需要改进。