PAIN ASSESSMENT USING NUMERICAL RATING SCALE TO GUIDE ANALGESIC
THERAPY IN POST OPERATIVE CARDIAC SURGERY PATIENTS
Project Report
Submitted in partial fulfillment of the requirements for the Diploma in Cardiovascular and Thoracic Nursing
Submitted by SREELEKHA.K Roll No : 5652
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY
TRIVANDRUM
OCTOBER 2007.
CERTIFICATE FROM SUPERVISORY GUIDE
This is to certify that Miss.Sreelekha.K has completed the project work
on Pain assessment using Numerical Rating Scale to guide analgesic
therapy in post operative cardiac surgery patients under my direct
supervision and guidance for the partial fulfillment for. the Diploma in
cardiovascular and Thoracic Nursing in the University of Sree Chitra
Tirunallnstitute for Medical Sciences and Technology, Trivandrum.
It is also certified that no part of this report has been included in any other
thesis for procuring any other degree by the candidate.
C?~~~~~ --~ 2 !&( /2-lo')
Mrs. Saramma.P.P
Lecturer in Nursing
Sree Chitra Tirunal Institute
For Sciences and Technology,
Trivandrum- 695011
October 2007.
CERTIFICATE FROM CANDIDATE
This is to certify that the project on Pain assessment using Numerical Rating
Scale to guide analgesic therapy in post operative cardiac surgery patients is
a genuine work done by me at the Sree Chitra Tirunal Institute for Medical
Sciences and Technology,Trivandrum, under the guidance of Mrs.
Saramma.P.P It is also certified that this work has not been presented
previously to any university for award of degree, diploma or other recognition.
Sreelekha.K
Roll No :5652
Sree Chitra Tirunal Institute For
Medical Sciences and
Technology,
Trivandrum- 695011.
Trivandrum
October 2007.
Approval sheet
This is to certify that Miss. Sreelekha.K bearing Roll No : 5652 has been
admitted to the Diploma in Cardiovascular and thoracic Nursing in January
2007 and she has undertaken the project entitled Pain assessment using
Numerical Rating Scale to guide analgesic therapy in post operative cardiac
surgery patients, which is approved for the Diploma in Cardiovascular and
Thoracic Nursing awarded by the Sree Chitra Tirunal Institute for Medical
Sciences and Technology, Trivandrum, as it is found satisfactory.
Trivandrum October 2007
(Examiners)
Guide
Mrs. Saramma.P.P
Lecturer in Nursing
Sree Chitra Tirunallnstitute For
Medical Sciences and Technology,
Trivandrum 695011
October 2007
ACKNOWLEDGEMENT
First of all let me thank God all mighty for the unending love, care and
blessing especially during the tenure of this study. I take this opportunity to
express my sincere gratitude to Mrs. Saramma. P. P. Lecturer in Nursing,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum, for the guidance she provided for executing this study. Her
advises regarding the concept, basic guidelines and analysis of data were
very much encouraging. Her contributions and suggestions have been of
great help for which I am extremely grateful. With profound sentiments and
gratitude the investigator acknowledge the encouragement and help received
from the following persons for the successful completion of this study.
I am thankful to Mrs. Valsala, Ward sister and all other staffs in the Cardiac
surgery Intensive Care unit, for their constant support and encouragement.
Finally, I wish to express my gratitude to all my colleagues who helped me to
carryout this project.
Miss. Sreelekha. K
ABSTRACT
Pain assessment using Numerical Rating Scale to guide analgesic
therapy in post operative cardiac surgery patients.
Post operative pain assessment and management is a unique area of clinical
practice. Repeated pain assessment is a fundamental tool for improving the
quality of acute pain management. The objectives of the study were to assess
pain using Numerical Rating Scale in post operative cardiac surgery patients
before and after giving analgesics and to find out association between pain
scale and selected variables.The study was conducted in the Cardiac surgical
ICU of Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum. Consecutive sampling technique was used for selecting the
sample. The sample size was 30. Post operative cardiac surgery patients
were the samples for the study. Total period of study was September 2007 to
October 2007. A Numerical Rating Scale and selected questions to assess
pain intensity and items to assess physiological changes were used as the
tool for the study. The data was analyzed by using descriptive and inferential
statistics. The study revealed that Numerical Rating Scale can be used as a
reliable tool to assess post operative pain and pain intensity was reduced
after giving analgesics and there was no significant difference between type of
analgesics and reduction in pain score. The study also revealed that pain
intensity was increased during coughing and position changing and there was
no significant relationship between pain intensity and physiological changes.
The studies using more number of samples may be useful to validate the
findings.
CONTENTS SL.NO Page Nos
Chapter 1 1-11
Introduction 1
2 12-23
Chapter 2 Review of Literature
3 Chapter 3 24-28
Methodology
4 Chapter 4 29-39
Analysis and Interpretation of Data
5 Chapter 5 40-43
Summary, Conclusion , Discussion & Recommendation
References
Appendix
LIST OF TABLES I SI.No. Title Page No.
1.1 Goal of assessment of post operative 6 '
pam
2.1 Key terms used for literature search 25
4.1 Distribution of samples according to age 30 category
4.2 Distribution of samples according to sex 31 4.3 Distribution of samples according to 32
type of surgery 4.4 Distribution of samples according to 33
analgesics used in the first post operative day
4.5 Distribution of samples according to 34 analgesics used in the second post
operative day 4.6 Distribution of samples according to 35
analgesics used in the third post operative day
4.7 Distribution of samples according to 36 pain intensity
4.8 Comparison of pain score before and 37 after giving analgesics in the first post
operative day 4.9 Comparison of pain score before and 37
after giving analgesics in the second post operative day
4.10 Comparison of pain score before and 38 after giving analgesics in the third post
operative day 4.11 Mean, Standard deviation and P value 38
of pain score by sex 4.12 Comparison of mean, standard 39
deviation and P value of reduction in pain score by analgesics
LIST OF FIGURES
51. No. Title Page No.
4.1 Distribution of samples according to 30 age category
4.2 Distribution of samples according to 31 sex
4.3 Distribution of samples according to 32 type of surgery
4.4 Distribution of samples according to 33 analgesics used in the first post
operative day 4.5 Distribution of samples according to 34
analgesics used in the second post operative day
4.6 Distribution of samples according to 35 analgesics used in the third post
operative day
4.7 Distribution of samples according to 36 pain intensity
ASD
AVR
CABG
CSICU
DVR
JCAHO
MVR
NRS
VAS
ABBREVIATIONS
Atrial Septal Defect
Aortic Valve Replacement
Coronary Artery Bypass Graft
Cardiac Surgical Intensive Care Unit
Double Valve Replacement
Joint Commission of the Accredition of the Health Care
Organization
Mitral Valve Replacement
Numerical Rating Scale
Visual Analogue Scale
1.1 Introduction
CHAPTER I
Introduction
Pain disables and distresses more people then any single disease entity. It is
probably the most common compelling reason why a person seeks medical
assistance. Pain is defined by the international association for the study of
pain as an unpleasant sensory and emotional e experience associate with
actual or potential tissue damage, or described in terms of such damage
(1979). Nociception described the mechanism by which pain information is
passed to the Central nervous system (CNS) Classically four processes are
described. They are transduction, transmission, perception and modulation. At
the very least, pain appears to have three components; a stimulus, physical or
mental, a bodily sensation of hurting and reaction of the person experiencing
it.
Pain management is considered such an important part of care that the
American Pain Society coined the phrase, pain-the fifth vital sign (Campbell
1995) to emphasis its significance and to increase awareness among
healthcare professionals of the importance of effective pain management.
Pain assessment and management are also mandated by the Joint
commission of the accredition of the healthcare organization (JCAHO). A
broad definition of pain is whatever the person says it is, existing whenever
the experiencing person says it does (McCaffery and Beebe, 1989). This
2
definition emphasizes the highly subjective nature of pain and pain
management. T~e patient is the best authority on the existence of pain.
Therefore validation of existence of pain is based on the patient's report that it
exists.
In the 1990's increasing emphasis was placed on the need for better acute
pain management with the aim of improving patient comfort and outcome after
surgery. Assessment of the person experiencing pain involves recognizing
whether the pain is acute or chronic, identifying the phases of experience and
observing the person's behavioral experiences to it. A number of pain
assessment instruments have been developed to assist in the assessment of
patients perception of pain. Rating scales are the most commonly reported
measure in clinical pain research. Careful assessments and immediate
intervention assist the patients in returning to optimal function quickly, safely
and comfortably as possible.
1.2 Background of the study
Post operative pain management is a unique area of clinical practice .Post
operative pain differs from other type of pain is that, it is usually transient with
progressive improvement over a relatively short time . A more comprehensive
assessment of postoperative pain is sometimes required involving history and
examination. Pain history should reveal location, intensity, characteristics and
temporal aspects of pain as well as factors aggravating and relieving the pain,
associated symptoms and treatment of date. Acute postoperative pain
3
management has been dominated by out dated concept of pain. Pain has
been viewed as the end product of passive system that faithfully transmits a
peripheral pain signal from receptors to a pain center in the brain.
Pain has been studied extensively for centuries and currently there are three
recognized theories of pain transmission .The specificity theory holds that
there are certain specific nerve receptors that respond to noxious stimuli and
that noxious stimuli are always interpreted as pain. In addition this theory
states that pain impulses are carried by pain fibers - fast myelinated A- delta
fibers and more slowly conducting unmyelinated c-fibers (Descartes') The
pattern theory suggest that pain is reduced by intense stimulation of non
specific fiber receptors. The classic gate control theory of pain described by
Melzack and Wall in 1965 was the first to clearly articulate the existence of a
pain modulating system (Melzack 1996). This theory proposes that stimulation
of the skin evokes nerves impulses that are then transmitted by three systems
located in the spinal cord. The substantia gelatinosa in the dorsal horn, the
dorsal column fibers and the central transmission cells act to influence
nociceptive impulses. The noxious impulses are influenced by a 'gating
mechanism '. Melzack and Wall proposed that stimulation of the large
diameter fibers inhibits the transmission of pain, thus 'closing the gate'.
Conversely, when small fibers are stimulated, the gate is opened. The gating
mechanism is influenced by nerve impulses that descend from the brain. This
theory proposes a specialized system of large diameter fibers that activate
selective cognitive process via the modulating properties of the spinal gate.
4
The gate control theory was important because it was the first theory to
suggest that psychosocial factors play a role in the perception of pain. The
theory guided research towards the cognitive and behavioral approach to pain
management.
A person's pain experience is influenced by a number of factors, including
past experience with pain, anxiety, culture, age, gender and expectation about
pain relief. Past experience tempting to expect that a person who has had
multiple or prolonged experiences with pain would be less anxious and more
tolerant of pain than one who has had little pain. The undesirable effects that
may result from previous experience point to the need for the nurse to be
aware of patients past experience with pain. Age has long been the focus of
research on pain perception and pain tolerance; some researchers have
found that older adults require a higher intensity of noxious stimuli than do
younger adults before they report pain (Washington, Gypson & Helme 2000).
Experts in the field of pain management have concluded that if pain
perception is diminished in the elderly person, it is most likely secondary to a
disease process rather than to aging. (American Geriatric Society, 1998).
Researchers have studied gender difference in pain level and response to
pain. Edwards, Augustan and Fillingin (2000) noted no difference between
genders regarding pain and depression.
5
The factors to consider in a complete pain assessment are the intensity,
timing, location, quality, personal meaning, aggravating and alleviating factors
and pain behaviors. Reducing pain to a tolerable level was once considered
the goal of pain management. This goal may be accomplished by
pharmacologic or non-pharmacologic means. Non -pharmacological
approaches such as guided imagery and relaxation can be used to decrease
pain. Careful patient positioning and environmental control are other methods
to increase patient comfort. Pharmacological agents such as analgesics,
narcotics, sedatives, tranquilizers and placebos are used for managing pain.
Recent improvement in acute pain management have been due largely to the
introduction of new techniques for the delivery of analgesic drugs such as
patient controlled and epidural analgesia. However, despite these advances
pain management remains unsatisfactory for many patients. Studies from the
mid to late 1990' suggest that up to three quarters of post operative patients
are still reporting moderate to severe pain. In 2003 Apfelbaum and colleagues
surveyed 250 adults who had recently undergone surgery and found that 80%
had experienced post surgical pain of these 86% reported having suffered
moderate to extreme pain. In Sree Chitra Tirunal Institute for Medical Science
and Technology, 90% of post operative cardiac surgery patients have
moderate to severe pain and most of them received analgesics such as
Voveran, Tramadol, Dolonex etc, and narcotics such as Morphine, Pethedine
and some of them have epidural analgesia.
6
Clinical assessment of post -operative pain refers to process of describing
pain and its effect on function in sufficient detail to achieve the goals as
shown in Table I. I.
Table I. I. Goal of assessment of postoperative pain.
(1) To assist in diagnosing and to quantify post operative pain
(2) To select appropriate therapy.
(3) To evaluate the response to therapy,
~he most common reason for the undertreatement of pain is the failure of
clinician to assess pain and pain relief. Pain is assessed regularly (every3-
4hours) at rest and on movement and the scores are documented. This
documentation makes pain, the fifth vital sign. Simple descriptive pain
intensity scale, numerical pain intensity scale, visual analogue scale and face
pain scale are usually used for pain assessment. In the Cardiac Surgery
Intensive Care Unit of Sree Chitra Tirunal Institute for Medical Science and
Technology none of these pain intensity scale used for assessing pain.
Patient's self-report only is used to assess pain. Patients self report along with
assessment using pain intensity scale is important for the effective
management of pain.
1.3 Need and significance of the study
Postoperative pain is defined primarily as acute pain caused by tissue injury
associated with surgery. Although surgery and the attendant trauma
themselves result in acute pain, they may not be the only cause of post
operative pain; considerable pain may result from patient positioning or
7
pressure effects owning to prolonged immobility. Post operative pain in
cardiac surgery patients is a very common problem in surgical ICU. During
patients stay in the surgical ICU nurses spend more time with the patient in
pain than any other health care providers. Nurses encounter patients in pain
in a variety of settings, including acute care, out patient and long-term care
setting as well as in home. Thus, they must have the skills to assess pain, to
implement pain relief strategies and to assess the effectiveness of these
strategies
Pain assessment and management require a good rapport with the person in
pain. In assessing a patient with pain, the nurse reviews the patient's
description of pain and other factors that may influence pain as well as the
person response to pain relief strategies. Documentation of pain level as rated
on a pain scale becomes part of patient's medical record, as does a record of
pain relief obtained from the interventions.
The nurse helps to relieve pain by administering pain-relieving interventions
including both pharmacological and non- pharmacological approaches
assessing the effectiveness of those interventions and monitoring for adverse
effects. The information the nurse obtains from the pain assessment is used
to identify goals for managing the pain. To determine the goal, a number of
factors are considered. The first is the severity of the pain as judged by the
patient. The second factor is the anticipated harmful effect of pain and the
third factor is the anticipated duration of the pain.
8
A positive nurse patient relationship and teaching are key to managing
analgesia in the patient with pain because open communication and patient
co-operation are essential to success. The nurse also provides information by
explaining how pain can be controlled. Assessment and treatment of pain
before it become severe diminishes sensitization and thus less medication is
needed. Providing physical care to the patient also gives opportunity to
perform a complete assessment and to identify problems that may contribute
the patients discomfort and pain. Appropriate and gentle physical touch during
care may be reassuring and comforting.
Only patient can accurately describe and assess his or her pain. Clinicians
consistently underestimate the patient's level of pain [Me Caffery and Ferrell,
1997; Puntillo et al 1997; Thomas et al 1998]. There fore a number of pain
assessment instruments have been developed to assist in the assessment.of
patient's perception of pain. Such instruments may be used to document the
need for intervention and to evaluate the effectiveness of intervention. For a
pain assessment instrument to be useful, it must require little effort on the part
of the patient, be easy to understand and use and to be easily scored. Many
peri- operative pain management programs, commonly called acute pain
services have been developed in 1998. Data suggest that all peri operative
pain services positively affect same preoperative patient out comes. The
introduction of an acute pain services may lower post operative pain scores in
many instance, with a reduction of serve pain by more than 50% in some
9
cases. This reduction in pain scores occurs with the introduction of nurse
based acute pain service.
The fundamental principle of postoperative pain management is founded on
the notion that pain relief is a basic human right and in itself is an achievable
endpoint that promotes healing and recovery. Thus the goal of post operative
pain management are to alleviate pain and suffering and to promote healing
and recovery. Pain assessment at rest and during activity is important it
should be done at regular time intervals consistent with surgery type and pain
severity, with each new report of pain and at a suitable interval after each
analgesic intervention. Measuring pain during function increases the
sensitivity of measurements for clinical research. Theoretically post operative
pain should be evaluated in the multiple dimensions such as intensity,
location, emotional consequences and semiological correlates. Scales are
developed to evaluate these dimensions. Repeated pain assessment is a
fundamental tool for improving the quality of acute pain management.
1.4 Statement of the problem
Pain assessment using numerical rating scale to guide analgesic therapy in
postoperative cardiac surgery patients.
1.5 Objectives
To assess pain using numerical rating scale in postoperative cardiac surgery
patients before and after giving analgesics.
To find out association between pain scale and selected variables.
1.6 Operational definition
Pain assessment:
10
Assessing the severity of pain in postoperative cardiac surgery patients using
numerical rating scale.
Numerical Rating Scale:
It is a 0-10 rating scale. The intensity of pain is assessed by using this scale.
Post-op cardiac surgery patients:
Patients who undergone any type of cardiac surgery such as Coronary Artery
Bypass Graft (CABG), Mitral Valve Replacement (MVR), Double Valve
Replacement (DVR) Atrial Septal Defect Closure (ASD) colure etc.
Analgesics:
Drugs used to reduce pain such as Morphine, Pethedine, Dolonex, and
Tramadols etc
1. 7 Research methodology
Setting: -Cardiac surgicaiiSU in SCTIMST TVM.
Population:- Post op cardiac surgery patients in SCTIMST.
Sample Size: - 30
Sampling technique: - Consecutive Sampling.
1.8 Tool preparation.
Only the patient can accurately describe and assess his or her pain. A
number of pain assessment instruments have been developed to assist in
assessment of patient's perception of pain.
ll
Here Numerical rating scale along with three questions to assess pain
intensity and three questions to assess physiological changes are used.
1.8 Delimitations
Patients who are not speaking Malayalam are excluded.
Patients who are on ventilator are not included.
Study is limited in cardiac surgery ICU.
The sample size is limited as 30.
1.9 Summary
The above chapter deals with introduction, background of the study, need and
significance of the study, statement of the problem, objectives, operational
definitions, research methodology and delimitations.
1.10 Organization of the report
Chapter Ill deals with the summary of related studies reviewed, chapter Ill
deals with the methodology of the study, chapter IV contains analysis and
interpretation of findings, Chapter V contains the summary and conclusion
and limitation of the study and recommendations. This report also includes a
selected bibliography and appendix.
12
CHAPTER II
Review of Literature
Review of literature can serve a number of important functions in the research
process. Literature review helps to lay the foundation for a study, and can also
inspire new research ideas. It gives character insight into the problem and
helps in selecting methodology, developing tool and also analyzing data. With
these in view an intensive review of literature has been done.
The review of literature relevant to this study is presented in the following
sections.
2.1 Studies related to pain management outcomes
2.2 Studies related to pain assessment and validation of pain observation
tool.
2.1 Studies related to pain management outcomes
Me Neill et al. (2001) conducted a study regarding pain management
outcomes for hospitalized Hispanic patients. A cross sectional, descriptive
study was done. The study sample consisted of hundred and four patients
who were post operative or diagnosed with a painful condition and who were
hospitalized for at least twenty-four hours. The researchers used the
American Pain Society's patient outcome questionnaire. Data related to
analgesic orders and administrations were obtained from the patients' medical
record. The findings of the study were, ninety-eight percentage of the patient
reported pain in the last twenty-four hours. The most interference caused by
the pain was for participation in activities related to post operative recovery.
13
(Mean=7.1 ,SD=2.9) {On a 0-10 NRS with the higher score indicating more
interference}. The mean score on satisfaction with pain management was
4.74 (SD=1.2). Satisfaction with pain management was inversely and
significantly correlated with pain intensity. The lower the patients pain score,
the greater the patients' satisfaction with management of pain. Sixty-six
percentages of patients who received analgesics within the previous twenty
four hours were satisfied with management of pain. The sample was divided
into two groups; Satisfied [n=77] and dis-satisfied [n=23] with pain
management. The dis-satisfied patients reported higher pain now, higher
general pain in the last twenty four hour and greater interference related to
pain for activity. Seventy-seven percentage of patients recalled receiving
information about the importance of pain management.
Me Caffery et al. (2000) conducted a study regarding nurse's personal opinion
about patients' pain and their effect on recorded assessment and titration of
opioid doses. The purpose of the study was to explore how nurse's personal
opinions about pain intensity influence their decision about pain assessment
and about titration of the prescribed opioids to relieve severe pain. In this
descriptive study, surveys were distributed as a pre test to a convenience
sample of nurse's attending pain conferences before receiving any
information on pain. Data were collected at twenty locations through out the
USA. The surveys presented two vignettes describing patients with
postoperative pain. The patients were identical except for their behavior; one
patient was smiling and joking while the other remained quiet in bed and
14
grimaced. Nurse's were asked to identify their personal opinions about both
patients reported pain intensity, what they would document in the patients
record and what opioid dose they would administer. Patients in both vignettes
rated their pain as 8 on a scale of 0-10, indicating inadequate pain
management and ineffective opioid dose to relieve severe pain. In both
vignettes, it was made clear that increasing the opioid dose would be safe and
nurses returned appropriate completed surveys. Of these a random sample of
hundred surveys from each section of the country was obtained for a total of
four hundred. Data from four hundred surveys were analyzed. The findings of
the study were, although nurses who completed the surveys indicated that
they would record the patients' pain as 8. More nurses believed [78.3] the
grimacing patients pain intensity is high and ninety percentages would have
documented it correctly. Nurses were also more likely to correctly increase the
opioid dose for the grimacing patient; Sixty-two percentage of nurses
indicated that they would have increased the dose for the grimacing patient,
while only forty-seven reported that they would do so for the smiling patient.
Of these nurses they would have increased the opioid dose for the grimacing
patient, sixteen percentage would not do so for the smiling patient. However
the findings demonstrated that there is a continuing need for education about
different patients responses to pain and the importance of the patients report
of the intensity of pain. More education is needed to address nurses'
responsibility for opioid titration.
15
Atangana et al. (2007) conducted a study regarding morphine versus
morphine - ketamine association in the management of postoperative pain in
thoracic Surgery. The aim of this study was to assess the quality of
postoperative analgesia obtained with morphine-ketamine association
administered in self-pain controlled analgesia, as well as the amount of
morphine that has been spared. Patients who had to undergo thoracic surgery
were selected. They were divided into two groups: G1 was made up of
patients receiving 0.5 mg/ml of morphine associated with a placebo, with
boluses of 2 ml and refractory periods of five minutes; and G2 made up of
patients receiving 0.5 mg/ml of ketamine associated with 0.5 mg/ml of
morphine with same boluses and refractory periods. The assessment of pain
at rest and on stimulation was carried out with the visual analogue scale. The
response to pain and the amount of morphine spared were evaluated. Fifty
patients with an average age of thirty four years were selected. The
assessment showed that the response to pain at rest was the same in the two
groups as from the twelfth hour. On stimulation, the analgesic response was
better in G2 as well as the amount of morphine spared. This study shows that
the administration of ketamine in association with morphine in the post
operative period procures a favorable efficiency-tolerance relationship and
provides a good means of sparing morphine.
Uniugenc et al. (2004) conducted a study regarding postoperative pain
management with intravenous patient controlled morphine; comparison of the
effect if adding magnesium or ketamine. Ninety patients (3 x 30) were
randomly allocated to receive either morphine 0.4 mg/ml (Group M) by
16
patient-controlled analgesia, morphine 0.4mg/ml + MgS04 30mg/ ml (Group
MM) or morphine 0.4 mg /ml + ketamine 1 mg/ ml (Group MK). Postoperative
analgesia was started when the verbal rating scale was > or = 2. Patients
were first given a standardized loading dose (0.05 mg/ kg) of the study
solution. They were then allowed to use bolus doses of this solution (0.0125
mg/kg every 20 min without time limit). Discomfort, sedation, pain scores,
cumulative morphine consumption and adverse effects were recorded up to
24 h after the start of the patient-controlled analgesia. The level of discomfort,
level of sedation and verbal rating scores decreased significantly with time in
all groups (P < 0.05). Both verbal rating and discomfort scores were
significantly lower in Groups MM and MK at 15, 30 and 60 min compared with
Group M (P < 0.001). Cumulative morphine consumption after 12 and 24 h
was significantly higher in Group M alone (median 26 and 49 mg,
respectively) compared with Group MM (24.2 and 45.7 mg) and Group MK
(24.4 and 46.5 mg). They concluded that, in the immediate postoperative
period, the addition of magnesium or ketamine to morphine for intravenous
patient-controlled analgesia led to a significantly lower consumption of
morphine. However, these differences were unlikely to be of any clinical
relevance.
Taura et al. (2003) conducted a study regarding postoperative pain relief after
hepatic resection in cirrhotic patients. In this study, they evaluated the efficacy
of a single dose of morphine combined with small-dose ketamine given
epidurally for postoperative pain relief. One-hundred-four classification "Child
A" cirrhotic patients were randomly assigned to two groups: 1) (MKG, n = 54):
17
epidural morphine (3.5-5 mg) plus ketamine (20/30 mg); and 2) epidural
morphine (3.5/5 mg) (MG, n ==50). The level of analgesia, side effects, psycho
mimetic and neurological disorders, additional analgesic needs, and overall
quality of the analgesia were recorded. The mean duration of analgesia was
longer in the MKG group (27.2 +/- 8 h versus 16.4 +/- 10 h; P < 0.05). In the
MKG group, the visual analog scale (VAS) score began to be significantly
lower from fourteen hours at rest and twelve hours on coughing until the end
of the study. The need for additional analgesia was also smaller in the MKG
group (P < 0.05): at , twenty four hours only ten percentage of patients in the
MKG group needed complementary analgesia, whereas in the MG group it
was hundred percentage (P == 0.003). Side effects were similar in both groups.
Psycho mimetic side effects and neurological disorders were not detected.
These results suggest that postoperative analgesia provided by a single dose
of epidural morphine with Small-dose ketamine is effective in cirrhotic Child's
A patients having major upper abdominal surgery.
2.2 Studies related to pain assessment and validation of pain
observation tool.
Gelinac et al. (2006) conducted a study regarding validation of critical care
pain observation tool in adult patients. A total of hundred and five patients
participated in this study. Following surgery, thirty three of the hundred and
five were evaluated while unconscious and intubated and ninety nine while
conscious and intubated, all hundred and five were evaluated after extubation.
For each of the three testing period, patients were evaluated by using the
18
critical care pain observation tool at rest, during a nociceptive procedure
(positioning), and twenty minutes after the procedure, for a total of nine
assessments. Each patients self report of pain was obtained while the patient
was conscious and intubated and after extubation. The results of the study
were, the reliability and validity of the critical care pain observation tool were
acceptable. Moderate to high weighted kappa coefficient supported interrater
reliability. For criterion validity, significant associations were found between
the patient self-report of pain and the score on the critical care pain
observation tool. Discriminant validity was supported by higher score during
positioning versus at rest. The critical care pain observation tool showed that
no' matter their level of consciousness, critically ill adult patients react to a
noxious stimulus by expressing different behaviors that may be associated
with pain. There for the tool could be used to assess the effect of various
measures for the management of pain.
Taylor et al.(2003) conducted a study regarding pain intensity assessment; a
comparison of selected pain intensity scale for use in cognitively intact and
cognitively impaired African American older adults was done. The purpose of
this study was to determine the reliability and validity of selected pain intensity
scale including the face pain scale, the verbal description scale, the numerical
rating scale and the Iowa pain thermometer. A descriptive correlation design
was used and a convenience sample of fifty-nine volunteers age fifty-eight
and older residing in south was recruited in this study. The sample consisted
of eight males and forty-nine females with a mean age of seventy-six. The
19
results of the study were, cognitive impairment did not inhibit older minority
participants' ability to use a variety of pain intensity scale.
Lahtinen et al. (2006) conducted a study regarding pain after cardiac surgery;
a prospective cohort study of one year incidence and intensity. The
investigator performed a prospective enquiry of adults and chronic post
sternotomy pain both before and after cardiac surgery. Two hundred and
thirteen CABG patients received a questionnaire pre operatively, four days
post operatively and one, two, three and twelve month post operatively. All
patients asked about their expectations, their performance, and the location
and intensity of postoperative pain. The return rates for the postal
questionnaire were two hundred and three (ninety five percentage) and one
hundred eighty six (eighty seven percentage) after one and twelve months
respectively. Patient experienced more pain post operatively at rest than they
had expected to pre operatively. At rest, the worst actual postoperative pain
was 6 (0-10), and the worst expected pain assessed pre operatively was 5 (0-
1 0} (p=0.013). The worst reported postoperative pain was severe (NRS score
7-1 0) in forty-nine percentages at rest, in seventy-nine percentages during
coughing and in sixty percentage of patient on movement. One year after
surgery twenty-six patients (fourteen percentage) reported mild chronic
postoperative pain at rest. One patient (one percentage) had moderate pain
and three patients (two percentage) had severe pain. Up on movement,
persistent pain was even more common: Forty-five patients (twenty four
percentage) had severe pain, five patients (three percentage) had moderate
20
and seven patients (four percentage) had severe pain. Patients who accepted
moderate to severe acute postoperative pain also reported any chronic post
sternotomy pain [NRS score 1-1 0] more frequently. They concluded that the
incidence of persistent pain after sternotomy was lower than previously
reported. One year after surgery this pain was mostly mild in nature both at
rest and on movement.
Young et al. (2006) conducted a study regarding use of a behavioral pain
scale (BPS) to assess pain in ventilated, unconscious and or sedated
patients. The aim of this study was to validate the behavioral pain scale for
the assessment of pain in critically ill patients by evaluating facial expressions,
upper limb movement and compliance with mechanical ventilation. A
prospective, descriptive, repeated study measure design was used to assess
the validity and reliability of BPS for assessing pain in critically ill patients
undergoing routine painful and non painful procedures. An average of
seventy-three of BPS scores increases pain after re positioning, as opposed
to fourteen percentage after eye care. The odds of an increase in BPS
between pre and post procedure assessment was more than twenty five times
higher for repositioning compared with eye care. They concluded that BPS
was found to be a valiant reliable tool in the assessment of pain in the
unconscious sedated patients. Result also highlighted that traditional pain
indicators, such as fluctuation in hemodynamic parameters were not always
an accurate measure for assessment of pain in the unconscious sedated
patients and more objective pain assessment measure are essential. Finally
21
further validation of BPS and identification of other painful routine procedures
is needed to enhance pain management delivery for unconscious patients.
Evans Jet al. (2004) conducted a study regarding development and validation
of the pain treatment satisfaction scale: a patient satisfaction questionnaire for
use in patients with chronic or acute pain. The purpose of this study was to
develop and validate a measure of patient satisfaction for patients receiving
treatment for either acute or chronic pain: the Pain Treatment Satisfaction
Scale (PTSS). Development of the initial questionnaire included a
comprehensive literature review and interviews with patients, physicians and
nurses in the United States, Italy and France. After initial items were created,
psychometric validation was run on responses from hundred and eleven acute
pain and eighty-nine chronic pain patients in the United States. Analyses
included principal components, factor analysis tests of reliability and clinical
validity. The hypothesized structure of the questionnaire was supported by
statistical analyses, and seven overlapping or inconsistent items were
removed. The multi-item domains of the final PTSS included thirty-nine items
grouped in five dimensions: information (five items); medical care (eight
items); impact of current pain medication (eight items); satisfaction with pain
medication which included the two subscales medication characteristics (three
items) and efficacy (three items); and side effects (twelve items). Internal
consistency reliability coefficients were good (ranging from 0.83 to 0.92). The
test-retest reliability coefficients (ranging from 0.67 to 0.81) were good for all
dimensions except medication characteristics (0.55). All dimensions except
22
medical care discriminated well according to pain severity. The satisfaction
with efficacy dimension, hypothesized to change in the acute pain population,
indicated good preliminary responsiveness properties (effect size 0.37;
P<0.001 ). The PTSS is a valid, comprehensive instrument to assess
satisfaction with treatment of pain based on independent modules that have
demonstrated satisfactory psychometric performance.
De Rond et al. (2000) conducted a study about daily pain assessment.
Numerical rating scale, and visual analogue scale were used for the study.
The result shows that compliance with daily pain assessment was feasible
and valued by nurses. However difference between the three hospitals and
two specialties were found. Almost all patients were able to give a pain score
and majority was positive about daily pain assessment.
Heikkinen katja et al. (2001) conducted a study about prostatectomy patients
post operative pain assessment in recovery rooms. Data were collected in the
recovery room from forty-five consecutive patients who had undergone
prostatectomy. Visual analogue scale, numerical rating scale and verbal
expressions are used to evaluate their pain. The result showed that patients
varied in their ability to assess the intensity of their pain using different tools
but assessments were correlated with each other and with nurses' estimation.
Kathleen et al. (2000) conducted a study regarding pain assessment and
intervention notation tool in critical care nursing practice. The study identified
23
many advantages of the use of standardized systematic approach to pain
assessment and treatment by health professionals.
Key word
Pain assessment
Pain assessment using VAS
Table 1.1
Key elements
Pain assessment & analgesic therapy
Evaluation of pain assessment tool
Pain assessment using pain scale
Number of articles
1626
150
44
18
122
24
CHAPTER Ill
Methodology
This chapter deals with research approach, study design, the sample and
sampling technique, development and description of the tool pilot study, data
collection procedure and plan of analysis.
3.1 Objectives of the study
To assess pain-using Numerical Rating Scale in
postoperative cardiac patients before and after giving
analgesics.
To find out association between pain scale and selected
variables.
3.2 Research approach
Survey method.
3.3 Settings
The study was conducted in the cardiac surgery intensive care unit of Sree
Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram
3.4 Population
Post operative cardiac surgery patients in the cardiac surgery ICU Of Sree
Chitra Tirunallnstitute for Medical Sciences and Technology.
25
3.5 Sample and sampling technique
Consecutive sampling technique was used. The sample consisted of
postoperative cardiac surgery patients in cardiac surgery ICU of SCTIMST.
The sample size was 30. Assessment of patients has been done while they
are in the intensive care unit, from the first to third postoperative day. If ICU
stay is less than three days, the day at which patient is shifted to ward is
taken. The assessment was done two times in one shift with an interval of
three to four hours. The duration of the study was from August 2007 to
October 2007.
3.6 Inclusion criteria
Patients who underwent cardiac surgeries such as valvular surgeries, CABG,
ASD closure, mediastinal mass excision and patients who underwent lung
surgeries and vascular surgeries.
3. 7 Exclusion Criteria
Patients who do not understand Malayalam.
Patients who are on ventilator
3.8 Development of the tool
An extensive study and review of literature helped in the preparation of the
tool. Numerical Rating Scale and assessment of physiological changes were
used as the tools for this study. Patients medical records also were reviewed.
26
The Numerical Rating Scale consists of an eleven point scale with "0" being
no pain and "1 0" being the worst pain imaginable. The patient picks or draws
a circle around the number that best describes the pain dimensions usually
intensity. Three questions regarding pain intensity and three items to assess
physiological changes were also included. The assessment is repeated three
to four hours after giving analgesics.
3.9 Description of the tool
Part 1: This part contains items such as patient name, age, sex, clinical
diagnosis, name of the surgery, post operative day and date and time of
assessment.
Part II: Numerical Rating Scale, three questions to assess intensity of pain
and three items to assess physiological changes, heart rate, respiratory rate
and other changes like sweating, palpitation and restlessness.
Part Ill: Date and time of analgesic administration, date and time of second
assessment, Numerical Rating Scale, two questions regarding intensity of
pain and three items regarding physiological changes.
The same will be repeated on Day two and Day three if the patient is
remaining in the ICU. The techniques used for data collection were
observation and interview.
27
3.10 Pilot study
Pilot study was done in September 2007. Five patients were taken for the pilot
study. The purpose of the study was to assess pain in post operative cardiac
surgery patients in cardiac surgery ICU of Sree Chitra Tirunal Institute for
Medical Science and Technology.
The pilot study was conducted to find out the compatibility of the selected tool.
A Numerical Rating Scale and selected questions to assess pain intensity and
physiological changes were used as the tool. After pilot study modification of
the tool was done.
3.11 Data collection
The data was collected from postoperative cardiac surgery patients in cardiac
surgery ICU of Sree Chitra Tirunal Institute for Medical Sciences and
Technology. The period of data collection was from September 2007 to
October 2007.
3.12 Plan of analysis
The investigator developed a plan of analysis after data collection.
28
3.13 Summary
This chapter deals with methodology, study setting, sample and sampling
technique, development and description of the tool, pilot study, data
collection and plan of analysis.
29
CHAPTER IV
Analysis and interpretation of data
This chapter represents analysis and interpretation of data collection from 30
post operative cardiac surgery patients in the cardiac surgery ICU of Sree
Chitra Tirunal institute for medical sciences and technologies, Trivandrum.
Analysis is a process of organizing and synthesizing data in such a way that,
project questions can be answered. The overall objective of analysis is to
organize, structure and to elucidate meaning from the collected data.
Interpretation is the process of making sense of the result and examining the
implication of findings within the broader content. The findings of the study
were arranged and analysed under the following sections.
4.1 Distribution of samples according to demographic data.
4.2 Distribution of samples according to type of surgery
4.3 Distribution of sample according to pain score, analgesics and selected
variables.
Table No. 4.1 Distribution of samples according to the age category
Age Group Frequency Percentage <20 3 10
21-30 3 10 31-40 6 20
41-50 6 20
51-60 8 26.7 61-70 3 10
71-80 1 3.3
Total 30 100
The data given in Table 4.1 shows that age of the sample ranged from 12-72
with a mean of 43.87 +__16, median48 and mode 52. This shows that more
patients are in the age group of 31-60 (66.7%).Same data is shown in Figure
4.1.
100%-,
90%-
80%
70%-I
& 60%-
1 50%
S. 40% H| 30%-
20%
10%
0% ink Age group
• 21-30 • 31-40 • 41-50 • 51-60 •61-70 •71-80
Figure 4.1 Bar diagram showing age category
Table 4. 2
Distribution of samples according to sex
Sex Frequency Percentage
Male 22 73.3
Female 8 26.7
Total 30 100
Table 4.2 shows more patients are male than female (Male= 73.3%,
Female=26.7%). The same data is shown as pie diagram in Figure 4.2
fenu
^male •female • Slice 4 • Slice 5
Figure 4.2
Pie diagram showing distribution of samples according to sex
Table 4.3
Distribution of samples according to type of surgery.
Type of surgery Frequency Percentage
Sternotomy 27 90
Thoracotomy 3 10
Total 30 100
Table 4.3 shows that more patients have sternotomy 27 (90%) compaired with
thoracotomy. Same data is shown as pie diagram in Figure 4.3.
10%
90%
Figure 4.3
Pie diagram showing samples according to type of surgery
Table 4.4
Distribution of samples according to analgesics used in the first post
operative day
Analgesics Frequency Percentage
Voveran 4 13.3 Tramadol 2 6.7 Morphine 7 23.3 Pethedine 10 33.3 Epidural 2 6.7
Morphine+Pethedine 3 10.0 Morphine + Voveran 2 6.7
Total 30 100
Table 4.4 shows analgesics used in the first post operative day. It shows that
narcotics were more used (Inj. Morphine 23.3% & Inj. Pethedine 33.3%) than
non-narcotics. Same data is shown as bar diagram in Figure 4.4
Percentage
100 90 80 70 60 50 40 30 20 10 0
Percentage
& J? *P > ^
Figure 4.4
Bar diagram showing analgesics used in the first post operative day
3<*
Table 4.5
Distribution of samples according to analgesics used in the second post operative day
Analgesics Frequency Percentage
Not used 4 13.3
Voveran 12 40.0
Tramadol 4 13.3
Pethedine 8 26.7
Not available 2 6.7
Total 30 100
Table 4.5 shows analgesics administered in the second post operative day.
This shows that 40.0% received non- narcotics (Inj. Voveran) and 13.3% not
received analgesics. Same data is shown as bar diagram in Figure 4.5
Figure 4.5
Bar diagram showing analgesics used in the second post operative day
3D
Table 4.6
Distribution of samples according to analgesics used in the third postoperative day
Analgesics Frequency Percentage
Not used 6 20
Voveran 4 13.30
Tramadol 3 10
Not available 17 56.7 Total 30 100
Table 4.6 shows analgesics administered in the third post operative day. It
shows that more patients were shifted to ward so that they were not assessed
and from the remaining patients 20% not received analgesics. Same data is
shown in Figure 4.6.
100 80 60 40 20
0
Percentage
I I I I I
H Percentage
Figure 4.6
Bar diagram showing analgesics used in the third post operative day
30
Table 4.7
Distribution of samples according to pain intensity
Activity Frequency Percentage
Coughing 13 43.3 Coughing and position
changing 14 46.7
Chest physiotherapy and coughing 2 6.7
Chest physiotherapy, coughing and position
changing 1 3.3
Total 30 100
Table 4.6 shows that pain intensity is high at the time of coughing and position
changing. Same data is shown in Figure 4.7
100 -. 90 -80 -70 -60 -
Figure 4.7
Bar diagram showing pain intensity
37
Table4.8
Comparison of pain score before and after giving analgesics in first post
operative day
Assessment Mean Standard deviation P value
Before 5.77 1.30 0.000
After 4.07 1.17
Table 4.8 shows mean pain score before giving analgesics (First assessment)
ranged from 2-8 with a mean of 5.77+ _1.30. Mean pain score after giving
analgesics (second assessment) ranged from 1-6 with a mean of 4.07+_1.17.
A paired 'T' test showed that there is a statistically reduction in the mean pain
score after giving analgesics (P=O.OOO).
Table 4.9
Comparison of pain score before and after giving analgesics in the
second post operative day
Assessment Mean Standard deviation P value
Before 3.83 1.95 0.000
After 1.58 1.58
Table 4.9 shows that in the second post operative day mean pain score
before giving analgesics ranged from 0-6 with a mean of 3.83+ _1.95 .Mean
pain score after giving analgesics ranged from 0-5 with a mean of 2.83+ _1.58.
38
A paired 'T' test showed that there is statistically significant reduction in mean
pain score after giving analgesics (P=O.OOO).
Table 4.10
Comparison of pain score before and after giving analgesics in the third
post operative day
Assessment Mean Standard deviation P value
Before 1.53 2.02 0.000
After 1.27 1.67
Table 4.10 shows that in the third post operative day mean pain score before
giving analgesics ranged from 2-5 with a mean of 1.53+ _2.02 Mean pain
score after giving analgesics ranged from 2-4 with a mean of 1.27+ _1.62.1n
the third post operative day 50% of patients were shifted to ward, so the
sample size was 12. A paired 'T' test showed that there is a statistically
significant reduction in the mean pain score after giving analgesics (p=O.OOO)
Table 4.11
Mean, standard deviation and P value of pain score by sex
Sex Mean Standard deviation P value
Male 5.64 1.22 0.37
Female 6.13 1.55
39
The pain score of male ranged from 2-8 with a mean of 5.64+ _1.22. The pain
score of female ranged from 4-8 with a mean of 6.13+ _ 1.55. Though the
mean pain score of female was higher. An unpaired 'T' test showed that there
was no statistically significant difference between the mean pain score of
male and female (P=0.37).
Table 4.12
Comparison of mean, standard deviation and P value of reduction in
pain score by analgesics.
Analgesic Mean Standard deviation P value
Non- narcotics 1.67 0.82
Narcotics 1.53 0.70 0.86
Combined 2.2 0.45
Table 4.12 shows that mean reduction in pain score by the use of narcotics
ranged from 1-3 with a mean of 1.67+ _0.82 and that of narcotics were '0' with
a mean of 1.53+ _0.70.Mean pain score of combined narcotics and non
narcotics were ranged from 2-3 with a mean of 2.2+ _ 0.45. There is no
statistically significant difference in mean pain score by the narcotics, non
narcotics and combination of narcotics and non- narcotics (P=0.86) that could
be due to small sample size.
40
Chapter V
Summary, Conclusion, Discussion and Recommendations
This chapter gives a brief account of the present study including conclusions
drawn from the findings and possible applications of the result.
Recommendations for future research and suggestions for improving the
present study are also included.
5.1 Summary
This study was undertaken to assess pain in post operative cardiac surgery
patients. The study was conducted in the cardiac surgery intensive care unit
of Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram. The specific objectives of the study were
-To assess pain using Numerical Rating Scale in post operative cardiac
Surgery patients before and after giving analgesics.
- To find out association between pain scale and selected variables.
The review of related literature helped the investigator to get a clear concept
about the topic, methodology of the study, tool preparation and plan of
analysis. The study was done by using a Numerical Rating Scale and
selected questions to assess pain intensity and items to assess physiological
changes. The assessment was done two times in one shift that is before and
3-4 hours after giving analgesics, from first to third post operative day or till
transfer of the patient whichever is earlier. Pilot study was done prior to the
main investigation. Five post operative cardiac surgery patients were
assessed. After pilot study modification of the tool was done. The actual study
41
was conducted in the cardiac surgery ICU of Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Thiruvananthapuram during the period of
September 2007 to October 2007. The sample size for the study was 30. The
data obtained from the study were analyzed by using descriptive and
inferential statistics. Both bar and pie diagrams were utilized to illustrate the
findings of the study.
5.2 Major findings of the study
The study revealed that Numerical Rating Scale can be used as a reliable tool
to assess post operative pain. Comparison between the pain score before and
after giving analgesics showed that pain intensity was reduced after giving
analgesics [Before M =5.77+_1.30, After M =4.07+_1.17, P= 0.000] When
compared to type of analgesics used there was only a minimal reduction in
pain score [P=0.17]. This showed that there is no statistical difference
between type of analgesics and reduction in pain score. This study also
revealed that there was no significant difference between the pain score of
male and female. The pain intensity was increased during coughing and
position changing. The study also showed that there was no significant
relationship between pain intensity and physiological changes.
5.3 Limitations
The study was conducted in a single group patients who have
undergone cardiac surgery
- The study was limited to cardiac surgery ICU of Sree Chitra Tirunal
Institute for Medical Sciences and Technology,
Thiruvananthapuram.
42
The study was limited to patients who could understand
Malayalam, who were conscious and co operative.
5.4 Conclusion
Based on the findings of the study, the following conclusions were drawn.
With this limited number of sample, it was not possible to generalize findings.
There fore the studie.s using more number of patients may be useful to
validate the findings. The Numerical Rating scale is a valid tool to assess the
intensity of pain. Patients self report of pain along with assessment using pain
scale is helpful for effective management of pain.
5.5 Discussion
There are many studies related to the different aspects of pain. This present
study emphasized to assess pain in post operative cardiac surgery patients
using Numerical Rating Scale. The aims of the study were to assess pain
before and after giving analgesics and to find out relationship between pain
scale and selected variables. Daily pain assessment by using pain scale was
feasible and valuable. In this study almost all the patients were able to give a
pain score and majority was positive about daily pain assessment. De Rond et
al (2000) conducted a study about daily pain assessment by using pain scale
and the result was comparable. Gelinac et al (2003) found out that the
intensity if pain increased during positioning rather than at rest. Me Neill
(2003) conducted a study regarding pain management outcomes and he
found out that sixty six percentage received analgesics within 24 hours and all
were satisfied with management of pain. The lower the patients pain score,
the greater the patients satisfaction with pain management. In the present
43
study investigator got similar result and also found out that there was no
significant relationship between pain scale and selected variables ( Age, Sex,
Physiological changes).
5.6 Recommendations
The same study can be done by using a large sample size
Same study can be done in another intensive care unit or in another
Institution.
This study can be done by using another pain scale.
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APPENDIX
PAIN ASSESSMENT SCALE (NUMERICAL RATING SCALE)
NAME: AGE: SEX:
DIAGNOSIS: SURGERY:
POSTOP DAY:
DATE AND TIME OF ASSESSMENT:
0 1 2 3 4 5 6 7 8 9 10
I I I I I I I l I I I
WHAT IS YOUR PAIN RIGHT NOW:
WHAT IS YOUR TYPICAL OR AVERAGE PAIN:
AT WHICH TIME PAIN INTENSITY IS INCREASING:
PHYSIOLOGICAL CHANGES
(1) HEART RATE CHANGES FROM NORMAL LEVEL
[NO CHANGES, INCREASED UP TO 10 b/ mt]
(2) RESPIRATORY RATE CHANGES FROM NORMAL LEVEL
[ NO CHANGES, >20 breaths/mt]
(3) OTHER CHANGES
SWEATING - PRESENT/ ABSENT
PALPITATION- PRESENT/ ABSENT
RESTLESSNESS-PRESENT/ ABSENT
TIME OF ANALGESIC ADMINISTRATION:
TIME OF SECOND ASSESSMENT:
0 1 2 3 4 5 6 7 8 9 10
I I I I I I I I I I I
WHAT IS YOUR PAIN RIGHT NOW;
WHAT IS YOUR TYPICAL OR AVERAGE PAIN:
PHYSIOLOGICAL CHANGES
(1) HEART RATE CHANGES FROM NORMAL LEVEL
[NO CHANGES, INCREASED UP TO 10 b/ mt]
(2) RESPIRATORY RATE CHANGES FROM NORMAL LEVEL
[NO CHANGES, >20 breaths/mt]
(3) OTHER CHANGES
SWEATING -PRESENT/ ABSENT
PALPITATION- PRESENT/ ABSENT
RESTLESSNESS-PRESENT/ABSENT
NAME: DATE AND TIME:
POSTOPDAY:
0 1 2 3 4 5 6 7 8 9 10
I I I I I I I I I I I
WHAT IS YOUR PAIN RIGHT NOW:
WHAT IS YOUR TYPICAL OR AVERAGE PAIN:
AT WHICH TIME PAIN INTENSITY IS INCREASING:
PHYSIOLOGICAL CHANGES
(2) HEART RATE CHANGES FROM NORMAL LEVEL
[NO CHANGES, INCREASED UP TO 10 b/ mt]
(2) RESPIRATORY RATE CHANGES FROM NORMAL LEVEL
[ NO CHANGES, >20 breaths/mt]
(3) OTHER CHANGES
SWEATING - PRESENT/ ABSENT
PALPITATION- PRESENT/ ABSENT
RESTLESSNESS-PRESENT/ABSENT