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.

References

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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