Portal de Periódicos da CAPES

Patients’ Versus Nurses’ Assessments of Pain and Sedation After Cesarean Section

1995; Elsevier BV; Volume: 24; Issue: 2 Linguagem: Inglês

10.1111/j.1552-6909.1995.tb02455.x

1552-6909

Angella J. Olden, Jordan Elizabeth T., Neal T. Sakima, Jeffrey A. Grass,

Cardiac, Anesthesia and Surgical Outcomes

To compare nurses’ and patients’ assessments of pain and sedation in patients receiving epidural or intravenous patientcontrolled analgesia (PCA) after cesarean section. Prospective, randomized study. The perinatal unit and labor and delivery unit in a 1,036 bed university hospital in the mid-Atlantic region. Twenty-six patients receiving epidural PCA or intravenous PCA. Nurses participating in the study were assigned as caregivers to the 26 patients. Pain and sedation were assessed using l0-cm visual analogue scales completed by both the patient and the patient’s nurse twice daily on the day of surgery and on the 1st and 2nd postoperative days. No significant correlation was found between the nurses’ and patients’ pain or sedation scores. Chi-square analysis showed that the nurse was as likely to underestimate as to overestimate the patient’s pain score. The nurse underestimated the patient’s sedation score 85% of the time. The results suggest that nurses’ and patients’ assessments of pain and sedation differ. The routine use of a standardized self-assessment tool, such as the visual analogue scale, is recommended to ensure that analgesic treatment is based on the subjective nature of the patient’s pain experience rather than the nurse’s judgment. women who undergo cesarean section are expected to assume the tasks of parenting a newborn while recovering from major abdominal surgery Pain, sedation due to analgesics, and immobility affect their ability to assume self-care activities and infant care after surgery. Because pain is a primary concern for patients undergoing any surgical procedure, it is essential that nurses routinely assess patient’s pain and select appropriate relief measures (Auvenshine and Enriquez, 1990Auvenshine M.A. Enriquez M.G. Comprehensive maternity nursing: Perinatal and women’s health.2nd ed. Jones and Bartlett, Boston1990Google Scholar, Jackson, 1989Jackson D. A study of pain management: Patient controlled analgesia versus intramuscular analgesia.Journal of Intravenous Nursing. 1989; 12: 42-51PubMed Google Scholar, Teske et al., 1983Teske K. Daut R. Cleeland C. Relationships between nurses’ observations and patients’ self-reports of pain.Pain. 1983; 16: 289-296Abstract Full Text PDF PubMed Scopus (184) Google Scholar). Patient-controlled analgesia (PCA) has become the primary method of pain relief after cesarean section and is well accepted by patients and health care providers. Studies have shown PCA to be more effective in relieving postoperative pain than traditional intramuscular administration of opioids (Bennett et al., 1982Bennett R.L. Batenhorst R.L. Bivins B.A. Bell R.M. Graves D.A. Foster T.S. Wright B.D. Griffen W.O. Patient-controlled analgesia: A new concept of postoperative pain relief.Annals of Surgery. 1982; 195: 700-705Crossref PubMed Scopus (120) Google Scholar, Rayburn et al., 1988Rayburn W.F. Geranis B.J. Ramadei C.A. Woods R.E. Patil K.D. Patient-controlled analgesia for postcesarean section pain.Obstetrics and Gynecology’. 1988; 72: 136-139PubMed Google Scholar, Smith et al., 1991Smith C.V. Rayburn W.F. Karaiskakis P.T. Morton R.D. Norvell M.J. Comparison of patient-controlled analgesia and epidural morphine for postcesarean pain and recovery.Journal of Reproductive Medicine. 1991; 36: 430-434PubMed Google Scholar). The primary aim of this study was to compare nurses’ and patients’ assessments of pain and sedation in patients receiving epidural PCA or intravenous PCA after cesarean section. The study was done in collaboration with another study (Grass et al., 1994Grass J.A. Zuckerman R.L. Sakima N.T. Harris A.P. Patient-controlled analgesia after cesarean delivery.Regional Anesthesia. 1994; 19: 90-97Google Scholar) designed to compare these two modalities of postoperative analgesia. Health-care providers traditionally have been responsible for determining whether a patient’s pain level is intense enough to require analgesia administered on an asneeded basis. The failure of this pain management technique has been attributed to several factors, including concerns about oversedation, overdosage, and opioid addiction (Collier, 1990Collier M. Controlling postoperative pain with patientcontrolled analgesia.Journal of Professional Nursing. 1990; 6: 121-126Abstract Full Text PDF PubMed Scopus (5) Google Scholar, Grossman et al., 1991Grossman S. Sheidler V. Swedeen K. Mucenski J. Piantadosi S. Correlation of patient and caregiver ratings of cancer pain.Journal of Pain and Symptom Management. 1991; 6: 53-57Abstract Full Text PDF PubMed Scopus (375) Google Scholar). Several researchers have examined the correlation between patients’ and nurses’ assessment of pain and found that nurses tend to underestimate patients’ pain and analgesic requirement (Camp and O’Sullivan, 1987Camp L. O’Sullivan P. Comparison of medical, surgical, and oncology patients’ descriptions of pain and nurses’ documentation of pain assessments.Journal of Advanced Nursing. 1987; 12: 593-598PubMed Google Scholar, Choinière et al., 1990Choinière M. Melzack R. Girard N. Rondeau J. Paquin M. Comparison between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries.Pain. 1990; 40: 143-152Abstract Full Text PDF PubMed Scopus (259) Google Scholar, Van der Does, 1989Van der Does A. Patients’ and nurses’ ratings of pain and anxiety during burn wound care.Pain. 1989; 39: 95-101Abstract Full Text PDF PubMed Scopus (68) Google Scholar). Grossman et al., 1991Grossman S. Sheidler V. Swedeen K. Mucenski J. Piantadosi S. Correlation of patient and caregiver ratings of cancer pain.Journal of Pain and Symptom Management. 1991; 6: 53-57Abstract Full Text PDF PubMed Scopus (375) Google Scholar compared pain scores among physicians, nurses, and patients with cancer using a visual analogue scale (VAS). They found that as patients’ pain scores increased, the agreement between caregivers’ and patients’ scores decreased. Similarly, Choinière et al., 1990Choinière M. Melzack R. Girard N. Rondeau J. Paquin M. Comparison between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries.Pain. 1990; 40: 143-152Abstract Full Text PDF PubMed Scopus (259) Google Scholar reported that nurses under estimated pain in burn patients 43% of the time and overestimated the success of analgesia compared with patients’ reports (57% versus 27%). The widespread recognition of inadequate pain management with as-needed opioids has prompted the development of alternative therapies. Epidural morphine and intravenous PCA have become widely accepted techniques for postcesarean pain management. Two randomized prospective studies found that patients who received a single dose of epidural morphine rated pain lower on a VAS than those who received intravenous PCA during a 24-hour study period (Eisenach et al., 1988Eisenach J.C. Grice S.C. Dewan D.M. Patient-controlled analgesia following cesarean section: A comparison with epidural and intramuscular narcotics.Anesthesiology. 1988; 68: 444-448Crossref PubMed Scopus (198) Google Scholar, Harrison et al., 1988Harrison D.M. Sinatra R. Morgese L. Chung J.H. Epidural narcotic and patient-controlled analgesia for postcesarean section pain relief.Anesthesiology. 1988; 68: 454-457Crossref PubMed Scopus (166) Google Scholar). Nonetheless, the patients who received intravenous PCA were more satisfied with their pain management. The higher incidence of side effects (nausea, vomiting, and pruritus) associated with epidural morphine, as well as the psychological benefit of self-control with the PCA mode of delivery, probably account for the superior patient satisfaction associated with intravenous PCA reported in these studies. Both studies found epidural morphine and intravenous morphine PCA to provide lower VAS pain scores and greater satisfaction than intramuscular morphine. To combine the superior patient satisfaction of the PCA mode of delivery with the superior pain relief of the epidural route of delivery, Zuckerman, 1989Zuckerman R. Options in post-cesarean section pain relief.Anesthesiology Report. 1989; 2: 44-51Google Scholar suggested the use of epidural fentanyl or sufentanil (epidural opioids were associated with fewer side effects than morphine) for epidural PCA. Sufentanil epidural PCA was compared with intravenous morphine PCA after cesarean section in a prospective randomized study (Grass et al., 1994Grass J.A. Zuckerman R.L. Sakima N.T. Harris A.P. Patient-controlled analgesia after cesarean delivery.Regional Anesthesia. 1994; 19: 90-97Google Scholar). A prospective randomized study was used to evaluate and compare nurses’ and patients’ assessments of pain and sedation in patients receiving sufentanil PCA or intravenous morphine PCA after cesarean section under epidural anesthesia. After approval by theInstitutional Review Board for the Protection of Human Subjects and informed consent had been obtained, 26 patients were randomized to receive either epidural (12 patients) or intravenous PCA (8 patients). Six patients were eliminated from analysis because of incomplete data. Patients with a history of substance abuse were excluded. Pain and sedation levels were assessed using a 10-cm VAS. The pain VAS consisted of a 10-cm horizontal line, the left end of which was labeled “no pain” and the right end “worst pain.” The left end of the 10-cm sedation VAS was labeled “wide awake” and the right end “very sleepy.” The VAS has been shown to be reliable and valid as a quantitative measure of clinical pain (Revill et al., 1976Revill S.I. Robinson J.O. Rosen M. Hogg M. The reliability of a linear analogue for evaluating pain.Anaesthesia. 1976; 31: 1191-1198Crossref PubMed Scopus (993) Google Scholar, Houde, 1982Houde R.W. Methods for measuring clinical pain in humans.Acta Anaesthesiologica Scandinavica Supplementum. 1982; 74: 25-29Crossref PubMed Scopus (54) Google Scholar, Sriwatanakul et al., 1982Sriwatanakul K. Kelvie W. Lasagna L. The quantification of pain: An analysis of words used to describe pain and analgesia in clinical trials.Clinical Pharmacology and Therapeutics. 1982; 32: 143-148Crossref PubMed Scopus (61) Google Scholar, Sriwatanakul et al., 1983Sriwatanakul K. Kelvie W. Lasagna L. Calimlim J. Weis O. Mehta G. Studies with different types of visual analog scales for measurement of pain.Clinical Pharmacology and Therapeutics. 1983; 34: 234-239Crossref PubMed Scopus (386) Google Scholar, Webb et al., 1989Webb C.J. Stergios D.A. Rodgers B.M. Patient-controlled analgesia as postoperative pain treatment for children.Journal of Pediatric Nursing. 1989; 4: 162-171PubMed Google Scholar). Besides the VAS for pain and sedation, nurses were asked to rate their overall satisfaction with the pain management technique the patient was receiving and their perception of time spent in caring for patients using PCA compared with traditional intramuscular narcotics. Nurses participating in the study were assigned as primary caregivers to the 20 patients. They received instructions on the use of the assessment tools by one of the nurse investigators. Some nurses were assigned more than one patient in the study. Patients completed the same assessment tools after receiving instructions from an anesthesiologist. Data were collected at 2 and 6 hours after surgery and at 9:00 a.m. and 5:00 p.m. on the 1st and 2nd days after surgery. Patient age, height, weight, and history of previous cesarean section were similar in both groups (see Table 1). The average length of hospital stay was 3.75 days (epidural PCA) and 3.9 days (intravenous PCA). No significant correlation (r=0.08, p<.05) was found between the nurses’ VAS pain score assessment and the patients’ VAS pain score. A chi-square analysis of pain scores showed that nurses were as likely to underestimate as to overestimate patients’ pain (55% versus 43% of the time, respectively). No difference was found in the incidence of overestimation and underestimation between the epidural versus the intravenous PCA groups. The average difference between the nurses’ assessment and the patients’ VAS pain score was 20±2 mm.Table 1Demographic Characteristics of the Subjects by PCA GroupEpidural Sufentanil n=8Intravenous Morphine n =12p <.05Age (years)28.6±1.827.5±1.3NSat-testHeight (inches)65.0±0.963.1±0.5NSat-test(centimeters)165.1±2.3160.3±1.3NSat-testWeight (pounds)176.4±11.2174.7±12.1NSat-test(kilograms)80.2±5.179.4±5.5NSat-testPrevious cesarean section75%83%NSbchi-square analysis.PCA=patient-controlled analgesia; NS=not significanta t-testb chi-square analysis. Open table in a new tab PCA=patient-controlled analgesia; NS=not significant There was also no significant correlation (r=0.25, p<.05) between the nurses’ VAS sedation assessment and the patients’ VAS scores. Nurses underestimated patients’ VAS sedation levels 85% of the time. No difference was found in the incidence of underestimation of the sedation score between the epidural and intravenous PCA groups. When a patient’s sedation score was underestimated, the average difference between it and the nurse’s assessment was 39±3 mm. Nurses were asked if they would recommend PCA for patients and whether PCA allowed them more time for other patient care activities. Of the 17 responses, 94% (n=16) indicated satisfaction with PCA, and 88% indicated that PCA saved time for other patient care activities. Nurses play an important role in postoperative pain management. The nurse must assess the patient’s pain level, the effectiveness of pain therapy, and the need for further intervention. No significant correlation was found between nurses’ and patients’ pain assessments, a finding that is consistent with previous studies (Choinière et al., 1990Choinière M. Melzack R. Girard N. Rondeau J. Paquin M. Comparison between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries.Pain. 1990; 40: 143-152Abstract Full Text PDF PubMed Scopus (259) Google Scholar, Grossman et al., 1991Grossman S. Sheidler V. Swedeen K. Mucenski J. Piantadosi S. Correlation of patient and caregiver ratings of cancer pain.Journal of Pain and Symptom Management. 1991; 6: 53-57Abstract Full Text PDF PubMed Scopus (375) Google Scholar).lt is essential that nurses assess patients’ pain and select appropriate relief measures. Several possible explanations exist for the underestimation of patients’ pain by nurses. First, patients may have expected to experience some pain after surgery and may not have exhibited nonverbal cues unless their pain levels became intolerable. Patients using PCA typically accept a level of discomfort to minimize side effects (Eisenach et al., 1988Eisenach J.C. Grice S.C. Dewan D.M. Patient-controlled analgesia following cesarean section: A comparison with epidural and intramuscular narcotics.Anesthesiology. 1988; 68: 444-448Crossref PubMed Scopus (198) Google Scholar, Zuckerman, 1989Zuckerman R. Options in post-cesarean section pain relief.Anesthesiology Report. 1989; 2: 44-51Google Scholar). Second, patients may have minimized their symptoms because pain could reflect a worsening of their overall condition (Grossman et al., 1991Grossman S. Sheidler V. Swedeen K. Mucenski J. Piantadosi S. Correlation of patient and caregiver ratings of cancer pain.Journal of Pain and Symptom Management. 1991; 6: 53-57Abstract Full Text PDF PubMed Scopus (375) Google Scholar). Third, nurses may have inaccurately interpreted the patients’ nonverbal cues. Fourth, nurses may have anticipated that patients would experience low levels of pain based on previously published studies comparing intravenous PCA with intramuscular opioid (Bucknell and Sikorski, 1989Bucknell S. Sikorski K. Putting patient-controlled analgesia to the test.MCN, The American Journal of Maternal Child Nursing. 1989; 14: 37-40Crossref PubMed Scopus (9) Google Scholar, Rayburn et al., 1988Rayburn W.F. Geranis B.J. Ramadei C.A. Woods R.E. Patil K.D. Patient-controlled analgesia for postcesarean section pain.Obstetrics and Gynecology’. 1988; 72: 136-139PubMed Google Scholar). Finally, nurses may have been so preoccupied with pain tolerance, side effects, and proper pump operation that they paid less attention to pain level (Grossman et al., 1991Grossman S. Sheidler V. Swedeen K. Mucenski J. Piantadosi S. Correlation of patient and caregiver ratings of cancer pain.Journal of Pain and Symptom Management. 1991; 6: 53-57Abstract Full Text PDF PubMed Scopus (375) Google Scholar). The finding that nurses were as likely to overestimate as to underestimate patients’ pain was surprising. This finding may be attributed to the low VAS patient scores achieved with intravenous and epidural PCA. Furthermore, the increased attention of studies documenting the underestimation of patient pain by medical and nursing personnel may have biased nurses to overestimate the patient’s pain (Camp and O’Sullivan, 1987Camp L. O’Sullivan P. Comparison of medical, surgical, and oncology patients’ descriptions of pain and nurses’ documentation of pain assessments.Journal of Advanced Nursing. 1987; 12: 593-598PubMed Google Scholar, Choinière et al., 1990Choinière M. Melzack R. Girard N. Rondeau J. Paquin M. Comparison between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries.Pain. 1990; 40: 143-152Abstract Full Text PDF PubMed Scopus (259) Google Scholar, Van der Does, 1989Van der Does A. Patients’ and nurses’ ratings of pain and anxiety during burn wound care.Pain. 1989; 39: 95-101Abstract Full Text PDF PubMed Scopus (68) Google Scholar). Alternatively, on the 1st and 2nd days after surgery, nurses may have incorporated into their VAS pain assessment their observations of the patient’s experience with getting out of bed and walking. The finding that nurses consistently underestimated patients’ subjective sedation scores has implications for care. Because patients using PCA may have begun ambulation and resumed self-care activities sooner and with less pain than patients who received intramuscular opioids, nurses may have assumed these differences indicated less sedation than the patients actually experienced. Moreover, patients may simply appear more alert than they feel. The danger in this discrepancy is that patients may receive permission to assume more complex activities that require greater cognitive function and physical coordination than they are ready to perform safely. Overall, nurses were satisfied with both intravenous and epidural PCA, a finding that is consistent with other reports (Bucknell and Sikorski, 1989Bucknell S. Sikorski K. Putting patient-controlled analgesia to the test.MCN, The American Journal of Maternal Child Nursing. 1989; 14: 37-40Crossref PubMed Scopus (9) Google Scholar, Panfilli et al., 1988Panfilli R. Brunckhorst L. Dundon R. Nursing implications of patient-controlled analgesia.Journal of Intravenous Nursing. 1988; 11: 75-77PubMed Google Scholar, Shade, 1992Shade P. Patient-controlled analgesia: Can client education improve outcomes?.Journal of Advanced Nursing. 1992; 17: 408-413Crossref PubMed Scopus (12) Google Scholar). Satisfaction has been attributed to the time saved in assessing the patient’s need for analgesia, determining the dose to be given, retrieving the drug, and administering the medication (Rayburn et al., 1988Rayburn W.F. Geranis B.J. Ramadei C.A. Woods R.E. Patil K.D. Patient-controlled analgesia for postcesarean section pain.Obstetrics and Gynecology’. 1988; 72: 136-139PubMed Google Scholar). The findings are limited by the small sample size and the use of only one clinical setting. Because Choinière et al., 1990Choinière M. Melzack R. Girard N. Rondeau J. Paquin M. Comparison between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries.Pain. 1990; 40: 143-152Abstract Full Text PDF PubMed Scopus (259) Google Scholar have reported that no significant relationship exists between years of experience in nursing and accuracy of nurses’ estimates of patients’ pain, that information was not collected for the study. A nursing goal for patients who have undergone cesarean section is to promote comfort and relieve pain. Postpartum women need to be alert and comfortable to parent, attach to their infants, and assume self-care and infant care. Optimal pain management depends on cooperation among members of the health care team throughout the patient’s course of treatment (U.S. Department of Health and Human Services, 1992U.S. Department of Health Services Human Acute pain management: Operative or medical procedures and trauma. Clinical practice guidelines. AHCPR Publication, Rockville1992Google Scholar). Nurses often depend on the nonverbal and verbal manifestations of pain to assess pain and sedation, as well as to evaluate the effectiveness of pain therapy. The results of the study suggest that although PCA may be effective in relieving pain after cesarean section, nurses’ and patients’ perceptions of pain and sedation differ. A standardized self-assessment tool used throughout an institution would ensure that pain and sedation levels are based on the subjective nature of the patients’ perceptions rather than the nurses’ judgments. This approach also would allow for individual variations in postoperative analgesia requirements and responses to pain. Furthermore, a training program may give healthcare providers the expertise and experience needed to assess and manage pain effectively.Although PCA may effectively relieve pain after cesarean section, nurses’ and patients’ perceptions of pain and sedation differ.