NURSE-LED PAIN ASSESSMENT PROTOCOL AND ITS EFFECT ON PAIN DOCUMENTATION ACCURACY IN POSTOPERATIVE UNITS
Keywords:
Postoperative pain; Nurse-led protocol; Pain assessment; Nursing documentation; Clinical audit; Surgical patients; Quality improvement; Patient safety; Pakistan.Abstract
Background: Postoperative pain remains a common concern among surgical patients and ineffective pain assessment may lead to delayed treatment, poor patient comfort, and reduced quality of care. Accurate nursing documentation plays an important role in identifying pain severity, monitoring treatment response, and ensuring continuity of patient management. This study evaluated the effect of a nurse-led pain assessment protocol on the accuracy of postoperative pain documentation in a surgical unit.
Objective: To determine whether implementation of a structured nurse-led pain assessment protocol improves the completeness and accuracy of postoperative pain documentation by comparing nursing records before and after protocol implementation.
Methods: A clinical audit and intervention study was conducted in the postoperative surgical units of Shalamar Hospital, Lahore, Pakistan. A total of 200 postoperative patient records were reviewed, including 100 records before protocol implementation and 100 records after implementation. A standardized audit checklist was used to assess documentation of pain intensity, pain location, analgesic administration, reassessment after medication, and patient response. Nursing staff received training regarding standardized pain assessment practices and documentation requirements before implementation of the protocol. Data were analyzed using descriptive statistics and comparative analysis.
Results: Implementation of the nurse-led protocol resulted in a marked improvement in postoperative pain documentation practices. Documentation of pain intensity scores increased from 62% before intervention to 94% after intervention. Pain reassessment following analgesic administration improved from 48% to 89%. Documentation of pain location increased from 55% to 91%, while recording of patient response improved from 46% to 87%. Overall documentation accuracy improved from 52.8% before protocol implementation to 90.3% after implementation, showing a statistically significant improvement (p < 0.001).
Conclusion: The nurse-led pain assessment protocol significantly improved the accuracy and completeness of postoperative pain documentation. Standardized assessment procedures combined with nursing education can strengthen pain management practices, improve communication among healthcare providers, and support better postoperative patient care. Integrating similar protocols into surgical units may provide an effective quality improvement strategy, particularly in healthcare settings where structured pain management systems are limited.
