Assessment of Pain Intensity by Nurses in the Emergency Department

急診護理人員對於疼痛之評估

董曉萍(Hsiao-Ping Tung) ； 陳美容(Mei-Jung Chen) ； 黃美倫(Mei-Lun Huang) ； 江慧珣(Hui-Hsun Chiang) ； 吳清平(Chin-Pyng Wu)

《Journal of Emergency Medicine, Taiwan》 8卷3期 (2006/09) Pp. 77-82

摘要

目的：本文之目的旨在藉由回溯急診護理紀錄中病患主訴『疼痛』之頻率以呈現病患因疼痛而至急診室求治之比率；此外，並藉此了解急診護理人員評估疼痛程度之情形及疼痛評估工具之使用狀況。
材料及方法：本研究採病歷回溯方式於北部某醫學中心急診室進行。所有93年間之急診病歷均進行回溯，針對急診護理紀錄之主訴欄位中紀錄為疼痛者，則再行檢視其護理紀錄中之疼痛程度評估紀錄。無法以言語表達或是因診察過程中所引發之疼痛者則不為本研究之收案對象。
研究結果：69,350人次之急診病患中，總計55,291 (79.7%)位主訴疼痛。急診護理紀錄中雖均敘述『…病人因XX（部位）疼痛求診…』，然僅50.8%之護理紀錄中呈現疼痛程度評估。其中，98.7%係以敘述性方式紀錄疼痛程度（如：輕微疼痛、很痛…），僅1.3%採用疼痛評估量表量化其疼痛程度。與其他部位之疼痛相較，護理人員對於胸痛程度之評估則有較完整之紀錄；遺憾的是，對於牙痛及喉嚨痛之評估則近乎完全忽略！
結論：研究結果顯示，疼痛確為常見之急診病患主訴，但疼痛之護理評估則未能詳盡紀錄。後續之研究將針對護理人員之特性進行分析比較，以了解影響疼痛評估之人為相關因素。

關鍵字

疼痛評估 ； 急診護理人員

並列摘要

Objective: The purpose of this study is to highlight the prevalence of pain as a chief complaint in the emergency department (ED) nurse record. Besides, we would like to demonstrate how often ED nurses performed pain intensity assessments and whether the pain scales were used as tools for assessment.
Material and Methods: A retrospectively observational study was conducted in the ED at a medical center. All of the ED medical charts were reviewed from January 1 2004 through December 31 2004. Special attention was paid on the pain documentation addressed in the ED nurse record. Those who cannot verbally communicate or/and with procedure pain were excluded while we analyzed the documentation.
Results: There were 69,350 ED visits during our study period. 55,291 (79.7%) of them had a chief complaint of pain. All of the patients complained of pain had been stated in the nursing note whereas only 50.8% of them had been evaluated about the intensity. Descriptive words were used most often while documenting pain intensity. Only 1.3% had been evaluated by using of pain scales such as numerical rating scale (NRS) or visual analog scales (VAS). Chest pain was most frequently evaluated. Intensity of toothache and sore throat was less likely to be evaluated by ED nurses.
Conclusion: This study demonstrated a very high prevalence of pain as a chief complaint in the ED nurse record and revealed, overall, pain was poorly documented. We will secondary analyze our data to get a better understanding of the staffs' characteristics affect on pain assessment.

並列關鍵字

pain assessment ； ED nurse