RESUMEN
Background: Although there are many recommendations and guidelines for adequate pain assessment, the quality of postoperative pain documentation does not meet the acceptable standards. Aim: The aim of the study is to review the pain assessment and analgesic records of nurses within the first 48 h in the postoperative period. Methods: This retrospective and descriptive study was conducted in a University Hospital. The records of a total of 421 patients who underwent surgery between January 2014 and January 2015 were analysed. The data of the patients were obtained using the patient files. Results: Pain assessment scale was not used, and the pain records did not include intensity, location, duration and quality of the pain. The analgesic records indicated that the highest percentage (70.8%) of analgesic use was within the first postoperative two hours. Diclofenac sodium was the most commonly administered and recorded analgesic, while pethidine HCl was the least used one. More than half of the all analgesic injections (63.9%) were administered by intramuscular route. No non-pharmacological intervention including massage, hotcold application, or positioning was reported in the nursing records. Conclusion: The postoperative pain was not assessed properly as recommended in the acute pain guidelines. Therefore, nurses should increase the awareness on the pain assessment records for effective pain management. In addition, the administration of the hospital should support the use of standard pain assessment and recording via electronic patient record system, continue online education courses and give feedback on the records of nurses regarding pain management.