Medication trends and documentation of pain management following surgery

The purpose of the present study was to examine prescribing and administering activities for sedative and analgesic medication in postoperative patients, and to describe nurses' documentation practices for pain management in nursing notes. A prospective audit was undertaken of medication order charts and nursing notes of 100 patients on the operation day and over the first four days following surgery. Almost all patients received some form of infusion, while the use of 'as required' analgesics varied from one-third to over two-thirds of patients during the postoperative period. Few patients were prescribed fixed-order analgesics or sedative medications. An audit of nursing entries found that nurses had documented inadequately in four major areas: pain assessment, use of non-pharmacological interventions, use of pharmacological interventions, and outcome of interventions. The findings contribute to improving our understanding of nurses' pain management and identify the need to use clinical judgement that is individualized to patients' needs.