Investigation of nurse's pain evaluation records in colorectal surgery : Retrospective study

Revealing the current pain assessment status after colorectal surgery is important in terms of establishing a pain profile in colorectal surgery. This study was planned to retrospectively and descriptively to examine the post-operative pain assessment records of nurses. The research population consisted of 173 patients who were hospitalized in Adana Training and Research Hospital General Surgery Intensive Care Unit and underwent colorectal surgery between November 2020 and November 2021. The sample of the research is; patients who received general anesthesia during surgery, were hospitalized for at least 48 hours after surgery and were older than 18 years of age. As a data collection tool; Patient Descriptive Information Form, Pain Evaluation Scale and Pain Evaluation Follow-up Form, which were created as a result of literature review, were used. The mean age of the patients included in the study was 61.32±14.21 years. Of the surgeries performed, 65.9% are colon surgery and 34.1% are rectal surgery. According to the distribution of pain levels of the patients, the mean of pain at postoperative 0-2 hours was 2.84±1.79, and at 37.-48. hours pain was found to be 1.68±1.44(0-4). When the pain records were evaluated, it was determined that 94.7% of the nurses used scales with proven validity and reliability suitable for the patient, but there were no records containing pain location, quality, duration, factors that increase or decrease pain. In addition, only postoperative 0-2 hours. It was determined that 60.6% of the patients were recorded after analgesia for pain assessment in the 1 hour interval. As a result of our study, it was determined that nurse records are lacking in terms of pain management process after colorectal surgery. In this context, it was determined that the records analyzed were not at a level to determine the pain profile after colorectal surgery. In this context, the role of pain and analgesia records, which include holistic pain assessment, in effective pain management should be considered and the management of the electronic record system should be supported. Key words: Pain assessment, colorectal surgery, pain recording, nurse