Swedish Nurses Pain Assessment Documentation of Children in the Perioperative Period.

In healthcare, pain is common in children, with a higher risk of pain in children admitted for surgery. According to guidelines, pain should be assessed with a pain scale suitable to the age and maturity of the child to be able to provide the right treatment. However, research indicates shortages in assessment and documentation regarding children's pain. The aim of the current study was to describe the frequency and nature of pain assessment documentation, including pain intensity scoring, in surgical patients across the perioperative period. We performed a quantitative descriptive retrospective review of medical records at two county hospitals in the south of Sweden. In all, 114 children 7-17 years of age admitted to one of the hospitals in connection to surgery were included. Demographic and clinical data such as age, sex, type of surgery, and documentation regarding pain were collected from the medical records according to a predetermined protocol including the number and type of pain assessments and pain intensity scores. Data were analyzed with descriptive and inferential statistics. The findings show that pain scales were used and documented in 89 children (78.8%) once or more during the stay, and 155 (63.8%) of these assessments were performed in the recovery unit. One or more pain narratives were found in 113 (99.1%) of the medical records, of which 350 (69.6%) were written postoperative on the pediatric ward. There was a significant difference in the number of children who had at least one documented pain scale assessment, both between the hospitals and between the different time periods within the hospitals (preoperative on ward, recovery unit and postoperative on ward), but not between age groups. Moderate to severe pain was reported in 38.6% of the pain scale ratings. In conclusion, all the children had some kind of documented assessment of pain during their hospital stay, but not all children had a documented pain scale assessment. Documented pain scale assessments were most common in the recovery unit, whereas pain narratives were most common on the pediatric ward after the surgery. Looking at the entire length of the hospital stay, the result indicates that national guidelines for pain assessment are not being followed.