Prevalence, pain management and registration in Internal Medicine units

Abstract

Objective: To analyze the prevalence and management of pain episodes, their evaluation and recording in internal medicine hospitalization units in a third level public hospital of the regional health service of Castilla y León.

Method: A descriptive cross-sectional study. The study population comprised patients hospitalized in internal medicine units. Pain prevalence was detected by the Brief Pain Inventory questionnaire. The management of pain episodes was analyzed as recorded in the clinical records.

Results: 83 patients were included, 73.5% of them reported pain and 67.2% did not know their analgesia regimen. More episodes of pain were identified in the women (P=.006) than in the men. The pharmacological administration was recorded in all cases; however, nurses recorded the episode in the clinical history of 29.5% of the patients. In no case, was the pain intensity or degree of relief recorded using the visual analogical scale.

Conclusions: There is evidence of a high prevalence of pain in hospitalized patients and deficiencies in the management of pain episodes by nurses, both in evaluation and recording. This implies the need for pain control protocols and the implementation of evidence-based best practice guidelines to provide nurses with the means and support for adequate pain management.

Keywords: Clinical records; Dimensión del dolor; Ficha clínica; Hospitalización; Hospitalization; Internal Medicine; Manejo del dolor; Medicina Interna; Pain management; Pain measurement.