1. Adult Pain Assessment on the Maternity-Newborn Unit Team Membership: Christine Murphy, RN, MSN Carol Anderson, RN Rita Risatti, RN

2. Opportunity Statement and Desired Outcome Goal: To increase nursing awareness of pain assessment and intervention needs in the adult patient, and to improve documentation to provide the most appropriate care for these patients. Patients on the maternity floor deal with a variety of pain related to surgery, incision, cramping, pre-term labor and breastfeeding, all of which can range from acute to chronic. In response to the pain needs of this patient population, it is important to assess pain and provide the most appropriate level of pain management. An opportunity exists to improve the documentation of pain assessment and interventions.

3. Identification of Most Likely Causes Decrease in documentation of pain. Limited knowledge awareness of staff in the use of the standardized pain assessment tool for the adult patient.

4. Potential Solutions Utilize adult pain assessment tool to assess an adult patient’s pain before and after pain medication is given. Two RNs volunteered to be the Pain Resource Nurses for the unit. Continue to attend hospital wide meetings and share information from those meetings with the staff. Unit goals developed along with the manager. Staff education completed on assessing a patient’s pain with every nursing assessment and documenting. The importance of a follow up assessment after pain medication is given was also stressed. In-servicing of nursing staff – 100% completed. A monitoring tool was developed to track assessment of an adult’s pain with each nursing assessment as well as, follow up after pain medication is given.

5. Solutions Implemented Chart audits done to determine the compliance of pain assessment documentation. Education through in-services to nursing staff regarding pain management issues. Posting of reminders throughout the unit to assess and document specific pain indicators.

6. Results Documentation of alternative comfort measures offered 0.00% 0.20% 0.40% 0.60% 0.80% 1.00% 1.20% 1.40% 1.60% 1.80% 2nd Qtr3rd Qtr1st Qtr Days Pms Nights In-serviced staff, developed monitoring tool, developed and posted unit prompts Slight increase in alternative comfort measures offered was seen on all three shifts.

7. Documentation of pain assessment twice a shift In-serviced staff, developed monitoring tool, developed and posted unit prompts Documentation twice a shift moderately improved.

8. Documentation of Pain Interventions In-serviced staff, developed monitoring tool, developed and posted unit prompts The % of charts with pain interventions documented increased on all three shifts.

9. Documentation of pain location In-serviced staff, developed monitoring tool, developed and posted unit prompts Increase seen in documentation on all shifts with night shift increasing the greatest.

10. Documentation of reassessment of pain after intervention In-serviced staff, developed monitoring tool, developed and posted unit prompts Increases in documentation were seen on all three shifts, with the greatest increase seen on night shift.

11. Improvement was seen in pain assessment documentation when reviewing data. Improvement continues in offering alternative comfort measures and documenting. Monitoring will continue in order to assess future adherence to pain management standards regarding documentation and interventions. Pain management resource nurses will in-service new staff and reinforce education throughout the unit. Conclusions and Next Steps