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The use of analgesics in managing post-operating pain Best, Lynette Sandra 1982

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THE USE OF A N A L G E S I C S POST-OPERATIVE  IN  MANAGING  PAIN  by  L Y N E T T E SANDRA BEST .Sc.N.,  The U n i v e r s i t y  A THESIS  of  British  SUBMITTED I N P A R T I A L  THE REQUIREMENTS  Columbia,  FULFILLMENT  FOR THE DEGREE OF  MASTER OF S C I E N C E  IN  NURSING  in  THE FACULTY OF GRADUATE School  We a c c e p t to  this  the  of  thesis  Lynette  as  conforming  standard  OF B R I T I S H  June  ©  Nursing  required  THE U N I V E R S I T Y  STUDIES  COLUMBIA  1982  Sandra Best,  1982  1972  OF  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may department or by h i s or her  be granted by the head o f representatives.  my  It is  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be allowed without my  permission.  Department of  /Jmasqs»  <z  The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T  1Y3  Z L X  Date —  DE-6  (3/81)  n  £ d,  written  ABSTRACT  This ordered pain.  pro  (PRN)  patient's  following  a  the  the  subjects  criteria two  of  first  of to  of  acute  analgesics post-operative  answer  the  following  are  ordered  following  analgesic  of  of  analgesic  following  description  use  48 h o u r s  of  survey  for  elective  Data were  pertinent  was  are  a  pain  given  at  PRN  cholecystby  a cholecystectomy?  his/her  nurses What  24 a n d  hospitals,  use  the  the  by  considerable  variability  amounts  the r e a s o n s  evidence  of  pain  evaluating  and  patterns  PRN-prescribed  48  is  hours  of  the  in  those  which  taken  auditing  the  the  at  of  study  one  charts  and a d m i n i s t r a t i o n  the  given  were  not  nurses  effectiveness  of  records. i i  amounts to  to for  the  the  There  prescribed  appeared by  in  identified.  analgesics  for  met  sample  of  the  for of  the  subjects.  were  analgesics  accountability  reviewed  gathered  subjects  cholecystectomy  prescriptions  prescribed  A convenience  These  the  in  two  to  used.  interviewing  difference  the  was  scheduled  used.  and by  design  study.  No r o u t i n e  the  the  the  subjects.  in  was  in  analgesics  and  purpose  48 h o u r s  participated  There cies  management  frequencies  in  the  cholecystectomy?  hospitals  analgesics  describe  frequencies  summational  and were  information  and  first  to  the  study  and  A descriptive 22  in  patients  amounts  in  designed  amounts  for  What  patients  the  nata  What  physicians  ectomy? to  re  was  Specifically,  questions. by  study  and  and  frequen-  post-operative was  a  given  significant between  the  explored.  The  decision  b e made b y  the  nurses  their  role  analgesics  in  to  but  assessing  was n o t  reflected  Analgesics immediate All  more  analgesics  Subjects  at  analgesics  orders  (83%)  orders  were  were  in  were  than  for  for  the  period  on  the  meperidine  prescribed  and  given  within  75  meperidine doses. vals  Doses  between  48-hour  of  doses  than  dosage  was  1154 m i l l i g r a m s .  the  or  56% o f  those  Hospital  at  amount the  were  operative and  of  The  complexities  the  pain  with  by  given  studied.  this  set-  considerably  hour  for  of  prescribed,  total  amount  g i v e n was  median  total  drug.  The  between  longer  inter-  For the  amount  the  maximum prescribed  625 m i l l i g r a m s  amount  Subjects  significantly  the  on  of  usually  drug.  based  all  amount  interval  the  surgeons.  PRN a n d  d o s e was  range  action  the  The  considerably  amount.  given  of  previous  pain  data  on  g i v e n was the  ward  or  587 at  more m e p e r i d i n e  than  The  literature collected  of  their  pain  physical  emphasized  sensations  descriptions reflected  the  of  des-  post-  difficul-  management.  assumption  analgesics  descriptions  experience.  subjective  An o f t e n - s t a t e d PRN-prescribed  and  summational  consistent  pain.  the  in  B.  The p a t i e n t s ' individuality  and  route  received  be  The m e d i a n  total  prescribed  prescribed  of  amount  The mean  prescribed  A were  ties  duration  mean t o t a l  Hospital  cribed  the  to  four  with  the  anaesthetists.  prescribed  dosage a  given  the  milligrams  the  were  and  intramuscular  with  the  Room i n  A.  period  optimal  prescribed  meperidine  1050 m i l l i g r a m s .  54% o f  per  100 m i l l i g r a m s  usually  ward were  period,  possible was  was  Hospital  48-hour  by  Recovery  intravenous  hydrochloride  for  to  the  prescribed  at  the  meperidine  prescribed  by  B were  unchanged  the  were  those  use  Post-Anaesthetic  given  Hospital  Analgesics All  use  post-operative  i n i t i a l  ting.  for  in  the  inappropriately  literature in  managing  is  that  nurses  post-operative  use  iv pain;  that  given  in  is,  adequate  relationship received This  by  finding  gesics  was  operative  not  suggests  Based pain  on  are  amounts  subjects  used would  gation.  further  patients  were  frequently  identified  between  and how t h e y that  the  enough. the  reported  of  comfort, this  and n u r s i n g  made.  because  assumption,  patient  findings  management  research  or  increase the  uncomfortable  the In  amounts their that  this of  study,  increasing  and  the  further  implications  practice,  are a  meperidine  post-operative  requires  study,  analgesics  pain. anal-  investi-  for  suggestions  postfor  not  T A B L E OF CONTENTS  Page ABSTRACT  i i  LIST  OF T A B L E S  ix  LIST  OF FIGURES  x i i  ACKNOWLEDGEMENTS  xiv  Chapter I.  INTRODUCTION  1  Context  of  the  Problem  1  Purpose  of  the  Study  4  Definition  of  Terms  5  Assumptions  .  Organization I I .  of  the  Study  Report  6  REVIEW OF THE L I T E R A T U R E Introduction Concept  of  5  7  .  7  Pain  7  Post-operative  Pain  .  10  Methodological  Problems  Post-operative  P a i n Management  of  Studying  Summary  .  .  Pain  13 17 27  v  , v i Chapter I I I .  Page METHODOLOGY  .  .  .  .  .  .  28  Introduction Description Selection  of  of  the  B.  Procedure  C.  Description  the  Setting  28  Sample  Criteria  Data  for  28  Sample  for  Selection  Selection  of  the  Considerations  of  29  the  Sample  31  Sample  33  Encountered  Research Process  33  Collection  Data Analysis  IV.  the  A.  Ethical in  28  34  .  38  Limitations  39  Summary  40  FINDINGS  AND D I S C U S S I O N  41  Introduction  41  Findings  Relevant  Recovery  Room ( P . A . R . R . ) of  to  the  41  A.  Length  B.  Analgesics  Ordered  C.  Analgesics  Given  to  D.  Discussion  about  Analgesics  and Those Findings A.  Time  Post-Anaesthetic  Given  Relevant  Meperidine First  Subjects  to  in  Use  in  Subjects  the  in  the  the in  P.A.R.R.  P.A.R.R.  the  .  for  P.A.R.R.  Amounts  of  2.  Frequencies  42  .  .  43  .  .  . . . . . . .  .  .  .  48 52  Use  on t h e Ward  in  Cholecystectomy  Meperidine of  41  Ordered  P.A.R.R.  Following  1.  .  . . .  t h e Ward  Ordered  48 H o u r s  for  Spent  Ordered  Meperidine  Ordered  the . . . .  52 53 56  v i i Chapter IV.  Page B.  Meperidine 48 H o u r s  C.  Given  Following  1.  Amounts  2.  Frequencies  Comparison with  of  2.  the 1.  E.  Meperidine of  of  Given  Meperidine  First .  .  57 58  Given on  the  62 Ward  .  71  Given  Compared  Ordered of  71  Meperidine  Summational  Given  Compared  Ordered  75  Descriptions  48 H o u r s  Subject  Following  of  Their  Pain  Cholecystectomy  .  Interviews  a.  First  b.  Second  2„  Pain  3.  Jacox  4.  Comparison  General  Meperidine  Frequencies  First  the  Given  Prescriptions  Frequencies  Subjects'  in  Cholecystectomy  Amounts  with  t h e Ward  Meperidine  Amounts with  in  of  Physicians'  1.  D.  on  80  24 H o u r s  -  24 H o u r s  Intensity  Scale  Subject -  .  Subject .  Interviews Interviews  .  80  .  82  .  84  Scale  86 of  Three  Subjective  Measures  .  .  Discussion  90 94  Summary V.  80  98  SUMMARY AND CONCLUSIONS  .  Summary  .  .  .  .  .  99 99  A.  P.A.R.R.  B.  Ward  Time P e r i o d  1.  Meperidine  Ordered  101  2.  Meperidine  Given  101  3.  Subjects' of  4.  Time P e r i o d  Their  100 101  Summational Pain  Comparisons  Descriptions 102 102  v i i i Chapter  Page  V.  Conclusions  of  this  Study  .  .  104  Implications Suggestions  105 for  Further  Research  . . . .  108  Conclusion  110  BIBLIOGRAPHY  I l l  APPENDICES A.  INTERVIEW  B.  CONSENT FORM FOR STUDY  121  C.  DATA C O L L E C T I O N TOOL FOR A N A L G E S I C RECORDING  123  D.  P E R M I S S I O N L E T T E R F O R USE OF JACOX P A I N  E.  AMOUNTS ( I N M I L L I G R A M S ) OF M E P E R I D I N E R E C E I V E D I N F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY O U T L I N E D BY H O S P I T A L , SUBJECT AND DOSES  F.  G.  H.  GUIDE -  PATIENT'S  SUMMATIONAL D E S C R I P T I O N  CHECKLIST  . . .  . . . .  118  126  THE 128  I N T E R V A L S ( I N M I N U T E S ) BETWEEN DOSES OF M E P E R I D I N E R E C E I V E D I N THE F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY SUMMARIZED FOR EACH H O S P I T A L AND SUBJECT  130  D I S T R I B U T I O N OF SUBJECTS SHOWING HOW EACH STATEMENT OF THE JACOX SCALE WAS ANSWERED FOR EACH 2 4 - H O U R P E R I O D A F T E R CHOLECYSTECTOMY AND THE D I F F E R E N C E I N RESPONSE BETWEEN THE TWO DAYS  132  M E D I C A T I O N S , OTHER THAN M E P E R I D I N E AND BUTORPHANOL, P R E S C R I B E D AND G I V E N TO SUBJECTS I N THE F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY  134  LIST  OF TABLES  Table 1.  2.  3.  Page Number Length  and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s o f Time Spent i n P . A . R . R . and H o s p i t a l  Number  and P e r c e n t a g e  Number  6.  7.  8.  and  10.  Given  in  the  Distribution  the  P.A.R.R.  Subjects  of  Showing  and H o s p i t a l  Subjects  and H o s p i t a l  . . .  44  Showing . ,  45  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g T o t a l Amount o f M e p e r i d i n e Each R e c e i v e d I . V . in P . A . R . R . and H o s p i t a l  47  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s Showing I n t e r v a l B e t w e e n t h e End o f t h e O p e r a t i o n a n d Initial P . A . R . R . A n a l g e s i c and H o s p i t a l . . . . . Comparison to  of  Analgesics  Subjects  in  the  Prescribed  with  Number  and P e r c e n t a g e of  Meperidine  and Percentage  48  Analgesics 50  D i s t r i b u t i o n o f Amounts and F r e q u e n c i e s o f O r d e r e d I . M . PRN f o r S u b j e c t s i n t h e F i r s t on t h e Ward a f t e r C h o l e c y s t e c t o m y Number  .  P.A.R.R  Distribution Prescribed  of  Per  Distribution  Maximum Amount o f M e p e r i d i n e and H o s p i t a l . . 12.  of  P.A.R.R.  46  Amounts 11.  Percentage  in  43  Number and P e r c e n t a g e D i s t r i b u t i o n o f I . V . Injections o f M e p e r i d i n e G i v e n i n P . A . R . R . Showing Dosage and Hospital  Given 9.  Distribution  Prescriptions  Analgesics 5.  42  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s Showing T y p e o f A n a l g e s i c s P r e s c r i b e d f o r Use i n P . A . R . R . and Hospital  Analgesic 4.  Showing  of  Meperidine 48 H o u r s 52  Subjects  Showing  Dose and H o s p i t a l Subjects  Prescribed  for  .  .  53  Showing  Each  Dose 54  D i s t r i b u t i o n o f S u b j e c t s Showing T o t a l Amount o f M e p e r i d i n e P r e s c r i b e d f o r each 24-Hour P e r i o d on the Ward a f t e r C h o l e c y s t e c t o m y and M e a n , M e d i a n and Mode Amounts  per  Hospital  Group  .  ix  .  55  X Table 13.  Page Distribution Meperidine t h e Ward  of  Subjects  Prescribed  after  Meperidine  Number Frame  20.  Distribution  Showing Amount  22.  23.  Per  Dose  58 of  Injections  Given,  of  Time  and H o s p i t a l  Distribution  of  59  Subjects  Given  Ward  Cholecystectomy  after  Per  for  Showing T o t a l  Meperidine  Each  Hospital  24-Hour  Amount  Period  of  on  the  and Mean, Median  and  Group  60  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g T o t a l Amount o f M e p e r i d i n e G i v e n f o r t h e 4 8 - H o u r P e r i o d on t h e Ward a f t e r C h o l e c y s t e c t o m y and Mean, Median and Per  Hospital  Group  D i s t r i b u t i o n o f S u b j e c t s S h o w i n g Number o f T i m e s M e p e r i d i n e Given f o r Each 24-Hour P e r i o d on t h e Ward a f t e r C h o l e c y s t e c t o m y and H o s p i t a l  61  62  D i s t r i b u t i o n o f S u b j e c t s S h o w i n g Number o f Times M e p e r i d i n e G i v e n i n 48-Hour P e r i o d on t h e Ward a f t e r C h o l e c y s t e c t o m y a n d M e a n , M e d i a n a n d Mode Frequency Per  21.  56  57  and P e r c e n t a g e  Mode A m o u n t s 19.  Median  and H o s p i t a l  and H o s p i t a l  Mode A m o u n t s 18.  and Mean,  of on  Group  Cholecystectomy  Meperidine  17.  Hospital  Amount Period  Number a n d P e r c e n t a g e D i s t r i b u t i o n o f I n j e c t i o n s of M e p e r i d i n e G i v e n on t h e Ward i n t h e F i r s t 48 H o u r s after  16.  Per  Total  48-Hour  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g I n t e r v a l B e t w e e n D o s e s P r e s c r i b e d PRN for  15.  the  Cholecystectomy  a n d Mode A m o u n t s 14.  Showing  for  Hospital  Group  63  D i s t r i b u t i o n of Subjects Showing I n t e r v a l Between P . A . R . R . A n a l g e s i c and I n i t i a l Ward M e p e r i d i n e Dose and Range, Mean and M e d i a n T i m e P e r H o s p i t a l Group  64  D i s t r i b u t i o n o f S u b j e c t s Showing I n t e r v a l Between Doses o f M e p e r i d i n e D u r i n g t h e F i r s t 24 H o u r s o n t h e W a r d a f t e r C h o l e c y s t e c t o m y and R a n g e , M e d i a n and Mean I n t e r v a l Per H o s p i t a l Group . . . . . . . .  66  D i s t r i b u t i o n o f S u b j e c t s Showing I n t e r v a l Between Doses o f M e p e r i d i n e D u r i n g t h e S e c o n d 24 H o u r s o n t h e Ward a f t e r C h o l e c y s t e c t o m y and Range, M e d i a n and Mean I n t e r v a l Per H o s p i t a l Group  67  xi Table 24.  Page D i s t r i b u t i o n o f S u b j e c t s Showing I n t e r v a l Between Doses o f M e p e r i d i n e f o r t h e F i r s t 48 H o u r s o n t h e W a r d a f t e r C h o l e c y s t e c t o m y and R a n g e , M e d i a n and Mean I n t e r v a l Per H o s p i t a l  25.  26.  Number in  and Percentage  Dosage was  Hospital  Hospital  32.  of  Range  Prescribed  71  Group  .  •  73  Group  74  Percentage  Per H o s p i t a l  Group  76  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g P e r c e n t a g e o f Times M e p e r i d i n e R e c e i v e d as Compared t o t h e Times P o s s i b l e by the P h y s i c i a n ' s Order i n t h e S e c o n d 24 H o u r s o n t h e Ward a f t e r C h o l e c y s t e c t o m y a n d Range  31.  Doses  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g P e r c e n t a g e o f T i m e s M e p e r i d i n e R e c e i v e d as Compared t o the Time P o s s i b l e by t h e P h y s i c i a n ' s Order i n t h e F i r s t 24 H o u r s o n t h e Ward a f t e r C h o l e c y s t e c t o m y a n d Range and Median  30.  of  G i v e n When a  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g P e r c e n t a g e o f t h e Amount o f M e p e r i d i n e R e c e i v e d as Compared t o t h e Amount P o s s i b l e by t h e P h y s i c i a n ' s O r d e r i n t h e S e c o n d 24 H o u r s o n t h e W a r d a f t e r C h o l e c y s t e c t o m y and Range and M e d i a n P e r c e n t a g e Per  29.  Distribution  Showing Amount  70  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g P e r c e n t a g e o f t h e A n o u n t o f M e p e r i d i n e R e c e i v e d as Compared t o t h e Amount P o s s i b l e by t h e P h y s i c i a n ' s O r d e r i n t h e F i r s t 24 H o u r s o n t h e W a r d a f t e r C h o l e c y s t e c t o m y and Range and M e d i a n P e r c e n t a g e Per  28.  68  Number and P e r c e n t a g e D i s t r i b u t i o n o f I n j e c t i o n s of M e p e r i d i n e , C h a r t e d as Given E x a c t l y on t h e Hour o r H a l f - h o u r , i n t h e F i r s t 48 H o u r s o n t h e W a r d a f t e r C h o l e c y s t e c t o m y Showing Time P e r i o d and H o s p i t a l  Meperidine  27.  Group  and M e d i a n  Percentage  Per H o s p i t a l  Group  77  D i f f e r e n c e i n Minutes Between P r e s c r i b e d Intervals B e t w e e n Doses and Mean I n t e r v a l B e t w e e n Doses G i v e n Per S u b j e c t f o r 48-Hour P e r i o d on t h e Ward a f t e r Cholecystectomy Number  and P e r c e n t a g e  Responses Period  to  on t h e  the  Pain  Distribution Intensity  Ward a f t e r  of  Scale  Subjects  Showing  for  24-Hour  Cholecystectomy  Each  and H o s p i t a l  79  .  .  85  x i i Table 33.  Page Number and P e r c e n t a g e D i s t r i b u t i o n o f Subjects Showing D i f f e r e n c e s i n t h e i r Responses on t h e Pain I n t e n s i t y Scale Between 24-Hour Periods on  34.  35.  t h e Ward  after  Number and P e r c e n t a g e D i s t r i b u t i o n Showing D i f f e r e n c e s i n T h e i r T o t a l Jacox Scale Between24-Hour Periods  86  87  of Subjects Scores on after  and H o s p i t a l  88  Comparison o f T o t a l Amount o f M e p e r i d i n e R e c e i v e d w i t h Responses t o the Three S u b j e c t i v e Measures by I n d i v i d u a l Subject f o r the F i r s t 24-Hour Period  37.  and H o s p i t a l  Number and P e r c e n t a g e D i s t r i b u t i o n o f Subjects Showing T o t a l Scores to the Jacox Scale by Time P e r i o d and H o s p i t a l , and Range and M e d i a n T o t a l Scores Per H o s p i t a l Group  Cholecystectomy 36.  Cholecystectomy  after  Cholecystectomy  Comparison o f T o t a l Amount of M e p e r i d i n e Received w i t h Responses t o t h e Three S u b j e c t i v e Measures by I n d i v i d u a l S u b j e c t f o r the Second 24-Hour Period a f t e r Cholecystectomy  91  92  LIST  OF FIGURES  Figure 1.  Page Percentage Cumulative R e l a t i v e Frequency Distribution o f S u b j e c t s Showing P e r c e n t a g e o f t h e Amount o f M e p e r i d i n e R e c e i v e d as Compared t o t h e Amount P o s s i b l e by the P h y s i c i a n ' s Order f o r the F i r s t 48 H o u r s  2.  on  t h e Ward  after  Cholecystectomy  .  .  .  .  .  .  .  .  75  Percentage Cumulative R e l a t i v e Frequency Distribution of S u b j e c t s Showing Percentage of the Times M e p e r i d i n e R e c e i v e d as Compared t o t h e Times P o s s i b l e b y t h e P h y s i c i a n ' s O r d e r f o r t h e F i r s t 48 H o u r s o n t h e Ward  after  Cholecystectomy  .  x i i i  78  ACKNOWLEDGEMENTS  I would Committee, sistent  like  to  express  Rose M u r a k a m i  support  g i v e n me b y  the  and  (Chairman)  guidance.  hospital  my t h a n k s  I  staffs  the  members  and M a u r e e n M u r p h y ,  greatly and  to  the  appreciate patients  of  my  for  the  Thesis  their  con-  co-operation  who made  this  study  possible. My their  support,  thanks English Robert  thanks  to  Irene  are  ideas  and  Herring  assistance, and  extended  Janet,  to  time for  to to  many o t h e r  assist  with  my w o r k s p a c e ,  Patricia  my f a m i l y ,  the  for  to  Porterfield their  xiv  persons  this  thesis.  Patricia for  patience.  who  her  contributed  Particularly,  Lawson  for  her  critical  eye  and  to  CHAPTER I  INTRODUCTION  Context o f the Problem  P a i n prompts people to seek m e d i c a l other  symptom (Johnson 1977, p. 139).  of the u n i v e r s a l g o a l s o f medicine "relief  h e l p more o f t e n than any  The management of p a i n i s one  (Melzack 1973, p. 49).  Similarily,  o f p a i n i s always a p r i o r i t y f o r n u r s i n g a c t i o n " (Dugas 1977,  p. 477).  Jarrett  (1965, p. 68) suggests t h a t "the v e r y nature o f  n u r s i n g r e s t s upon the premise that t h e r e i s a need to r e l i e v e and with  s u f f e r i n g , t o comfort those the r o l e of n u r s i n g  in distress."  i s concerned  i n p a i n management.  A degree of p a i n and d i s c o m f o r t i a b l y , follows surgery.  T h i s study  pain  u s u a l l y , although  not i n v a r -  The s u c c e s s f u l management o f p o s t - o p e r a t i v e  pain f a c i l i t a t e s optimal recovery  and a l l e v i a t e s s u f f e r i n g (Knight and  Mehta 1978, p. 462; Wallace and N o r r i s , 1975, p. 114). S a t i s f a c t o r y pain r e l i e f  a l l o w s f u l l e r r e s p i r a t o r y movements and e f f e c t i v e  both o f which improve o x y g e n a t i o n . prevents  complications  coughing,  T h i s , i n t u r n , promotes h e a l i n g and  (Cooper and Schumann 1979, p. 717; Drummond and  L i t t l e w o o d 1977, p. 999). The lowing  primary method t o manage p a i n f o r the f i r s t  surgery  fol-  i s the p a r e n t e r a l a d m i n i s t r a t i o n o f n a r c o t i c a n a l g e s i c  medications  (Gebhart 1977, p. 240).  ered  to use.  simple  24-72 hours  P a r e n t e r a l analgesics are consid-  T h e i r a d m i n i s t r a t i o n r e q u i r e s l i t t l e time, minimal  1  personal  involvement  tion,  they  1973,  p.  are  92;  low  and  in  cost  Parkhouse  that  "relief  of  pain  able  therapeutic  the  (PRN)  1971, the  p.  238;  nurse  is  given  Sweeney  at  in  minimizing  345).  Hollister  analgesics  physicians  342;  of  In  pain p.  addi-  (Halpern 435)  states  the most  predict-  make." analgesics  actively  (Gibbs  Venter  skill.  (1976,  one  these  is  discretion  p.  is  can  prescribes  therefore,  her*  1977,  whether  or  -  when  give  -  which  -  whether  the  -  whether  or  to  not  drug  1977,  involved  1975, p.  on a p r o  p.  21).  re  because  373;  Masson  Specifically.,  management been of  to  the  to  give  analgesic,  analgesic  give  given not  the  if  within  more  than  analgesic  to  consult  analgesic  is  is  with  ordered  one  is  ordered  effective, the  boundaries,  and  physician  ineffective  PRN,  if  (McCaffery  the 1979,  186-188).  Analgesics  relieved  effective  generally  -  has  technical  determines:  pp.  there  of  narcotic  The n u r s e ,  prescribed  pain  level  p.  interventions  basis.  analgesic  and  1975,  by  The p h y s i c i a n nata  a limited  ordered  for  decades.  l i t t l e  their  PRN h a v e b e e n Despite  investigation  pain.  It  has  commonly  reliance  of  been  used  the  in  post-operative  on  this  method,  extent  that  patients  this  method  assumed  that  however, are  is  effec-  tive. Recent (1979,  p.  pronouns nurses.  320)  commentaries cite  19  challenge  current,  this  published  assumption. reviews,  Utting  editorials  and and  Standardized pronouns are used t h r o u g h o u t t h i s s t u d y : f o r p h y s i c i a n s and p a t i e n t s , and f e m i n i n e p r o n o u n s f o r T h i s i s done f o r s i m p l i c i t y o f p r e s e n t a t i o n .  Smith letters  masculine the  3 in  the  medical  approach (1979,  from  p.  to  the  the  pain  patient's  patients  is  the  from  both  there  is  appallingly  McCaffery  the  evidence  present Graffam  that  nurses'  a n d may e v e n b e  and H a r t  often  of  and p h y s i c i a n s .  asked  p a i n when n a r c o t i c  pain  support  management.  such  The Marks  challenges  and  Sachar  are  cited  and Heaman s t u d y  (1972)  relief  from PRN-ordered  analgesics  that  73% o f  cians  patients  than  tion  sample  the  patients. their  for  (1976,  herself,  p.  detrimental 1586)  "Why  analgesics  do  are  pose adult  available  ordered  or  analgesics  received. ordered  Data analgesics of  acute of  Neither  not  about  p a i n management  is  about  o n a PRN p r e s c r i p t i o n  the  be u s e f u l actually  might  that  nor  found  physi-  substantially The  popula-  the  surgery  They  patterns discussed  patients when  described  of  analgesics  the  use  of  patients. of  describe  used w i t h  also  pain  post-operative  used.  the  Keeri-  Sachar  that  gave  20% o f  frequency to  of  and  extensive  was  the  method  inadequate  pain,  include  specifically  dosage,  patterns  in  nurses  following  performed  study  when  PRN p r e s c r i p t i o n .  did  pain  and  Marks  be  that  post-operative  PRN w o u l d  Information  to  PRN a n a l g e s i c s  procedures  PRN f o r  gathered  ordered  in  (1973)  discussed.  the  PRN a n a l g e s i c  frequently  and  however,  the  study  continued  with  to  and Heaman c o n c l u d e d  method  surgical  is  analgesics  study,  remained  management the  patient.  this  Keeri-Szanto  neither  method  the  maximum p o s s i b l e  study  pain  based  interviewed  underprescribed  less  the  patients  inadequate  Szanto  in  inadequacy  "considerable  investigator acute  the  effective?" Few s t u d i e s  of  that  stress  of  well-being."  that  suffer  which  viewpoints  states  of  question  and  the  23)  management  literature  provide  how  the  analgesic  use' and the  effect  of  PRN-analgesic  post-operative  use  post-operatively  a baseline  to  guide  4 nursing  actions.  Currently,  for  example:  "While  ing  the  24  first  patient. PRN"  .  cribed 1979,  hours  before  clarification  because  of  few  studies  This  study  agents  are  usually  by  physicians  do n o t  338)  i t "  for  representative the  variables  exist  about  of  of  the  amounts  for  dur-  ask  the  his  use  of  the  of  the  the  is  the  suggest  to  base  q3-4h  pain  within  Long,  is the  and  pres-  Woods  discretion  i t ,  analgesics  study  with-  possibly post-operatively.  analgesics  addresses  the  g i v e n by  the  ordered  PRN  analgesic nurse  and  the  patient.  Study  to  answer  frequencies  in  patient  analgesic  of  severe  (Phipps,  the  injection  the  narcotic  p a i n by  study  and  patients  use  by  "If  on w h i c h  pain  overmedicate  and  examples  the  the  Purpose  What  for  to  description  1.  given  he has  physician,  purpose  routinely  to  ordered  The  only,  offered  Specifically,  summational  guidance  be  explores  the  vague  administered  p.  1975,  post-operatively. PRN b y  are  provide  should  These  410).  texts  post-operatively,  and Sorenson  medication  limits p.  narcotic  . Narcotics  (Luckmann  expected,  out  .  nursing  first  of  the  following  analgesic  48 h o u r s  are  questions:  ordered  following  a  PRN  cholecyst-  ectomy? What  2. to  patients  24  and  the  What  3. at  in  48  amounts f i r s t  are  hours  the  and 48  frequencies hours  patients'  following  a  of  following  analgesic a  are  given  by  cholecystectomy?  summational  descriptions  of  their  s t u d y axe used  in  two  descriptive  data  obtained  1.  To d e s c r i b e  t h e u s e : £ . . a n a l g e s i c s - o r d e r e d ' a n d ; . - ' g i v e n ..to  cholecystectomy  pain  cholecystectomy?  The  post-operative  nurses  in  this  :  0  patients:  to  support  or  question  ways: :  this .  5 usage known  consideringabout 2.  patients  the To  view  the  patients'  actions  of  contribute the  pain  the to  they  pain  analgesics,  experience  Analgesic:  The  two  (Demerol) Amount:  Each  Frequency:  in  The number  Patient:  of  recorded  registered  in  A p e r s o n who m e e t s elective  A physician  Pro  (PRN):  nata  Summational the  in  "According  description preceding  and J a c o x  of  scales  of  how  are  follow:  meperidine  hydrochloride  (Staedol).  the  total  the  48-hour  dosage  period  in  and  milligrams. the  time  span  minutes. Columbia. criteria  at  one  in  British  to  pain:  24 h o u r  study  and  study  licensed  this  study  British the  understanding  tartrate  in  cholecystectomy  Physician: re  doses  information  post-operatively.  in  under  milligrams  the  Terms  used  and b u t o r p h a n o l  dosage  A nurse  terms  analgesics  between doses Nurse:  of  of  and  and  practitioners'  Definition  The d e f i n i t i o n  experiences  of  two  and  scheduled  non-teaching  circumstances"  period  is  for  hospitals.  Columbia.  Patient's  (Appendix  and who  (Taber  description  scores  on  the  1977, of  p.  his  pain  146).  pain  for  intensity  A).  Assumptions  is  with  The  assumptions  1.  Most  2.  The  patients primary  analgesics 3.  The  made  this  experience  method  injected  chart  in  of  study pain  following  alleviating  subcutaneously  information  follow:  or  accurately  acute  a  cholecystectomy.  post-operative  pain  intramuscularly. reflects  the  given  analgesics.  6  Each  4. action  is  therapeutic  effective The  5.  in  dosage  relieving  patients  are  of  or  analgesic  minimizing  sufficiently  for  its  duration  post-operative  alert  to  participate  of  pain. in  the  interview.  Organization  This focussed  review  describes findings Chapter  thesis  the  of  literature  V outlines for  to  the  organized  research  pertinent  suggestions  is  of  into  appears  methodology. the  research  conclusions,  further  Study  five in The  Report  chapters  the  next  analysis  and  appendices.  chapter. of  the  are  presented  implications  for  nursing  research.  Chapter  data  questions  The  in  and  I I I  the  Chapter  practice  and  IV.  CHAPTER  REVIEW OF THE  I I  LITERATURE  Introduction  The cept in  of  literature  pain,  pain  2)  of  fully  are  iables,  Although  is  The  not  gate  in  research.  The  of  a  this  certain  involving  the to  into  four  sections:  methodological  pain  1)  con-  considerations  management.  and  both  theory,  most  this  level  that  in  1965 b y  to  state  suggested  of that  routes  system  and  specific  centers  the  brain.  that of  7  pain  nervous  and  the  was  of of  pattern  resulted  var-  Wall,  pain theories  prevailing  pain  specific  The  of  the  and  experience.  and p a t t e r n  receptors,  in  and  nature  Melzack  understanding  specificity  the  necessary  and p s y c h o l o g i c a l  proposed  theorists  intensity  its  a subjective  the  is  p a i n measurement  is  and p r o p o s e d  and  pain  Pain  comprehensive  interpretation  notion  of  agree  physiological  according  nervous  in  generally  proposal,  specialized  understanding inherent  understood.  specificity  central  appreciation rejected  3)  current  investigators  popularity  phenomenon w i t h the  the  difficulties  control  Prior  alternated  of  fully  provides  mechanism.  through  pain,  post-operative  the  complex,  i t  currently  4)  review  appreciate  management. causes  and  organized  Pain  A brief to  is  post-operative  research  Concept  review  from  stimulation.  a  sensory  transmission registration, theorists the  attainment  While  neither  8 theory  fully  relevant  explained  (Bond  1979,  Melzack tially and  painful  cerebral  gelatinosa, length to  of  fibres  or  blocking tion,  impulses  spinal  stimuli  by  the  of  the  the  (Carregal  1975;  generally  been  perceptual  body  to and  p.  the  the in  to  brain  of  body the  p.  and  cells  extending  the  opened  closed  which  by  is  small  cerebral in  or  of  some  a  1979,  p.  25;  input  sensory evokes  gate  pain  is  or  large  or  nerve The  no p a i n  of  percep-  1978,  by and  criticized  mechanism p.  pain  altered  perception  experimental  been  control  that  mechanisms  the  have  Wall  hypothesis input  substantia  specific  considerations of  the  stem  stimuli.  interpretation  notion  brain  processes.  l i t t l e  noxious  cord,  poten-  packed  the  believed  of  of  as  which  that  transmission  such  the  generally in  the  8-12).  cells  the  theory,  (McCaffery  14).  is a  a  has The  complex  distinctive  response  501). in  gating  the  produces  24).  various and  The p a i n analgesia  spinal  cord,  area  of  mechanism.  production  produce  of  remain  The  can r e s u l t  conceptual  1976),  advances  a type  1979,  appear  the  experience  1974,  involved Bond  Nathan  the  and  the  accepted  Recent dence  of  system before  (Siegele  of  validity  some  supports  cells  pp.  both  spinal  a gate  from  intensity  details  as  the  of  the  transmitted  messages  regardless  in  densely  operate  1970,  that  mechanism.  of  impetus  these  and  neural  cord,  of  evidence,  theory  unit  portions  and W a l l  suggest  gating  ability  gate,  Melzack  (1970)  a  by  experience,  can be m o d u l a t e d  descending  Although of  by  pain  20;  functional  the  incoming  p.  and W a l l  cortex a  the  chemistry  Opiate  receptor  endogenous  reduction  reducing by  brain  acting  decreasing  of  pain  the  the  exist  which  (Armstrong  of  in  the  p.  389;  endorphins,  receptor pain  cre-  are  1980,  known as  opiate  passage  further  sites  substances  substances, on  lend  sites  in  information  9 from  one n e u r o n  on  these  of  the  to  chemical  (Wilson  frontiers  physiology The  another  involved  assumption  may in  that  and  theory  an e x p l a n a t i o n  experience.  patterns  of  the  to  pain  pain of  Which v a r i a b l e s  predictable  eventually  is  how  lead  1981). to  Continued  a clear  study  explanation  experience.  psychological  son p e r c e i v e s offers  responds  and E l m a s s i n  variables  influence  well-accepted.  these  variables  and  the  possible  response  for  each v a r i a b l e ,  The may  presence  how  gate  per-  control  affect of  a  the  pain  consistent,  however,  needs  clar-  ification. The the  pain  effects  of  experience  have  either  conflicted  or  iables  which  been  age,  sex,  ground  have  marital  various been  been  psychological studied,  inconclusive  examined  status,  education factors  and n e u r o t i c i s m ;  situational  or  debility  and  such  state  nausea which  findings, 1977;  social as  variables  to  date,  Kim 1980). factors  class,  thought  and to  on  have  Varsuch  cultural  extraversion,  anxiety;  are  social  demographic  level,  personality  the  (Jacox  include:  and r a c e ;  fatigue,  but  and/or  as back-  intraversion  factors  such  aggravate  the  as pain  experience. Other onable effects  to  variables  expect  operate  modelling, attention  past  they  intensity most  on  pain  universally  unknown.  the  studies  attaches  to  not  the  with  in  the  examined. the  These pain  sensation  and  of  1940's  (Beecher  influencing  pain  include  Although experience the  illness  i t  seems  how  their  following:  and  the  reas-  social  amount  of  pain. demonstrated  pain-producing  experienced accepted  been  influence  experiences  focussed  of  would  remains  Beecher's individual  have  situation  1965). factor.  This  that  the  meaning  does  influence  last  variable  the  the is  the  10 Many v a r i a b l e s response-in pain,  or  any  may  situation.  serve  to  extensive  physical  needed  delineate  pain  to  he  of  what  is  described whenever  as, he  i t  1967, and  pain  i t  pain  perception  may p r o m o t e  even p.  to  to  in  the  90).  or  outline  aggravate  presence  Further their  and  of  study  is  effects  on  the  thesis  considered hours  The  pain.  is,  the  the  excretory  skin,  is  body  phenomenon,  does  about  physiology  point  in  person  1972,  need  consider  p.  time, says  the  and  a  blend-  sensation  psychology  p a i n may b e  it  is,  of  best  existing  8).  barriers,  of  such  is  contain  capabilities.  post-operative  pain being and  of  post-operative  most  severe  treated  background  descriptions  pain,  their pain  for  24  to  is 72  diminishes.  structures 1975,  separated  of  of  treatment  direct  and N o r r i s  normally  type  subjects'  quickly  somatic  one method  the  acute  a result  (Wallace  producing  of for  the as  of  phenomenon w h i c h  and w h i c h  deep  use  review  the  largely  fluids,  membrane  pain  the  this  the  Categorized  the  operation  cellular have  of  to  surgery  Such p a i n  during  following  a self-limiting  following  and  experiencing  investigates  from which  post-operative  At  of  (McCaffery  an u n d e r s t a n d i n g  information  thinks  details  the  does"  psychological  Pain  management.  provides  and  feels,  specific  "whatever  says  This  that  variables  remain unclear.  Post-operative  by  abolish  (Merskey  individual The  experience  that  the  or  a physiological  the  perceives.  the  These v a r i a b l e s  abate  trauma  contribute  experience. Pain  ing  undoubtably  from  various These  trauma and p. the  the  to  the  involved  113).  viscera,  Secretory  sensory  endogenous chemical  tissues,  nerve  and  network  substances  substances  11 stimulate  a pain  result  the  of  tissue  There pain,  s e n s a t i o n when r e l e a s e d  are  somatic  three  pain  from  damage  to  with  movement,  damage  categories  and v i s c e r a l  the is  skin  difficult  cutting,  tearing  age  muscles,  tendons,  ficult  to  localize.  aching.  Visceral  parietal  peritoneum  of  somatic  (Sweeney  pain  1977, The  and  post-operative  tors  such  muscle  intensity to  the  amount and  the  of  is  described  felt  and  of  and  is  expected  (1961),  and Loan  kind  point  that  chest  or  most  upper There  of  a  is  primarily  associated  described  associated  sensation to  is  dam-  generally  dif-  dull  visceral  dull,  as  with  include  a sensation  people abdomen few  variables  they  affect  aching  and  organs,  similar  to  type  that  of  pain  (Pflug studies  also  experience.  operation, contribute  Fac-  associated to  the  of  surgical  relevant  factor  in  predicting  by  acute  and B o n i c a  pain.  (1967)  Parkhouse,  found  closely  received  about  the  influ-  amount  correlated  experience  any p a i n  earlier  The  and Dundee  observations  discussed  during  distention  most  manipulation  clinical  are  arises  arteries  damage  post-operative  sion  and  social  the  post-operatively  conclusions  as  incisional  often  and  pain,  a diffuse,  management  requirements the  with  post-operatively.  however,  and  its  produces  as  and v i s c e r a l  tissues,  Simpson  I t  p a i n because  spasms  type  describe  pleura.  is  completely  and  pain:  pain  It  Somatic  associated  anaesthetic  pain  membranes.  bones  area  335).  Incisional  relieve  or  p.  surrounding  337-339).  ence  reflex  is  psychological  as  pain.  ligaments, to  the  post-operative  stabbing.  Words  pain  pp.  or  to  1977,  of  and mucous  sharp, to  (Sweeney  into  by  with  the  internal  others pain  that  have  following  1977,  p.  post-operative  the  Lambrechts  analgesic site  organs.  led  trauma  to  the  of  inci-  Their view-  operations  to  the  776). pain,  which  include  its  incidence,  discomforts other  descriptions  commonly  influencing  p.  286).  to  study.  pain  management  pain  is  the  of  There  is  clinical  this  of  post-operative with  and u p p e r p.  deep b r e a t h e ,  hypoxemia p.  does 717;  encouraged venous  has  been  In  alters  surgery  pain  other  and  is  necessitate  problems.  intensity  (Sweeney  the  about  a considerable  especially  and B o n i c a pain  and move;  occur,  lack  or and  1975,  difficult  withholding  Further,  changes  the  rapidly  1977,  p.  but  of  subsequent  fully  understood.  natural  reasons course,  the  330)  i t  as  which  p.  also  is  and  the the  the  The  certain  pneumonitis of  the  and  chest  Norris ability  incidence  of  to  the  tissues,  (Cooper  and  Schuman  999).  The  mobility,  reduces  the  incidence  to lung if  of  emboli. a self-limiting  procedure. for  of  patient's  oxygenation  wound h e a l i n g  pain  Wallace  the  relief.  and  operations  reduces  1977,  its  etiology  775;  enhances  pain,  of  atelectasis  p.  pulmonary  surgical  the  in  following  increased  enhances  reduction  a  part  therefore  the  not  importance  1977,  relief  post-operative  following  is  particularly  Drummond and L i t t l e w o o d  its  of  however,  addition  not  explained  among p e o p l e ,  level  pain  (Pflug  summary,  occurs  would  ethical  of  L o a n and M o r r i s o n  post-operative  post-operative  Effective  thrombosis In  which  by  its  descriptions  following  900;  course  poses  condition  hypoxemia,  cough  complications.  1979,  plays  abdomen 113).  and  p.  because  which  pain,  patients  1979,  natural  complications,  consequent  1975,  time,  pain  is  of  formidable.  no q u e s t i o n ,  presence  its  duration  examination At  of  by  (Jacox  lack  measures  short  patient's  makes  this  Scrutiny  patterns  experienced  factors  Perhaps  of  Its  sensation  physiological  variations variables  in  which  its  cause  intensity  affect  i t  13 remain unclear. prevention  of  Management  post-operative  Methodological  Problems  Measurement study lar  of  pain,  problem.  pain  is  of  and  limitations  are  discussed  of  as  frequently  notes  approach  is  occur  a direct  as  tivity  of  the  panied  by  other  out  control  his  Stewart  (1973)  that  experienced  If  these  with  from  the  they  study  fully  of  have  any  important  in  problems  phenomenon.  been  and  arise  appreciate  in  are the  the  associated  found  a  the  In  the  particu-  study  of  complexities  with  pain  research  and/or  behavioural  The m a j o r  and  be  that  the  the  in  objective of  that  two-thirds  of  of  c a l m and  Guzman  that  is  trained signs  this  or  349).  responses The  usually  subjec-  accom-  such an a s s u m p t i o n  measurement  the  sensation  response 102  not  let  (Huskinson  one must  to  others  1975, as  p.  approach felt.  pain.  interviewed  p a i n were u n r e l i a b l e  accurate,  i t  p.  a  in  with-  pain.  indicative  stay  1976,  of  with  behaviours  nullify  his  to  the  fact  that  difficulty  (Chapman  thoughts  subject  Lim and  are  physiological  therefore,  manifestations findings  of  pain  and  techniques  favour  assumption of  measurement  in  and  tried  pain.  objective  discounted  pain.  about  may n o t  behaviour  used  is  experience  concern  response  more  various  sensations  subject  visible  the  function  pain  confirmation  cated  have  underlying  Another  the  same d i f f i c u l t i e s  to  opinion  associated the  as  follows.  subject's  observer.who  accepted  Pain  to  research,  Some r e s e a r c h e r s the  is  i n measurement  the  order  pain  pain  complications.  essential  Obviously, In  the  Studying  difficulties  management.  which  of  Man  Jacox  subjects  know when 1129)  indicators  question whether  is  can and  indithey  showed of  that  that  pain.  behavioural  14 signs  noted  by  an o b s e r v e r  can be  considered  representative  of  the  pain  experienced. Observer measurement. by  the  bias  The  a common w e a k n e s s  interpretation  observer's  of  own e x p e r i e n c e s  suggests,  "everyone  likely  to  include  son  the  in  is  who r e c e i v e s  perceptions  evaluation,  although  subject  objective  response  and b e l i e f s . messages  of  of  they  may b e  As T a y l o r  about  extraneous  another  qualities  may b e  techniques  irrelevant  influenced  (1977,  p.  person's  of  the  to  of  334)  pain  other  the  is  per-  problem  of  pain." "At report or  of  present  its  estimate  support  presence  its  this  belief,  This  sation  occurring  subjective  b y many  report  pain  Prior in  to  pain  no  and  longer  by  the  tors  as  also  Clark  the  the  rife by  suggestion  by  and  is  used  the  the  applied  decisions the  the  Clark pain to  researcher  pain  researchers in  pain  assume w h a t  pain;  therefore,  sen-  however,  were  the  or  may  be  subject's of  pain.  particularly  verbal  t i m e when  i t  sensation  stimulus  threshold  report  The  his  demonstrated  and  to  his  researchers,  t i m e when  either  need  with  subject's  stimulus.  feel  frequently  factors.  equated  level,  can  subject's  problems.  the  tolerance  the  B e c a u s e many  subject;  many  than  subject  estimates  social  be  pain  the  6).  with the  of  on  report  subject's  p.  subject  (1974),  relied  only  eliminates  necessarily  pain  tolerate  The  the  assigned  settings,  chose when he would levels.  is  cannot  threshold,  painful,  is  as  1977,  style  because  measure  measurement  psychological  findings  laboratory  the  subjective  measurement  distorted of  (Houde  measurement  The measure  no b e t t e r  and s e v e r i t y ,  severity"  studies. is  we h a v e  report f i r s t  the  pain  the  identify  became could  subject  tolerance  influenced  expectancy  to  subject  that  those  or  by  such  anxiety  facof  15 the of  subject. earlier  tolerance decision between  Clark's  studies being  and  The w o r d  "pain"  concept  varies  to  (1979). they  this  ledge (Jacox  1979,  iencing  p.  "Do y o u group  This  response  jective  like  to  replied  as  the  score  is  assigned  (Chapman  the  previously  tional treated  and h i s  label  as  of  proposal  is  conclusions  threshold  no  and  of  simple  pain  sensory relationship  categorizing  the word  relies  what  in  is  because  happening  In  in addition  subject's in  his  the  by  variation  experience. on t h e  endless  a study  considerable  discomforting  an  anchorage  demonstrated  showed  to  to  1976,  or  his  p.  the  have  scale  351).  is  further  know-  body  numbers  and  is  response  others?"  the  in  to  at  least  their  exper-  the  ques70%  in  response.  reliability  been developed  most is  scale  used  in  assist  on which  assumed  with  that  to  commonly u s e d .  assumption  difficulties scales  who w e r e  of  a  sub-  in  subjec-  pain.  which This  In  ambivalent  descriptive pain  subjects  pain.  were  of  102  pain with  question  scales  the  outlined  interval  your  indicator  of  studied  progressive  A simple  problem w i t h as  of  discuss  rating  intensity  sity  or  (1973)  or  one  an  measurement.  cates  person  negatively  leads  report  pain  no u n i v e r s a l  discriminate  Stewart  chronic  Various tive  to  has  subjects  the use  validity  895).  and  acute,  each  to  of  there  linguistic  a painful  perception  Jacox  tion,  as  that  the  response.  The word  person  variability,  and  belief  a  Two h u n d r e d  defined  studies  subjective is  in  on r e p o r t s  His  the  sensations. from  resulted  relied  support  stimulus  of  what  that  has  questioned.  theory  variety  Jacox  work  the  to  A  subject  subjective numerical  indi-  numerical  reflect  can be  statistical  the  pain  inten-  challenged, reports. scores analysis  given  An  are  addi-  commonly  procedures.  16 In  reality  ance  of  suited  these  the to  equality  such  of  work  in  major  generalizing  on p a i n  are  has  from  of  the  stimuli  to  pain  induced  and how p a i n  making  comparisons  generate  of  laboratory  control  time-limited  in  the  the  cause  the  meaning  alter  of  the of  the  responses  therefore  not  pain  pain  always  348).  many  studies.  laboratories  is  Many  defined,  the  involve  the  among  based  explanatory  Much  pp.  They  In  of  of  as  the  how  More  who h a v e  some  aware  clinical  control  studies,  49-53).  are  i t  may  studies  understanding  of  situations  over  on l a b o r a t o r y  in  valid-  various  subjects  stimulus.  not  the  such  the  situation.  lack  is  assur-  experimentally  (Kim 1980,  healthy  subject's  Conclusions or  exist  difficult  stop  using  inconsistencies,  experimental  useful  p.  1976,  of  in  no  are  conclusions  can  markedly.  (Chapman  is  they  research  pain.  and  numbers;  pain  studies  and  the  there  in  conclusions  significantly,  because  difficulty  conducted  induced is  between  compilations  area  been  o r d i n a l ? numbers  distance  statistical  Another ity  scores  are  clinical  pain. Detailed ethical pain  considerations  treatments  can be  studied,  focussed aspects more  descriptive  so  of  that  the  tools  pain. which  Examples  complex  more  Melzack  scale  p.  used  133)  (Jeans in  this  et  natural  is  of  tools al.  study.  in  In  pain  in  to  the  the  the  date  Jacox  or  various  ignored  as  limited.  pain  have  qualitative  sensory  tool  situations  measures  about  include  The  withholding  development  information  as w e l l  the  are  studies,  toward  gather  and  pain  clinical  and have  developed  1979)  of  ongoing  to  pain  inflicting  course  intensity  attempt  properties  clinical  either  Work  tional-affective of  on  such works.  on p a i n  clinical  complex  involved  prohibit  primarily  works  the  of  motiva-  features.  the  (Stewart  /  McGill1977,  -  17 Attempts with  problems.  measurement research. its as  A measure  a composite and h i s  Hogg  1976,  of  to  goals  sufficiently he  gesics,  to  the  to  meet  this  aspect  may b l o c k  crude  and  replete  development frontiers  research  the  (Reville,  of  even  used must  stimulus,  of  be  pain though  accepted  subject's  reac-  Robinson,  and  are  defined  an  of be  integral  care able  as  of  pain without  p.  185).  are to  to  mode  the  of to  multiple  to  of  assure  move,  deep  post-operative that  the  breathe  following  particularily  effect  of  at the  of  of  pain (Loan  these  of  patient  and  the  cough,  operative  narcotic  anal-  are  of  discrete stimuli,  is  systems  in  is  these  the  suffering  elevation 1973,  s t i l l  to the  occurring, prototype.  drugs,  mechanisms  sites  analgesic  reduce  naturally  and M o r r i s o n drugs  or  consciousness  morphine  effect  receptor  narcotic  neurotransmitter  loss  which  several  various  relieve  analgesics  therapeutic of  that  causing  drugs  perceived  action act  The b i n d i n g  part  suffering  drugs  Narcotic  synthetic  a sedative  thought  to  are  goals.  a combination  indifference  system.  pain  pain  on d r u g s ,  to  are  the  a reliance  attributed  they  in  pain  is  outstanding  the  the  undue  the  of  that  unrecognized  experience  Analgesia,  ledge  been  The measure  report  pain  these  1979,  and  the  essential  of  manage  or  threshold  is  effects  semi-synthetic  in  advises  not  There  intensity  (McCaffery  pain  comfortable  Analgesics or  353)  one o f  have  Management  of  does  procedure.  far,  be r e c o g n i z e d .  the  Pain  Methods  that  p.  thus  1191).  Post-operative  and  is  preparedness  p.  The  of  must  pain,  (1976,  methodologies  tion  is  measure  Chapman  limitations  care.  to  is  which  the  these  result  of  the  p.  116).  fragmentary  in  usually  central  pain Knowalthough nervous  receptor  transmission  sites of  the  pain In  sensation  addition  common t o phoria) , venous  to  hormone 1977,  provides  morphine  (Ryan  per  or  of  morphine  since  be  expected  to  of  the  p.  115).  is  used  as  alternate  the  pain  of  dose  (Austin,  Stapleton, between  for  depression  release,  1384).  effects  (euphoria  center  dependence  defined  effects  of  (I.M.)  p.  as  with  or  dys-  depression, of  the  cough  increased  (Achong  anti-  1979,  been  75% o f  of  against  study  steady  morphine,  which  to  given  considered  p.  182;  dose  the  undesirable  (Wallace  measure  the  (mgm.)  optimal  of  dose  The dosage  pain but  10 m g m . / 7 0  that  subcutaneously  (1954).  wound  post-operatively  dosage  minimal  Ten m i l l i g r a m s  body w e i g h t , has  the  a minimum o f  160).  and Beecher  and Mather subject's  and  the  weight  a l l  surface  previously  an a d u l t  As w i t h  is  1980,  (kg.)  movement  as h a d  received  a drug  about  and body  often  1 9 8 1 , p.  less  than  and N o r r i s  kg.  body  can 50% 1975,  weight,  effectiveness  of  analgesics.  narcotic  analgesic  of  Lasagna  optimal  narcotic  lications,  gonadotropin  and C l a y t o n  a yardstick  correlation  mood c h a n g e s  respiratory  and  (Mar  pharmacological  constipation,  therapeutic  relieve  Weight  narcotic  dose  intramuscularily  This  include  tolerance  70 k i l o g r a m s  sharp  other  effect  231).  desired  effects  analgesic  miosis,  ACTH a n d  release,  p.  drugs  dilation,  of  optimal  the  of  the  property,  vomiting,  arteriolar  The  (s.c.)  category  inhibition  Gebhart  producing  analgesic  drowsiness,  diuretic  side  the  this  and  reflex,  thereby  is is  areas  may n o t  weight  not  related  been assumed. 1980;  level  be  of  Two  Bellville and b o d y  analgesia  mentioned  when  et  to  the  size  clinical al.  1971)  of  the  studies reported  no  surface,  the  dosage  of  achieved.  In  recent  pub-  the  optimal  dosage  of  discussed. of  pain  research,  investigations  of  analgesic  drugs, and  such  as  their  comparisons  culties. ponse, gesic the  of  effects,  the  pain  properties  evaluation  individual.  is  of  of  the  Although  of  action  variable  absorption  Meperidine,  gesic mgm.  is  I.M.  It or  action a  is  dose  effects  and  1975).  Meperidine  thought  but  1977,  p.  patients p.  172).  longer  has  with In  to  be  of  is  two  (McCaffery action  to  pain,  of  the  only  drugs  such  multifarious  this  study  is  as  the  because  of  hours p.  is  not  effect tract  or  efficacy  levophanol  or  of  s.c.  with  p.  in  of  1979,  ten minutes  1587).  dosing  of  as was the  (Achong  p.  181;  analgesic (Ryan  14 p r e p a r a t i o n s  2 mgm. w a s  found  to  et  hours  of al.  gastroGebhart  indicated  for  and C l a y t o n in be  of  originally  on  the  of  three  than morphine 1979,  p.  Duration  (Mather  anti-spasmodic  is  75-100  System a c c u m u l a t i o n  multiple  dis-  equianal-  (Achong  an a v e r a g e  pancreatitis of  (Staedol).  dosage  within  1976,  meperidine  structurally  morphine  231).  in  are  tartrate  agent,  usually  therefore,  disease  the  same e f f e c t s  I.M.  and H a r t  may o c c u r  Meperidine,  a study  An  the  10 mgm.  1979,  and b i l a r y  in  a synthetic  four  spasmodic  anal-  complicates  details,  and b u t o r p h a n o l  action,  hydrochloride  a less  concern  basically  to  to  res-  the  fact  response  are  of  d i f f i -  rates.  242).  of  This  with  a placebo  irrespective  addition,  effects,  replete  experience  1976).  responses,  (McCaffery  gallbladder  post-operative  p.  onset  musculature  242).  having  equivalent  injection  single  1939  is  a common r e a c t i o n ,  Pethidine)  1977,  a quick  thought  intestinal  but  (Gebhart  s.c.  In  analgesics  in  people  (Bush  cumulative  drugs,  reduced,  and m e t a b o l i s m  morphine  has  of  drug  is  action,  various  or  specific  (Demerol,  considered  given  there  introduced  doses  181).  for  to  one-third  actions.  and  The n a r c o t i c hydrochloride  of  relieved  drug  duration  similar  efficacy  Approximately  whereby  durationsof  the  relief  1980, of  significantly  20 superior  to  meperidine  drug  (Morrison,  Loan,  that  meperidine  is  North  with  partial  shown  that  qualitatively 1976;  Heel  after  I.M.  four  appear  of  to  be  to  the  standard  (1978,  used  p.  reference  181)  narcotic  the  of It  (Utting  team,  is  suggests  analgesic  in  2),  easily  to  meet  to  learn,  reasons,  analgesics  unambiguous  Strauss  1977,  p.  The  I.M.  a practical the  needs  Surprisingly,  the  of  does  patient  or  is,  method  not  does  not is  older,  more  in  rely  post-operative popularity  of  in  its  that  the  it  as  cause  is  criteria  adapted  patients, minimal  relatively  time.  For  method  of  narcotic  method  of  managing  pain. this  the  administration T  and uses on  s.c.  as w e l l  by M c C a f f e r y s  individual  effective,  generally  manage  given  relief  a variety  safe,  practitioners PRN t o  o n a PRN b a s i s  pain of  available,  given  the  is  given  three  narcotic  analgesic  by  and  analgesics  minutes  other  the  to  322).  anticipated  65).  to  over  al.  generally  dosage  This  advantages p.  ten  depression  duration  of  p.  1979,  is  et  comparable  within  the  patients  (Gilbert  is  similar  depression.  Smith is  are  trials  post-operative  action  increasing  possess  pain  of  anal-  Controlled  begins  respiratory  not  synthetic  meperidine  short  and  (1979,  drug  is,  a  two m i l l i g r a m s  duration  respiratory  and  with  action  the  is  in  of  (Fagerhaugh narcotic  to  that  That  does  Post-operative care  of  1972,  analgesia  of  the  effects  dose-related. chances  one  Onset  exception  occasionally.  health  of  in  properties.  achieved  injection;  Other  drugs  developed  that  A dosage  s.c.  with  the  familiar  these  as  Achong  widely  provides  meperidine.  hours.  increase  easy  most  antagonist  butorphanol  similar  or  analgesics  tartrate, narcotic  1978).  7 5 - 1 0 0 mgm.  used  the  1971).  used  America.  gesic  to  and Dundee  probably  Butorphanol  have  1 0 0 mgm. w h i c h w a s  post-operative ordered  PRN,  physician, rently,  pain,  that  the  no  is,  investigated lems .  They -  the  amounts  how p a t i e n t s those found  reports  considered  less  75-100  The  The  mgm.  those  duration  findings address  with  5 0 mgm. that p.  the  244)  of  to  They  suggests  that  I.M.  most to  interval  prescribed  the  Marks  nurse and  suffering  of  by  and  the  concur-  Sachar  (1973)  from medical  meperidine  sample.  This  recommended prescribed  of  the  prob-  three  dosage  optimal  amount  dosage  doses  experienced  to is  of  did  not  only  a  two-  by  the  drug, less  dose  of  were  not  distress  every  between  who may h a v e  action  severe  (Grier, of  than  permitted  90 mgm.  given,  relieved  of  and a f u r t h e r  at  four  relief  or  only  of  realize  PRN  and  their  pain,  41% b e i n g  hours  PRN."  Cohen 1 9 7 9 , Sachar  type  this  few in  of  or  relation  usual  patient  in  with mod-  212) They  reported did  not  population  modal  order  was  300 mgm./24  hours  and  amount.  studies  p.  study.  physician's  intervals  very  the  and  the  22% o f  physicians  and  the  that  four-hour  "although  nurses  Howard,  the Marks  indicate  received  practices  three  the  patients  pain  did  prescribing  every  than  the  substantially  those  meperidine  patients  doses,  63% o f  a mean d a i l y  and G r i e r  patient's  investigated.  analgesics  distress.  similar the  of  gave  39% r e p o r t i n g  Grier  by  pain.  5 0 mgm.  patients  interviewed  erate  given  37 p a t i e n t s  ordered  PRN f o r  The n u r s e s  -  addressed  frequencies  their  with  considerably  order,  and  that  that:  hours  hour  found  frequencies  aspects  consider  -  amounts  and  The p h y s i c i a n s four  were  McCaffery  have to  documented  intervals  prescription  (1979,  is  the  between  meperidine  22 The of  when  to  that  the  demonstrated  see p.  nurse  103)  that ask  as  found,  for  or  percent  have  liked  tion  that  of  to the  No  a similar  in  findings  drugs or  given  to  were  but  did  studies  found  were  not;  were  given  to  patients  they  "PRN"  may n o t  McNicol  by Haywood  all  (Campbell  and  they  (1975,  needed  1977,  patients,  an i m p l i c i t  know when t h e y  that  always  could  p.  post-operatively  held  the  "PRN" by  prescribed  interviewed  nurse would  to  115 p o s t - o p e r a t i v e  reported  he  involved,  same m e a n i n g  process.  "pain-killers"  40 p a t i e n t s  doctor  the  that  responsibility  everyone  m e a n i n g was  indicated  a voice  that  request  that  g i v e n when r e q u i r e d .  questionnaires  the  is  the  not  Similar  decision-making  attach  having  unaware  the  patient,  Two r e p o r t s  from  them.  nurse  assumption  the  are  parties.  48% w e r e  Sixty  and  whether  themselves  the  A major  analgesics  concerned  gives  medicate.  physician, and  PRN o r d e r  57).  would  assump-  analgesic  medication. Although analgesics authors  concluded  by  a further  found severe  from  20% h a d  patients,  ate  pain.  the  interviewed  Chronin  unpleasant". their  that  conclusion  nine  that  in  half  linking  percent (1972)  of  outlined  the that  severe  (Church patients  pain  of  to  of  were  1979,  her  outlined  analgesic  106  several  of  further found  their  discomfort (1976) very 20  how  post-  six that  pain  how t h e y use,  in  patients  severe  survey  of  inadequate  reported  978)  classified  frequency  and U t t i n g  and a p.  is  in  patients in  or  patients,  the  Smith  pain  investigators the  amount  surveys  analgesia.  reported  these  the  PRN a n a l g e s i c s  a n d Heaman  and R e d f e r n  of  of  Twenty  post-operative  None  use  incomplete  (1978)  with  following  the  pain.  questionnaires Whitby  explicitly  given,  Reeri-Szanto  pain.  operative  or  post-operative  interviewed and  linked  prescribed  have  managing  not  as  moder50%  of  "very  reached "severe  pain"  23 was  defined  or  when,  in  the  post-operative  period,  patients  were  sur-  veyed . Although post-operative narcotic  narcotic  pain,  supportive  analgesics,  post-operatively. -  are  preoperative  -  sensation  -  suggestion  -  positioning  care  given  (McCaffery  Although  these  Loan,  and Dundee I n many  supportive PRN i s  Diers  et  the  and  measures  listening  to  al.  way  of  relieving  conjunction  patients  with  achieve  the  comfort  are: (Flaherty  and  pp.  1964),  and Rice  wound  (Pflug  incisions  1979),  be  effective  other  medications, are  208-214;  pain  Bonica  during  1977),  coughing  1966). such  frequently  Wallace  manage  and  and  and Meyer  the  1974),  measure w i l l  (Moss  do h e l p  ease  al.  1972),  the  analgesics,  1979,  help  of  et  relief  surgical  Vaterlaus  with  as  used  sedatives as  and N o r r i s  other  symptoms,  (McCaffery  1979,  p.  and  supportive  1975, i t  p.  is  116).  probable  208;  Morrison,  1971). of  the  measures,  studies  the  a dependent  measurement  of  analgesics not  exist  investigating  incidence  as  and does  in  help  (Johnson  splinting  used  given  used  to  (Egbert  pain  medications  do n o t  primary  when a m b u l a t i n g  the  administration  measures  they  of  1972;  empathetic  tranquilizers  that  that  proper  addition,  these  teaching  1970;  (Copple  of  the  measures,  interpretation  -  is  1978),  -  (Billars  use  by nurses  techniques  Fitspatrick  In  used  Examples  relaxation  -  analgesic  of  variable. used  if  is  that  analgesics  use  of  the  effectiveness  narcotic  The a s s u m p t i o n pain  exists  are withheld  if  of  analgesics underlying analgesics  (Sweeney  .these ordered the are  1977,  24 p.  333).  belief  This  that  a s s u m p t i o n may p r o v e  analgesics  outlined,  no  currently  challenged  of  the  studies  conclusions  questioned;  portive extend  the  Ryan and  by  of  Clayton  given  p.  161).  1980,  the  methods  development include, -  the  of  for  use  nerve  acupuncture  -  inhalation  -  transcutaneous  -  Tomlin -  large  new  placebo  drugs  use  of to  is  validity  measures  proven  such which  (Parkhouse  1975,  ordered  can  be  effective  tools  analgesics manage  previously  the  effect,  the  supoften p.  PRN h a s  post-operative  344;  led  pain.  These  (Engberg  1978;  Kaplan,  Miller  and  and Mehta (Wallace  electrical  Bourke  1978,  p.  464),  and N o r r i s  nerve  1975,  stimulation  p.  117),  (Rosenberg,  1978), (Addison  et  al.  1974;  Gjessling  and  1979), doses  Cooper  These methods  (Knight  of  (Kay  stronger  Eeise  have  analgesic  blocks  analgesia  procedure -  supportive  on  belief  assumption,  they  the  As  and t h e  adjunctive  methods  analgesia  and  epidural  use,  based  1975),  -  Curtis  this of  true  effective  the  is  example:  of  Gallagher  with  other  of  of  i t  effectively. is  studies  recognition  because  this  empirical  the  Dissatisfaction to  the  considered  of  that  used  Because  many o f  the  are  effects  many.  through  Due t o  measures  PRN a r e  demonstrate  however,  and h e l p f u l .  ordered  unfounded  analgesic 1978),  at  the  end o f  the  operative  and  analgesics  and Morgan  given  1979)  given or  the  by  the  sublingual  rectal  route  route  (Beaver  (Edge,  and  1977).  are  reported  in  the  literature  and  some a r e  currently  25 under  investigation.  At  this  point  in  time  none  are  used  commonly  in  practice. A further managing  post-operative  tenance  of  valleys  which  Glynn  and  a  steady  Thomas  the  were  reported  elective  unpredictable  blood  and  the  pain. hours mitted  The of  of  mean amount reported  of  I.M.  depressive  or  or  analgesic  use  in  who  recommend  the  main-  peaks  and  avoiding s.c.  the  between  analgesic  surgery.  and Mather  (1980)  intensity  in  of  in  excess  four-hour  concluded  variable  due  to  women  study  pain  of  following  found  interval  used,  correlations  their  They  blood  being  t h e minimum  dosing  that  was  of  Bond,  the  Similar  cholecystectomy.  were  the  injections.  relationship  (Talwin),  injection  these  similar  that  analgesic over  the  control  inadequate,  total  when t h e in  fluctuating,  pain.  75-100  The hours  was  continuous  m e t h o d was  used.  the  subjects of  3.5  reports  1  percent  of  of  mgm./kg./24  q 4 h PRN p r e s c r i p t i o n  continuous of  data  PRN m e t h o d  mgm.  Twelve  He g a t h e r e d  I.M,  to  the  a mean amount  dosage.  mgm./kg./24  when  I.V.  relation  the  pain.  conclusions.  received  received  although  depressive 7.2  I.M.  and p a i n  each  They  PRN g r o u p  a much h i g h e r of  35% o f  received  meperidine  complained  Stapleton  reached  each of  I.M.  analgesic,  26 men f o l l o w i n g  meperidine  amount  He t h e n v i e w e d  those  to  concentrations.  (1979)  amount  by  a direct  hysterectomy  studied.  Church the  found  in  intermittent  of  pentazocine  only  PRN a p p r o a c h  given  level  concentrations  for  period  is  concentrations  abdominal  following  used  pain  blood  concentration 48-hour  of  the  intermittent  by A u s t i n ,  meperidine blood  about  (1976)  recorded  meperidine  with  level  to  pain  plasma  occur  concentration and  challenge  these  per-  patients  I.V.  group  received  meperidine;  3% o f  this  a  group  26 The Szanto and a  authors  a n d Heaman  Church  steady  studies  that  approach.  This  is  of  a  steady  titrated  the  s.c.  Bonica  1976).  action  is  This  fact  control as  of  by n u r s i n g  cannot  they  gesic  The  to  policy,  of  that  why  They  action the  the  is  I.M. are  patients.  the  patient  produce  analgesic recommend given  prescribed  is  further a steady  should that  the  be  in  the  is  to  Halpern the The  duration chances  intravenous used be  therefore, care  intervals  route.  for  pain  area.  the  scheduled  recorded  of  prohibited  and even  action  of  accepted  level  be  The  and  plasma  of  basis,  three-quarters  i f  on a  the  778).  that,  given  the  maintain  suggest  duration  regular  to  may n o t  use,  PRN  technique.  p.  rarely  a special  intramuscularily at  the  the  1977,  routes.  its  their  intermittent  Such p r a c t i c e and  from  be m a i n t a i n e d ,  immediate;  route  maintain  required,  recommended  with  Wright  routinely.  of  241 c i t i n g  greater  unless  (1977)  stages  Bonica  s.c.  intravenous  used  two-thirds  p.  or  hospital  to  and  Keeri-  to  than  supervision  is  almost  the  analgesic  subsequently  1979,  not  on an  need,  (Pflug  relief  cannot  intravenously  however,  and B o n i c a  the  infusion  approximately  of  is  narcotics concluded  pain  skilled  individual's  be  a l l  method  including  and D a v e n p o r t ,  of  experimental  in  recommend  of  the  (McCaffery  onset  technique  be u s e d ,  doses  should  better  close,  analgesic  post-operative  a PRN b a s i s . two  of  may e x p l a i n  Pflug route  the  depression,  a nursing  and  They  this  intravenous  dosage  similar  respiratory  to  level  dosage  or  produces  the  (1979)  infusions  analgesic.  administered  intravenous I.M.  needed  a continuous  plasma  of  and o t h e r s ,  and V i c k e r s  however,  because  analgesics  carefully  the  date,  equipment  If  of  studies  continuous  a strategy  To  probably  expensive  use  level  three  Rosen  advocate  such  I.M.  these  (1972),  (1979)  plasma  of  for  intravenous analgesia  rather the  and t h e  30 m i n u t e s  than  first anal-  shorter  than  the  duration  of  action.  managing  the  usual  post-operative  in  progressive  Despite  recent  cotic  analgesics  usual  method  and n u r s e s strating  of  rely  its  Although  pain  of  pain  a  is  common  when  terminal  illness,  it  is  currently  suggesting  alternative  or  s.c.  o n a PRN b a s i s  post-operative  pain  management.  on  usual  I.M.  practice  this  approach.  patterns  not  situations.  literature  given  this  of  Studies  use  or  have  its  methods,  continues  to  Habitually, been  nar-  be  the  physicians  limited  in  demon-  effectiveness.  Summary  The pain  concept  research  studies  of  have  in  of  light  narcotic  post-operative  of  the  this  pain  analgesics  management.  study.  pain  in  pain,  management  popularity  shown how a n a l g e s i c s  post-operative intent  pain,  and p o s t - o p e r a t i v e  Surprisingly, istration  of  of  managing  ordered  difficulties have  been  PRN-prescribed post-operative  PRN a r e  actually  Such a d e s c r i p t i o n  of  use  with  reviewed. I.M.  admin-  pain, used is  few in  the  CHAPTER  I I I  METHODOLOGY  Introduction  This  chapter  describes  following  topics  w i l l  selection  of  sample,  analysis  and The  Marks  and  tions, was  the  be  discussed: ethical  limitations research  Sachar  although  of  the  who  a description  in  this  of  data  the  obtained.  The  settings,  collection,  the data  to  population.  was  influenced  similar  by  research  A descriptive  that  of  ques-  survey  design  used.  The politan  reduce  nurses  The  the  of  were  was  conducted  investigator  incidence  the  alone  subjects two  study  city.  Because  and  study  answers  Description  to  data were  study.  sought  a different  research  considerations,  methodology  (1972) for  how t h e  absence  would  of  decide  selected  general  of  gesics  study  prescribed  is PRN,  assessments students  the  of  use  three in  concerned  general  of  done  a  metro-  hospitals  in  order  post-operatively.  resident  house  prescribed  surgery  in  wards  in  staff,  PRN. one  The hospital  other.  the  with  amount  and  analgesics  the  hospitals  non-teaching  medical  wards  the  community  selected  Selection  This  Setting  two  medical  from  surgery  in  of  and 28  the  Sample  amount  frequency  and of  frequency analgesics  of  anal-  given,  and  29 patients'  summational  following  a cholecystectomy.  was  used.  A.  Criteria The -  for  descriptions  Sample  criteria  scheduled  of  pain  in  A convenience  the  first  sample  of  48  22  hours  subjects  Selection  for  selection  for  elective  of  this  group  were:  cholecystectomy  at  one  of  the  selected  hospitals,  The  -  no  chronic  -  male  or  -  ages  20-65  -  weighs  between  -  speaks  and reads  rationales  disease  of  sample  size  Dundee  1967;  most  for  is  use  expected.  Meperidine  other p.  narcotic  172).  limited  This  criteria was  and  chosen  as  taken,  to  need  The  operation  the  carries  alteration  Fitspatrick  1978,  in  353;  the  the  no  the  1 8 1 ; Ryan and analgesics  efficacy  of  various  social  stigma  and that  could  be  following tract  than  Clayton  prescribed  1980, and  medications.  neither  lifestyle  and Henderson  shown  bilary  of  a  procedure;  prescribed the  for  (Loan  population  spasm o f p.  verbally.  reasonable  have  types  person's  Morris  this  a  studies  1961)  following  usually  procedure  allowed  Previous  Simpson  1979,  communicate  discussed.  common,  with  is  to  operative  pain  less  (Achong  compare  significant  p.  causes  restricted  the  and  analgesics  it  analgesics  the  period.  hydrochloride  because  fact  time  and  able  now be  being  experience  narcotic  is  will  Lambrechts,  95%,  therefore,  cholecystectomy  90 k i l o g r a m s ,  English  a limited  Parkhouse,  of  50 and  The o p e r a t i o n ,  within  that  is  years,  these  reasons.  people,  which medication  female,  Cholecystectomy number  for  does  (Flaherty  1978).  The  it  create  and surgical  30 signifies  intervention pain in  is  short  society,  that  the  pain  would  of  the  term,  be  pain  that  all  gesics may  the  no  chronic  occur.  person  can  better.  and w o u l d  specific  soon  For  that  not  or  recurring  return  these  the  to  problem,  his  reasons,  subjects  markedly  references  a patient  diseases  the  In  a persistent  previous  it  was  attached  influence  the  their  role  expected  to  their  perception  experienced.  perception  given,  to  significance  similar  they  the  feeling  and  Although alters  and  usually  meaning  an end  alter  has  of  the  analgesics  investigator's  addition,  it  indicate his  pain  empirical  seemed  that  following  to  was  disease  surgery  prescribed  appraisal  reasonable  chronic  or  the  that  minimize  or anal-  all  three  extraneous  variables. Gallbladder t h a n men  (Thorpe  men w e r e  expected  to  restrict  no  definitive  differently no  disease  and in  affects  Caprini the  1980,  sample;  women f o u r p.  2181).  however,  men a n d u s e women s u b j e c t s work  (Jacox  difference  in  supports  a claim  1977,  66).  the  p.  overall  there  was  As  frequently  m o r e women  no p a r t i c u l a r  described  in  of  Mather  et  meperidine  al.  than reason  Chapter  men a n d women e x p e r i e n c e  Further,  kinetics  more  Obviously  only.  that  times  (1975)  b e t w e e n men  I I ,  pain report  and  women. The age  to  older  between patients  analgesic to  regard  (Jacox  20 and  1977,  of  was  p.  the  lower  there  effects  65).  of  limited  in  Bellville  doses  prolonged.  age a l t h o u g h to  age were  65 y e a r s .  required  action  restrict  with  extremes  In is  age  of  et  sample  al.  analgesics  light  great  the  of  this,  (1971) and it  disagreement  on p a i n  by  perception  restricting found  the  duration  seemed in and  that  the  of  reasonable literature  response  31 The between  50 and  and Mather valid  these  to  were  that It  size  limited  Although  1971)  prescribe  findings. body  weight  Bellville  believes  because  of  90 k i l o g r a m s .  1980;  reason  tigator  of  extremes  have  by  establishing  researchers reported  (Austin,  that  there  a  on w e i g h t ,  the  inves-  based  practitioners  may n o t  necessarily  may i n f l u e n c e  the  Stapleton, not  dosages  appropriate,  criteria  is  analgesic  seemed  the  therefore,  to  be  cognizant  restrict  prescriptions and/or  of  weight  given  amounts  analgesic. The  final  criterion,  communicate  verbally,  pain  investigator  to  and  the  tion.  As  group,  marital  possible  discussed  perception  B.  in  status,  therefore  Procedure  described.  the with  and  to  to  to  speak  allow  understand  not  for  social  the the  and r e a d subject  English,  to  and  describe  investigator's  his  purpose  nursing  the  because  chronic  of The  of  placed  the  thought  have n o t  on  the  variables  by  been  the  Sample  by which  the  subjects  through  of  disease  study,  sample  such  some  to  affect  shown  to  do  and  to  were  eliminated:  flip  the  selected  determine  approached  obtained six  room s l a t e s  one because  the  were  during  operating  area  were  then  showed  Thursday  subjects  the  candidates  investigator  the  not  of  hospitals'  staff  Five  many  class,  date,  Potential  criteria.  I I ,  were  as  selecethnic  pain  so.  These  considered.  Sunday  investigator.  explained  Chapter  Selection  Every  collection,  the  restrictions  and r e s p o n s e , t o  The p r o c e d u r e  data  required  able  questions. Other  were  was  being  two of  the  chart  if  were  met  because  which would  of  of  be the  reviewed  then  they  subjects  now  weeks  and  language  will  by  discussed the  study  age,  two  barrier. individually, be used  and  32 obtained form  consent.  ( Appendix  Two s u b j e c t s  B)  -  there  was  -  participation  -  the  -  refusal  -  any  to  in  plications Two  subjects  being  ordered group  in  and  and  I.M.  the  the  study  the  surgery,  subjects  for  the  deleted  ward  from  anaesthetist.  similar  IT.  In  by  the  of  the in  the  the  were the  study,  results.  following  P.A.R.R.,  the  considered  second  from  the  received,  subject  drug  consent  and  would  form  one  for  the  separately  on  was  the  or  room  are  if  com-  tartrate,  (P.A.R.R.) to  retain is  as  usually the  as  described given  I.V.  analgesic  situations,  data  description, did  this  considered  both  period  if  reason.  butorphanol  wards,  the  P.'A.R,R.  each  study  investigation.  meperidine  Because in  the  Butorphanol  analgesics  whereas  the  to  under  decided  reasons.  effects  from  meperidine  period  recovery  surgeon.  for  deleted  investigator  analgesic  by  the  the  a new a n a l g e s i c ,  The  anaesthetist  ordered  were  post-operative  post-anaesthetic  for  treatment  use was n o t  the  study  the  withdrawal  record.  in  and  or  investigator,  used  ward,  inclusion  by  health  during  that:  confidential.  hospitals  ordered  study  identifying  the  specified  time,  personally  the  the  any  the  of  Chapter  given  in  at  information  were  qualitatively in  withdraw  participate  strictly  and  consent  voluntary,  could  prescription  the  study  The  subjects,  one  by  the  with  arose  At was  was  subject's  analgesic  to  of  participate.  interfered  Following the  risk  and w i t n e s s e d  on t h e  details  to  no way  remain When s i g n e d  no  subject  study  placed  outlined  declined  not  is  P.A.R.R. the  compromise  33 C.  Description  of  the  Twenty-two in  the  study.  straints from  of  Initially,  time  limited  age  of  subjects  and  a mean w e i g h t  weight  from  weight  of  with  The years  46  the  ranged  to  72  79  kg.  of  65.7  90  kg.  this  number.  ages  of  to  with the  males  women r a n g e d  kg.  and  considerations  have been  of  the  to  t h e way  consent  shredding  of  thesis.  The  subjects'  ethical  In  the  course  arose.  became  aware  not  ignore  caring  for  action  might  their  the  situation  affect  A further In  not  the  of  the  study  until  ethical  kg.  Research  upon  thus  the  This of  to  action  The  interview for  the  analgesics  be  the  or  to  course  were  project  given  design  of  the  well-attended. ethical  of  whether the  aware of  s e s s i o n was  investigator  sub-  approached  inform  assessment,  that  to  investigator  a dilemma,  latter  for  to  kg.  80  Process  unanticipated  subjects, led  to  completion  appeared  study,  three  the  in  mean  relation  the  of kg.  65.6  a  62.6  in  with  62  ranging  50  As w e l l ,  results.  one h o s p i t a l ,  the  of  from  signed.  investigator's  dilemma  of  to  24  and  were  terms  the  kg.  77  subjects  rights  in  in  included  heavier,  discussed  transcripts  pain.  of  con-  The w e i g h t s  i n which  conducting  acute  subject  although  audits.  the  form  When i n t e r v i e w i n g  of  the  of  were  a mean w e i g h t  Ethical  specific  years.  in weight  Encountered  were  from  involved  the  a median weight  a median weight  for  chart  four  goal;  ranged  44.9  with  the  subjects  subjects  kg.  The  provided  chosen,  90  was  Eleven  a mean age o f  kg.  63  the  thirty  Considerations  the nature  to  of  Ethical  selection  concerns  men a n d e i g h t e e n w o m e n , w e r e  a sample  50  whereas of  four  and  from  a median weight  ject and  subjects,  each h o s p i t a l .  a median  Sample  arose in  the  or  nurse that  action  this was  complete. from  the  P.A.R.R.  34 without  a record  of  did  not  directly  affect  the  study  but  was  the  not  physician's the  subjects;  discussed  with  Data  The jects were  on  the  first  audited  about  this  mary  and  summary  subject  and  to  sheet  from day  and  Additional  was  in  P.A.R.R.  The  interviews  from  is  the  four  cases.  recorded  hospital  chart  audits  in  This the  staff  C)  at  action  results the  of  time.  developed  chart  to  the  medications  with  the  subjects  with  sub-  The  charts  information  and  data  A  data  by  surgery. the  that  included  and  interviews  surgery.  following  information  the  and  their  demographic  received  (Appendix  collected  i t  following  gather  prescribed  collection.  sheet  second  in  Collection  gathered  specifically  medications  collection in  data were  order  investigator  outlined  the  length  prescribed  and  aided  on t h e of  sum-  time  given  the  in  P.A.R.R.  tion  of  pain  memory,  pain  showed  ogy  of  pain  their  this  pain  for  Hunter,  decay  study,  in  the  person  more  native  to  about  measures, out  24-hour  Rochman  time.  the  This  subjects  period.  (1979)  for  In  found  finding  would  and r e l i a b l y  a summational  be  supports able  the  to  collected  with  investigator  believes  that  pain  can be  Three measures  were  used  i t .  to  an  about  the  open-ended  a pain-intensity on a  flip  chart.  pain  oral  question  scale The  (Appendix  and  use  of  the  both  in  the  24  order  two  scale,  open-ended  for  methodoltheir  hours.  judged  The  then  Jacox  memory  subjective  A).  and  about  recall  preceding  p a i n was  descrip-  a study that  the  information  respond  pointed  that  experiencing  complete  asked  and  the  and  over  accurately  Information because  previous  Phillips  l i t t l e  experiences  ures  the  provided  meas-  only to  gather  subject fixed read and  by  was alter-  aloud fixed-  35 alternative  questions  type  and H u n g l e r  in  (Polit  order  the  to  avoid  numerical  ten by  the  made o f  confusion  as  stated  by  the  developed  by  the  flip  chart,  the  and  15  pages  the  chart  and  statements with  the  represented  underneath.  As  the  could  subject  the  After position  to  open-ended generally was  which  greeting  the  the  flip  question. felt  your  slightly  yesterday?".  to,  Jacox  it  subject  the  the  day,  operation?"; you  belief  in  of  its  -  as  a check  -  to  gather  "the  presence on  best and  the  For  the  his  the  question  the  severity  in  his  of  was  statement pain  on  is own  the  was  separate  read  i t  or  in  a  i n i t i a l l y  felt  visual  was  they  aloud,  response,  he was  second  a  intensity  was  spoke  question  of  validity  writ-  categories  statement  measure  descriptive  the  generally  investigator's that  and  answer,  for  this  were  11" chart  printed  investigator  first  x  The p a i n  assuring  asking  6)  or  his  and  and  referred,  added  8h"  were  page.  of  p.  The  tool  question  reflected  each  taped  number  investigator,  choices  on t h e  were  statements  unsupported.  "How h a v e  The p u r p o s e  the  the  chart,  For  since  the  of  subject.  measures.  numerical  read  number  see  changed  -  also  stood of  the  fixed-alternative  fixed-alternative  cardboard  interviews  which .statement  investigator  heavy  to  about  and weaknesses  The  330).  the  question  pointed  p.  strengths  to  for  of  1978,  the  responses  The stimulus  balanced  he  either  did  both.  comfortable asked  the  "How h a v e  day, since  the I  you  wording saw  you  threefold: by  Houde  patient's  (1977, report  words",  the  other  two measures,  information  about  the  and  post-operative  experience. Because ther  the  investigator  non-directed,  was  open-ended  seeking  the  questions  subject's were  asked  view, or  the  sometimes subject's  fur-  36 response  was  given  response  in  reflected to  "How h a v e  S.  "Much b e t t e r  positive "Better  S.  "Yes to  .  the  "The  S.  "That  Although  the  fication,  have  "no  pain,"  scores, the  one  selected  used method p.  to  1127)  " l i t t l e mild,  to  moderate The  helped."  been up and  at  I  twice,  all  once  haven't  except  give  me t o  pursued  operation?"  It  hurts  a  l i t t l e  . . .  I  think  my  to  the  door  managed  too  badly  just  after  control  the  to  the  felt  pain,"  the  questions  four-point  pain  be  bad  was  expected?"  clear  the  and  once  at  a l l .  shots."  pain  today?"  This  assessment  given gained  the from  subject  pain,"  type  measure  anything  severe"  (Parkhouse  third  measure  used  The  of  using  developed  this  tool  was  of  more 1975,  gather by  Jacox to  seeking  the  rate his  clari-  as  that  either  Numerical  were  applied  the most  p.  351; Huskisson  pain  measure  pain  pain."  to  frequently  measurement  an e s t i m a t e  1974,  technique,  of  pain  as  341).  information (Stewart  collect  the  is  than p.  second  pain  categories  1976,  state  you  "severe  of  or  instrument  or  these  current  was  rated  to  (Chapman  to  scale  "How w o u l d  the  "moderate  statement,  asked.  intensity  question,  pain."  i n i t i a l  were  corresponding  p a i n was. a n purpose  I've  is  four,  because, is  has  you  your  Sore.  attitude  statement. of  expected.  than  example:  since  not  .  .  I  felt  For  but  they  generally "mild  question.  information  shots?"  response  you  .  more  .  additional  A simple In  than  investigator  no  gather  generally  lavatory,  My h e a d I.  you  than  .  to  i n i t i a l  1' m o v e  I.  order  the  I.  when  used.  in  about  1977,  information  the  pp.  subject's  111-112).  about  affective  aspects  of  mission  was  subject  rated  of  the  over to  the  each or  selected after  a minimum of  struct  of  the  according  time,"  24 h o u r s ,  Numerical  questions  and maximum o f  60.  Jacox*  of  15  in  this  that  the  to  in  the  changes  investigator discomfort  read  enhanced  their  eously.  Before  This  the  to  pilot  question  seemed  Personal  to  to  the  question  shown on t h e  no m a t t e r  respond  by the  days,  communication.  the  seven,  for  in  to  a  have  con-  summational  interviews  the  how  was  and Jacox  subjects  the  confuse  applied  expectations.  subject's  of  attributed  him  of  that,  and  with  procedure  for  both  reliable  The  were  and  "most  to  addition  reported  procedure  as  t r i a l ,  by  an average  are  as w e l l  chart  ability  same o p e n - e n d e d hours?"  the  four,  three  consistent the  applied  The  varied  7.5  minutes.  primarily  to  responded.  w e r e made  aloud  be  with  lengths  to  per-  D).  "sometimes,"  reached  24 h o u r s .  collection  The p a i n - i n t e n s i t y  to  gave  minutes,  subject  data  were  previous  interview  the  found  measures  twelve  the  which  the  was  results  subjective  five  Three  tool  was  one  Written  (Appendix  how i t  for  from  to  to  scores,  score  a l l , "  numbers  experience.  straining  at  the  for  reduced  "not  reversing  Initially,  change  instrument  "all  pain  the  the  information.  total  The d i f f e r e n c e s  by  use as  of  subjects.  to  statements  three  speed w i t h  Jacox  intensity  The  validity  length  pain  15  600 p e o p l e ,  description  the  from  the  rating.  score  The  as  of  previous  numbers,  in  as w e l l  received  time,"  the  study  pain  after  f l i p  they were them  investigator  with  the  were  chart.  observed  stimuli  planned  to the  "How h a v e  you  felt  subjects,  but  was  in  read  This to  positioned  two  five  pilot  statements  who w e r e  giving  tested  be and  it  simultanask  the  last  clarified  24  when  i t  38 was  rephrased  t o "How have  "How h a v e  you generally  change  the planned  the  to  P.A.R.R.  include  f i r s t the  proved  span  of  audits  after  of  on the i n v e s t i g a t o r ' s  enough  experience  to alter  in  that  the  analgesic  two  24-hour  analgesic  and  third  information  about  the study  sample.  completion  changes reason  in not  t o b e done  the subject's terms  of  to  of  including arrived,  time  timing.  I t  is  pain  was done  on an  anticipated  visit  that  the time  the subject  in  time  t h e s u b j e c t was  the f i r s t  because  after  The v a r i a t i o n s that  This  On t h e  45 m i n u t e s  the investigator  until  approx-  operation.  exact  period.  on t h e outcome of  planned  day, the collection  time.  the level  and  these  spans  would  was other varia-  were  not  be expected  to  period.  statistics  patterns.  blocks  in  and t h e above  on an average  reasons  Data  Descriptive  in  the investigator  effect  included  were  t h e 48-hour  demands  large  of  The  t o be no apparent  t h e end o f  was done  of  l i t t l e  seemed  on t h e second  the operation  were  criteria  to realize  unaware  have  operation?"  group.  after  f o r a number  c a r e when  cases  there  collection  94 m i n u t e s  tions  your  I saw y o u y e s t e r d a y ? "  and i n t e r v i e w s  difficult  period:  occurred  receiving  pilot  this  24 a n d 48 h o u r s  24-hour  since  was t h e c o l l e c t i o n  met the study  from  chart  day, data  average  the five  the data  criteria  since  procedure  had been made,  The imately  of  the subjects  methodology  felt  felt  experience.  Three Because  you generally  were  used  The d a t a were  and f o r  prescriptions  Analysis  the entire  were  to analyze  considered 48-hour  described,  for  the.data  for  each  period.  example,  relating  subject  in  The p h y s i c i a n s ' in  terms  of  to  39 averages and  (mean, median  intervals  described  between  and  the  outlined.  The  pital  also  were  established  compared  from  directed  which  permitted  the  the  (Chapman dual  using  data  tapes  subject,  analgesic  dosage,  analgesics  that  ordered  prescribed  a t-test.  gathered  in  348).  with  the  toward  summation scale  Chapter  p.  from  and a n a l y z e d .  intensity  rank-ordered  1976,  total  given  between  investigator  As d i s c u s s e d can be  The  the  frequencies  meaningful  The p a i n  they  and  for  range  were  and and  given  given  level  of  the  open-ended  The  data  dosage  similarily  that  The  of  at  were  each  hos-  significance  was  p<.05.  jects  of  differences  subjective  transcribed  ues.  dosages.  amounts  as  The  and mode)  but  of  these not  descriptive  scale  numbers  yielded are  for  scores  data  of  by  were  the  sub-  categories  data.  suited  The n u m e r i c a l  provided  development  the  and Jacox  I I , are  the  question  numerical  ordinal:  therefore,  arithmetical  were  and w i t h  procedures  compared,  the  amount  val-  per and  indivifrequency  received.  Limitations  have  following  1.  Supportive  altered  quired or  The  to  the  keep  are  pain  amount  the  limitations  of  relief  the  measures  analgesic  subject  of  and  comfortable.  study: may h a v e b e e n u s e d  frequency  of  and  may  administration  These measures  were  not  only  be  re-  explored  controlled. 2.  No a t t e m p t  The v a l i d i t y was made  individual's summational  to  criteria  of  the  subjective  distinguish for  description  of  reporting pain  for  between it. the  measures  can  the  experienced  The  pain  subject's  previous  verbal  24 h o u r s ,  assumed. and  report,  would  be  the his  influenced  by  ingness  discuss  the  to  sensation 3.  ling  principle  operative  tudes  of  skills  of  in  analgesic  pain  were  is  time  of  the  and h i s  not  was b o u n d  interview,  ability  to  his  w i l l -  distinguish  w h i c h may  explored  situation toward  the would  post-operative  and  time  of the  or  length  use  of  influence  rather  than  the  samp-  the  the  amount  staffing  of.narcotic  effect were  the  operative  procedure of  post-  controlled.  including  These v a r i a b l e s  sample  by  data.  management,  Generalizability  a convenience  that  of  all  assessment  given.  the  experience  process  richness  nurses  at  experiencing.  The w a r d  6.  pain  technique,  the  state  anaesthetic  pain,  5.  the  sampling  The  and s u r g i c a l  comfort  he was  The  4.  of  his  amounts  not  explored is  specificity  cholecystectomy  analgesics  the  study  ratios,  and  of  the  a t t i -  the  nurses'  frequency  or  limited  and  the  of  controlled.  because  selected  of  the  use  population,  patients.  Summary  This sample, the  chapter  ethical  procedures  sis.  The  prescribed  the  patients'  hours ter.  considerations used  products  ics  on methodology  PRN,  in of  subject this  the  following  and  the  are  of  data  of  settings the  of  their  presented  and  used,  study  collection  amounts  frequency  descriptions  a cholecystectomy,  the  limitations  selection,  process,  amounts  summational  and  described  and  frequency  analgesics pain in  and  in the  the  the outlined  data of  analges-  given, first  following  analy-  and 48 chap-  CHAPTER TV  F I N D I N G S AND  DISCUSSION  Introduction  This  chapter  those  given  by  first  48 h o u r s  the  time  the  ward  situation.  two  reasons: area  rather  and  than The  for  nurses,  following  P.A.R.R.  this  period  are  1)  the  2)  most  findings  the  and  the  analgesics  the  pain  reported  by  by  the  results  discussed  and  then  initially results  anaesthetist  rather  medications as  they  throughout group.  are  this  between  surgeon  intravenously the  in  the to  relevant  to  separately  for  prescribes in  the  the  in  P.A.R.R.  wards.  delineated  Although  differences  on  the  physicians,  pertinent  those  considered  than  given  are  are  are  the  subjects  The  The P . A . R . R .  obvious  ordered  a cholecystectomy.  intramuscularly  each h o s p i t a l ' s  intended,  describes  for  the  total  group  separation  was n o t  the  warranted  groups  and  initially such  delineation.  A.  Length, o f The  in  order  given  in  stayed with  in  to  Time  length give  Findings  Relevant  to  Subjects  Spent  the  of  the  time reader  subjects a basis  this  setting.  Table  the  P.A.R.R.  The  a mean  time  of  time  explain  spent to  spent and  the  P.A.R.R.  P.A.R.R. in  view  1 outlines  113 m i n u t e s  was n o t h i n g r e c o r d e d t o  in  the  the the  the  varied  P.A.R.R.  medications  length from  a median  time  variations  in  41  is  of 50  of the  time to  270  described ordered subjects minutes  97 m i n u t e s . time  and  spent  There in  the  42 P.A.R.R.;  all  for  the  the  P.A.R.R.  for  which  subjects  immediate for  were  appeared  to  post-operative significantly  not  have  period.  less  time  and P e r c e n t a g e  Length  Time Span (Minutes)  a  stable,  Hospital  uneventful  B kept  than Hospital  course  subjects  A,  the  in  reasons  explored.  TABLE Number  had  of  Time  -  60-119  3  120-179  Distribution  Spent  in  of  P.A.R.R.  Number  Number a t Hospital A  0-59  1 Subjects and  Showing  Hospital  at  Hospital  B  Total  Subjects  Percent  1  1  4.5  10  13  59.1  5  5  22.8  180-239  2  2  9.1  240-300  1  1  4.5  22  100.0  Total  B.  11  11  t  = 12.6.  P  > .001.  df  == 2 0 .  Analgesics The  O r d e r e d f o r . Use i n t h e  anaesthetist  P.A.R.R.  The  type  of  study  outlined  in  are  prescribes  P.A.R.R. the  analgesics  analgesics prescribed Table  2.  for  the  to  be  given in  subjects  of  the  this  43 TABLE  2  Number and P e r c e n t a g e D i s t r i b u t i o n o f Showing Type o f A n a l g e s i c s P r e s c r i b e d i n P . A . R . R . and H o s p i t a l  Number a t Hospital A  Analgesic Ordered  Number a t Hospital B  Subjects f o r Use  Total  Subjects  Percent  Meperidine  6  2  8  36.4  Butorphanol  -  8  8  36.4  5  1  6  27.2  11  11  22  100.0  No R e c o r d e d  Order  Total  Use prescribed orders the  the  intravenous  for  all  subjects  gave  decision  dosages  and  different orders. was  of  the of  choice which  No f r e q u e n c y for  any.  with  using  route  frequencies  combinations  outlined  of  to  varied were  was The  route  in  administering  recorded the  use  orders.  intramuscular to  the  P.A.R.R.  considerably  as  In  the  addition,  route  shown i n  for  the  16 s u b j e c t s  specified  for  six  subjects  PRN w a s  stated  for  Table with  and no  only  The  one  was  five  as w e l l ,  nurse.  ordered  term  analgesic  leaving prescribed  3.  Nine  recorded time  frame  subject.  44 TABLE Number  Analgesic  and P e r c e n t a g e D i s t r i b u t i o n o f Showing A n a l g e s i c Prescriptions i n t h e P . A . R . R . and H o s p i t a l  . Dosage,  Ordered  Frequency  Meperidine  5-10  Route,  Number  Ordered  Hospital  mgm.  10 mgm.  x  mgm.  Butorphanol  1 mgm. 1-2  mgm.  1 mgm. No  I.V.  1  1  4.5  -  1  1  4.5  2  -  2  9.0  1  -  1  4.5  2  0  2  9.0  -  1  1  4.5  -  1  1  4.5  -  6  6  • 27.5  5  1  6  27.5  11  11  22  100.0  to  P.R.N. x x  2  2  Recorded Order  Total  C.  -  to  I.V.  I.V.  Analgesics  Given  Analgesics Table  4.  to  given  Percent  to  5 - 1 0 mgm. I . V . 40 mgm. I . M . I.V. I.M.  Total Subjects  4.5  I.M.  10 mgm. 50 mgm.  Number a t Hospital B  1  4  I.V.  A  -  I.V.  50 mgm.  at  Subjects  1  I.V.  I.V.  2 0 mgm. 5-10  3  Subjects to  the  in 22  the  P ., A . R . R .  subjects  in  the  P.A.R.R.  are  shown  in  45 TABLE  4  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g A n a l g e s i c s G i v e n i n t h e P . A . R . R . and H o s p i t a l  Analgesic  Number  Given  Hospital  None Meperidine  Subjects  in Hospital  Twelve  subjects  the  P.A.R.R.  Table mgm.  5,  ranged  and  12  54.5  0  6  6  27.3  11  11  22  100.0  the  of  this  is  of  meperidine Heel  et  5 mgm. of  40 mgm.  al. or  1978,  1 0 mgm.  20 m g m . ,  half  2.5  in p. and  the  i n i t i a l  subjects a total of  of  doses  mgm.  interest  to  of  20 I . V . given  received  a  per  doses  total  effect  of  ten  given were  (Gilbert  et  yet  the  modal  doses  only  one  out  of  injections  given  dose  of  butorphanol.  of  in  shown  in  doses  being  5  injections The  amount  approximates  1976,  meperidine was  injections  as  1 mgm.  al.  I.V.  meperidine  I.V.  1 mgm.  493);  20  of  the modal  the  I.M.  injection,  because butorphanol  analgesic  by  received  injections  20 m g m . , w i t h  All  analgesic  subsequently  meperidine  P.A.R.R.  in  dosage  a l l  subjects  butorphanol  Percent  2  Six  of  Subjects  10  amount  1 0 mgm.  Total  18.2  A four  from  B  4  received  The  at  Hospital  3  received  route;  Number A  1  Butorphanol  Total  at  for  p.  363;  given the  were  amount  46 TABLE Number  and P e r c e n t a g e  Injections  of  Showing  Amount (mgm.)  Number  Distribution  Meperidine Dosage  at  Hospital  5  Given  and  I.V.  P.A.R.R.  Hospital  Number A  of  in  at  Hospital  . B  Total  I.V.  Injections  Percent  1-5  9  -  9  45.0  6-10  8  2  10  50.0  11-15  -  -  -  -  16-20  -  1  1  5.0  3  20  100.0  Total  17  Table jects was  in  P.A. R.R.  11.75  mgm .  butorphanol, total. ered of  6 shows  It  is  and  two  administered.  t o t a l amount  The  mean amount  the  modal  received  interesting  approximately  meperidine  the  to  equivalent  g i v e n was  13.5  given  amount  1 mgm. note to mgm.  of  in  was  1 0 mgm.  mgm., For  and f o u r  2 mgm.  8 0 mgm. or  meperidine  was 1 3 . 5  total  that  I.V.  of  of  the  the  to sub-  median amount  subjects given  received  2 mgm.  butorphanol  meperidine;  16.9% of  given  the  is mean  butorphanol  in  considamount  dosage  47 TABLE  6  Number a n d P e r c e n t a g e D i s t r i b u t i o n o f Subjects Showing T o t a l Amount o f M e p e r i d i n e Each Received I.V. i n P . A . R . R . and H o s p i t a l r  Amount (mgm.)  . Number a t Hospital A  0  1  1-5  1  6-10  5  11-15  2  16-20  2  Total  10  The received the  interval  the  I.V.  the  injection  89 m i n u t e s  later  minutes  after  arrival  the  T h e r e was  groups  the  in  i n i t i a l  time  Eighteen these, three  seven doses.  no  received  more  than  with  a mean i n t e r v a l  utes.  once,  the  the  Subsequent  to  Subjects  1  4.5  5  22.7  2  9.1  2  4  18.2  2  22  100.0  was  received  subjects  interval  the  the  operation  analgesic  (See  Table  difference the  end  varied  7).  the  until  median  the  from  The mean  between  of  the  subject  arrival time  t i m e was the  two  operation  in  was  23.5  hospital and  when  given.  one d o s e ,  of  of  between  Percent  45.5  P.A.R.R.;  significant  subjects  For  in  interval  analgesic  Total  10  end o f  until  minutes.  B  -  between  i n i t i a l  at  9  P.A.R.R.  29.7  the  Number  Hospital  23.4 I.V.  I.V.  ten (N =  analgesic  received 11)  who  between  doses  minutes  and  injections,  in  the  two doses received  ranged  a median four  P.A.R.R.  and  I.V.  from  12  interval  subjects  at  one  Of  received  analgesics to of  51  minutes  19.5  Hospital  minA  48 received dosages  I.M. and  interval  injections  I.M.  time  of  of  meperidine.  injections 26.5  varied  from  and P e r c e n t a g e  Showing and  Interval Minutes  two  interval to  between  50 m i n u t e s  the  I.V.  a  median  with  minutes.  TABLE Number  The  Interval  I n i t i a l  Distribution  Between  P.A.R.R.  7  the  of  End o f  Analgesic  and  Subjects  Operation Hospital  Number a t Hospital A  Number a t Hospital B  0-19  4  3  7  31.8  20-39  1  5  6  27.3  40-59  3  3  13.6  60-79  1  1  4.5  80-99  1  1  4.5  None  Received  Total  t  =  1.489.  p  <  .05.  df  D.  =  of  the  i t  unclear  meperidine  Percent  1  3  4  18.3  11  11  22  100.0  About  Analgesics  anaesthetists'  terms is  Subjects  16.  Discussion The  Total  is  amounts for to  and  the be  Ordered  prescriptions frequency of  p r e s c r i p t i o n,  given  and Those  once  were  open  analgesic  meperidine  o r PRN a n d  if  Given  to 5-10  the  in  P.A.R.R.  to  interpretation  be  given.  mgm.  5-10  I.V.,  mgm.  in  For example, i f the  d e f i n e s each  49 dosage in  or  the  total  the majority  the  orders.  when  to  dosage  the  them,  how  on  as  the  their  prescribed  explanation  the as  in  pain  the  nervous  meperidine  of  of  usual  recommended  3-4  hours  (Ryan and  however,  that  received  the The  in  not was  the  consider  small  lack  the  analgesics  of  the  close  after  p.  398)  proximity  without  depressant  outlined given  to  analgesics,  some c a s e s ,  prescribed  Clayton doses  may e x p l a i n  what  received,  as  data  about  vagueness  of  four  the  these  need  in  the  perhaps  to  the  I.V.  I t  is not  analges-  on  e x p l a i n why  interesting  effects  the  the than  every to  note,  subjects  dosages.  of  the  the  less  meperidine  given;  at  provide  considerably  of  an  compounding  the  and  of  the  orders  8.  The v a g u e n e s s  findings.  of  to  period  Table  the  order.  medications  i d e a may  were  for  subjects  physician's  recommended m e p e r i d i n e  shown  summation  of  function,  172).  need  administration  of  dependent  anaesthetist  and why  light  mgm.  the  medica-  c a s e s may p r o v i d e  given were  post-operative the  that  butorphanol  the  concrete  p.  the  This  50-100  1970,  of  of  of  and  the  a recorded  effects  anaesthesia.  of  giving  anaesthesia,  assessed  orders  in  and r e s p i r a t o r y  dosage  of  suggests  controversial  the  nurses  the  immediate  detailed  conscious  of  equivalent  subject  prohibits  give  would  vagueness  the  the  of  to  P.A.R.R.  many  system  amounts  each  not  and  of  the  effect  in  or  them,  nature  is  carry-over  gesics  interpretation  give  a n d how  The  (1980,  versus  the  meperidine  P.A.R.R.  relief  central  became  routine  A received  the  in  status,  to  Sweeney ics  to  PRN a p p r o a c h w a s  that  whether  frequently  analgesics.  and  Hospital  decided  nurses  subjects  physical  P.A.R.R.  the  give.  Generally, tions  Although  prescriptions,  The n u r s e s  give to  of  dosage.  use of  individuality and  the  analof  variations and  variety  TABLE 8 Comparison of  Analgesics  Analgesic Drug  Meperidine  Butorphanol  Prescribed  with  Analgesics  Given  to  Prescribed  in  Analgesic  Dosage, Frequency, Route  Drug  1  5-10  Meperidine  2  5 - 1 0 mgm. I . V . 5 0 mgm. I . M .  Number o f Subj e c t s  Subjects  mgm.  I.V.  1  5 - 1 0 mgm. I . V . 4 0 mgm. I . M .  2  1 0 mgm. 5 0 mgm.  I.V. I.M.  1  1 0 mgm.  I.V.  1  2 0 mgm.  1  1 mgm.  1  1-2  6  1 mgm.  to  1  5 mgm.  1  (5 mgm.  x  4  Butorphanol x x  I.V.  2  2  x  I.V.  2 x  2)  +  I.M.)  1  (5 mgm. I . V . x ( 7 . 5 mgm. I . V .  1  (5 mgm, I . V . x 2 ) + ( 1 0 mgm. I . V . x 1 )  2  ( 1 0 mgm. ( 5 0 mgm.  1  1 0 mgm.  I.V.  x  2  1  20 mgm.  I.V.  x  1  1  1 mgm.  I.V-  x  2  1  1 mgm.  I.V,  x  2  2  1 mgm-  I.V.  x  1  2  1 mgm,  I.V.  x  1  2  no  -  PRN  I.V.  Dosage, Frequency, Route  ( 4 0 mgm.  to  I.V-  P.A.R.R.  Given  Number o f -Subjects  to  L,V,  mgm.  the  1) + x 1)  I.V. x I.M.)  analgesic  1)  given  +  TABLE-8  Analgesic  Drug  No  Recorded Order  Prescribed  .Number o f Subjects  6  (Continued)  .Dosage, Frequency, Route  Analgesic  Drug  No  Analgesic Given  Meperidine  Total  22  Given  Number o f Subjects  Dosage, Frequency, Route  2 1  5 mgm.  1  (5 mgm. I . V . x 1 ) + ( 1 0 mgm. I . V . x 1 )  1  1 0 mgm.  I.V.  x  1  1  1 0 mgm.  I.V.  x  2  22  I.V.  x  1  52 Findings  A.  Meperidine First  Ordered  48 H o u r s  The  surgeon  tions  (See  for  Eight  9).  period.  Two o r d e r s  12 h o u r s  after  received  fentanyl  the  other  22  the  on  surgeons  the  specified operation  the  the  subjects; All  analgesics  Ward  there  orders  were  variations because  the  in  1 1 2 3 4 5 6 7 8  Number o f Subjects  unchanged  analgesic  subjects,  Krogh  in  for  dosage  during  Cyr  to the the for  ward  be  use  given  1980,  two-day the  first had  potentiates p,  275).  9  Amount  in  Meperidine Ward a f t e r  mgm.  for  O r d e r e d I . M . PRN Cholecystectomy  each Dose  Frequency 2 - 3 - -4 3-4 h 3 h 3 h q 3-4 h q 3-4 h q 4 h  q q q q  1 2  100 50 75-100 75 75 50-75 50-75  q 3-4 h q 4 h q 4 h q 3-4 h q 4 h q 4-6 h  1 1  50 50  1 1 4 1 1 2  22  on  prescrip-  anaesthesia,  a drug which and  for  50-75 50-75 75-100 100 50-100 75 75  1 1 1 2  1 1  Total  I.M.  14 v a r i a t i o n s  (Innovar),  (Thompson,  analgesics  meperidine  remained  D i s t r i b u t i o n o f Amounts and F r e q u e n c i e s o f f o r S u b j e c t s i n t h e F i r s t 48 H o u r s o n t h e  Physician  the  ordered  prescribed  TABLE  Hospital  W/ard  in  surgery  citrate-droperidol  narcotic  'to t h e  Cholecystectomy  performing  the  Table  Use  Following  post-operatively. a PRN b a s i s  for  Relevant  f o r 12 h r s . ; t h e n f o r 12 h r s . ; t h e n  75-100 100  q 4 q 4 q 4  h h h  h  53 Amounts  1.  The mgm. the  For  of  Meperidine  amounts  half  other  of  half,  of  the  Ordered  meperidine subjects,  a dosage  range  ordered  an exact was  Amount in  Prescribed  Number  amount was as  from  specified  outlined  50  to  100  whereas  in  Table  for  10.  10  D i s t r i b u t i o n of S u b j e c t s * Showing P r e s c r i b e d p e r Dose and H o s p i t a l  Number  at  Hospital  mgm.  dose v a r i e d  prescribed,  TABLE Number and P e r c e n t a g e Amounts o f M e p e r i d i n e  per  at  Hospital  A  Total  B  Percentage  Subjects  -  1  1  4.1  -  2  2  8.4  50-75  2  5  7  29.2  50-100  1  -  1  4.1  75  5  2  7  29.2  75-100  1  2  3  12.5  100  2  1  3  12.5  11  13  24  100.0  50 50  (for  12  hours)  Total  Two  subjects  Table each dose. ject.  1 1 shows  and  therefore,  the  received  the  of  milligrams,  1 0 0 mgm. w a s ordered  Innovar  are  maximum amounts  A maximum dosage  Seventy-five  subjects  who  5 0 mgm. w a s the  permitted  amounts  of  modal for  dose,  the  twice.  meperidine  specified  seven  were w i t h i n  counted  was  prescribed  for  only  permitted  subjects.  For  recommended  one for  21  for sub-  14 subjects,  optimal  dosage  54 range from and  of  7 5 - 1 0 0 mgm.  that  of  Marks  Cohen 1 9 7 9 ,  (McCaffery  and  p.  Sachar  212)  who  1979,  (1973)  found  p.  231).  and G r i e r  that  the  This and  finding  Grier  prescribed  differs  (Grier,  modal  Howard  dose  was  5 0 mgm.  TABLE Number  11  and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s Showing Maximum Amount o f M e p e r i d i n e P r e s c r i b e d f o r e a c h Dose and H o s p i t a l  Amount  Number  in  Hospital  mgm.  Number a t Hospital B  at A  Total  Percentage  Subjects  50  -  1  1  4.5  75  7  7  14  63.6  100  4  3  7  31.9  11  11  22  100.0  Total  periods 13.  The  The  total  and  for  total  prescribed  per  Hospital  A were  Hospital  B.  amounts  the  total  were  dose by  the  ordered  For  the  described  by  prescribed  period  determined  are  group,  than  outlined  the modal  amount  amount  (Grier,  the in the  then  and  24-hour 12  maximum  and amount  Subjects those  prescribed  prescribed  Howard  two  Tables  prescribed.  more m e p e r i d i n e  the modal  and G r i e r  for  by m u l t i p l y i n g  maximum f r e q u e n c y  significantly  total  Grier  meperidine  48-hour  amounts  4 5 0 mgm. w a s m u c h h i g h e r mgm.  of  at  daily  daily  Cohen 1 9 7 9 ,  at  of p.  of 300 212).  55 TABLE  12  D i s t r i b u t i o n o f S u b j e c t s Showing T o t a l Amount o f M e p e r i d i n e P r e s c r i b e d f o r e a c h 24 H o u r P e r i o d * on t h e Ward a f t e r C h o l e c y s t e c t o m y and Mean, M e d i a n a n d Mode A m o u n t s p e r H o s p i t a l G r o u p  Amount  (mgm.)  Number  at  Hospital  A  Number  at  Hospital  B  Total  Subjects  1-150  -  -  151-300  -  301-450  4  4  8  451-600  2  5  7  601-750  -  -  -  751-900  5  1  Median Mean  Amount  Amount  Standard  Deviation  t  = 5.18  p  >  df  Hospital  A  Total  B  Group  4 5 0 mgm.  6 0 0 mgm.  6 0 0 mgm.  6 0 0 mgm.  6 4 6 mgm.  5 3 6 mgm.  5 9 1 mgm.  1 7 8 mgm.  132  1 6 3 mgm.  between  mgm.  Hospital  A and H o s p i t a l  mgm.  B  groups,  .05. =  20.  The amounts 24 h o u r  22  600 mgm.  450/800  Amount  6  11  Hospital  Mode  1  1  11  Total  -  period  for  2 subjects  the  second  (Hospital  24 h o u r  period  B)  prescribed  were  are  used.  In  150 mgm.  the less.  first  56 TABLE Distribution  of  Meperidine on  the  Median  Amount  (mgm.)  Subjects  Prescribed  Ward  after  13 Showing  for  at  Hospital  A  per  Amount  24 H o u r  Cholecystectomy  a n d Mode A m o u n t s  Number  Total  each  and Mean,  Hospital  Number  of  Period  at  Group  Hospital  B  Total  Subjects  1-300  -  -  -  ,301-600  -  1  1  601-900  4  4  8  901-1200  2  5  7  1201-1500  -  -  -  1501-1800  5  Amount  Median Mean  Amount  Amount  Standard  = 5.89  p  >  df  2.  A  900-1600  mgm.  Total  B  Group  9 0 0 mgm.  9 0 0 mgm.  1 2 0 0 mgm.  1 0 5 0 mgm.  1 1 2 5 mgm.  1 2 9 1 mgm.  1 0 4 6 mgm.  1 1 6 8 mgm.  3 5 6 mgm.  257 mgm.  3 2 8 mgm.  between  Hospital  A and H o s p i t a l  B  groups,  .05. =  20.  Frequencies  between  22  Hospital  Hospital  Deviation  t  6  11  11  Total  Mode  1  of Meperidine  Ordered  The  frequencies  with  the  two  periods.  24-hour  which meperidine Table  14  was  shows  ordered the  did  ordered  not time  vary  57 intervals; listed. stated modal and  if  of  Seven o r d e r s the minimum  prescribed  Grier's  interval tent  a range  of  with  gave  time  is  of  (Grier,  three  four  time  four  Howard  hours  every  three  the  "most to  TABLE  is  other  consistent p.  hours  is  realize PRN"  15  Grier  The  the  (197  The  with  also  is orders  9),  212).  subjects  nurses  four  the  interval  (See T a b l e  Cohen 1 9 7 9 ,  21 of  that  and  dosages  hours  and  for  the minimum  interval  between  every  statement  meperidine  prescribed,  a range  findings or  was  permitted  interval  McCaffery's  scription  time  ordered  consisusual  , p.  pre-  244).  14  Number and P e r c e n t a g e D i s t r i b u t i o n o f Subjects S h o w i n g I n t e r v a l B e t w e e n D o s e s P r e s c r i b e d PRN f o r M e p e r i d i n e and H o s p i t a l  Interval  Subj e c t s  'Percent  120  12  1  -  1  4.5  180  8  6  2  8  36.4  240  6  4  9  13  59.1  11  11  22  100.0  Total  B.  Total  Number a t Hospital B  Number a t Hospital A  Number o f D o s e s / 24 H o u r P e r i o d  (minutes)  M e p e r i d i n e G i y e n on t h e Ward i n t h e 48 H o u r s F o l l o w i n g C h o l e c y s t e c t o m y In  tions  of  Appendix shows period  the  first  meperidine E for  the and  48-hour were  details  breakdown those  of  given  given  of the in  period  the  on  each  studied,  the  ward  injections  number  of  First  »  a  to  total the  given  injections  hospital.  of  22  each  183  I.M.  subjects. subject.)  given  for  each  injec(See  Table  15  24-hour  58 TABLE Number  and  Percentage  Meperidine Hours  after  Number Time  First  24  Second Total  1.  48  Amounts  of  Table  given  were  for  range  per  1979,  p.  were  231).  within  Hospital  B were Table  24-hour total df  periods  amounts  =. 2 0 ) .  37  48.1  89  48.6  106  100.0  77  100.0  183  100.0  of  for  studied.  total  .05;  df  Table  amounts  is  dose  varied  Seventy—two of  75 mgm.  considered  percent  the  of  range;  total  There  the  two  amount  p  E.)  per  75  percent The  to  50  of  given  100  doses  dosage  (McCaffery at  injections  to  all  optimal  1 0 0 mgm.  injections 65% o f  from  Hospital  given  A  at  amount.  outlines  on  given  amount  dosage  that  2.12;  lesser  dose  meperidine  significantly  shown i n  meperidine  modal  was  are  Given  and Appendix  ever,  >  Percent  49.1  given  The  Injections  52  optimal  17  Percent  51.4  Ninety-eight  this  Total B  94  16  of  Hospital  at  Hospital  of  48  51.9  the  dose  First  40  The a m o u n t s (See  Injections  the  and  Number Percent  of  in  Cholecystectomy  A  Meperidine  mgm.  Ward  50.9  Hours Hours  the  54  Hours  24  Distribution  on  at  Hospital  Frame  Given  15  was no days  given  less  than  = 20).  The  18,  Subjects  of - m e p e r i d i n e  amounts  at  total at  on b o t h  for  significant Hospital  on t h e the  given  second  amount  amounts Hospital days  A  given  (t  = 1.38; at  consecutive  the for  those  in p  f i r s t the  at  the  <  Hospital  B received  than  two  difference  day  given  the  .05; B,  day  48-hour  how-  (t  =  period  significantly Hospital  A,  TABLE Number  and Percentage Amount Per  Amount Time  Frame  (mgm.)  First 24 H o u r s  A  Distribution Dose  Given,  of  Injections  Time  Percent  Frame  Number Hospital  Showing  Total B  Percent  Injections  Percent  13  32.5  15  16.0  75  44  81.5  25  62.5  69  73.4  100  8  14.8  2  5.0  10  10.6  54  100.0  40  100.0  94  100.0  —.  13  35.1  13  14.6  1  2.7  1  1.1  —  * 75  41  78.8  22  59.5  63  70.8  100  11  21.2  1  2.7  12  13.5  52  100.0  37  100.0  89  100.0  2  1-9  26  33.8  28  15.3  65  -  -  1  1.3  1  0.5  75  85  80.2  47  61.0  132  72.1  100  19  17.9  3  3.9  22  12.1  100.0  77  100.0  183  100.0  Total 50  *  Hours  Total  106,  * Although  Meperidine  Hospital  3.7  65  48  of  2  50  Total  and  50  Total Second 24 H o u r s  Number Hospital  16  not  an o r d e r e d  a m o u n t , one  injection  was  recorded for  t h i s amount.  TABLE Distribution Ward  o f S u b j e c t s Showing T o t a l Amount o f M e p e r i d i n e G i v e n f o r Each 2 4 - H o u r P e r i o d a f t e r C h o l e c y s t e c t o m y and M e a n , M e d i a n and Mode A m o u n t s P e r H o s p i t a l G r o u p  First Number Amount  (mgm.)  17  at  Hospital  24-Hour  Period  Hospital  Number  Total  Number:at A  Second  B  at  Hospital  Subjects  24-Hour Number  A  the  Period  at  Hospital  on  Total B  Subj ects  1-100  -  -  -  -  2  2  101-200  -  4  4  -  3  3  201-300  2  5  7  4  4  8  301-400  2  2  4  4  2  6  401-500  7  -  7  1  -  1  501-600  -  -  -  2  -  2  11  11  22  11  11  22  Total  Mode  Amount  Median Mean  Amount  Amount  Standard Deviation  Hospital  A  425/450  mgm  B  Total  Group  Hospital  225.0  mgm.  225.0  mgm.  375.0  mgm.  Hospital  A  Hospital  B  Total  Group  300.0  mgm.  375.0  mgm.  425.0  mgm.  225.0  mgm.  325.0  mgm.  375.0  mgm.  225.0  mgm.  300.0  mgm.  399.0  mgm.  247.7  mgm.  323.4  mgm.  379.5  mgm.  2 2 4 . 1 mgm.  301.8  mgm.  8 1 . 1 mgm.  72.8  mgm.  108.0  mgm.  123.4  mgm.  132.4  mgm.  Between Amounts  Given a t  Hospital t = 14.5 p > .05 d f = 20  A and H o s p i t a l  91.2  mgm.  B t  =  p  >  df  =  10.6 .05 20  TABLE Number  Amount  18  and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s Showing T o t a l Amount o f M e p e r i d i n e G i v e n f o r t h e 4 8 - H o u r P e r i o d on t h e Ward A f t e r Cholecystectomy a n d M e a n , M e d i a n a n d Mode A m o u n t s P e r H o s p i t a l G r o u p  (mgm.)  Number a t Hospital A  Number a t Hospital B  Total  Subjects  Percent  1-250  -  1  1  4.5  251-500  -  6  6  27.3  501-750  5  4  9  40.9  751-1000  4  -  4  18.2  1001-1250  2  -  2  9.1  11  11  22  100.0  Total  Hospital Mode  Mean  -  Amount  Median  A  Amount  Amount  Standard Deviation  t  =  11.2  p  >  .05  df  =  20  Hospital  B  425.0  mgm.  Total  Group  -  790.0  mgm.  450.0  mgm.  587.2  mgm.  778.6  mgm.  471.8  mgm.  625.2  mgm.  181.2  mgm.  128.8  mgm.  219.5  mgm.  62 2.  Frequencies The  hour  20.  Meperidine  number  period  and  of  and  of  for  When t h e  the  frequency  sistent subjects than  with at  times  their  at  of  daily and  both as  days  times  of  B in  period are  the modal  as  in  each  in  Tables  subjects five  t h e mean  total  24-hour  TABLE  described  combined,  meperidine each  are  frequency,  daily  increased  A received  Hospital  were, g i v e n m e p e r i d i n e  48-hour  4.25  receipts  Hospital  subjects  total  results  four  median  times, s u b j e c t s  the  meperidine  Given  amounts  daily  frequency.  approximately  19  received  times  of  24-  as  Con-  meperidine, 1.5  times  more  period.  19  D i s t r i b u t i o n o f S u b j e c t s S h o w i n g Number o f T i m e s M e p e r i d i n e Given f o r each 24-Hour P e r i o d on t h e Ward a f t e r C h o l e c y s t e c t o m y and H o s p i t a l  First Number a t Number of Times H o s p i t a l A  24  Second  Hours  Number a t Hospital B  Total Subjects  Number a t Hospital A  24  Number  Hours at  Hospital  B  Total Subjects  1  -  -  -  -  1  1  2  -  -  -  -  1  1  3  1  5  6  2  4  6  4  1  5  6  2  3  5  5  3  1  4  4  2  6  6  6  -  6  3  -  3  11  11  22  11  11  22  Total  63 TABLE Distribution Given  in  of  and Mean,  Number  of  Subjects  48-Hour  Times  Period  Median  Number  S h o w i n g Number on  is  Per  Number  Meperidine  Cholecystectomy Hospital  at  Group  Hospital  B  Total  Subjects  -  -  -  3-4  -  -  -  5-6  -  5  5  7-8  3  5  8  9-10  2  11-12  6  -  6  Total  11  11  22  Frequency Frequency  Frequency  The doses  Times  1-2  Median Mean  A  of  after  Frequency  Hospital  1  Hospital Mode  t h e Ward  a n d Mode  at  20  of  length  of  meperidine  outlined  236 m i n u t e s  in  on  Table  21.  meperidine  jects  Hospital  on  This  Hospital  B who  subjects  at  markedly  higher  doses  than  Total  Group  8  8  11  7  8  10  7  8.5  between when  For  and  the  four  the ward  B.  B  11  the ward  (approximately  received at  time  Hospital  A  3  their  total  hours).  last  received who  received  P.A.R.R.  group,  the  may b e  2 hours explained  butorphanol received  in  initial  I.M.  analgesic  dose  mean i n t e r v a l  The s u b j e c t s  approximately  difference  those  subjects  the  at  Hospital  earlier in  than  that  P.A.R.R.  meperidine.  was  the  A subsix  received  64 TABLE  21  D i s t r i b u t i o n of S u b j e c t s Showing I n t e r v a l Between P.A.R.R. A n a l g e s i c and I n i t i a l Ward M e p e r i d i n e Dose and R a n g e , Mean a n d M e d i a n T i m e P e r H o s p i t a l G r o u p  Hospital Number  Hospital  A  Number  Number  Interval  after I.V. Meperidine  (minutes)  in  after I.M. Meperidine i n P.A.R.R.  P.A.R.R.  B  Number after I.V.  Total  after I.V. Meperidine i n P.A.R.R.  Subjects all  Butorphanol i n P.A.R.R.  Categories  -  -  1  0-60  1  61-120  3  1  -  1  5  121-180  1  -  -  -  1  181-240  -  2  -  2  4  241-300  -  1  -  1  2  301-360  -  -  1  1  2  361-420  -  -  -  -  -  421-480  -  -  1  1  2  481-540  -  -  -  -  541-600  1  -  -  -  1  Total  6  4  2  6  18  Hospital Interval Range  56-566  Median Time  116 m i n . ,  Mean Time  132 m i n .  Hospital  A  min  115-475  B  Total  min.  56 - 5 6 6  Group  min.  285 m i n .  219  min.  297 m i n .  214 m i n . (236 m i n .  **  Four  subjects  Mean when one  (175.6 min.  who  )  received  skewed  score  no P . A . R . R . is  included.  analgesics  are  not  )  included.  65 Four received utes  their  (3 h o u r s  completion hours not  lined  the  in  data.)  (5 h o u r s  (McCaffery doses val;  this  p.  nificantly  during  less  (Hospital .05,  interval  group  for  df  = 20;  between  13 m i n u t e s )  that parts  t  of  that  compared w i t h  approximately  an h o u r ,  48-hour  p  data  the  the  until  the (4 did  they  for  and  the  The mean interval of  that  usual  was  343  of  minutes is  120-  the  dose  received  action  were w i t h o u t  was  a single  subjects  length  inter-  interval  for  most  subject  longest  meperidine  hours  out-  inter-  effect  of  period. the  df  = 7.76,  369 m i n u t e s  individual  7 minutes)  median  second  first  are  smallest  subjects  .05,  the  min-  subjects  the  the  48-hour  t  these  period,  reflects  than  >  195  after  meperidine  F for  30 m i n u t e s ) .  and  the  from  260 m i n u t e s  level  of  three  the  for  doses  of  for  They  ward.  (1 hour  doses  why  comfort  an a v e r a g e  group: for  suggest  action  of  P.A.R.R.  35 m i n u t e s ) being  of  the  = 6.75,  doses  their  the  apart  between  Total  or  the  the ward  hours  length  The  many  on  (See A p p e n d i x  usual  in  interval  not  the  33 m i n u t e s )  with  (8  does  (13 hours  further  than A:  median  67 m i n u t e s  The  meperidine  subsequent  24.  231).  interval  on  and  hours)  suggests  The  of  was  considerably  analgesics  tals  23,  (5 h o u r s  1979,  the  P.A.R.R.  810 m i n u t e s  (2-4  I.M.  analgesics  515 m i n u t e s  between  43 m i n u t e s ) .  240 m i n u t e s  to  in  total  between doses  333 m i n u t e s  of  meperidine  22,  the  was  dose  receive  The,recording  intervals  For  not  operation,  I.M.  Tables  interval  >  the  analgesic  The  p  i n i t i a l  20 m i n u t e s ) .  received  did  15 m i n u t e s )  of  receive  val  subjects  f i r s t  24-hour = 20; p  >  24 h o u r s (6  second  hours  24-hour  period  period  in  Hospital  B:  .05, was  df  t  = 42).  313 m i n u t e s  9 minutes),  24-hour  both  period.  a  =  was  hospi3.79,  The (5  sig-  mean hours  difference  TABLE Distribution on  the  of  Ward  Subjects  after  Showing  Interval  Cholecystectomy  22  Between Doses  and Range,  Median  of  Meperidine  During  and Mean I n t e r v a l  Longest  Subject Mean  Interval Hospital  Interval Hospital  Per  the  First  Hospital  24  Hours  Group  Subject Median Interval Hospital  Interval  Shortest Interval Hospital  (minutes)  A  B  Total  A  B  Total  A  B  Total  A  B  1-90 91-180 181-270 271-360  1 1  _  _  _  _  _  _  _  _  _  -  1 1  -  -  8 2  17 2  3 3  -  -  9  3 8  7 4  -  -  5  1  1  -  -  -  361-450 451-540 541-630 631-720 721-810 Total  Range  11  of  Median  Subject  of  Mean o f  11  Subject  Subject  Standard  Mean  Deviation  t  =  10.72  p  >  .05  df  =  20  Intervals  Mean  Mean  22  Intervals  Intervals  - • 11  5  1 1  5 4 1 1  -  -  -  11  22  11  4  -  Total  -  -  -  -  1 6  8 10  10 1  1  11  6  7  3  3  -  3  -  1  1  22  11  Hospital  A  Hospital  223-350  min.  259-573  B min.  11  3  -  -  1  1  -  -  11  22  Total  Group  223-573  255  min.  345  min.  295  min.  265  min.  361  min.  313  min.  38.5  min.  85.4  min.  81.2  min.  min.  TABLE  23  . D i s t r i b u t i o n o f S u b j e c t s Showing I n t e r v a l Between Doses o f M e p e r i d i n e D u r i n g o n t h e Ward a f t e r C h o l e c y s t e c t o m y and R a n g e , M e d i a n and Mean I n t e r v a l P e r  Shortest Interval Hospital A B  Interval (minutes) 1-90 91-180 181-270 271-360 361-450 451-540 541-630  10 1 -  631-720 721-810  -  Interval  6 2  Hospital A B  1 1  16 3 1 1  2 2 4 1  -  2  -  2  11  10  21  11  2  3 6 2 -  21  11  5 7 2  2  Total  10  "Range o f S u b j e c t Mean I n t e r v a l s M e d i a n o f S u b j e c t Mean I n t e r v a l s Mean o f S u b j e c t Mean I n t e r v a l s Standard Deviation  =  B  -  Total  3  received  one  dose  in  B  4 7  3  _Total  5 10 3 2 1  1  5 2 1 2  11 4 1 2  -  3 2 1  10  21  11  10  A  Hospital  B  this  Total  21*  Group  240-445 m i n . 308 m i n .  288-775 m i n . 371 m i n .  240-775 min. 314 m i n .  311 m i n . 59 m i n .  427 m i n . 160.5 min.  369 m i n . 132.1 min.  7.11  p > .05 d f = 20 * One s u b j e c t  A  2  Hospital  t  A  Total  3 3 1  Subject Median Interval Hospital  Subject Mean Interval Hospital  Longest  Total  t h e S e c o n d 24 H o u r s H o s p i t a l Group  time  period  and i s  not  included  in  data.  TABLE Distribution on  the  of  Subjects  Ward a f t e r  .Shortest Interval  1-90 91-180 181-270  1  Total  of  Mean o f  11  Subject  of  Subject  Median  _  _  -  -  1 2  -1  -  19 1  -  4 2  1  22  Mean I n t e r v a l s  Mean I n t e r v a l s  of  for  First  48  Hours Group  Sub j e c t  .Mean Interval  Median Interval  _  Hospital ,Total  _  -  1  5  3 5  6  5 3  the  Per H o s p i t a l  Subj ect  -  3 3 1 2  3 2  -  11  11  22  11  2  Meperidine  and Mean I n t e r v a l  Hospital A B  „Total  _  Mean I n t e r v a l s  Subject  Hospital B A  1 1  -  11  Median  .Total  -  631-720 721-810  Range  10 1  451-540 541-630  B e t w e e n Doses  and Range,  Interval  Hospital A B  271-360 361-450  Interval  .Longest  Interval (minutes)  1 9  Showing  Cholecystectomy  24  A  B  _  _  -  -  6 4 1  9 4  -  -  5  8  6  12  3  3 2  3 2  -  -  -  -  11  22  11  11  .Hospital  A  -Hospital  B  241-356  min.  275-473  min.  .Total  8  1  22  Total  Group  241-473  275 m i n .  348 m i n .  343  min.  287 m i n .  380 m i n .  333  min.  min.  Consistent meperidine  and  received  doses  subjects  at In  the Of  times the  the  number  with  Hospital review  of  the  total  183  injections  recording actually  at if  given  at  light  there  may h a v e  the  given  at  of  the  times  only  day  during  injection  of  by  the  24-hour  period  exactly  at  2200.  subjects  amounts at  intervals  of  Hospital  between  that  and  given were  the  ward  B  doses  than  the  than or  25),  on t h e  the  the  25).  period,  hour  or  Whether  this  analgesics  number  were  time which routine  14 s u b j e c t s  12  Table  48-hour  0814.  if  (see  were  explored.  periods  nine  meperidine,  noted  was  showed  were a  settling  (63.6%)  that  subjects  (54.5%)  five  injections to  trend time  dose  received  deter-  given  received  received  period;  of  examined  day when a n a l g e s i c s  dosage  time  of  exactly  rather  Table  reviewed,  same  given  not  time  2230;  over  practice  was  the  surgery,  In  in  the  was  0830  hospital  2130  meperidine  to  between doses  been  (see  24-hour  between  second  or  times  meperidine  of  on  a charting  exact  influenced  On t h e  0800  of  dose  intervals  of t h i s f i n d i n g  were  The  been  evening.  longer  meperidine  reflects  each hour  routinely.  that  example  simply  In  given,  w e r e r e c o r d e d as h a v i n g for  related  A.  day  hour,  doses  significantly  the  half  findings  of  of  (67.2%)  mine  the  the  123  given  with  which in  a at  the  dose 2200.  received the  dose  a  TABLE Number and P e r c e n t a g e D i s t r i b u t i o n H a l f - h o u r , i n t h e F i r s t 48 H o u r s  25  o f I n j e c t i o n s o f M e p e r i d i n e , C h a r t e d as G i v e n E x a c t l y on t h e Ward a f t e r C h o l e c y s t e c t o m y S h o w i n g Time P e r i o d  Given Time Period  Injections  Given on Hour  Total Group  Percent  on Half Hour  Percent  on the Hour or and H o s p i t a l  Combined Number Given on Hour and H a l f Hour  Percent  First  Hospital  A  54  23  42.6  15  27.8  38  70.4  24-Hour Period  Hospital  B  40  15  37.5  8  20.0  23  57.5  94  38  40.4  23  24.5  61  64.9  Total  Second 24-Hour Period  Hospital  A  52  31  59.6  10  19.2  41  78.8  Hospital  B  37  10  27.0  11  29.7  21  56.8  89  41  46.1  21  23.6  62  69.7  Total  Total 48 Hours  Group  Group  Hospital  A  106  54  50.1  25  23.6  79  74.5  Hospital  B  77  25  32.5  19  24.7  44  57.1  183  79  43.2  44  24.0  123  67.2  Total  Group  71 C.  Comparisons of M e p e r i d i n e Given on the w i t h the Physicians' Prescriptions  1.  Amounts  from  50  modal dose a  per  of  to  (see  for  doses  100 mgm.  prescribed  72% o f of  was  dose  Meperidine  The amounts  dose  range  of  the  dosage  Given  Compared w i t h  meperidine Appendix  was  injections.  75 mgm.  None  prescribed  as  prescribed E).  consistent  amount was of  75-100  Amounts and  with  Table  75 mgm.  26  shows  the  Ordered  given  Seventy-five  ordered;  the  Ward  given  Number  Total  50  of Subjects  Doses Given  mgm. Doses  given  four  subjects  who h a d  mgm.,  received  any  TABLE  26  Percent  50-75  5  32  9  28.0  50-100  1  11  -  -  75-100  4  30  3  10.0  No s u b j e c t s Liberty  was  taken,  Thirty-three orders (12%) for  for  1 0 0 mgm.  however,  injections  specified were  received  as  in  a dosage  50 m g m . ,  a dosage in  giving  total amount  15  prescribed.  (46%) As  were of  75 mgm. Doses  dose  3  27.0  27  90.0  larger  than  given  to  100 mgm.  were  for  shown i n  the the  Of  26,  modal  given  when  73% o f in  those  amount  100 mgm.  100 mgm. Doses  Percent  8  73  -  prescribed.  prescribed four  and  the  Meperidine Prescribed  than  these  75 mgm. Table  of  Percent  72.0  less  for  ranged as  the  a range  23  amount  as  amounts  Number and P e r c e n t a g e D i s t r i b u t i o n o f Doses o f S h o w i n g Amount G i v e n When a Range i n D o s a g e was  Amount Ordered (mgm.)  dose  milligrams  the  amount  per  amount.  subjects  whose  injections, only  three  14  doses  four  (42%) of  50  were  72 mgm.  were  given  scribed.  but  or  under  in  as  the  to  group  jects  was  the  by  nurses  48-hour  finding  This  that  the  (Grier,  A further  received  first  the  at  lated  to  amount  group  at  and  of  for  50% g i v e n  B in  of  five  frequency those  meperidine  what  was  than  was  1979,  the  total  amount  p.  and  period,  two  B.  two  where  given period.  based  The m e d i a n  or  54.2% was  the  amount  who  22% o f  the  received  Hospital the  each  than  at  more  50% o f  more  de-  the  than the  than  those  re-  B  order  percentage  of  prethe  1 graphically  for  50%.  50% o f  with  Hospital  percentage  sub-  were  A in  as  prescribed  physician's  p r e s c r i b e d , w i t h a range  sub-  prescription  consistent  Figure  on t h e  for  amount  received  subjects A.  the  Grier  subject the  received is  dosages  For  55.9% of  50% o f  more  finding  informa-  subjects  and  At  subjects  subjects  Hospital  of  1.  than  received  This  given,  Figure  the  232).  doctor's  more  or  each  The p e r c e n t a g e s the  for  appropriately  Cohen  28,  6 2 5 mgm.  Grier  and  received  at  of  certain  prescribed  587 mgm.  that  no  injections.  given  received  by  T h e r e was  prescribed  g i v e n was  studied  of  A and  48-hour  amount  subjects  Hospital  than  the  median  possible  this  Hospital  less  percentage  total was  at  mean amount  follows.  subjects  24 h o u r s ,  amount  significantly the  nine  mean amount  27,  given  during  ( s e e T a b l e s 1 2 a n d 13)  to-give  the  Howard  Tables  chose  period,  they  amount  in  Hospital  amount  prescribed  the  shown  second  scribed  ordered  of  24 h o u r s ,  amount; In  that  18).  pre-  deviations.  received  order  183  higher  delineation  and  mgm. w a s  these  subjects  the  mean amount is  for  of  the  the  subjects  amount  as  as  prescribed;  prescribed.  termined,  17  any  the  ject  Tables  of  the  75-100  physicians'  effectiveness over  to  that  t o why n u r s e s  1 0 5 0 mgm. w h e r e a s  compared  (see  of  account  as  1 1 5 4 mgm. w h e r e  prescribed  to  meperidine the  dose  records  amount  reported  of  charted  were bound by  the  health  when a r a n g e  were  amounts  review  the  total  of  total  determined  tion  subjects  No e x p l a n a t i o n s The  period  to  the  received shows for  the  group  25% t o  100%.  73 TABLE Number  and P e r c e n t a g e  Amount  of  Meperidine  Physician's  Distribution Received  as  27  of  Subjects  Compared  O r d e r i n t h e F i r s t 24 H o u r s  and  Range  Percentage  Number  Received  Hospital  to  Showing  the  Percentage  Amount  on  the  Ward a f t e r  and Median P e r c e n t a g e  Per  Hospital  at  Number A  Percent  <10  -  -  11-20  -  -  21-30  1  9.1  31-40  1  41-50  Possible  Cholecystectomy  Total B  Percent  Subjects  Percent  -  -  -  -  -  -  -  -  -  4.5  9.1  2  18.2  3  13.6  -  -  7  63.6  7  31.8  51-60  3  27.3  2  18.2  5  22.7  61-70  2  18.2  -  -  2  9.2  71-80  -  -  -  -  -  -  81-90  -  -  -  -  -  -  91-100  4  36.4  -  -  4  18.2  11  100.0  11  22  100.0  Total  -  the the  Group  at  Hospital  of by  Hospital Percentage Median  Range  Range  25-100% 63%  100.0  A  Hospital 33-66% 50%  B  Total  Group  25-100% 53%  74 TABLE  28  Number and P e r c e n t a g e D i s t r i b u t i o n o f Subjects Showing P e r c e n t a g e o f t h e Amount o f M e p e r i d i n e R e c e i v e d as Compared t o t h e Amount P o s s i b l e b y t h e P h y s i c i a n ' s O r d e r i n t h e S e c o n d 24 H o u r s on t h e Ward a f t e r C h o l e c y s t e c t o m y and Range and Median P e r c e n t a g e Per H o s p i t a l Group  Percentage Received  Number a t Hospital A  Percent  10  -  11-20  -  21-30  -  31-40  3  27.3  41-50  2  18.2  51-60  -  61-70  1  71-80  Number a t Hospital B  1  Total Subjects  Percent  1  4.5  -  -  9.1  1  4.5  -  3  13.8  7.  63.6  9  40.9  2  18.2  2  9.0  9.1  -  1  4.5  2  18.2  -  2  9.0  81-90  2  18.2  -  2  9.0  91-100  -  9.1  -  1  4.5  11  100.0  22  100.0  Total  •-  1  11  Hospital Percentage Median  Range  Range  9.1  Percent  33.-100% 63%  100.0  A  Hospital 9-58% 50%  B  Total  Group  9-- 1 0 0 % 50%  75 FIGURE  1  Percentage Cumulative R e l a t i v e Frequency D i s t r i b u t i o n of Subjects Showing P e r c e n t a g e o f t h e Amount o f M e p e r i d i n e R e c e i v e d as Compared t o t h e Amount P o s s i b l e b y t h e P h y s i c i a n ' s Order f o r t h e F i r s t 48 H o u r s on t h e Ward a f t e r Cholecystectomy  10  20  30  Percentage  2.  Frequencies  of  40 of  50  60  70  Physician's  Meperidine  Given  .80  90  Order  100  Received  Compared w i t h  Frequencies  Ordered  The f r e q u e n c i e s w i t h w h i c h m e p e r i d i n e was p r e s c r i b e d a r e o u t l i n e d i n T a b l e 15; the  frequencies  and  20.  the  frequencies  and  Figure  received at  with  Comparisons  2.  B.  in  with  Consistent  For  total  received  meperidine  as  was  during  second  less  percentage was  65%.  was  the  the  with  a higher the  meperidine  percentages  possible  meperidine  Hospital  which  of  the  percentage group,  compared w i t h  29-100% r e c e i v e d  of  given  the  the  outlined given  shown  in  subjects  times  possible  from  the  For  possible  the and  total  29,  Hospital  prescribed times  Tables  as r e l a t e d  at  of  period.  in  Tables  percentage  that  that  are  findings, of  are  frequencies  prescription  previous  24-hour  was  than  that  the median  30, A  those  subjects  doctor's  group,  to  the  order range  percentage  19  76 TABLE  29  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s Showing P e r c e n t a g e o f Times M e p e r i d i n e R e c e i v e d as Compared t o t h e Time P o s s i b l e by t h e P h y s i c i a n ' s Order i n t h e F i r s t 24 H o u r s on t h e Ward a f t e r C h o l e c y s t e c t o m y and Range and Median P e r c e n t a g e Per H o s p i t a l Group  Percentage Received  Number  at  .Hospital  Number A.  Percent  at  Hospital  Total B  Percent  Subjects  Percent  <10  -  -  -  -  -  -  11-20  -  -  -  -  -  -  21-30  1  9.0  -  -  1  5.0  31-40  -  -  -  -  -  -  41-50  1  9.0  6  55.0  7  32.0  51-60  -  -  -  -  -  -  61-70  3  28.0  5  45.0  8  36.0  71-80  2  18.0  -  -  2  9.0  81-90  -  -  -  -  -  -  91-100  4  36.0  -  -  4  18.0  11  100.0  11  22  100.0  Total  Hospital Percentage Median  Range  Percentage  25-100% 69%  100.0  A  Hospital 50-67% 50%  B  Total  Group  2 5 - 100% 65%  77 TABLE  30  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g P e r c e n t a g e o f Times M e p e r i d i n e R e c e i v e d as Compared t o t h e Times P o s s i b l e by t h e P h y s i c i a n ' s Order i n t h e Second 24 H o u r s o n t h e Ward a f t e r Cholecystectomy and Range and M e d i a n P e r c e n t a g e Per H o s p i t a l Group  Percentage Received  Number  at  Hospital  Number A  Percent  at  Hospital  Total B  Percent  Subj ects  Percent  <10  -  -  -  -  -  -  11-20  -  -  1  9.0  1  5.0  21-30  -  -  -  -  -  -  31-40  2  18.0  1  9.0  3  14.0  41-50  3  28.0  4  36.5  7  32.0  51-60  -  -  -  -  -  -  61-70  2  18.0  4  36.5  6  26.0  71-80  2  18.0  -  -  2  9.0  81-90  1  9.0  1  9.0  2  9.0  91-100  1  9.0  -  -  1  5.0  11  100.0  11  22  100.0  Total  Hospital Percentage Median  Range  Percentage  33-100% 63%  100.0  A  Hospital 13-83% 50%  B  T o t a l.  Group  1 3 - •100% 56.5%  78 FIGURE  2  Percentage Cumulative R e l a t i v e Frequency D i s t r i b u t i o n of Subjects P e r c e n t a g e o f t h e Times M e p e r i d i n e R e c e i v e d as Compared t o t h e Times P o s s i b l e by the P h y s i c i a n ' s Order f o r the F i r s t 48 H o u r s on t h e Ward a f t e r Cholecystectomy  Showing  100  10  20  30  40  Percentage  The Table  15;  Tables  intervals  the  of  between  intervals  23,  and  pared w i t h  the  prescription  period hours  was  24.  between which 43 m i n u t e s ) .  val  prescribed  the  total  between  48-hour  the  doses  that  to  240 m i n u t e s ,  of  the  the  differences  doses  For  98  of  70  of  the  occurred  100  Received  ordered  meperidine the  subjects.  were  given  between group,  and  the  the  differences  are  outlined  in  are  outlined  in  doses  com-  between  The m e d i a n  interval  differences  whole  given  interval  The median  meperidine  minutes.  90  Order  individual  the  80  meperidine  F shows  3 1 shows  order  median was  of  which  period.  physician's  for  of  (4 h o u r s ) .  Table  and  doses  Appendix  240 m i n u t e s  60  Physician's  between  22,  interval  50  was  for  the  the  doses  for  each  the  range  of  was  ordered 48-hour  343 m i n u t e s  between  mean i n t e r v a l  as  between  92 m i n u t e s  mean  (5 inter-  subject  over  differences doses and  was the  one mean  TABLE Difference Doses  in  Minutes  Given Per  Between P r e s c r i b e d Subject  Hospital Mean Per  Interval Subject  for  48-Hour  31  Intervals Period  Between Doses  on  t h e Ward  A  Physician s Order  a n d Mean I n t e r v a l  after  Hospital  1  Difference  Mean Per  Interval Subject  Between  Cholecystectomy  B  Physician's Difference  Order  241  240  1  275  240  35  253  240  13  336  240  96  256  240  16  343  240  103  275  240  35  343  240  103  277  240  37  345  240  105  310  240  70  348  240  108  252  180  72  410  240  170  322  240  82  423  240  183  266  180  86  448  240  208  356  240  116  473  240  233  343  180  163  480  240  240  Range Median  of of  Differences Differences  1-163 70  minutes  minutes  Range Median  of of  Differences Differences  35-240 105  minutes  minutes  80 D.  S u b j e c t s ' Summational i n t h e F i r s t 48 H o u r s  1.  Subject As  tigator jects with  Interviews described  in  approximately  appeared  to  question  ferences  in  24  a n d 48 h o u r s  how  subjects'  with  the  sensations  they  described  abdominal  differences  in  by  the  subjects -  -  the  the  of  whether  or  generally of  how  The  in  subject  felt  would  before  be  with  the  included  referred  to  were  physical  expected  following  no  obvious  settings.  themes  the  dif-  pain  The  two h o s p i t a l  talk  openThe  their  There were  sub-  to  the  short.  viewed  certain  inves-  All  asking  were  those  10).  the  coming  experience.  reviewed,  themes  seen by  operations.  they  pain  on page  subjects  the  the  of  the  d a t a were  i n i t i a l l y  their  responses  consistent  evident.  description  The  of  (described  were  investigator  felt.  were  interview  how he  after  descriptions  comments  were  subjects  were necessary  individuality  surgery  When t h e  that  they  consistent  upper  Three,  explanations  about  the  Chapter  remember  them; minimal  ended  Descriptions of their Pain Following Cholecystectomy  as  expressed  following:  physical  sensations  in  evaluative  terms,  physical  sensations  felt  in  the  better  or  worse,  operative  area,  These  -  information  -  other  themes  sensations  provide  data which  follows.  initially,  followed  a.  First In  your  about  24 H o u r s response  operation?",  made  the  pain  framework  for  the  descriptions  The  responses  for  the  first  those  Subject to  eight  the  and  experienced.  the  by  -  what  from  the  second  of  24 h o u r s  24-hour  the are  period  interview discussed  studied.  Interviews  question  subjects  "How h a v e  (five  at  you  Hospital  generally A;  three  felt at  since  Hospital  B)  referred "Sore like  directly  and v e r y  (six  evaluative  their  sleepy,"  something  subjects  to  "Very,  splitting at  Six  using  One s u b j e c t  who d e s c r i b e d  did  not  rible.  expect . . .  Hospital  A,  "Quite  good,"  in  in  this  as  All ative  area.  "sore,"  as  such  as,  are pain  "The  (1977, ache  awareness i t ' s  not  of  p.  his  state by  i t B)  of  they at  felt  stated feel  hurt  the  a l l "  "Horrible.  14  in  that  subjects  who  "Pretty they  than  good  felt I  answered  in  state  and  just  Eight  more p o s i t i v e  and  better  so m u c h . "  14  that  feel  answered  better  thought  I  at  in  such  really."  he ter-  (three  terms  as  "terrible."  stated  I  is  other  their  "horrible" also  pain  The  i n i t i a l l y  unpleasant,  saying,  "The  and s o r e . "  "awful,"  as  would  words  and the  study  like  Another  the  pain.  I  eval-  as:  Three  than  sub-  anticipated,  would.  .  five a  i t  .  .  .  It's  cut"; was  . You j u s t  of  exactly  described  is  feel  i t  where  there."  of these  sensation  statements These  reports  incisional  sensation  described  "You  oper-  what  the  me a p a r t . "  the  the  system  post-operative  another  i t  in  no  sensation with  reported  feel  was  unclear  tearing  made,  felt  "uncomfortable,"  there  subjects  description  was  is  tearing  subject  they  included:  Because  something  incision .  sensation  used  design,  Only  Sweeney's  337).  the  they  described  feels  with  to  "painful."  subjects.  behind where  really  "rotten,"  referred  Three  where  "Sleepy  example:  thought."  in  pain  consistent  "A d u l l  I  the  concretely.  described  " I  "hurt"  more  setting)  bad  Descriptive  to  each  group  as,  anchorage  meant  B)  how  subjects  "ache,"  semantic words  such  22  Hospital  as:  not  latter  painful  at  in  for  painful,"  eight  Hospital  " I t ' s  very  A,  think  described  statements  not  at  sore, and  discomfort  didn't  five  terms  jects  such  I  uative  terms  very  stating,  open"  (three  unpleasant,  sensations,  you  Hospital  terms.  physical  as the  he  felt  as,  simply cut  is  but  Nineteen felt  was  hurts  with  move  even  awful.  . . .  the  (Sweeney Fourteen  Five  ments  such  s t i l l  makes  of  their  under  help  sleepy Nine  operative (five  b.  I  at  Nine  of  is  work  not  it  in  made a b o u t  f e l t " t h i r s t y , " at  Hospital  to  the  question,  saw y o u y e s t e r d a y ? " ,  six  subjects  tired.  with  the  (three about  at how  attacks," Hospital they  Subject  sensations .  .  .  The  "Very A,  felt.  associated  are: and  is  "It "Getting  consistent  closely  about  the  what  with  the to  pain" the  and  to  better."  One s u b j e c t  was  state-  Examples  everything  make  i t  described  expected,  surprised.  the  "Lying  keep  "The needles  he had  with  analgesic.  me i n j e c t i o n s  I  lessened  discomfort  me,"  "The  They  pain  make  you  Their  at  "nauseated"  B)  "sleepy"  "How h a v e (three  were I'm  painful,"  four  other  than  and  or  pain  seven  the  subjects  "drowsy."  Interviews  they pain  sensations  one  response  of  finding  they  away."  In  "Kind  move,"  for  t h e manner  -  the  when I  referred  is  24 H o u r s  to  better  relaxes  Second  directly  comments  is  helped  much r e a l l y .  were  two  sensation  these  information  giving  Demerol  not  A,  the  This  pain  s t i l l  are  did  One  terrible  subjects  a shot  comments  hospital  "They  it  of  painful."  s t i l l  get  take  area.  lying  I  but  is  volunteered  lying  shot  a bit than  "It  that  337).  that  are:  "After  Examples  really  p.  better."  "A  reported  post-operative  subjects  analgesic  killers more  and  was  that  "Just  control,"  the  It  1977,  comments  better," how  i t  subjects  by movement.  suggested as:  22  a l i t t l e " ,  knowledge  movement  pain.  the  aggravated  to  up was  of  feeling,  having and  Hospital  responses  at  is  "Very B)  you  each h o s p i t a l ) with less  responses than  tired."  spoke  were,  generally  for  in  the  evaluative  since  referred such  pain  Seven  example:  felt  I  as, had  subjects terms  "Pretty  good  -  much b e t t e r sick  .  .  ferent  than  .  very  from  I  expected,"  much p a i n . "  those  who  the belief  that  other  subjects  how  nine  they  felt  "Better," subjects  as  "About  the  same,"  who made as  Two,  One r e p o r t e d other body  is  there."  a "tight  .  operative  they  aggravated  move,"  and  is  "It  Ten Two  was to  (different  for  at  you  up  from  I  and  for  not the  grip  worse.  in  in  the  the  "hurt"  I  just  inside  there"  know  clearly.  sunburn";  all  oper  sensations  more  a  these  described  sore,  and  you  For  "painful,"  like  The  compared  felt  sensation  dif-  expressed  one was  really  wound,  two  example:  A)  they  t h e wound  to  B)  described  each h o s p i t a l )  have  with  subjects A,  five  "Without don't  feel  you  "It  the my  (points  to  at  the i t ;  the  is  Examples very,  about  first  Hospital  day) B)  painkillers, that's  outlined  very  of  that  the  comments  painful  to  move."  information  from  again  movement.  pain,"  sore whenever  volunteered  Hospital  example:  sleep,  get  s t i l l  subjects  (three  "When y o u  the  seems  felt try  gesics,  i t  (six  "When I  Eight  " i t ' s  around  subjects  were:  pain.  you move,  day,  I'm  anticipated.  Hospital  "discomfort,"  around  A,  than yesterday." at  .  day)  Hospital  sensations  described  .  site).  Twelve sensation  the  and  soreness  had  at  .  Hospital first  unchanged  previous  ache"  sensation  two  (all  were  included  subjects  awful  . whenever  to  the  the  they  worse  five  three  had  a dull  other  "an  that  at  good.  Comments made w e r e ,  "It's  referred  they  like  Two  reported .  better,  words as  day.  A,  "No  (all  than  Hospital  and  and  statements  better  comparison,  subjects  "sore." pain  the  feeling  using  i t ' s  at  previous  area,  "the  (seven  bad,"  subjects  the  doing  the  Twenty  and  expressed were  too  Three  to  themselves  ative  they  "Not  why  what  improved  suggested  commented i t they  would give  on be you  the  lying the  s t i l l  anal-  worse," the  needle,'  84 "The  painkillers  without  the  gas;  the  area.  five  of  comments  the  first  were  think  "They're  at  (one  anyone  giving  made a b o u t at  could  me s h o t s  sensations  A;  one  at  get to  other  each h o s p i t a l )  Hospital  comments  of  fourteen  reflected  no  felt  Pain  through k i l l  than  the pain  commented  Hospital  B)  on  this pain." in  the  having  mentioned  Hospital  The B)  the  24 h o u r s  comments  reflected (five  at  comments  of  that  showed  no m a j o r  changes  seven  subjects  (six  they  Hospital  of  A,  felt  improved;  nine  at  one s u b j e c t  at the  Hospital  (Hospital  B)  from  B)  described  Scale  second  their  part  of  of  responses for  both  categorized  gorization  second  subjects and  Intensity  More  ferences  at  change  responses  subjects  the  worse.  The p a i n was  for  24 h o u r s .  one  these  and  (four  A,  2.  don't  Two s u b j e c t s  Hospital  how h e  I  sleepy. The  those  comments  other  feeling  i t .  painkillers"  Seven operative  help  than pain  subjects  24 h o u r pain  the  intensity made  in  subjects'  on a p a i n  their  50% o f  the  intensity  periods. as  scale.  On b o t h  descriptions Table  days  the  32  of  outlines  majority  moderate.  subjects between  their  summational  were days.  responses  consistent Table between  33  in  their  shows  days.  the  catedif-  of  TABLE  32  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g Responses t o t h e P a i n I n t e n s i t y Scale f o r Each 24-Hour P e r i o d on t h e Ward a f t e r C h o l e c y s t e c t o m y and H o s p i t a l  First Number Scale  at  Hospital  No pain  -  1  1  Mild pain  -  2  2  -  2.5  Severe pain -  Number A  Second  Hours at  Hospital  B  Total Subjects  Percent  Number a t Hospital A  24  Hours  Number a t Hospital B  Total Subj e c t s  Percent  1  4.5  2  4  18.4  5  2  7  31.8  1  2  3  13.6  1  1  2  9.0  6  5  11  50.0  5  8  13  59.2  3.5  -  1  1  4.5  -  -  -  -  4  1  1  2  9.0  -  -  -  -  11  11  22  100.0  11  11  Moderate pain - 3 -  24  Total  *  6 subjects  used the  .5  category;  these groupings  were  added  to r e f l e c t  22  t h e i r responses.  100.0  TABLE Numb e r  and P e r c e n t a g e  Showing Pain  Differences  Intensity  on t h e Ward  Difference Response Second  after  Distribution  in  Scale  33  their  of  Subjects  Responses  Between  24-Hour  Cholecystectomy  on  the  Periods  and  Hospital  in  on  Number  Day  at  Hospital  Number A  at  Hospital  B  Total  Subjects  Percent  1.5  less  1  -  1  1.0  less  3  1  4  18.2  0.5  less  -  1  1  4.4  4  8  12  54.7  Same  4-5.  0.5  more  1  1  2  9.1  1.0  more  2  -  2  9.1  11  11  22  100.0  Total  3.  Jacox  Scale  The was  their  Appendix tions the  A).  for  whole  score  day for  Table  both group  outlined  second  of  the subj e c t s '  scaled responses  All as  third part  34  24- h o u r  t o 15  outlines  31.  but  two  subjects'  in  Table  and  35.  seven had  the whole  group  the  t o t a l scores  On b o t h  total  Thirteen a higher was  d e s c r i p t i o n s of  questions •developed  periods  was  summational  one  days,  scores  from  the  varied  subjects  had  by  Jacox  these  median  between  a lower  ( s ee  15  ques-  score for  the  score  two on  score.  The m e d i a n d i f f e r e n c e  less  the  on  second  day.  pain  days, the  in  TABLE Number  and P e r c e n t a g e  Time P e r i o d  Range of  First  Total  Number  Scores  24 H o u r s  at  Hospital  Distribution  and H o s p i t a l ,  Number A  2  1  25-29  1  4  30-34  3  3  35-39  3  40-44  2  3  45-49  -  -  11  11  -  Hospital Range  A  Subjects  Cholecystectomy Total  B  . 5 6 3 5  Percent  Second  Group  the  after  Number A  Jacox  Hospital  24 H o u r s  at  Hospital  to  Per  at  Hospital  Scale  Cholecystectomy Total  B  Subjects  1  2  9.0  22.8  4  4  8  36.6  27.3  5  2  7  31.8  13.5  1  3  13.6  1  1  4.5  1  1  4.5  11  22  100.0  '  11  Hospital  A  2  Hospital  B  Total  Group  22-44  20-41  23-37  21-47  21-47  34  30  31  31  31  31  * Possible  range  of  total  score  is  15-60.  Percent  1  20-24  Median  by  Group  13.6  100.0  Total  Scores  Scores  22.8  22  B  Total  Total  Number  Subjects 3  Hospital  Showing  and Range and M e d i a n  at  Hospital  20-24  Total  after  of  34  88 TABLE  35  Number and P e r c e n t a g e D i s t r i b u t i o n o f S u b j e c t s S h o w i n g D i f f e r e n c e s i n t h e i r T o t a l Scores on Jacox S c a l e Between 24-Hour P e r i o d s a f t e r C h o l e c y s t e c t o m y and H o s p i t a l  Difference in Response on Second Day  10  to  5 to  Number a t Hospital A  6 points 1 points  to  5 points  6  to  10 p o i n t s  scale  are  shown  consistent  in  The three  in  their  5  9  40.9  1  1  2  9.1  2  4  6  27.3  —  1  1  4.5  11  11  22  100.0  15 d e s c r i p t i v e  categories:  reflect  the  reflect  other  G.  responses  subject's  or  that  that  I  feel  aching,  -  I  have  stabbing  -  I  feel  sharp  -  I  have  pulsing  the  50% o f  days of  the  for  the  reflect  of  15 s t a t e m e n t s the  subjects  13 o f  scale  the  15  the  and  Jacox  remained statements.  can be d i v i d e d  sensations,  sensations  of  into  statements  that  statements  that  feelings.  reflect  -  least  between  evaluation  sensations  Statements  At  to  statements  statements  Percent  4  responses  Appendix  Subjects  18.2  more  subject  Total  4  more  Individual  B  -  less  Total  at  Hospital  4  less  Unchanged 1  Number  sensations  sensations,  sensations, sensations,  related  to  pain  included:  -  My a b d o m e n  -  I  -  I t  am f r e e hurts  Over as  descriptors ional  pain  second  pain  1977,  pp.  least  some  jects. pain  move  the  is  with  expected  the  Most  time. with  upper  subjects  subject,  who  in  felt  that  -  My p a i n  -  The  -  My b o d y  -  I  -  My b o d y  is  pain  sometimes  sensations data  surgery  indicated  as  that  data  responded  the  that were  and  hurt  h e was  subject's  this  somatic  and  by most  with move  the  evaluation  sub-  movement, around.  free  of  of  at  describing  sensation  always  vis-  (Sweeney  literature  to  the  abdomen h u r t  felt  associated i t  (96% o n  surgery  not  incis-  time;  their  the  described  that  the  of  abdominal  responded  interview  subjects  of  these  of  of  descriptions  upper  felt;  descriptions  most  "stabbing"  the  Only  he  felt  as  pain.  the  sensa-  have  depressing,  is  sickening,  feels  miserable,  annoying is  sickening.  statements  subjects  or  and  include:  The m a j o r i t y or  literature  reflect  "sharp"  The m a j o r i t y  aching.some  interview  painful,  Statements tions  the  they  literature  337).  abdominal  all  not  the  following  the  the words  sensation  Pulsing  of  but  p.  chose  the  with  experienced  338-339). of  subjects  1977,  consistent and  and around.  consistent  also  following  present  sing  pain  describing  Consistent  responses one  to  (Sweeney  is  ceral  in  are  day)  response  of  75% o f  appropriate  hurts,  and a l s o  sensations  and  comfortable. of The  subjects two  scored  did  not  categorize  subjects  who  scored  the  statement  highly  on  their  highly " I  for feel  pain  as  these  deprestwo  depressed"  were  those  such  as  who,  "Rotten,"  one who was were  not  agreed  in  free  the "No  of  that  their  bodies that  -  I  am n a u s e a t e d  -  I  feel  subjects at  sometimes  jects  not  that  some  the  As imperfect pain.  least  sometimes  the  The  of  of  any  acute  the  discussed  Three  to  definite  Two,  68% t h e  measures  two  interview  Tables  36  24-hour  least the  subject,  their  the  bodies  second  time  and  day)  spans.  feelings  and  the  of  the  include:  time.  24 h o u r s ;  22%  The m a j o r i t y  This  finding  would have  surgery  indicate  was they  post-operative  Over felt  of  is  sub-  consisis  not  responded  not  to  explored;  felt  depressed  course  is  unknown.  Measures  all  data  three to  show for  subjective be  drawn  to the each  those  measures  about  consistency  and Jacox  mainly  periods  first  time.  reflected  37  part  period.  conclusions  and p e r t i n e n t  the  that  varying  subjects  Subjective  Chapter  these  the  tenuous  for  one  terms  t e r m p a i n when d e p r e s s i o n  before  however,  measures  the  the  the  responses.  in  short  between  extreme  at  t h o s e who d i d  related  in  allowing from  for  of  particularly are  for  24-hour  How  depression  feeling,  data  day,  sensations  tired  second  response.  t i m e , was  in  other  felt  in  about  Comparison  responded  first  miserable  but  with  and  depressed  a usual  whether  4.  feel  statement  time,  (90%)  descriptions  considered  the  All  felt  depressed.  nauseated  with  they  much p a i n . "  (54% t h e  felt  how  tired,  nauseated  did  of  reflect  feel  described  "Very  all  Many  I  50% f e l t  of  pain  -  Most  the  good,"  comfortable.  Statements  tent  interview,  scale.  of  subject.  of  the  subject's  response,  The  subjects  results  a  are  trends,  who  gave  three  91 TABLE Comparison to  the  of  Three  Total  Amount  Subjective  First  24-Hour  of  36  Meperidine  Measures Period  by  after  Received  Individual  with  Responses  Subject  for  the  Cholecystectomy  Pain Hospital  Subject Number  Amount (mgm.)  Intensity Score  Jacox Score  Interview Highlights  B  21  150  3  28  A l r i g h t , Sore, at night.  B  15  175  3  27  B  18  200  2  30.5  Sleepy, Sore, Better today, I t ' s eased. Quite good, Better than I t h o u g h t , No d i s t r e s s f u l p a i n .  B  10  200  3.5  44  Rotten,  T e r r i b l e t o move. Not bad, Hurts under r i b t o move.  Sore,  Very  Pain  painful  bad,  B  15  225  2  26  B  19  225  3  22  P r e t t y good, ter than I  B  17  225  4  37  A  1  225  3  30  Very uncomfortable, Pain is very bad. T e r r i b l e , Like something t e a r i n g me a p a r t , I t ' s ; b e t t e r n o w .  A  4  300  1  20  S l e e p y , No p a i n , the cut i s .  B  3  300  2.5  28  B  22  300  2.5  30  A  6  350  2  24  B B  5 13  350 375  3 3  31 41  A  9  375  3  41  Drowsy, Hurts to cough, o t h e r w i s e n o t bad a t a l l . P r e t t y good, but sore everytime you move. Much b e t t e r t h a n I e x p e c t e d , S o r e , H u r t s a l i t t l e t o move. H u r t s t o move. H u r t s t o move e v e n a l i t t l e , Pain l i k e tearing, Sore. Pain is l i k e something s p l i t t i n g you open.  A  12  415  3  34  A  2  425  2  44  A A  11 7  425 450  3 2.5  34 37  A  20  450  3  28  A  8  475  4  40  16  500  39  Groggy, thought  I  right Feel b e t I would.  feel  where  P r e t t y s o r e , n a u s e a t e d and dopey. Pain under r i g h t rib. Real good, i t ' s improving, It h u r t s when you move. A l i t t l e b i t s o r e o n my s i d e . Sore, very sleepy, I t ' s gett i n g l e s s and l e s s now. Sleepy, D u l l ache, Moving . makes i t w o r s e . H o r r i b l e , H u r t s to move,  to  breathe. I didn't think i t w o u l d h u r t so much. A w f u l , P a i n f u l , G e t t i n g up was a w f u l .  92 TABLE Comparison to  of  Total  Second  Hospital  Amount  the Three'Subjective  of  Meperidine  Measures  24-Hour  37  Period  by  Received w i t h  Individual  after  Subject  Responses for  the  Cholecystectomy  Subject  Amount  Pain Intensity  Jacox  Interview  Score  Score  Highlights  Number  (mgm.)  B  5  75  3  38  H u r t s t o move, to cough, P a i n is worse than yesterday.  B  21  100  3  26  B  10  150  3  43  Very t i r e d , but I'm feeling r e a l l y good. No g o o d , I ' m s i c k , V e r y m u c h  B  18  190  2  31  pain. About the lot  of  same,  B  19  200  3  21  P r e t t y good, tight pain  A  2  225  2  34  Milder yet, as m u c h .  A B B  6  225  3  17 3  225 250  3 2.5  25 36  B  14  300  2  28  A  1  300  2  28  27  B  22  300  3  30  A  4  300  2  23  B  15  325  3  28  B  13  350  3  47  A  11  375  3  31  A  12  375  2  33  A  9  375  2  33  A  16  375  3  39  A  20  450  3  26  A  7  575  3  33  A  8  600  2.5  31  Quite  Not  a  terrible  discomfort. Feels l i k e a - a sunburn. i t  doesn't  hurt  good, i t h u r t s when I move.  Better, but the pain is s t i l l bad. F u n n y p a i n s i n my c u t . I can't complain. S t i l l h u r t s t o move, o t h e r w i s e i t ' s not too bad. Better,  p a i n was  great  when  I  moved. Not bad, awful soreness around the wound. Very good, s t i l l sleepy, it's not r e a l l y sore. Gassy f e e l i n g , q u i t e s o r e e x cept for the medication. S o r e , p a i n f u l t o move, no better than yesterday. Kind of t i r e d , pain less than with attack. P r e t t y g o o d , much b e t t e r than I expected. S l e e p y , i t ' s j u s t when I move i t ' s really sore. Bad p a i n a l l d a y , P a i n k i l l e r s o n l y work an h o u r . I think I'm improving, i t w a s n ' t as Very l i t t l e gas now. A l i t t l e when I  bad as I thought. change, a l o t of  better, get up.  I  have  pain  93  he had  The  pain  intensity  felt  that  day.  moderate pain.  or  As  moderate  (three).  score  good"  or  was  by  of  subjects  (18)  on a more the  term  Jacox  "pain," in  considered  with  score. The  tently about than ments two  on  the  the  ation  as  bad,"  and  is  15  the  fact  of  subjects  extremes no p a i n with  who  in  the and  As  therefore in  using  statements  to  data  and  of  moderate  such hurt  the  so  36  felt  As  with  common  and  must 37  said  be  there  and  his  scale. below  30 w e r e  "All  one  "Rotten," much."  consis-  Their  such  t h o s e who  as  had no  subject  and  with  subject  scale.  distress.  good" 35,  the  Tables  statements  consistently  would  were there  bulk  conclusions  the  scored  verbalize  "Pretty  painful  it  who  above  how  statements  shown  evaluative  scored  a  scale  (four),  the  or  intensity  validity  were  think  (two)  had  "Pretty  interview  as m i l d  lends  good,"  as  of  pain  not  they  pain  For  mild,  predominantly  intensity  high.  pain  experienced  were  felt  the  the  exists.  simple  subjects  he  severe  the  mind.  who d i d  they  addressed  day),  didn't  pain  or  context  of  defined  score when  statements  first  " I  results low  how h e  pain  or  between what  the  "Quite  the  (one)  the  their  of  rating  scores  how  level  included  subjects  described  subjects  in  finding  felt  they  the words  on a crude  expected," of  to  this  This  they  descriptor  if  to  i n what  this  than  of  as  used  relationship  of  level  comments  those how  I  tool  most  and  correspondingly  such  meaning  consistency  Jacox  no  anchorage  intensity  categorized  indepth  anchorage  was  who  subject's  pain  relationship  however, The  or  that  which were  no  the  the  When t h e  subjects,  tool,  (three)  47  gave  frequently  Subjects  "Horrible." the  how  earlier,  21 or  a consistent  Jacox  T h e r e was  or  discussed  Jacox  used  severe,  measure  as  comments  "much  right."  exception described "The  pain  better The  com-  (subject their is  situ-  very  94  tion the  of  The  Jacox  his  condition  comments  subjects drop the  in  their  days  to  less,  four  changes  uating  is  pretation  of  to  more  consistent  needed,  views,  E.  change  the  General The  meperidine.  in  in  the  in  the  with  scale  36  and  on  the  37).  the  from  correspondingly  their  no  clear  Jacox of  a score view  of  to  Jacox  between  ten  of  feels,  seven had  that  a  he  was  six  change  from  four  two  not  and  points,  score  the  does  of  all  suggested  varied  how h e  scores  day;  indication  change  percep-  Comments  two  his  scores  zero  Jacox  second  One s u b j e c t  gave  subject's  more  days.  necessarily  larger  score  change.  phenomenon.  The is  or  reflecting  in  mean b y  "moderate"  pain.  between  interview Jacox  appear  to  not  and  data. tool  reflect  this  or  to  the  Although  results how a n  Lack  "moderate"  Jacox  and  study  useful  change.  open  The  days  of  particularly  "mild"  vague  the  findings  scale  scores  subject  does  between  points.  although  period  the  the  ranged  subjects  the  comparing  Tables  difference  subjects  or  trend  in  decrease  and  intensity  from  changes  improved  subjects  reflect  what  "mild"  tive  is  day  that,  a time  drawn  felt  eight  to  the  (see  The  a median  pain  of  in  interviews;  do  over  conclusions  they  a complex  simple  understanding  days  being  the  probably  pain  two  suggests  Pain  shown  second  with  sensitive  score.  alteration  the  as  Fourteen  in  finding  indicate  that  the  higher.  between  This  Jacox  on  was  that  decrease  worse  points  the  suggested  median  felt  for  tool  to  imply  in  of  eval-  a  makes  common any  the  reader's  inter-  tool  was m o r e  sensi-  score  results  further more  investigation  indepth  individual  were  inter-  feels.  Discussion 22  subjects  This  had  14 v a r i a t i o n s  may s u g g e s t  that  the  in  eight  their  prescriptions  surgeons  who  ordered  for the  PRN  analgesic  considered  routinely  ordering  within  the  ordered  than Hospital ordered  Hospital No  notes  iencing  or  p a i n was far  as  the  be  can  and  that  nurse  managing  and S t r a u s s  nurses  pain  (1977),  period.  existed  in  the  received.  No  variability gesic tively  and as  As  or  orders  of  were  guessed:  the  pain  effectively;  183  after  injections  shown  in  and  each  of  for  of  meperidine E and F, of  administration  carefully,  subject;  about  the  to  22  expected  he  assumed by  subjects  that  the  for  the  in  the  variation  identified; using  were  the  subjects  p a i n was managed there  he  Fagerhaugh  considerable  were  as  PRN-ordered  assumed w h a t e v e r  Perhaps,  although  regime  accountability  meperidine  many r e a s o n s .  subject  and  exper-  recording  suggested  accept  operation,  frequencies  each  not  Appendixes  patterns  may h a v e b e e n  for  the  did  as  no  effectively,  of  no  a problem,  or,  were  physician  and because  were  recording  use  the  amounts.  there  subjects  treated  nurses'  were  dosage  review;  and no  because  the  p a i n management  verbally;  a problem  physicians  the  for  individual  the  A  meperidine  shorter  under  were  Hospital  was  p a i n was  by  of  than  orders  predominantly  altered  the  concerned,  amount  discomfort  the  routine  possible  pain  22  was  in  period  management  amounts  assessing  differences  the  rather  meperidine.  total  doses  pain  the  of  difference  or  adequate.  48-hour  of  range  48-hour  p a i n was  was  gave  Twenty-one  higher  communicated  expected  Nurses  the  be  pain,  did  subjects  permitted  than  no  was  individual  effectiveness  was  if  indicated  patient's  that  this  dosage  This  the  the  only  informed  was  in  mentioning  physician  meperidine would  rather  changed  reasons  done  optimal  between  outlining  The  the  regime.  B physicians.  were  of  significantly  interval  medical  used.  a  A subjects  orders  needs  a certain  recommended  physicians  the  the  no  the as  the  PRN  anal-  effec-  recorded  notes  describing  different  the  nurses,  this  Possibly  each nurse  beliefs,  knowledge  the  differences  jects.  treating  variability Fagerhaugh  of  were  Strauss  post-operatively; Subjects those  at  subject's  at  B,  was  difference  between h o s p i t a l s  perhaps  perhaps use  the  than  seemed  the  those  to  at  was  interested  at  more not  in  received  would have  shown  Tables  to  in  suggest  that  difference one  in  exception  subject  who  received sample  of  the  how  one makes  37,  no  is on  the  analgesic such  a  as  and  nurses  directed  toward  as w i t h  Hospital  the  nurses  purpose  of  and  their  the  on  the  second  at  by  conclusions also  day  the  of  to  give  more,  A  more. investigator  analgesics data. from  As  the  that  subject  data  made  discomfort. is  the  analgesic  subjects  (75 m g m . ) ;  impossible.  for  speculated  the  can be reached received  order,  Hospital  subjective  post-operative draw  be  about  study,  frequencies  by  analgesics  reasons  were" g i v e n  this  d a y was  conclusion  beliefs  subjects  the  pain  physicians  influenced  meperidine  on  more  only  therefore  reflects  it.  can  the  sub-  suggested  and  and  second  the  her  nurses  expected  significantly  different  to  again  on  reflects  the  Perhaps,  perhaps  tempted  by  data  clear  effects  perceived  considered  based  individual  s u b j e c t and t h e  conclusions  of  of  The  amounts  obvious  one  worse  least  the  amounts  they  where  felt  any  36 and the  or  analgesics  whether  variability  A.  not  A had  a specified  the  not  at  orders  B,  and  because,  were  Hospital  analgesic  given  frequently  Hospital  require  Although  more  the  needs  among  communicated.  used  subjects was  regime  been v e r b a l l y  different  the  A were  physicians  nurses  the  mainly  meperidine  upon:  given  by  attention  Hospital  Hospital  the  requests.  (1977),  l i t t l e  may h a v e  p a i n was  requested  p a i n management  skills,  not  perhaps  the  subject  and assessment  the  and  the  among n u r s e s ,  analgesics  of  information  Alternatively,  unless  than  effectiveness  the  any The one  who  however,  a  97 The b e l i e f gesics  regularly  analgesics, to  the  only  was  i n i t i a l  improved  the  48-hour In  in  mented  the  received  this  pain  study,  the  intensity  he  felt  "Very  of  (see  relationship  between  been because  of  trends  and v e r b a l i z e d  quate  not  and  the  may  simply  the  The to  receive  receive the  had six  who  study  was  limited  sample  subjects of  anal-  irregular  a small  1 0 7 5 mgm.  subject  used  in  requires  subjects' reflect  individualization prescriptions.  meperidine  the  who  and  felt  meperidine  because  frequently  the  they over  enough.  less  individuality  and  This  of  management  the  the  of  are  the  the  may the  have lack  received  management.  suggested  that  anal-  patient,  that  is  in  maximum amount  through  times in  pain  given  suggested  experience  20  obvious  pain  not  variations  pain  an  meperidine  have  study  four  compares  of  post-operative  analgesics  over  com-  Subject  measurement,  of  his  26 and h e  reported  problems  authors  example,  good";  pain  lack  the  amounts  The w i d e than  day when  reported  the  the  second  period,  the  influence  For  really  time  not  pain.  subjective  the  the  questioning.  pain  his  did  s c o r e was  feeling  T w o , many with  the  Jacox  same  reflects  Chapter  on  received in  received  their  Although  between  comfort  of  his I'm  37).  inherent  receipt  of  but in  effectively  and/or  analgesic  reported  analgesic  uncomfortable  amounts  of  21, yet  Table  relationship  discussed  are  assumptions  however,  surgery,  5 2 5 mgm.  tired,  Subject  problems  in  of  meperidine  measures  patients  the  subjects  t h o s e who  data;  was m o d e r a t e ,  subjective  are  of  amount  1 0 0 mgm.  by  gesics  than  reviewed.  way how s u b j e c t s  4 5 0 mgm.  As  the  after  a range  received  any  by  data were  amount  of  rapidly  that  period.  that  received  more  period  verbal  21 received  reported  some n u r s e s ,  supported  48-hour  any m e a s u r a b l e  Subject  by  improve not  subjective  had  held  use  in  ade-  that  such  of  analgesics  prescribed  and  appropriate  PRN  subsequently, use  of  PRN  Summary  relevant first to  data  presented  to  what  analgesics  48 h o u r s  these  their  The  subjects  pain  d i n e was  at  bearing  in  this  this  time  48 h o u r s  ordered  and  g i v e n was  are on  two.  discussed the  Other in  findings.  period  H;  A relationship  amounts  meperidine  received  pain.  by  in  was  subjects  detail  use data, not  subjects  and  not  based  the  nurses  gave  described How  in  appear on  identified  and how  in  meperi-  comparisons  and used  did  findings  subjects  analgesics  the  ordered  their  The s u b j e c t i v e  PRN f o r  the  a cholecystectomy.  medications  Appendix  outlined  what  and how  discussed  reviewed.  post-operative  ordered  following  ments were of  have  a cholecystectomy,  and  the  chapter  physicians  24  made b e t w e e n period  following  in  they  three  this to  were time  have  any  measure-  between reported  the their  CHAPTER V  SUMMARY AND  CONCLUSIONS  Summary  The the  effective  alleviation  complications. the  parenteral  basis.  study  the  tomy,  PRN f o r  the  pain  and  to  the  of  The u s u a l method  of  pain  suffering  the  the  patients  in  the  patients  to  their  and  same  uled  for  22  gathered  prescriptions  viewing ponses  the to  24 h o u r s ,  time  by and  a simple  the  first of  the  the at  one  of  The  for  their  99  to  physicians  these  these  surgery. sample  and who w e r e  the  to  of  convenience  general  and  This  gave  reactions  analgesics,  have  cholecystec-  nurses  information  of  studies  that a  their  is  o n a PRN  two n o n - t e a c h i n g  the  scale  Jacox.  that  after  consisted  about  pain-intensity  following  criteria  of  charts  interviews  question  analgesics  used.  study  given  surgery  population.  subjective  48 h o u r s  d e s i g n was  the  of  to  post-operative  previous  this  48 h o u r s  and  and  few  analgesics  administration  by  for  frequencies  auditing  developed  method,  contributes  following  analgesics  and  who met  The  management  analgesics  cholecystectomy  an open-ended  questionnaire  this  period,  survey  subjects.  to  of  24 h o u r s  subjects  elective  Data were the  of  in  prevention  narcotic  frequencies  pain  A descriptive consisted  of  amounts  patients  amounts  of  popularity  administration  described  ordered  post-operative  administration  Despite  analyzed  of  of  management  sched-  hospitals.  pertinent  and by subjects'  comfort  in  15 s t a t e m e n t s  to  interresthe on a  last pain  100 Descriptive to  analgesic  and  patterns-  given were  pital the  group  48-hour period  tabulated  t i m e was  further  t h e n was  of  analgesic  A.  P.A.R.R. The  jects.  Of  The  these,  specified  the  I.V.  of  of  exact  this  nine  into  for  analyze  to  group to  the  each  each  the  (N = 22)  two  time  24-hour  pertaining  for  the ward  time  individual  and  prescribed each  periods.  described  w i l l  data  analgesics  subsequently  data were  prescribed  subjects  route  for  Initially  and  each  subject  hos-  experience  frame  the  entire  24-hour  with  now b e b r i e f l y  to  and  four  specified  be  in  in  the  the  orders  given; only to  be  the  amount  summarized.  a l l  order  the  case by  and  of  the  butorphanol. the  one  16  meperidine  I.M.  regarding  however,  amounts  for  prescribed  prescribed  assumed  variation  were  were  Although  was  analgesics  B,  variations  analgesics  direction  and  The f i n d i n g s  Hospital  meaning.  siderable  compared  eight  at  quency  considered  anaesthetists  all  were  total  according  subjective  to  relating  the  each)  used  Period  subjects,  There  for  received.  Time  were  data  categorized  period. and  The  (N = 1 1 f o r  P.A.R.R.  w h i c h was  statistics  orders  specified the  as  subeight  orders well.  dosage  and  were vague the  PRN  nurses.  frequencies  and All  route  the  22  of  frein  terms  approach,  T h e r e was  con-  analgesics  received. Eighteen gesics  in  idine,  each dose v a r y i n g  5 or of  the  subjects,  P.A.R.R.  1 0 mgm.  Three  meperidine,  received  ten  of  four  Twelve from  these  with  subjects 2.5  doses  of  to  from  orders,  received  20 mgm. w i t h  subjects,  each dose v a r y i n g  I.V.  no w r i t t e n  in 40  butorphanol;  20  all  5 0 mgm. doses  I.V.  of  meper-  dose  of  either  received Six  were  anal-  doses  a modal  addition, to  received  for  I.M.  doses  subjects one  milligram.  101 The ranged  total  of  meperidine  received  5 to  2 0 mgm. w i t h  a mean t o t a l  total  amount was  considerably  less  ages)  than  In  from  amount  the  the  P.A.R.R.,  amounts  of  I.V.  B.  Ward Time  1.  Meperedine  given  I.M.  tions  in  the  The a m o u n t s  surgeons  butorphanol  subjects  at  than  ten  were  the  ordered at  22  per  least  optimal  quencies  of  the  cription  outlining  the  terms  of  received  Hospital  13.5  mgm.  by  at  This  equivalent each  B received  subjects  subject  dos-  subject. higher  Hospital  total  A.  involved  subjects all  dose  dosage  PRN o r d e r s every  in  were  ranged  7 5 mgm. w a s range  in  prescribing  the  study.  unchanged from  50  permitted; of  ranged  75  from  two h o u r s ,  to  There were  for  to  meperidine  the  two  eight  to  four  every  For  amount  1 0 0 mgm, p e r  is  be  variaperiod.  21 o f  the  within  the  dose.  hours,  three  14  48-hour  1 0 0 mgm.  this  to  The  with  hours  fre-  one  pres-  13  every  and  hours. The  total  iod  for  was  450 m g m . ,  each  amount was higher because  the  525  total their  48-hour  of  ranged  mean  mgm.  total  The  amounts  Meperidine  the  amount  subject  Nurses in  in  of  each  Ordered  recommended  2.  of  prescriptions;  subjects,  four  eight  analgesics  PRN f o r  the  amount  amount  by  Period  Eight  22  total  (16.9%  I.V.  of  orders  meperidine from  300  prescribed  for  each  900 mgm.,  the  modal  to  amount was  surgeons  at  meperidine  permitted  more  577  mgm.  Hospital  than  those  frequent  and  the  24-hour  per-  total  amount  median  A prescribed at  Hospital  total  significantly B  predominantly  administration.  Given gave  183  period.  I.M. The  injections amount  given  of  meperidine  per  dose  to  ranged  the from  22 50  subjects to  100  102 mgm.,  with  72% o f  each  subject  with  a mean  mgm. iod  The  in  total  received On b o t h dine  amount  75  to  total  amounts  than  The number in  each  times,  over (13  a mean o f  4.25  of  A received period  the hr.  median  that  time  those  48-hour  period  30 m i n . ) ,  with  between  of  been  idine  in  f o u n d was the  a median  exactly  evening  (5  longer  percent  that  1.5  from  of  hr.  more B.  the  on t h e  over  2130  or  of  (1 hr.  2230,  the  period. meperi-  meperidine  a mode o f  in  between  7 min.) hr.  to  were  days  each  doses 810  had of  four  at  min.  33 m i n . )  action  usual  B  Subjects  The  per-  received  meperidine  meperidine  on b o t h  A  of  with  325  mgm.  more  All. subjects of  of  Hospital  a dose  (5  mgm.,  302  24-hour  half-hour.  subjects and  at  to  24-hour  of  times.  333 m i n .  of  amount  at Hospital  interval  duration  doses  hour  50% o f  between  the  475  to  amount  times,  doses The  of  225  second  second  four  67 m i n .  given  significantly  six  43 m i n . ) .  than  the  received  of  amount  total  subjects  the  to  a mean i n t e r v a l  dosages  given  one  Hospital  ranged  in  subjects  from  and  at  343 m i n .  Sixty-seven  pattern  ranged times  days;  A received  approximately  than  interval  having  times  in  Subjects  meperidine  of  from  a mean t o t a l  on b o t h  B.  total  a median  subject  3 0 0 mgm.  Hospital  The ranged  and  each  Hospital  period  24-hour  to  of  less at  24-hour  Hospital  period  3 2 3 mgm.  meperidine  at  7 5 mgm.  600 m g m . , w i t h  subjects  those  of  amount  of  for  24-hour  given  significantly days  being  f i r s t  amount  from  and a m e d i a n similar  the  total  ranged  doses  and  a  periods meperidine.  charted  only  as  routine  received  "settling  meper-  time"  in  hospitals.  3.  Subjects'  Summational  There were no the  two h o s p i t a l  Descriptions  obvious  settings.  of  differences  The v e r b a l  their in  the  responses  Pain subjective to  the  data  question  between about  how  they  felt  experienced pain.  The  with  pain  the  sensations  given  the to  to  suggested sistent  4.  sensations  descriptions  responses,  in  felt,  no  of  consistent  distress  with  subjects  a median  suggested  their  these  of  subjects  post-operative  descriptions  emphasized  the  of  how  individuality  they of  the  measure  The  subjects  score with  the  improvement  or  of  the  distress in  categorized  in  prevented scored  31.  The  interview the v e r b a l  verbal  their  data  pain  intensity  significant  from  20  scores data data,  to  from  in  meaning  47  on  the  that  as  the  Jacox  those  those w i t h  scale  with  low  scores  and  changes  in  scores were  of  comfort  in  the  deterioration  to  verbal  condata.  Comparisons The  amounts  compared w i t h  the  and  modal  amount  the  doses  given were  physician's than  the  the  subject,  for  t h e mean amount  55.9%  of  the  total  amount  the  6 2 5 mgm. per  Consistent  of  No d o s e s  were  given which  doses  (33/183)  mean amount  or  median On t h e  ranging  of  dosage,  54.2% of  subject,  the  amount.  meperidine  subjects  dose  maximum p o s s i b l e  1 0 5 0 mgm. w h e r e a s  of  prescribed.  to  meperidine,  were  were  with  72%  of  exceeded  given  for  the  less  amount.  prescribed  prescribed  given  per  18% o f  period  the  meperidine  prescribed  yet  g i v e n was  amount  was  on  of  frequencies  75 mgm.  dosage  48-hour  based  and  75 mgm.  prescription  For  dosage,  of  prescribed  The m e d i a n  frequencies  amounts  the  per  the  documented  they  finding.  with be  scores  of  grossness  this  scale,  appeared high  in  experience.  moderate;  Jacox  similarity  varied  The m a j o r i t y  be  a  previously  subjects'  interpreted the  suggested  from  the  based amount  on  meperidine was  1 1 5 4 mgm.  prescribed, the  maximum  g i v e n was  first  day,  25  100% o f  to  prescribed  amount. possible  587 mgm.  subjects the  whereas  or  received  doctor's  a order  104 on t h e the  second  doctor's  63% a t  examined.  they  order.  Hospital The  dine  day,  received  A and  50% a t  Hospital  responses  A relationship by  total  was  subjects  and  not  and how  The  findings  1.  The  of  assumption,  effectively  uncomfortable  this  because  in the  needs  this  that  obvious  subjective  responses  2. cies  of  There  3.  Although  team members  information dine  were  analgesics ment  by  given  the  except  or  not  effective.  literature,  are  pain  not  were  and  and  in  that  pain,  given in  in  the  amounts in  the  the  about  meperidine dosage  pain.  to  patients  amounts  are  amounts  and/or  finding  from  the  patients'  meperidine received.  and  and  frequen-  frequencies  communication  of  the  certain  lack  of  dosages of  the  post-operative  between  of  given  in  dosage  recommended  for  recorded meperi-  administered pain  a consistent, accountable  may b e  use  patients.  effectiveness  approach than  were  meperi-  do n o t  is  the  amounts  amounts  about why the  of  of  record,  pain,  of  nurses  between  patient  optimal  was  conclusions:  adequate  the  rather  days  received  amounts  that  light  evident  variability  a laissez-faire  the  following  through  P.A.R.R.,  than  the  for  or  on b o t h  of  Study  account  given  100%  post-operative  not  4.  less  in  the  did  and n u r s e s  the  this  post-operative  post-operative  suggests  In  to  study  physicians  siderably be  about  given  9 to  meperidine  their  post-operative  prescriptions  analgesics  of  reported  correlations their  received  between  investigation  considerable  PRN a n a l g e s i c  PRN-ordered  health  about  is  noted  further  amount  suggest  analgesics  enough, no  the  of  managing  frequently study  as  from  B.  they  study  ranging  amount  identified  Conclusions  analgesics  amount  The m e d i a n p e r c e n t a g e  subjective  received  a  manageapproach.  amounts the  drug  conto  105 5. the  hospital  gesics  is  A factor setting,  6.  The  amount  within  the  of  between  Doses  between that  doses  the  and p e r i o d s  of  of  and  doses  are  given  per  of  prescribed  given with  duration  experience  time with  and  of  by  anal-  setting.  dosage range  usually  determined  frequency  a particular  optimal  but  75  I.M. to  with  dose  1 0 0 mgm.  a  four  outlined.  the  patients  and  prescribed  PRN i s  meperidine  than  identified  amount  in  meperidine  ordered  not  the  given  recommended  Meperidine  8.  as y e t  influence  prescribed  interval  gests  may  are  7.  vals  factors,  that  usually  hour  or  no  of  considerably  action  of  fluctuating  effects  that  the  blood  can be  longer  drug.  inter-  This  levels  of  attributable  sug-  the  to  drug  the  analgesic. 9. amounts  The  of  boundary;  physician's  meperidine however,  10.  The  of  the  to  are  the  throughout  as  somatic  distress 11.  ing  and  less  they  exact  hour  time  outlines  given.  than  the  outlined  minimal  pain.  in  of  respect  amount  previous  individual  half-hour  rather  and  the  prescribed pain  these  maximum  maximum  literature  evaluate  are recorded u s u a l l y or  minimum  post-operative  Patients  on an  the  Nurses  sensations  cause  Analgesics  the  be  physical  cholecystectomy incisional  to  order  dosage  may b e  given.  following  descriptions sensations  in  a of terms  basis. as h a v i n g  than  been  evenly  given  accord-  interspersed  period.  Implications  Although convenience the  the  sample,  contemplation  of  findings by  the  only  of  this  study  specificity one a s p e c t  of  of  are  the  limited  selected  by  the  use  population  p a i n management,  that  is  of and  a by  analgesic  106 usage,  they  management  suggest  in  this  study.  this  in  evaluation  objective is  problem  tools,  essential.  reference  is  an  are  tice  and  research  only  be v i e w e d w i t h  quencies  the  given  reports  of  light  3. of the  a dependent  p a i n management The  analgesics facts  durations 4. below  the  to  give  as  i t  the  action In  this  would  than for In  this  pain  of  p a i n measurement  were  assessment  least  of  study,  the  other study,  by  the  clinical  of  that  in  analgesic  prac-  use  can  the  amounts  and  fre-  there  use  seeking  of  to  was  and  no  patient  analgesic  support  con-  or  refute  questionable.  the  nurse  their  exercises  that  effects,  analgesic  she be optimal  can be  used  meperidine  were  physician. this  drug,  in  and  its  received  the  common  mind.  study;  this  more  anchorage,  used  through  in  as  of  drawn  of  and  reliability  widely  in  imperative  the  its  a  exper-  pain  semantic  evident  i t  of  is  tool  studies  whether  type  of  becomes  dosages  or  was  pain  used w i t h o u t  scale  findings,  in  control  that  scale  the  the  The development  conclusions  these  such  of  of  a degree  this  amounts  PRN m a k e s  of  subjectivity  subjects  techniques  ordered  any  to  variable  drugs, so  post-operative  measurement d e v i c e ;  the  of  minimum p r e s c r i b e d  less  5.  ordered  about of  amount  for  methods.  variability  between  In  at  limitations  relationship  other  in  situations,  meperidine  as  the  Although  obvious  sumption  in  the  pain-intensity  questionable.  pain.  of  inadequate  Considerable  of  complexities  p a i n management  simple  validity  2.  exists  which build  The  point  and  Because  also  of  implications  practice:  The d i f f i c u l t i e s  ience, the  following  and n u r s i n g  1. apparent  the  needs  variations  in  cognizant dosages  given it  for is  use of  and  amounts appropriate  a medication  clarification. the  the  effectively.  Whether  constitutes  over  physicians'  error,  107 prescriptions  seemed  to  individual'analgesic however,  to  analgesics after use  suggest or  i f  writing  their  aries  that  the  considered  i n i t i a l  own j u d g e m e n t  PRN p r e s c r i p t i o n .  indicate  the  effectiveness  why  certain  ication  about  and  absence  the  of  of  the  support  health  care  team does  pain.  to  the  either  may h a v e  of  data  about  accept  Individuals  and  about  It  the  would  seem  appear  selection  management  of  measures  6.  At  this  agers  of  would  seem i m p o r t a n t  be  a patient's  reflected  ficulties Nurses  in  with  to  must  inherent  in  practice  and  outline pain in  written  certain  regimes  would  enhance p a i n  point  in  pain. for  written its  that  the  time, If  have  themselves  assessment research  Pain  were  and  its  studies.  and  usage  its  the  of  the  management appeared  maximum  analgesic  thesis for  for  communication and  about  management appear  accept  this of  a  the  this  emphasized  to  of  a  and  not .  rationales,  be  the  of  patient.  the  area  primary  of  man-  in  this  the  to dif-  study.  the  difficulties  both  accountable  it  practice  phenomenon;  treatment, be  the  individual  disciplines  subsequent  that  responsibility,  complex  other  actions  effectiveness  for to  commun-  any  (1977)  about  for  disciplines  isolation  the  other  of  management  in  to  rationales  of  to  bound-  any  lack  effectiveness  pain  Failure  the  This  be working  is  or  between h e a l t h  Strauss'  of  or  given.  the  been  communication,  the or  subjects'  The n u r s e s  been used  accountability  measurement for  given  nurses  nurses  records.  the  nothing recorded, however,  accountability  c o n s i s t e n t l y f o c u s s i n g on t h e management patients.  pain  within  p a i n management  Fagerhaugh  not  the  for  orders.  drug,  analgesics  recorded  offers  patients'  T h e r e was  that  expectations  taken  patient's  of  techniques  dosages  the  giving  the  management  expectations  post-operative  in  considering  T h e r e was no w r i t t e n  physicians'  of  pain  they were  requirements.  they  the  imply  in  for  daily this  108 area  of  practice  pain  management  may for  result  in  others  suggestions 1.  is  PRN i n  meant  nurses  think  and  what  in  of  the  for  research clarify  about expect  and  responsibility  of  include  the  analgesic terms  about  this  the  they  drug  usage  of  what  direct  PRN,  usage when of  of  study,  following:  An e x p l o r a t i o n  usage when  in  Research  implications  expectations  analgesic  meant  Further  findings  p a i n management.  about  is  the  of  physicians of  what  a PRN o r d e r  usage  drugs  is  may s h o w  outlined  differences  expectations.  for  A study  pain  perceives  in  management.  complement  the If  the  3. the  would 4.  decision useful  in  surgery  and how  period  a predictive  the  pain  management  to  determine  analgesics  be  useful  and  influence  may p r o v i d e factor  that  techniques  in  what  factors  prescribed explaining  determine  an a n a l g e s i c  analyzing  expectations the  guidance could  could  a  be  patient  pain in  he  his  pain  established  be designed  to  expectations.  of  to  the  pre-operatively  is  patient's  give  if  there  A study  to  determine  post-operative  A study  amounts  settings  to  following  pre-operatively,  in  to  patients  2. has  of  further  A study  prescribed think  basis  for  over  patients.  Suggestions  On t h e  taking  what  subsequently  and g i v e n these  factors  and w h a t in  account in  for  the  different  differences hospital  differences. the  nurse  influences  her  teaching  pain  considers  decision  in  would  management  her be  with  analgesics. 5.  A study  to  examine  if  analgesics  are  indeed  given  on t h e  hour  or h a l f - h o u r  e x a c t l y o r simply recorded as h a v i n g been g i v e n  times would e x p l a i n t h a t f i n d i n g i n t h i s study. the  factors responsible  a t those  I f the former i s t r u e ,  f o r t h i s t r e n d needs e x p l o r a t i o n .  I f the l a t t e r  i s t r u e , t h e l e g a l r a m i f i c a t i o n s f o r nurses i n r e c o r d i n g i n a c c u r a t e  times  needs emphasis. 6.  The Jacox t o o l appeared t o have v a l i d i t y  s i s t e n c y w i t h t h e v e r b a l data. the  A f u r t h e r study s p e c i f i c  t o o l compared w i t h responses to more indepth  i t s usefulness 7.  as a p a i n measurement  Further  i n l i g h t of i t s con t o the use o f  i n t e r v i e w s may enhance  tool.  s t u d i e s , l i k e t h a t done by Jacox (1979) , t o deter—,  mine semantic anchorage p o i n t s by which d i s t r e s s and p a i n s e n s a t i o n s can be measured and t h e words used commonly understood by a l l i n v o l v e d may be u s e f u l i n a s s i s t i n g nurses t o assess p a i n i n p r a c t i c e and i n a s s i s t ing researchers 8. 624),  to measure p a i n more o b j e c t i v e l y .  Some a u t h o r s , f o r example, G j e s s l i n g and T o m l i n (1979, p.  Ryan and C l a y t o n  (1980, p. 160) and S t a p l e t o n ,  (1979) suggest t h a t a n a l g e s i c s must be a d m i n i s t e r e d to e f f e c t i v e l y c o n t r o l p a i n .  A u s t i n and Mather on a r e g u l a r  T h i s approach was n o t seen as a p r a c t i c e  i n t h i s study; t h e s u b j e c t s who d i d r e c e i v e more r e g u l a r although a t longer  analgesic,  i n t e r v a l s than the a c t i o n o f t h e drug, were n o t d i s -  t i n g u i s h a b l e from those who r e c e i v e d  irregularily  timed a n a l g e s i c s .  c o n t r o l l e d study comparing two groups, one which r e c e i v e d  regular  g e s i c s and one which d i d not, may be u s e f u l i n c l a r i f y i n g  this  ence between t h e l i t e r a t u r e and the f i n d i n g s of t h i s 9. mal  basis  A  anal-  differ-  study.  A c o n t r o l l e d study to determine the e f f e c t o f r e c e i v i n g o p t i  dosage amounts of a n a l g e s i c s  s m a l l dosage amounts may p r o v i d e immediate p o s t - o p e r a t i v e  period.  i n the P.A.R.R. compared to r e c e i v i n g guidance to p a i n management i n t h e  110 Conclusion  This given  to  study  a select  has  described  group  emphasized  variability  analgesics  given.  of  patients  both  analgesic  The r e a s o n s  for  this  the  effectiveness  of  when  nurses to  taken by  nurses  the  reflected lack  of the  pain  the  the  in  the  difficulties  patients'  relationship pain  of  pain  pain  The  between  the  suggests  of  about  initial  and  pre-  PRN-ordered  analgesic  accountability  and  evaluating not  experience.  of  their  The  previous  pain  the  reflected.  descriptions  data  physical  literature collection  measurement.  amounts there  or  notations  subjective  complexities  the  explored;  pain  the  of  with  of  the  t a k e n was  consistent  experiences  the  evidence  the  pain.  than  those  findings and  their  physician  summational  of  were  and  but  measures  individuality described  the use  The  were not  about  other  assessing  patients'  post-operative  an obvious  of  are  The  analgesic no  easy  received  answers  to  management. 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Controlled comparisons fourteen preparations in the r e l i e f of postB r i t i s h Medical Journal 3:287-90.  of  Moss, F a y , and M e y e r , B u r t o n . 1966. The e f f e c t s o f n u r s i n g intervention upon p a i n r e l i e f i n p a t i e n t s . Nursing Research 1 5 : 4 : 3 0 3 - 6 . Nathan,  P.  Brain  1976.  The  gate-control  theory  of  pain  -  a critical  review.  99:123-58.  P a r k h o u s e , J . , L a m b r e c h t s , W . , a n d S i m p s o n , W. 1961. The i n c i d e n c e post-operative pain. B r i t i s h Journal of Anaesthesia 33:345-53. Parkhouse,  J.  Pflug,  and B o n i c a ,  A,,  operative  1975.  pain.  Drug J.  treatment 1977.  Archives  of  D.,  and H a n g l e r ,  methods.  Toronto:  B, J.  1978. B.  pain.  Anaesthesia  Physiopathology Surgery  P h i p p s , W. , L o n g , B , , a n d W o o d s , N . c o n c e p t s and c l i n i c a l p r a c t i c e . Polit,  of  and  30:338-45.  control  of  post-  112:773-81.  1979. Medical-surgical Toronto: C. V . M o s b y . Nursing  Lippincott.  of  research:  nursing  principles  and  -  116 Reville,  S.  et  al.  evaluating Rosen,  M. ,  Medical  Rosenberg, M., electrical Pain Ryan,  a linear  analogue  for  1979.  Relief  of  post-operative  pain.  6173:1278-9.  pain.  5:129-33,  Sheila,  and C l a y t o n , 2nd e d .  Dorthey.  Nursing Smith,  M.  Journal  of  31:1191-8,  C u r t i s , T . , a n d B o u r k e , D. 1978. Transcutaneous nerve stimulation f o r the r e l i e f of post-operative  pharmacology. Siegele,  Anaesthesia  and V i c k e r s ,  British  The r e l i a b i l i t y  1976.  pain.  J . ,  1974,  Bruce,  1980.  Toronto:  Handbook  C.  V.  The g a t e - c o n t r o l  of  practical  Mosby. theory.  American  Journal  and U t t i n g ,  Journal  J.  1976.  Post-operative  pain.  British  Medical  2:8 75.  S t a p l e t o n , J . , A u s t i n , K., and M a t h e r , L. 1979. approach to post-operative p a i n : continuous Anaesthetic  Intensive  Care  A pharmakinetic infusion of pethidine.  7:1:25-32.  Stewart, Mary. 1977. Measurement o f c l i n i c a l p a i n . In Pain: a book f o r nurses and o t h e r h e a l t h p r o f e s s i o n a l s , e d . A. Jacox, 107-38. Boston: L i t t l e , Brown and Company. Sweeney, Sanda. source book pp. 329-48. .  of  74:498-502.  1980.  Operating  source pp.  1977. Pain associated with surgery. In Pain: a f o r n u r s e s and o t h e r h e a l t h p r o f e s s i o n a l s , e d . A. J a c o x , Boston: L i t t l e , Brown and Company. O.R.  observations:  Room N u r s e s '  Taber, Clarence. 1977. C l a y t o n L. Thomas.  Journal  Taber's 13th ed.  key  to  post-operative  pain.  American  32:3:391-400.  cyclopedic medical Philadelphia: F.  Taylor, Jacqueline. 1977. Factors in the labelling Communicating Nursing Research 9:333-38.  dictionary, A. Davis.  ed.  process.  Thompson, D . , K r o g h , C . , and C y r , J . 1980. Compendium o f p h a r m a c e u t i c a l s and s p e c i a l i t i e s . Ottawa: Canadian Pharmaceutical A s s o c i a t i o n . Thorpe,  Constance,  current  trends  and C a p r i n i ,  Joseph.  and t r e a t m e n t s .  1980.  American  Gallbladder  Journal  of  disease:  Nursing  80:  2181-85. Utting,  J . ,  and S m i t h ,  Anaesthesia  J.  1979.  Post-operative  analgesia.  34:320-32,  Vaterlaus, E. 1979. A h o l i s t i c approach to nursing the patient i n pain. Canadian Nurse 75:6:22-25.  117 V e n t e r , C. 1977, South A f r i c a n W a l l , P. 1978. examination Wallace,  P.,  pain. Whitby,  and N o r r i s ,  Pamela.  Ronald,  Journal  The g a t e c o n t r o l and r e - s t a t e m e n t .  British  assessment. Wilson,  The p h a r m a c o l o g i c a l management Medical Journal 52:21-7.  of  W,  Journal  1978.  1975. of  and  of  a  re-  post-operative  47:113-20.  post-operative  pain  -  an  33:8:757-8.  Elmassian,  Nursing  The management  of  post-operative  of p a i n mechanism: 101:1-18.  Anaesthesia  The r e l i e f  Anaesthesia  theory Brain  of  Bonnie.  81:722-25.  1981.  Endorphins.  American  pain.  APPENDIX A  INTERVIEW GUIDE - PATIENT'S SUMMATIONAL DESCRIPTION  118  119 INTERVIEW GUIDE -  Patient  Number  Date  Ward  I.  Date  Open-Ended How h a v e  I I .  This to  you  felt  in  Surgery  Time  Surgery  Interview  Time  of  last  be  on a  you r a t e  Ended  Interview  24  hours?  asked v e r b a l l y .  The  scale  w i l l  be  shown  card. the  2  pain  that  you have  3  No Pain B.  the  will  subject  How w o u l d 1  of  DESCRIPTION  Questions  question  the  of  SUMMATIONAL  Question  Fixed-Alternative A.  PATIENT'S  Mild Pain  Moderate Pain  generally  felt  today?  4  Severe Pain  The i n s t r u c t i o n s f o r t h e l a s t p a r t o f t h e i n t e r v i e w w i l l be r e a d to the subject. The s t a t e m e n t s w i l l t h e n be shown on a c a r d , as w i l l the scale. The s u b j e c t w i l l i n d i c a t e b y p o i n t i n g o r v e r b a l l y t h e number s e l e c t e d . Directions:  Scale:  A number o f s t a t e m e n t s w h i c h p e o p l e have used t o d e s c r i b e t h e m s e l v e s w i l l be shown t o y o u . Point o r t e l l me t h e n u m b e r w h i c h i n d i c a t e s h o w y o u h a v e generally f e l t today. There a r e no r i g h t o r w r o n g answers. Do n o t s p e n d t o o m u c h t i m e o n a n y o n e s t a t e m e n t b u t g i v e t h e a n s w e r w h i c h seems t o describe your feelings best. 1  Not a t all  2  3  Sometimes  Most of t h e t ime  4  A l l of the time  120 Statements:  NOTE:  Part  I I  1.  I  feel  aching.  2.  My p a i n  3.  I  am f r e e  4.  I  have  5.  I  feel  tired.  6.  I  have  stabbing  7.  My b o d y  8.  The p a i n  sickening.  9.  It  to  is  depressing. of  pain.  annoying  is  hurts  move  My a b d o m e n  11.  I  12.  My b o d y  13.  I  have  14,  I  am n a u s e a t e d .  15.  I  feel  B Developed  by  sensations.  comfortable.  10.  feel  sensations.  hurts.  sharp  sensations.  feels  miserable.  pulsing  sensations.  depressed.  Ada  around.  Jacox.  APPENDIX B  CONSENT FORM FOR STUDY  121  CONSENT FORM  My n a m e i s Masters i n Columbia. discomfort  Lynette Best. I am a R e g i s t e r e d N u r s e a n d a s t u d e n t i n t h e the Science of Nursing program at the U n i v e r s i t y of British I am i n t e r e s t e d i n l e a r n i n g h o w p a t i e n t s d e s c r i b e their after having a g a l l bladder operation.  I w o u l d l i k e p e r m i s s i o n t o r e v i e w y o u r m e d i c a l c h a r t and t o interview you t w i c e . The f i r s t i n t e r v i e w w o u l d b e a p p r o x i m a t e l y 24 h o u r s a f t e r y o u r s u r g e r y ; t h e s e c o n d w o u l d t a k e p l a c e a b o u t 24 h o u r s l a t e r . These i n t e r v i e w s w i l l t a k e a b o u t 10 m i n u t e s . You w i l l be r e q u e s t e d t o : 1 ) a n s w e r a q u e s t i o n a b o u t how y o u h a v e f e l t t h a t d a y and 2) r e a d s t a t e m e n t s o n c a r d s a n d i n d i c a t e o n a s c a l e o f one t o f o u r how t h e s t a t e m e n t s d e s c r i b e how y o u h a v e g e n e r a l l y f e l t t h a t d a y . I w i l l tape record the interview. T h e t a p e r e c o r d i n g s w i l l b e f o r my u s e o n l y . Y o u w i l l n o t b e i d e n t i f i e d b y name i n t h e s t u d y . I t is anticipated that the findings from t h i s study w i l l provide i n f o r m a t i o n t o n u r s e s , t o h e l p them i n t h e i r management o f p a t i e n t s ' post-operative experiences. However, t h e r e w i l l be no d i r e c t benefit to you from t h i s study. A l t h o u g h y o u r p a r t i c i p a t i o n w o u l d be o f g r e a t v a l u e , you s h o u l d u n d e r s t a n d t h a t y o u may w i t h d r a w f r o m t h i s s t u d y a t a n y t i m e o r c h o o s e n o t to p a r t i c i p a t e without prejudicing your future care. I f you have any q u e s t i o n s c o n c e r n i n g t h i s a s k me. T h i s consent f o r m w i l l be p l a c e d  I  understand  the  nature  of  this  study,  and  study, please feel on your chart.  give  Date  Patient's  Investigator's  Signature  Signature  consent  to  free  to  participate.  APPENDIX C  DATA C O L L E C T I O N TOOL FOR A N A L G E S I C  123  RECORDING  124 DATA C O L L E C T I N G TOOL -  Patient  Number  Sex  Ward  Key:  FIRST  Date  Amount  -  Span -  time  Age  of  orders  Surgery  Weight  Time  Surgery  milligrams  span  in  minutes  2 4 HOURS P O S T - O P E R A T I V E L Y  Doctor's  ANALGESICS  for  meperidine  between  administrations  TIME:  hydrochloride:  Amount Frequency  For  other  Medications  Time  Given  medications:  Received:  Amount  Span  Other  Medications  Kg,  Ended  125  Patient  Number  SECOND 2 4 HOURS P O S T - O P E R A T I V E L Y  Doctor's  orders  for  meperedine  No c h a n g e  TIME:  hydrochloride: or  Amount Frequency  For  other  Medications  Time  Given  medications:  Received:  Amount  Span  Other  Medications  APPENDIX D  PERMISSION LETTER FOR USE OF JACOX PAIN CHECKLIST  126  APPENDIX E  AMOUNTS FIRST  (IN  MILLIGRAMS)  OF M E P E R I D I N E  4 8 HOURS A F T E R CHOLECYSTECTOMY HOSPITAL,  RECEIVED I N O U T L I N E D BY  SUBJECT AND DOSES  128  THE  AMOUNTS (IN MILLIGRAMS) OF MEPERIDINE RECEIVED IN THE FIRST- 48 HOURS AFTER CHOLECYSTECTOMY OUTLINED BY HOSPITAL, SUBJECT AND DOSES SUBJECT  II  SEX  AGE  WEIGHT (kg)  HOSPITAL A M 1 2 M F 4 M , 6 F , 7 8 F F 9 F . 11 12 F F 16 F 20 HOSPITAL B F 3 F 10 F 13 F 14 F 15 F 17 F 18 F 19 F 21 M 22 F 5  47 45 42 60 38 38 29 24 26 26 53  80 90 65 72 67 72 64 80 61 62 59  42 55 49 58 52 36 45 52 49 62 61  51 50 49 70 71 55 60 54 72 74 66  AMOUNT(mgm) ORDERED/DOSE •  50-75/ 75 75-100 50-75 100 50-100 75 75 75 100 75  75-100 50 75 5 0 x l 2 h r s ; 75-100 5 - x l 2 h r s ; 100 75 50-75 50-75 50-75 75-100 100  P.A.R.R. TOTAL I.V. |I.M. 20 10  -  10 15 10 5 10 10 12.5 20 B-2 B-2 B-2  . -  20 B-l B-2 B-2 20 B-l B-2  50  -  50  -  50 40  _  -  1  WARD - FIRST 24 HOURS | 2 | 3 | 4 | 5 | 6 [TOTAL  75 75- 75 75 75 75 75 75 75 75 75 75 50 75 75 75 75 75 75 100 100 100 75 75 75 100 100 75 75 75 75 75 75 75 75 75 75 75 75 75 75 75 50 100 100 100 75 75 75 75 75 75 75 75 50 50 75 75 50 50 50 50 75 75 75 75 75 75 50 50 75 75 100 100  75 50 75 50 75 75 50 75 50 75 75  75 50 75 75  -  75 75  _  75  75 75  -  -. _ _  _  _  _  -  _  -  225 425 300 350 450 475 375 425 415 500 450 300 200 375 225 175 225 200 225 150 300 350  1  WARD - SECOND 24 HOURS | 2 | 3 | 4 | 5 | 6 fTOTAL  (  1  1  f  1  _ 75 75 75 75 75 75 75 _ 75 75 75 75 _ _ 75 75 75 100 100 100 100 100 75 100 100 100 100 100 100 75 75 75 75 75 _ 75 75 75 75 75 _ 75 75 75 75 75 75 75 75 75 75 _ 75 75 75 75 75 75  75 75 50 50 75 75 75 75 75 100 75 75 50 65 75 75 50 50 75 75 75  50 50 50 75 50 75 75 50  50 75 75 50 _  -  •-  _  -  75  _  _  _  50 _  -  -  -  _  _  -  _ _  _  _ _  75  75  -  -  _  )  TOTAL 48 HOURS  300 225 300 225 575 600 375 375 375 375 450  525 650 600 575 1025 1075 750 800 790 875 900  250 150 350 300 325 225 190 200 100 300 75  550 350 725 525 500 450 390 425 250 600 425  The amount o f m e p e r i d i n e i s o u t l i n e d w i t h the e x c e p t i o n of the b u t o r p h a n o l (B) g i v e n i n t h e P.A.R.R. o f H o s p i t a l B, which i s a l s o o u t l i n e d .  to  APPENDIX  F  I N T E R V A L S ( I N M I N U T E S ) BETWEEN DOSES OF M E P E R I D I N E R E C E I V E D I N THE F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY SUMMARIZED FOR EACH H O S P I T A L AND SUBJECT  130  INTERVALS (IN MINUTES) BETWEEN DOSES OF MEPERIDINE RECEIVED IN THE FIRST 48 HOURS AFTER CHOLECYSTECTOMY SUMMARIZED FOR EACH HOSPITAL AND SUBJECT  SUBJECT //  FREQUENCY | ORDERED  FIRST 24 HOURS //OF DOSES | RANGE MEDIAN  MEAN  #OF DOSES  SECOND 24 HOURS | RANGE | MEDIAN  j MEAN  TOTAL 48 HOUR PERIOD #OF DOSES j RANGE MEDIAN  | MEAN  HOSPITAL A 1  120-240  3  240-460  350  350  4  240-435  277  308  7  240-460  277  322  2  240  6  238-315  240  258  3  240-390  300  310  9  238-390  248  277  4  180  4  240-450  240  310  4  225-690  278  368  8  225-690  225  343  6  180-240  5  210-450  247  290  3  315-660  360  445  8  210-660  255  356  7  180  5  210-390  225  270  6  230-250  240  240  11  210-390  240  252  8  180-240  6  210-270  243  242  6  225-345  255  264  11  210-345  250  253  9  180-240  5  180-390  270  278  5  210-540  310  343  10  180-540  310  310  11  240  6  193-280  230  234  5  270-375  315  317  11  193-375  280  275  12  240  6  67-330  240  223  5  240-420  240  288  11  67-420  240  256  16  180  6  200-260  250  240  5  210-345  290  291  11 .  200-345  255  266  20  240  6  225-240  240  237  6  225-270  240  245  12  225-270  240  241  240  4  270-360  300  310  4  275-465  373  371  8  270-465  340  345  10  240  4  240-330  320  297  3  435-735  480  550  7  240-735  383  423  13  180-240  5  235-275  267  259  5  255-325  315  288  10  235-325  275  275  HOSPITAL B 3  14  240  4  210-495  330  345  4  240-405  380  351  8  210-495  355  348  15  240  3  265-585  425  425  5  225-360  320  310  8  225-585  320  343  17  240  3  300-490  395  395  3  240-345  300  297  6  240-490  300  336  18  240  3  465-680  573  573  3  245-410  250  302  6  245-680  410  410  19  240  3  240-510  375  375  3  300-630  510  480  6  240-630  510  480  21  420  448  240^360  3  320-360  340  340  2  480-630  555  555  5  320-630  22  240  4  270-330  280  293  4  270-435  407  380  8  270-435  330  343  5  180-240  4  240-540  360  360  1  N/A  N/A  N/A  5  240-810  420  473  APPENDIX G  D I S T R I B U T I O N OF SUBJECTS SHOWING HOW EACH STATEMENT OF THE J A C O X ' S C A L E WAS ANSWERED FOR EACH 2 4 - H O U R P E R I O D A F T E R CHOLECYSTECTOMY AND THE D I F F E R E N C E I N RESPONSE BETWEEN THE TWO DAYS (  132  D I S T R I B U T I O N OF SUBJECTS SHOWING HOW EACH STATEMENT OF THE JACOX SCALE WAS ANSWERED FOR EACH 2 4 - H O U R P E R I O D A F T E R CHOLECYSTECTOMY AND THE DIFFERENCE I N RESPONSE BETWEEN THE TWO DAYS  First Statement  Category 2 3  4  -2  -1  0  +1  +2  6  10  4  2  1  14  7  -  1  3  11  5  2  5  16  1  -  7  14  -  1  -  4  16  1  1  7  11  3  1  5  16  1  -  1  5  13  3  -  19  3  -  -  17  4  1  -  -  2  16  3  1  7  3  4  8  2  13  6  1  3  8  6  4  1  1  3  6  12  1  2  7  12  1  3  14  3  1  -  3  3  16  -  5  7  10  3  6  9  4  -  depressing  13  7  2  -  14  6  2  -  -  5  13  3  1  sickening  14  6  1  1  13  7  2  -  -  3  15  3  1  10  5  3  4  7  10  3  2  3  -  14  5  -  13  4  2  3  10  11  1  -  4  2  11  4  1  1  6  7  8  1  8  6  7  1  5  14  2  -  1  5  5  11  1  7  6  8  2  4  13  3  -  10  8  3  1  16  6  -  -  1  6  13  1  -  15  5  -  2  13  7  2  -  1  2  15  4  -  I  feel  sharp  I  have  pulsing  My p a i n The  pain  My b o d y I  have  sensations  of  move  * around  miserable  annoying  My b o d y  is  I  feel  tired  I  am  I  feel  Key  sensations  pain  is is  sensations  hurts  is  2 Days  1  stabbing  to  Between  4  have  hurts  Difference  3  I  My a b d o m e n  24 H o u r s •  ,2  aching  It  Second  -  Category  feel  am f r e e  Hours  1 I  I  24  sensations  comfortable  *  nauseated depressed  categories:  1 2  not at a l l sometimes  3  most  4  all  of of  the the  * Scores time time  are  reversed  for  these  two  statements.  APPENDIX H  M E D I C A T I O N S , OTHER THAN M E P E R I D I N E AND BUTORPHANOL, PRESCRIBED A N D ' G I V E N TO SUBJECTS I N THE F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY  134  M E D I C A T I O N S , OTHER THAN M E P E R I D I N E AND BUTORPHANOL, P R E S C R I B E D AND G I V E N TO SUBJECTS I N THE F I R S T 4 8 HOURS A F T E R CHOLECYSTECTOMY  The p u r p o s e given  to  subjects  medications noted  jects  in in  the  this this  this  the  prescribed  during  sented  in  of  first  and  course  the  although  anaesthetists stated tion  the  for  in  nine  although  one  of  order  after  subjects  study;  Relevant  the  and  to  to  were  the  prescribed  in  this  time of  period  their  were  were  use  given  is to  presub-  P.A.R.R.  were  (seeTable  ordered H-l) .  a frequency  immediate  action  No  of  by  by  the  orders  administra-  use  of  the  term  "stat." Two in  the  mgm. and  subjects  P.A.R.R.  I.V., only  both one  received  Both were received  subject  at  medications  in  Hospital  both  the medication  had had  a recorded  A,  addition  to  received  prior  to  order  for  analgesics Atropine  analgesic this  and  Other  prescribed.  analgesics,  suggested  prescribed  cholecystectomy.  medications  22 s u b j e c t s  none  analgesics  a description  a variety  addition  PRN a p p r o a c h  to  review  Few a d d i t i o n a l  Findings  Medications,  to  48 h o u r s  given  of  appendix. study  s t u d y was  being  0.3 given  medication.  136 TABLE Distribution Other  of  Subjects  than Analgesics  H-l  Showing P r e s c r i p t i o n s Ordered  in  Medication Ordered  Dosage and R o u t e Ordered  di-Hyoscyamine (Atropine)  0.3  Thiethylperazine Maleate (Torecan)  5-10  mgm.  I.V.  mgm.  the  stat  2 1/2 5 mgm. 5-10  I.V,  I.V.  mgm.  I.M.  Total  Findings  A.  for  use  in  the  Relevant to  directly  were  changes  lines  the  medications  post-operative  written no  of  after made  ordered  to  the the  in  the  surgery, orders  medications:  addition  period  the  under all  in  Number a t Hospital B  Total Subjects  1  4  -  4  1  -  1  -  1  1  -  1  1  1  -  1  8  1  9  Ward  Medications other than Meperidine Ordered f o r i n t h e F i r s t 48 H o u r s a f t e r Cholecystectomy A variety  Hospital  1  I.M.  mgm.  Medications  and  Number a t Hospital A  10 mgm. Diazepam (Valium)  for  P.A.R.R,  meperidine  review.  were  the  to  All  were  orders  PRN p r e s c r i p t i o n s  48-hour  dosages  Use  period.  prescribed  are  ordered were and  TableH-2 not  there out-  specified.  TABLE  H-2  D i s t r i b u t i o n of P r e s c r i p t i o n s f o r Medications, Excluding M e p e r i d i n e , F o r Use F o l l o w i n g C h o l e c y s t e c t o m y and H o s p i t a l  Type Antiemetic  Generic  Ordered Name  Name  Dimenhydrinate  Number a t Hospital A  Dramamine Gravol  8  AntiemeticAntianxiety  Prochlorperazine  Stematil  1  Antihistaminic  Promethazine  Phenergan  4  Anxioltic-sedative Muscle r e l a x a n t  Diazepam  Valium  3  Analgesicantipyretic  Acetamininophen Codeine  with Tylenol  #3  1  292  1  Number  at  Hospital  10  Total B  Prescriptions  18  1 1  5  3  _  1  A.S.A. Caffeine Codeine  Frosst  Analgesic  Anileridine  Leritine  2  -  2  Sedative-hypnotic  Secobarbitol  Seconal  2  -  2  Hypnotic  Amobarbitol Secobarbitol  Tuinal  1  F l u r a z e p a m HC1  Dalmane  1  -  24  11  Total  sodium  1  sodium 1  35  138 B.  Medications, other than Meperidine, Given F i r s t 48 H o u r s a f t e r Cholecystectomy Fifty-five  dine,  were  given  meperidine. f i r s t the  At  24 h o u r s  second  doses  to  15  and  in  the  first  given  in  the  second  At  24  principal Gravol),  meperidine. did  not  I.M.  the  The  indicate  In  given  to  six  eight  of  to  medication  to  nine  the  other  Second Total  24 24 48  doses for  with  given  the  13  medication  Number of Subjects  Hours  hours.  Hours  five  in  the  subjects to  in  six  subwas  dimenhydrinate  of  the  meperidine;  (87.5%) subjects  was  25  given  were  its  subjects  doses  the  its  All given  second  administered  who r e c e i v e d or  usage.  24  with  dimenhydrinate  effect.  H-3  A  Dimenhydrinate and H o s p i t a l  Hospital  Number of Doses  5  6  7  29  also  29  in  Number of Subjects  B  received  Total  Number of Doses  23  Hours  All 24  the  subjects  given  g i v e n was  24 h o u r s ,  concurrently  eight  the  first  Hospital  First  meperi-  than meperidine  D i s t r i b u t i o n o f S u b j e c t s and Doses S h o w i n g Use o f i n t h e F i r s t 48 H o u r s F o l l o w i n g C h o l e c y s t e c t o m y  Frame  I.M. only  same  T a b l e H-3 o u t l i n e s  TABLE  Time  the  received  doses were  and n o o m e d i c a t i o n  the  charting why  B,  an a n t i e m e t i c .  administered of  Hospital  additional  (86%)  seven  given  addition  subjects  were  the  hours.  given  hours,  33 d o s e s  24 h o u r s  doses were were  A,  in  Seven  14 doses w e r e  jects  (Dramamine,  medication,  subjects.  Hospital  24 h o u r s .  The  of  In  Numb e r of Subjects  8  8  Dimenhydrinate  in  the  Group Numb e r of Doses  13  31  5  6  13  37  first  139 Eighteen at  Hospital -  doses  A over  at  48-hour sodium  2200  subjects  three  given  I.M.;  two  three  oral  doses  days were  promethazine  medications period.  first  were  the  24-hour  first  orally. of  given  Two  the  separately  sedative  from  settling  time  (approximately  received  a second  dose  later.  period, time,  two  subjects  combined w i t h  of  I.M.  one  doses  subjects day.  All  subject  relaxant were  received doses  on  three  sub-  meperidine.  2200).  In  the  to One  doses were  meperidine.  received  to  and muscle  an a n t i h i s t a m i n e  at  a dose  included:  Three  same  second  All  subjects  period.  the  the  HC1 ( P h e n e r g a n ) ,  seven  given  24 h o u r s .  of  drug  to  sedative-hynotic  an a n x i o l y t i c , in  given  Medications  (Seconal),  the  to  combined w i t h  subject  given  second  promethazine  IvM. 24-hour  at  settling  meperidine.  Comparison of M e d i c a t i o n s , other than Meperidine, Given and t h e P h y s i c i a n ' s Prescriptions T a b l e H-4 shows  the  in  (Valium),  jects  C.  other  diazepam  both -  the  secobarbitol orally  -  of  doctor's  medications,  the  prescription. 20 w e r e  given  comparison Of at  the least  of  medications  35 p r e s c r i p t i o n s once d u r i n g  the  received for  with  additional  48-hour  period.  TABLE  H-4  D i s t r i b u t i o n o f P r e s c r i p t i o n s Showing Those Ordered and Those G i v e n t o S u b j e c t s i n t h e 48 H o u r s on t h e Ward a f t e r C h o l e c y s t e c t o m y and H o s p i t a l  Hospital Number Prescribed  Medication  A  Number Given  Hospital Number Prescribed  B  Number Given  Total  Prescriptions  Number Prescribed  Number Given  13  Dimenhydrinate  8  7  10  6  18  Prochlorperazine  1  -  -  -  1  Promethazine  4  3  3  3  -  -  3  1  -  -  -  1  Codeine  1  -  -  -  1  -  Anileridine  1  -  -  -  2  -  2  1  -  -  2  1  1  -  -  -  1  2 41  14  1-1  6  3 51  HC1  Diazepam  1  -  5  3 3  Acetaminophene with  Codeine  ASA-Caffeine-  Secobarbitol Sodium Amobarbitol Sodium F lout raalz e p a m H C 1 T  20  

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