A STUDY TO ASSESS THE POSTOPERATIVE PAIN AND ITS MANAGEMENT AMONG

PATIENTS UNDERGOING CRANIOTOMY

PROJECT REPORT

Submitted in partial fulfillment of the requirements

For the

DIPLOMA IN NEURONURSING

Submitted by

RIKKU MATHEW

Code No: 6065

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY,

TRIVANDRUM. NOVEMBER 2010

CERTIFICATE FROM SUPERVISORY GUIDE

This is to certify that Miss. RIKKU MATHEW has completed the project

work on" A STUDY TO ASSESS THE POST OPERATIVE PAIN AND

ITS MANAGEMENT AMONG PATIENTS UNDERGOING

CRANIOTOMY " in the Neuro Surgical Unit at SCTIMST, Trivandrum

under my direct supervision and guidance for the partial fulfillment for the

Diploma in Neuro Nursing in the university of Sree Chitra Tirunal Institute for

Medical Sciences and Technology. It is also certified that no part of this report

has been included in any other thesis for procuring any other degree by the

candidate.

Trivandrum,

November 2010.

Dr Saramma P. P 9 MN, PhD

Senior Lecturer in Nursing

SCTIMST

Trivandrum-695011.

CERTIFICATE FROM THE CANDIDATE

This is to certify that the project :report on "A STUDY TO ASSESS THE

POST OPERATIVE PAIN AND ITS MANAGEMENT AMONG

PATIENTS UNDERGOING CRANIOTOMY" in the NeuroSurgical Unit

at SCTIMST, Trivandrum is a genuine work done by me under the guidance

of Dr.Saramma.P.P, MN, PhD, Senior Lecturer in Nursing, SCTIMST,

Trivandrum. It is also certified that this work has not been presented

previously to any University for award of degree, diploma, fellowship or

other recognition.

Trivandrum,

November 2010.

/

Ms. Ril<ku Mathew

Code No: 6065

Sree Chitra Tirunal Institute for

Medical Sciences and Technology,

Trivandrum- 695011.

APPROVAL SHEET

This is to certify that Miss. RIKKU MATHEW bearing Roll No .. 6065 has

been admitted to the Diploma in Neuro Nursing in January 2010 and she has

undertaken the project entitled "A STUDY TO ASSESS THE POST

OPERATIVE PAIN AND ITS MANAGEMENT AMONG PATIENTS

UNDERGOING CRANIOTOMY" in Neuro Surgical Unit of SCTIMST,

Trivandrum, which is approved for the Diploma in Neuro Nursing, awarded

by Sree Chitra Tirunal Institute for Medical Sciences and Technology,

Trivandrum, as it is found satisfactory.

/ EXAMINERS:

(1) ____ _

(2)

GUIDES:

(1) ____ _

(2) ____ _

Place:

Date:

ACKNOWLEDGEMENT

First of all let me thank God Almighty, who accompanied and provided

une~ding love, care, blessing and directed me to achieve success throughout

the tenure of this study.

The present study has been completed under the expert guidance of

Dr.Saramma P.P, Senior Lecturer in Nursing, Sree Chitra Tirunal Institute for

Medical Sciences and Technology, Trivandrum. I express my sincere

gratitude for the valuable guidance and encouragement given from the

inception to the completion of the study. Her advices regarding the concept,

basic guidelines and analysis of data were very much encouraging. Her

contributions and suggestions have been of great help for which I am

extremely grateful.

The researcher expresses her sincere thanks to Dr.K.Radhakrishnan, Director

and Dr.A.V.George, Registrar, SCTIMST, Trivandrum, for giving this

opportunity for conducting this study.

The researcher greatly values the favor extended by Prof. Suresh Nair, Head

of the Department ofNeuro Surgery, SCTIMST, Trivandrum.

With profound sentiments and gratitude I acknowledge the encouragement and

help received from the following persons for the successful completion of the

study.

I am thankful to Mrs. Sudarsa.S (NSICU) and Mrs. Saramma Antony (NSW)

Ward Sisters for the constant support and encouragement. All the staff in the

neurosurgery unit, helped for completion of this study I am indebted to them.

I thank all my friends and colleagues who directly or indirectly supported me

in completing this study. ~

Special thanks to computer division and library staff of SCTIMST for granting

permission to utilize the computer and library.

I would also like to acknowledge the contribution of all participants who

kindly agreed to take part in the study and generously gave their time and

attention to the research. This study would have been impossible without such

generosity.

Rikku Mathew

ABSTRACT

Topic: A study to assess the post operative pain and its management among

patients undergoing craniotomy. Background: Assessment and management

of patients' pain across practice settings have recently received the increased

attention of care providers, patients, and their families. Scientific advances in

understanding pain mechanisms, pain assessment and analgesic have

improved pain management practices. However, pain assessment and

management for critical care patients, especially those with communication

barriers, continue to present challenges to clinicians and researchers. Aim:

The objectives of the study were to assess the level of pain suffered by the

patient after craniotomy during hospitalization and to fmd out association

between pain score of patients after. craniotomy and selected variables.

Method: This study was conducted in the Neuro surgery Intensive Care Unit

and Neuro surgery Wards of Sree Chitra Tirunal Institute for Medical Sciences

and Technology, Trivandrum. Forty patients after craniotomy were

purposively selected for this study. Wong Bakers Faces Pain Rating Scale and

a validated questionnaire to assess the level of pain and the effectiveness of

pain management.were used as the tools for the study. Results: The data was

analyzed by using Epi Info.Version 3.5.1. Most of the patients pain gradually

decreased from first post operative day to third post operative day and pain

relief from pain medications was adequate. The usage of analgesics also

decreased from first to third post operative day. This study revealed that there

was no significant difference between gender and age of the patient on pain

perception. The pain intensity was increased during dressing. This study also

revealed that the Wong Bakers Faces Pain Rating Scale could be used as an

easy tool to assess post operative pain. Daily pain assessment by using pain

scale was feasible and valuable. Conclusion: The postoperative pain in

craniotomy patients gradually decreased from first to third day and pain

medications provided were adequate for pain relief. Studies using more

sample size may be useful to validate fmdings.

I

I CONTENTS

CHAPTER TITLE PAGE NO NO

I INTRODUCTION 1-22

II REVIEW OF LITERATURE 23-36

III METHODOLOGY 37-41

N ANALYSIS AND INTERPRETATION OF 42-55

DATA /

v SUMMARY, CONCLUSION, DISCUSSION 56-61

AND RECOMMENDATIONS

VI REFERENCES 62-66

VII APPENDIX

' J

I TABLE OF CONTENTS

NO CONTENTS PAGE NO

I INTRODUCTION

1.1 Introduction 1

1.2 Background of the study 8

1.3 Need and significance of the study 16

1.4 Statement of the problem 18

1.5 Objectives of the study 19

1.6 Operational definitions 19

1.7 Research methodology 24

1.8 Tool preparation 21

1.9 Delimitations 21

1.10 Summary 22

1.11 Organization of the report 22

II REVIEW OF LITERATURE

2.1 Introduction 23

2.2 Studies related to pain assessment and validation of 24

pain observation tool.

2.3 Studies related to pain assessment and management 28

outcomes

1 J

I 2.4 Summary 35

III METHODOLOGY

3.1 Introduction 37

3.2 Objectives of the study 37

3.3 Research approach 38

3.4 Setting of the study 38

3.5 Study population 38

3.6 Sample and sampling techniques 38

3.7 Inclusion criteria 39

3.8 Exclusion criteria 39

3.9 Development of the tool 39

3.10 Description of the tool 40

3.11 Pilot study 40

3.12 Data collection 41

3.13 Plan of analysis 41

3.14 Summary 41

IV ANALYSIS AND INTERPRETATION .

4.1 Introduction 42

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I I ll

4.2

4.3

4.4

4.5

v

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

Distribution of sample according to demographic 43

data

Distribution of sample according to selected 45

variables

Association between mean post operative pain score 52

and selected variables

Summary 55

SUMMARY, CONCLUSION, DISCUSSION

AND RECOMMENDATIONS

Introduction 56

Summary 56

Objectives of the study 57

Limitations 57

Major findings of the study 58

Discussion 59

Recommendations 60

Conclusion 60

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I LIST OF TABLES

TABLE CONTENTS PAGE NO NO

Adverse effects of post operative pain . . m vanous

1.1 systems 4

2.1 Key words used for review of literature 36

4.1 Distribution of sample according to age category 43

4.2 Distribution of sample according to sex 44

. 4.3 Distribution of sample according to type of surgery 45 Distribution of sample according to activity that

4.4 caused maximum pain 46 Distribution of sample according to alleviating factors

4.5 of pain 47 Distribution of sample according to severity of pain in

4.6 the post operative days 48 Distribution of sample according to analgesics used in

4.7 the first post operative day 49 Distribution of sample according to analgesics used in

4.8 the second post operative day 50 Distribution of sample according to analgesics used in

4.9 the third post operative day 51 Mean, Standard deviation and p value of pain score in

4.10 first post operative day by age category 52 Mean, Standard deviation and p value of pain score in

4.11 first post operative day by sex 53 Mean, Standard deviation and p value of pain score in

4.12 first post operative day by type of surgery 53 Mean, Standard deviation and p value of pain score of

4.13 first post operative day and second post operative day 54 Mean, Standard deviation and p value of pain score of

4.14 second post operative day and third post operative 55 day

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I LIST OF FIGURES

FIGURE CONTENTS PAGE NO NO

Bar diagram showing distribution of sample 4.1 according to age category 43

Pie diagram showing distribution of sample 4.2 according to sex 44

Pie diagram showing distribution of sample 4.3 according to type of surgery 45

Bar diagram showing distribution of sample 4.4 according to activity that caused maximum pain 46

Bar diagram showing distribution of sample 4.5 according to alleviating factors of pain 47

Bar diagram showing distribution of sample according to severity of pain in the post operative 48

4.6 days Bar diagram showing distribution of sample according to analgesics used in the first post 49

4.7 operative day Bar diagram showing distribution of sample according to analgesics used in the second post 50

4.8 operative day Bar diagram showing distribution of sample according to analgesics used in the third post 51

4.9 operative day

------------~~-~---~-----~~-

ABBREVIATIONS

ASP AN American Society of Peri Anaesthesia Nurses

JCAHO Joint Commission on Accreditation of Health Care

Organization

ICU Intensive Care Unit

IASP International Association for the Study of Pain

NSAIDs Non-Steroidal Anti Inflammatory Drugs

NSICU NeuroSurgical Intensive Care Unit

NSW NeuroSurgery Ward

NRS Numerical Rating Scale

POD Post Operative Days

PCA Patient Controlled Analgesia

VAS Visual Analogue Scale

· 1.1 Introduction

1

CHAPTER-1 INTRODUCTION

Pain can be defined as a neurologic response to unpleasant stimuli. Pain is

derived from the Latin Word "poena" or penalty. Pain is an individual,

subjective and complex biopsychosocial process whose existence cannot be .

proved or disproved. Unrelieved pain is a major psychologic and physiologic

stress for patients. (Dewit, 2009).

Craniotomy is an operation that involves the opening of the cranium and

removing tm)lOr or diseased portion . This helps to provide access to the brain.

The term craniotomy is derived from Latin words cranium (head) and otomy

(act of cutting). The following are the indications for craniotomy - Brain

tumors, bleeding, blood clots, weakness of blood vessels, and abnormal blood

vessels. (Hickey, 2003).

For scientific and clinical purposes, pain is defined by the International

Association for the Study of Pain (IASP) as "an unpleasant sensory and

emotional experience associated with actual or potential tissue damage, or

describe in terms of such damage" (IASP, 1979, as cited in Mactinyre, 2002).

-···-······-··-···-··--~·--·--·--·~·---

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2

I In medicine, pain is considered as highly subjective. Margo McCaffery gave a

definition that is widely used in nursing as early as 1968: "Pain is whatever

the experiencing person says it is, existing whenever he says it does". The

patient is the best authority on the existence of pain. Therefore validation of

existence of pain is based on the patient's report that it exists. Pain is one of

the most common experience and stressors in patients. Pain management has

become a national priority in recent years (St. Marie, 2002).

Most reliable indicator of pain is the patient's self report. Pain is a subjective

experience; only the patient knows the location of the pain and its degree of

intensity. Pain is a major symptom in many medical conditions, significantly

interfering with a person's quality of life and general functioning. It is

probably the most common compelling reason why a person seeks medical

assistance. (Dewit, 2009).

Assessment of pain is a critical step to providing good pain management. A

pain assessment should include a detailed history of physical examination,

psychological assessment and diagnostic evaluation. Diagnosis is based on

characterizing pain in various ways, according to duration, intensity, type

(dull, burning, throbbing or stabing), source or location in body. "Pain is

described by the person experiencing it; it doesn't have to be diagnosed any

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3

I other way"(Puntillo, 1995, as cited in Dewit, 2009). Usually pam stops

without treatment or responds to simple measures such as resting or taking an

analgesic and it is then called "acute pain" But it may also become intractable

and develop into a condition called "chronic pain", in which pain is no longer

considered a symptom but an illness by itself. (Dewit, 2009).

The study of pain has in recent years attracted many different fields such as

Pharmacology, Neurobiology, Nursing, Dentistry, Physiotherapy and

Psychology. Pain medicine is a separate sub specially figuring under some

medical specialities like Anaesthesiology, Physiatry, Neurology and

Psychiatry. Acute pain, which usually occurs in response to tissue injury,

results from activation of peripheral pain receptors and their specific A delta

and C sensory nerve fibers (nociceptors). Chronic pain related to ongoing

tissue injury is presumably caused by persistant activation of these fibers.

Chronic pain may also result from ongoing damage to or dysfunction of the

peripheral or central nervous system (which causes neuropathic pain). (Dewit,

2009).

Postoperative pain is a complex process influenced by both physiological and

psychological factors. Post operative pain can affect all organs systems

include as shown in Table 1.1.

4

Tablel.l Adverse effects of post operative pain in various systems

Systems Response

Respiratory system Reduced cough, atelectasis, sputum retention and hypoxemia

Tachycardia, hypertension, increased myocardial oxygen consumption and

Cardiovascular system ischemia

Gastro intestinal system Decreased gastric emptying, reduced gut motility and constipation

Genitourinary system Urinary retention

Neuroendocrine system Hyperglycemia, protein catabolism and sodium retention

Modified from:- Macintyre,PE., & Ready,L.B. (2002). Acute pain management (A Practical Guide)

Two pathophysiologic classification of pain are nociceptive and neuropathic

pain. Nociceptive pain may be somatic or visceral. Somatic pain receptors are

located in skin, subcutaneous tissues, fascia, other connective tissues,

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I 5

periosteum, endosteum and joint capsules. Stimulation of these receptors

usually produces sharp or dull localized pain, but burning is not uncommon if

the skin or subcutaneous tissues are involved. Visceral pain receptors are

located in most viscera and the surrounding connective tissue. Visceral pain is

due to obstruction of a hollow organ, is poorly localized, deep and cramping

and may be referred to remote cutaneous sites. Visceral pain due to injury of

organ capsules or other deep connective tissues may be more localized and

sharp. Neuropathic pain is associated with a dysfunction of the nervous system

that involves an abnormality in the processing of sensations. These

dysfunctions in the nervous system are often associated with medical

· conditions rather than tissue damage. The dysfunction may occur in the

peripheral or central nervous system. In peripheral nervous system neuropathic

pain, it is believed that pain receptors become sensitive to stimuli and send

pain signals more easily. Another dysfunction of the central nervous system

occurs when the pain signal that would normally move from the periphery

toward the brain reverses and the signal is sent in the opposite direction. ( eg:

phantom limb). (Dewit, 2009).

Pain is the fifth vital sign. Pain that is assessed at regular intervals and treated

with the same zeal as abnormalities in other vital signs has a much better

chance of being treated effectively (Campbell, 1995, as cited in Smeltzer,

6

2004 ). Patients have the right to effective pain management and every effort

should be made to include analgesia in the treatment plan. Effective pain

management is not just a matter of giving the right medicine at right time. It is

a combination of pharmacologic and non-pharmacologic approaches that

together give the individual the greatest possible degree of comfort for the

longest possible time. (Dewit, 2009).

The Joint Commission of the accreditation of health care organization also

mandates pain assessment and management. Despite a growing trend in acute

pain management, many deficiencies still account for the high incidence of

moderate to severe postoperative pain to date. Patient nowadays continues to

receive inadequate doses of analgesics, but additionally the identification and

treatment of those patients with pain still remains a significant health care

problem. Advanced techniques are available including epidural or intrathecal

administration of local anaesthetics and opioids, various opioid administration

techniques such as patient-controlled analgesia and infusions via sublingual,

oral-transmucosal, nasal, intra-articular and rectal routes. Non-opioid

analgesics such as nonsteroidal anti-inflammatory drugs and newer non-opioid

drugs such as alpha2-adrenergic agonists, calcium channel antagonists and

various combinations of the above are possible. However the solution to the

problem of inadequate pain relief lies not so much in the development of

7

newer drugs and new techniques, but in the effective strategy of delivering

these to patients through the introduction of acute pain management services

on surgical wards. (Filos and Lehmann, 2007).

Post Surgical Pain is common and expected after surgery. Effective post

surgical pain management is associated with patient satisfaction, earlier

mobilization, shortened hospital stays, and reduced costs. Despite these

benefits, there are substantial numbers of patients who suffer from post

surgical pain. The goal of pain management following a surgical procedure is

to prevent and control pain. Post surgical pain is expected to be present

continuously during the first 24 to 48 hours after surgery, with spikes of

increased pain with movement, deep breathing and coughing, and ambulation.

Around-the-clock dosing is recommended during this early post surgical

period to prevent severe pain and control continuous pain. Post surgical pain

management should be multi-modal (use of a combination of pain cor..trol

strategies including opioids, nonsteroidal anti-inflammatory drugs (NSAIDS),

nonpharmacologic interventions) and designed for the particular patient,

operation, and circumstances. Pain management requires systematic patient

assessment post surgically, at scheduled intervals, in response to new pain, anq

prior to discharge. (Smeltzer, 2004).

8

Pain complaints should be evaluated with a complete history and physical

examination with laboratory and diagnostic tests when indicated. The most

critical aspect of pain assessment is that it be done on a regular basis using a

standard format. Standardized tools enable us to do this. Hospital, unit, or

clinic policies and procedures should explicitly direct a tool's assessment

parameters. To meet patients' needs, pain should be re-assessed after each

intervention to evaluate the effect and determine whether modification is

needed. The time frame for re-assessment also should be directed by hospital

or unit policies and procedures.

Poor pain management may put clinicians at risk for legal action. Current

standards for pain management, such as those outlined by The Joint

Commission, require that pain be promptly addressed and managed. There is

an increased risk of legal action against clinicians and institutions that have

poor pain management practices and there are instances of lawsuits filed

against physicians for poor pain management. Nurses and other practitioners

also may be liable for legal action.

1.2 Background of the study

Craniotomy is a neuro surgical procedure in which an opening is madder into

the cranium. The location and dimension of the opening will be decided

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I

9

according to the site and size of the lesion. Craniotomy can be classified into

two major categories supratentorial and infratentorial. Supratentorial

craniotomy involves brain structures above the tentorium including frontal

lobe, parietal lobe, temporal lobe and occipital lobe. Infratentorial craniotomy

involves the structures below the tentorium including, cerebellum and brain

stem. (Hickey, 2003).

Surgical procedures are characterized by incisional damage to skin and various

other tissues, application of thermal and chemical stimuli to wound and often-

prolonged traction and manipulation of somatic and visceral structures.

Nociceptive pain is often regarded as the key feature of acute postoperative

pain. Besides inflammatory, visceral and neuropathic pain other mechanisms

may contribute to pain occurring during the postoperative period (Chaturvedi,

2007).

There are four phases of pain associated with nociceptive pain (McCaffery and

Pasero, 1999, as cited in Dewit, 2009). Transduction is the first phase and

begins when the tissue damage the release of substances (prostaglandin's,

bradykinin, serotonin, substance p, histamine) that stimulate nociceptors and

initiate the sensation of pain. Transmission is the second phase and involves

movement of the pain sensation to the spinal cord. Perception, the third phase,

10

occur when impulses reach the brain and the pain is recognized (conscious

experience of pain). The fourth phase, Modulation, occurs when neurons in

the brain send signals back down the spinal cord by release of

neurotransmitters (eg: endogenous opioids) (Dewit, 2009).

Physiologic sources of acute postoperative pain are incisional pain, pain at

insertion sites of tubes and drains, wound complications, orthopedic

procedures, skeletal muscle tissue. Perception of pain varies widely from

person to person and in the same individual under different circumstances.

Pain threshold and pain tolerance are concepts that are used when discussing

the perception of pain. Pain threshold is the point at which pain is perceived.

Research indicates that the threshold of pain does not vary significantly among

people. Pain tolerance is the length of time or the intensity of time a person

will endure before outwardly responding to it Research indicates that the

tolerance varies among people. (Dewit, 2009).

Factors that affect pain tolerance include culture, pain experience, expectations

and role behaviours. Coping with pain takes a lot of energy, and patients who

are debilitated are less able to withstand pain than are strong, robust people.

Fatigue caused by pain can lead to an increase in pain perception. A person's

cultural.background influences feelings about pain. In much of western culture

11

it is considered valuable to have pain tolerance, particularly among men. Some

cultures allow free expressions of pain- moaning, crying and other actions are

considered appropriate. A nurse whose cultural background approves the "stiff

upper lip" approach to handling pain may see the patient who outwardly

expresses pain as weak or manipulative. Those patients whose cultural

upbringing causes them to hide and deny pain may suffer needlessly unless the

nurse can intervene by helping them to understand that analgesia will aid the

healing process by encouraging movement and decreasing fatigue. Learning to

accept without judgement the various ways of coping with and expressing pain

is a very necessary process for nurses. (Dewit, 2009).

Pain has been studied extensively for centuries and currently there are

recognized theories of pain transmission. The gate control theory of pain, put

forward by Ronald Melzack (a Canadian psychologist) and Patrick David Wall

(a British physician) in 1962, and again in 1965, is the idea that the perception

of physical pain is not a direct result of activation of nociceptors, but instead is

modulated by interaction between different neurons, both pain-transmitting

and non-pain- transmitting. The theory asserts that activation of nerves that do

not transmit pain signals can interfere with signals from pain fibers and inhibit

an individual's perception of pain. Both Specifity and Pattern theories are used

to help explain how different kinds of pain can occur. In short Specificity

12

theories consider pain as an independent sensation with specialized peripheral

sensory receptors [nociceptors], which respond to damage and send signals

through nerve fibers to target centers in the brain. These brain centres process

the signals to produce the experience of pain. This specificity theory has been

challenged by the theory, proposed initially in 1874 by Wilhelm Erb, that a

pain signal can be generated by stimulation of any sensory receptor, provided

the stimulation is intense enough: the pattern of stimulation (intensity over

time and area), not the receptor type, determines whether pain is felt. Alfred

Goldscheider (1894) proposed that stimulation might accumulate or

"summate" in the dorsal horns of the spinal cord and begins to signal pain

once a certain threshold has been crossed. (Smeltzer, 2004).

Even with improved and advanced surgical techniques, people still feel some

pain and discomfort after surgery, since even minor surgery causes swelling

and breakup of tissue. Everyone has a different pain threshold and re:tcts to

pain in an individual way. It is important for the patient to communicate with

the health care team for better control of postoperative pain. Some of the

patients, who undergo surgery under local or regional anaesthesia, may not

have pain for a while. Different surgical procedures cause different types of

pain. Postoperative pain can range from mild to intense, it can be throbbing,

burning and irritating. There are medications and relaxation techniques that

13

can help the patient to feel better. Pain will be assessed with the help of pain

scale where 0 means no pain and 10 is the worst pain possible. To relieve the

pain most effectively, the health care team needs to know how well pain relief

measures are working. Medications can be adjusted to meet the patient's

needs. It is most important to try to relax after surgical procedure. When the

patient is relaxed, pain medications work better. When the muscles aren't

tense, this decreases the amount of fear and anxiety signals sent to the brain.

The patient can position himself for comfort and ease of breathing. A pillow

can be placed against the incision site or to help support the injured area of the

patient body. Deep breathing can help relax tense muscles. Soft music can

help the patient to relax. Pain medication allows the patient to be up and

around more comfortably. Movement is easier when it doesn't hurt. This helps

healing and circulation and can prevent postoperative problems such as blood

clots and pneumonia. All this can add upto a shorter hospital stay.

Pain management is based on the surgery, medical history, and the amount of

pain the patient having and the phase of recovery. Initially, to help and relieve

immediate postoperative pain, medications may be given intravenously (IV) or

intramuscularly (IM). One popular IV method is called a Patient Controlled

Analgesia (PCA). This is a pain medication administration apparatus that is

connected to the patient's IV. The nurse will give the patient a button, which

14

narcotic is delivered with each use and the patient can only receive a certain

amount of medication each hour. It is important for the patient to

communicate with the health care team if the pain medication is not effective.

Adjustments can be made to PCA, IV or IM injections. As hospital stay nears

its end, the patient will probably be switched to oral pain medication. The

patient may also be given a prescription for pain relieving pills to take home.

(Smeltzer, 2004).

Many state and professional organizations have developed clinical practice

guidelines to direct health care providers in adequate management of acute

pain. The 1992 Acute Pain Clinical Practice Guideline 22 lays the foundation

for the more current guidelines. Listed below is a sample of current guidelines

available from the National Guideline Clearing House.

Pain Management Guideline; developed by the Health Care Association of

New Jersey; released July 2006. This guideline includes definitions of pain

(acute and chronic); clear direction for assessment and treatment with

pharmacological and non-pharmacological interventions (including physical

15

and occupational therapy); policies for pain education for staff, patients, and

families; and direction for quality monitoring. The guideline is applicable to

pain management in acute care and long term care nursing facilities.

(Hamilton, 2006).

"Pain Management'; written for the Second edition of Geriatric Nursing

Protocols for Best Practice; published in 2003. This guideline addresses pain

in the elderly, assessment strategies, and nursing interventions to control pain.

Pharmacological and non-pharmacological interventions are included in the

guideline. (Mezey, 2003).

ASP AN Pain and Comfort Clinical Guidelines; developed by American

Society of Perianaesthesia Nurses; released August 2003. This guideline

provides direction for assessment, interventions and expected outcomes for the

preoperative and postoperative phases of treatment. Use of pharmacological

and nonpharmacological interventions is endorsed. (Krenzischeck, 2003).

Pain is a worry for most people. But it 'is comforting to know that pain control

is an important part of patient recovery after surgery. Every effort is made to

minimize the pain; however, it is normal to experience some discomfort after

surgery.

16

1.3 Need and significance

Knowing enough information about pain and its management to adequately

care for people in pain may seem challenging. "Pain is a neurologic response

to unpleasant stimuli. Only the patient know where the pain is and its degree

of intensity "{Borum, as cited in Dewit, 2009).

Evaluation ofanother person's pain is a major challenge. Because, there is no

technology for accurate measurement, a combination of evaluation method is

used. The complete assessment of the person's pain should include

information about the location, characteristics, quantity and pattern of pain. In

addition, the assessment should include data concerning other symptom that

occur when the person js in pain, and what f&ctors aggravate the pain.

Effective pain management depends on regular assessment of the presence and

severity of pain and the patient's response to pain and what factors aggravate

the pain. (Dewit, 2009).

Pain management is considered an important part of care. Pain is considered

as the fifth vital sign to emphasis its significance and to increase awareness

among health care professionals of the importance of effective pain

management. The American Pain Society gives further by stating that it is "not

17

the responsibility of clients to prove they are in pain, it is the responsibility to I accept the clients report of pain" (2005). (Smeltzer, 2004).

Current thinking views "pain not as just a symptom, but as a specific problem

that needs to be treated" (Dewit, 2009). The real challenge for critical care

nurses is monitoring and assessing pain in patients who are not able to self-

report. Nurses caring for critically ill patients must be aware of potential

problems associated with pain management. Critically ill patients are

particularly vulnerable to pain, citing it as their greatest ICU stressor. Pain has

also been identified as a complicating factor in critical illness. Effective

management can only be achieved with accurate pain management. However,

this is difficult in the critically ill as patients are often unable to communicate

verbally due to the presence of ET /Tracheostomy tubes, sedation and

paralyzing agents. Nurses therefore relay on behavioural and physiological

indicators in establishing the presence of pain.

Pain perception is highly subjective, it is important for the health care team to

be aware of pain sensitivity differences in patient and to value patient self-

report as a reliable tool for pain assessment. Surgically related pain is

frequently described as aching in nature ordinarily near the surgical site. Post

surgical pain is a complex response to tissue trauma during surgery that

-- ----------~--------- -------------~--~-- --------------~

18

stimulates hypersensitivity of the central nervous system. The result is pain in

areas not directly affected by the surgical procedures. "The uncomplicated

post craniotomy patient typically has mild to moderate pain, is readily

managed by a short period of parenteral medications followed by oral

analgesics. Laminectomy and other spinal procedures usually are more painful

than craniotomies" (Hickey, 2003).

Pain management is often not considered priority by the ICU team. Pain

management needs to be an . integral part of an organizations quality

improvement programme. Systematic objective tools for pain assessment such

as Visual analogue scale, Graphic-rating scales, Numerical rating scale and

Wong Bakers Faces pain scale are not a part of clinical assessment in the

NSICU. An effective routine pain assessment and management is needed to

increase the ·level of nurses understanding regarding pain assessment and

management.

1.4 Statement of the problem

A study to assess the postoperative pain and its management among patients

undergoing craniotomy.

19

1.5 Objectives

• To assess the level of pain suffered by the patient after craniotomy

during hospitalization.

• To find out the association between pam score of patients after

craniotomy and selected variables.

1.6 Operational definitions

Pain assessment: Assessing the severity of post operative pam m

neurosurgical patients using Wong Bakers faces pain-rating scale. The.nature,

location, duration, aggravating factors are also assessed by using a pain impact

questionnaire.

Pain management: The measures tried to relieve pain such as medications,

certain positions, application of cold and distraction.

Wong Bakers Faces Pain Rating Scale: It combines pictures and numbers to

allow pain to be rated by the user. The faces range from a smiling face to a

sad, crying face. A numerical rating scale is assigned to each of the six faces.

Craniotomy: A craniotomy is a surgical operation in which a bone flap is

(temporarily) removed from the skull, to access the brain. A craniotomy is the

20

most commonly performed surgery for brain tumor removaL It may also be

done to remove a blood clot and control hemorrhage, inspect the brain,

perform a biopsy, or relieve pressure inside the skull.

Craniotomy patients: Patients who have undergone craniotomies such as

supratentorial tumor exc1s10n, aneurysm clipping and infratentorial tumor

exc1s10n.

Analgesics: Drug used to reduce pain such as diclofenac sodium, tramadol,

paracetamol.

1 .. 7 Research methodology

Setting : N euro Surgery Intensive Care Unit and

NeuroSurgery Wards in SCTIMST,

Trivandrum.

Population :Craniotomy patients in SCTIMST.

Sample size : 40

Sampling technique : Purposive sampling

21

1.8 Tool preparation

The first step in safely relieving pain is to ensure that patients are properly

assessed for pain so that appropriate pain relief measures can be implemented.

Otherwise, pain may go unnoticed by clinicians or may be under treated. Self­

report is the most reliable way to assess pain intensity. Only the patient can

accurately describe the pain. A number of pain assessment instruments have

been developed to assist in assessment of patient's perception of pain. The

Joint Commission developed pain standards for assessment and treatment

based upon the recommendations in the Acute Pain Clinical Practice

Guideline. The Joint Commission requires that hospitals select and use the

same pain assessment tools across all departments. This standard suggests

providing options among scales such as the Numerical Rating Scale (NRS),

Wong-Bakers Faces Pain Scale and a Verbal Descriptor Scale. Here Wong

Bakers Faces Pain Rating Scale along with thirteen questions to assess the

location, nature, intensity, aggravating and alleviating factors and the

effectiveness of pain management.

1.9 Delimitations

~ Patients who are speaking either Malayalam or English.

~ Study is limited to patients after craniotomy.

~ The sample size is limited to 40.

22

1.10 Summary

This chapter deals with introduction, background of the study, need and

significance of the study, statement of the problem, objectives, operational

definitions, research methodology and delimitations.

1.11 Organization of the report

Chapter 2 deals with the summary of related studies reviewed, chapter 3 deals

with the methodology of the study, chapter 4 contains analysis and

interpretation of findings and chapter 5 contains summary, conclusion,

limitation of the study and recommendations. This report also includes a

reference list and the tool used is given in appendix.

I

23

CHAPTER-2 REVIEW OF LITERATURE

2.1 Introduction

Review of literature can serve a number of important functions in the research

process. It is the critical summary of research on a topic of interest, often

prepared to put a research problem in context. Literature review helps to lay

the foundation for a study, and can also inspire new research ideas. It gives

character insight into the problem and helps in selecting methodology,

developing tool and also analyzing data. With these in view an intensive

review of literature has been done.

The review of literature relevant to this study is presented in the following

sections.

2.2 Studies related to pain assessment and validation of pain

observation tool.

2.3 Studies related to pain assessment and management outcomes.

I

24

2.2 Studies related to pain assessment and validation of pain observation tool

Vranic et al. (2010) conducted a study on patient satisfaction arid

documentation of pain assessments and management after implementing the

adult nonverbal pain scale. This study evaluated the effect of implementing a

new pain assessment tool in a trauma/neurosurgery intensive care unit. Staff

and patient satisfaction questionnaires and retrospective chart reviews were

used before and after implementation of the nonverbal pain scale. The

questionnaire responses, frequency of pain documentation, and amount of pain

medication given were compared from before to after implementation. Most

staff (78%) ranked the tool as easy to use. Implementation of the tool ·

increased staff confidence in assessing pain in nonverbal, sedated patients

(57% before vs 81% after implementation, P=.02) and increased the number of

pain assessments documented by the nursing staff for noncommunicative

patients per day in the intensive care unit (2.2 before vs 3.4 after, P=.02).

Patients reported decreased retrospective pain ratings (8.5 before vs 7.2 after,

P =.04) and a trend toward a decrease in the time required to receive pain

medication(38% before vs 10% after requiring>5 minutes to receive

medication, P=.06). Implementation of the Nonverbal Pain Scale in a critical

care setting improved patients' ratings of their pain experience, improved

25

documentation by nurses and increased nurses' confidence in assessing pain in

nonverbal patients.

Gelinas and Johnson (2007) conducted a study on pain assessment in the

critically ill ventilated adult to validate the critical -care pain observation tool

and physiologic indicators. A total of 30 conscious and 25 unconscious

patients in the intensive care unit participated in the study. Patients were

assessed by staff nurses and research team members before, during, and 20

minutes after the 2 following procedures: ( 1) nociceptive procedure: turning,

and (2) non-nociceptive procedure: taking noninvasive blood pressure (NIBP).

Conscious ventilated patients provided self-report level of pain. Inter-rater

reliability of the CPOT was supported with high intraclass correlation

coefficients (0.80 to 0.93). Discriminant validity was supported with increases

of the CPOT and physiologic indicators, and a decrease in Sp02 during

turning, but remaining stable during NIBP. Conscious patients had higher

CPOT scores during turning compared with unconscious patients. For criterion

validity, the CPOT scores were correlated to the patients' self-reports of pain,

whereas physiologic measures were not. Using a CPOT cutoff score of >3

yielded a sensitivity of 66.7% and a specificity of 83.3%. The CPOT is a

reliable and valid tool to assess pain in critically ill adults. Behavioral

indicators represent more valid information in pain assessment than

26

physiologic indicators. Further research is needed to explore how specific

critically ill populations ( eg, head injury) react to a painful procedure.

Ahlers et al. (2008) conducted a study on comparison of different pain scoring

systems in critically ill patients in a general ICU. They performed a study (a)

to determine the inter-rater reliability of the Numerical Rating Scale (NRS)

and the Behavioral Pain Scale (BPS), (b) to compare pain scores of different

observers and the patient, and (c) to compare NRS, BPS, and the Visual

Analog Scale (VAS) for measuring pain in patients in the ICU. They

performed a prospective observational study in 113 non-paralyzed critically ill

patients. Inter-rater reliability of the NRS and BPS proved to be adequate

(kappa= 0.71 and 0.67, respectively). The level of agreement within one scale

point between NRS rated by the patient and NRS scored by attending nurses

was 73%. However, high patient scores (NRS >or= 4) were underestimated

by nurses (patients 33% versus nurses 18% ). In responsive patients, a high

correlation between NRS and VAS was found (rs = 0.84, P < 0.001). In

ventilated patients, a ·moderate positive correlation was found between the

NRS and the BPS (rs = 0.55, P < 0.001). However, whereas 6% of the

observations were NRS of greater than or equal to 4, BPS scores were all very

low (median 3.0, range 3.0 to 5.0). The different scales show a high reliability,

but observer-based evaluation often underestimates the pain, particularly in the

27

case of high NRS values (> or = 4) rated by the patient. Therefore, whenever

this is possible, ICU patients should rate their pain. In unresponsive patients,

primarily the attending nurse involved in daily care should score the patient's

pain. In ventilated patients, the BPS should be used only in conjunction with

the NRS nurse to measure pain levels in the absence of painful stimuli.

Puntillo et al. (2002) conducted a study to describe the Pain Assessment and

Intervention Notation (P.A.I.N.) tool, a detail critical care nurse participants'

evaluations of the P.A.I.N. intervention tool when used during care of

postoperative patients in pain, and evaluate the tool's usefulness in practice

and education. Eleven intensive care unit (n = 7) and post anesthesia care unit

(n = 4) nurses completed a questionnaire after they had used the pain tool in

their clinical practices with 31 postoperative patients. Ten of the 11 nurses

who returned an evaluation questionnaire found that the P.A.I.N. tool provided

a consistent, systematic method of quantifying their assessment of patient pain

and analgesic responsiveness. Five nurse participants believed that the

P.A.I.N. tool improved their practice with regard to pain and sedation

assessment. Three of the 11 nurses believed that the usefulness of the tool was

limited because it was too detailed to be used routinely when caring for

critically ill patients. All but one of the 11 nurses believed that the tool would

have helped them earlier in their practice (ie, when they had less critical care

1 J

28

nursing experience). The assessment and treatment of pain in critically ill

patients are highly complex processes. This study identified many advantages

of the use of a standardized, systematic approach to pain assessment and

treatment by health professionals.

2.3 Studies related to pain assessment and management outcomes

Thibault et al. (2007) conducted a study to assess the intensity of postoperative

pain in relation to the location of craniotomy .. Collecting scores obtained

using an 11-point verbal rating scale and calculating the cumulative analgesic

requirements for the first 48 hr postoperatively assessed the severity of post-

craniotomy pai11. Data were compared according to the craniotomy location.

Data from 299 patients was available for analysis. On average, 76% of patients

experienced moderate to severe postoperative pain. Frontal craniotomy was

associated with lower pain scores than four of six craniotomy sites analyzed,

with 49% of patients reporting mild pain, a significant difference (P < 0.05)

compared with all other groups except for parietal craniotomies. Frontal

craniotomy patients also had lower opioid analgesic requirements compared to

patients who underwent posterior fossa craniotomy (P < 0.05). Logistic

regression analysis showed that craniotomy location (P < 0.0001) and age (P =

0.004) were both independent predictors of the intensity of postoperative pain,

29

with lower pain scores as age increased. Postoperative use of steroids, gender

and presence of preoperative pain were not statistically linked to postoperative

pain intensity. The prevalence of postoperative nausea and vomiting was 56%

and it did not vary according to the location of craniotomy. This study showed

that the intensity of post operative pain in neurosurgery is affected by the site

of craniotomy. Frontal craniotomy patients experienced the lowest pain scores,

and required significantly less opioid than patients undergoing posterior fossa

interventions.

Eric et al. (2002) conducted a study to compare the analgesic efficacy of three

different postoperative treatments after supratentorial craniotomy. Sixty-four

patients were allocated prospectively and randomly into three groups:

paracetamol {the P group, n = 8), paracetamol and tramadol (the PT group, n =

29), and paracetamol and nalbuphirie (the PN group, n = 27). Post operative

pain was assessed in the fully awake patient after extubation (hour 0) and at 1,

2, 4, 8, and 24 hours using a visual analog scale (VAS). In all patients,

extubation was obtained within 6 ± 3 minutes after remifentanil

administration. Postoperative analgesia was ineffective in the P group;

therefore, inclusions in this group were stopped after the eighth patient.

Postoperative analgesia was effective in the two remaining groups because

VAS scores were similar, except at hour 1, when nalbuphine was more

30

effective (P = .001). Nevertheless, acquiring such a result demanded

significantly more tramadol than nalbuphine (P < .05). More cases of nausea

and vomiting were observed in the PT group but the difference was not

significant (P<.06). In conclusion, pain after supratentorial neurosurgery must

be taken into account, and paracetamol alone is insufficient in bringing relief

to the patient. Addition of either tramadol or nalbuphine to paracetamol seems

necessary to achieve adequate analgesia, with, nevertheless, a larger dose of

tramadol to fulfill this objective.

Christine et al. (2010) conducted a study on prospective assessment of post

operative pain after craniotomy. This study investigated the incidence and

intensity of pain after craniotomy and characterized the influencing

parameters. During a 1-year period 256 patients undergoing elective

craniotomy were prospectively included in the study. Intensity of pain was

evaluated 1, 4, and 24 hours after extubation using a verbal numerical rating

scale (NRS) ranging from 0 (no pain) to 10 (maximal pain). Parameters

including patient-related factors, drug administration, and surgical factors

were correlated with incidence and intensity of post craniotomy pain. During

the first 24 hours 87% of the patients experienced pain (NRS 1 to 3: 32%,

NRS 4 to 7: 44%, NRS 8 to 10: 11 %). For postoperative analgesia, the opioid

piritramide (a J..L-receptor agonist) was administered to 70% and nonopiod

31

analgesics to 73% of the patients. The probability of expenencmg post

craniotomy pain was reduced by 3% for each year of life. Maintenance of

anesthesia with sevoflurane increased the probability of suffering from post

craniotomy pain by 147% and the absence of corticosteroids by 119%. Other

investigated parameters did not influence pain after craniotomy. This study

showed that the majority of patients experienced pain after craniotomy, despite

conventional pain management, emphasizing the necessity for improved and

individualized pain management in this special group of patients.

Giuseppe et aL (1996) conducted a study on post operative pam m

neurosurgery. The incidence, magnitude, and duration of acute pain

experienced by neurosurgical patients after various brain operations are

assessed in 37 consecutive patients. Postoperative pain was more common

than generally assumed (60%). In two-thirds of the patients with postoperative

pain, the int~nsity was moderate to severe. Pain most frequently occurred

within the first 48 hours after surgery, but a significant number of patients

endured pain for longer periods. Pain was predominantly superficial (86% ),

suggesting somatic rather than visceral origin and possibly involving

pericranial muscles and soft tissues. Subtemporal and suboccipital surgical

routes yielded the highest incidence of postoperative pain. Age and sex were

significantly associated with the onset of pain, with female and younger

32

patients reporting higher percentages of postoperative pain. Results of this

pilot study indicate that postoperative pain after brain surgery is an important,

although neglected, clinical problem, that deserves greater attention by

surgical teams, to provide better and more appropriate treatment.

Kincaid and Lam (2007) conducted a study on pain and craniotomy. This

prospective study is to evaluate the incidence, severity, and treatment of post

operative pain in patients who underwent major intracranial surgery. One

hundred eighty-seven patients (77 men and 110 women, mean age 52 ± 15

years, mean weight 78.1 ± 19.9 kg) underwent either supratentorial (129

patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the

patients reported experiencing moderate to severe pain (2:: 4 on a 0-10 scale)

during the first postoperative day. Pain scores greater than or equal to 4

persisted in 48% on the 2nd postoperative day. Approximately 80% of patients

were treated with acetarainophen on the 1st postoperative day, whereas

opioids (primarily intravenous fentanyl) were administered to 58%. Compared

with patients who underwent supratentorial procedures, those who underwent

infratentorial procedures reported more severe pain at rest (mean score 4.9 ±

2.2 compared with 3.8 ± 2.6; p = 0.015) and with movement (mean score 6.3 ±

2.6 compared with 4.5 ± 2.7; p <0.001) on the first postoperative day. On both

the first and second postoperative days, patients who underwent infratentorial

33

procedures received greater quantities of opioid (p ~ 0.019) and nonopioid (p

~ 0.013) analgesics than those who underwent supratentorial procedures.

Patients' dissatisfaction with analgesic therapy was significantly associated

with elevated pain levels on the first two postoperative days (p <0.00 1 ). In

contrast to prevailing assumptions, the study findings revealed that most

patients undergoing elective major intracranial surgery will experienced

moderate to severe pain for the first two days after surgery and that this pain

was often inadequately treated.

Rahimi et aL (20 1 0) conducted a study on post operative management with

tramadol after craniotomy: evaluation and c9st analysis. A randomized,

blinded prospective study to evaluate the efficacy of alternative pain

management strategies for patients following craniotomies. Fifty patients were

randomly assigned either to a control group who received narcotics and

acetaminophen alone or an experimental group who received tramadol in

addition to narcotic pain medications (25 patients assigned to each group). The

control group was noted to have statistically significant higher visual analog

scale pain scores, an increased length of hospital stay, and increased narcotic

use compared with the tramadol group. The narcotics and acetaminophen

group also had increased hospitalization costs when compared with the

34

tramadol group. The use of scheduled atypical analgesics such as tramadol in

addition to narcotics with acetaminophen for the management of postoperative

pain after craniotomy might provide better pain control, decrease the side

effects associated with narcotic pain medications, encourage earlier

postoperative ambulation, and reduce total hospitalization costs.

Kotak et al. (2009) conducted a survey of post-craniotomy analgesia in British

neurosurgical centers to ascertain whether there was a general consensus

regarding post craniotomy pain management, all 31 adult n~urosurgical units

were surveyed. Twenty three percent (7 units) had a standardized analgesic

regime/protocol and 65% routinely assessed pain post-operatively (20 units).

Seventy percent of units used codeine phosphate or dihydrocodeine (22 units)

as the first line opioid the other 30% using morphine (9 units). Forty two

percent (13 units) used tramadol; patient controlled analgesia was used in 3

units. Regular paracetamol was prescribed in all but five (16%) units. Fifty

two percent of units (16) used NSAIDS; of those that used NSAIDS 19%

(3/16) prescribed them regularly. One unit used clonidine infusions. The

authors concluded that there was no consensus on pain management after

craniotomy in neurosurgical centres in the UK, during the study period.

~~~ ~- ~ ---- ~~------- --- --- ------~ --~~------ -·------------

35

2.6 Summary

Related studies summarizes that the pa~n scale in a critical setting improved

patients ratings of their pain experience, improved documentation by nurses

and increase nurses' confidence in assessing pain. So many studies identified

many advantages of the use of a standardized, systematic approach to pain

assessment and treatment by health professionals. The majority of patients

experienced pain after craniotomy, although neglected, clinical problem,

despite conventional pain management, emphasizing the necessity for

improved and individualized pain management in this special group of

patients. Frontal craniotomy patients experienced the lowest pain scores, and

required significantly less opioid than patients undergoing posterior fossa

interventions. Most patients undergoing elective major intracranial surgery

will experienced moderate to severe pain for the first two days after surgery

and that this pain was often inadequately treated.

Review of literature is an important aspect of any research project from

beginning to end. This chapter-covered introduction, review of literature

related to the pain assessment and validation of pain observation tool, studies

related to the pain assessment and management outcomes.

KeyWords

36

Table 2.1

Keywords

Pain assessment and management outcomes

Pain assessment using pain rating scales

Number of articles

18

83

3.1 Introduction

37

CHAPTER-3 METHODOLOGY

Research methodology is the systemic way to solve the research problem. It

includes the step that researcher adopts to study his problem with the logic

behind. It indicates the general pattern of organizing the procedure of

gathering valid and reliable· data for an investigation.

This chapter provides a brief description of the method adopted by the

investigator to conduct this study. This chapter deals with research approach,

study design, the sample and sampling technique. It further deals with the

. development and description of the tool, pilot study, data collection, procedure

and plan of analysis.

3.2 Objectives of the study

The objectives of the study were

• To assess the level of pain suffered by the patient after craniotomy

during hospitalization.

• To find out association between pain score of patients after craniotomy

and selected variables.

38

3.3 Research approach

Survey method

3.4 Setting of the study

The study was conducted in the NeuroSurgery Intensive Care Unit and Neuro

Surgery Wards of Sree Chitra Tirunal Institute for Medical Sciences and

Technology, Trivandrum. The total number of craniotomy undergone during

the period of data collection from September to October was seventy six. In

these Supratentorial surgery - forty four, Infratentorial surgery - thirteen and

nineteen aneurysm clipping.

3.5 Study population

Post operative patients in the Neuro Surgery Intensive Care Unit and

Neurosurgery Wards of Sree ChitraTirunal Institute for Medical Sciences and

Technology, Trivandrum.

3.6 Sample and sampling techniques

Purposive sampling technique was used. The sample consisted of post

operative patients in Neuro Surgery Intensive Care Unit (NSICU) and

Neurosurgery Wards (NSW) of SCTIMST. The sample size was 40.The

duration of the study was from September 2010 to November 2010.

~/

39

3. 7 Inclusion Criteria

+ Patients who were willing to participate.

+ Patients who have age above 18.

+ Patients who underwent Supratentorial tumour excision,

Infra Tentorial tumour excision and aneurysm clipping.

3.8 Exclusion Criteria

• .Patient who do not understand Malayalam and English.

• Patient who remain on ventilator, in the assessment days.

• Patients who are not fully conscious .

3.9 Development of the tool

An extensive study and review of literature helped in the preparation of the

tool. A self -prepared validated questionnaire and Wong Bakers Faces pain

rating scale were used as the tools for this study. Patients' medical records also

were reviewed to collect data on analgesic use.

40

3.1 0 Description of the tool

Part 1: This part contains item such as patient name, age, sex, name of the

surgery, hospital number, date and type of surgery, medication and its

frequency, date of assessment.

Part II: Questionnaire about pain experience after craniotomy in first three

post operative days. These include thirteen questions regarding the intensity of

pain. First three question carries score ranging from zero to three and the

fourth question (Wong Baker Faces Pain rating scale) carries score ranging

from zero to ten. Total pain score was 19. The highest score indicates the

highest intensity of pain. Questions about pain aggravating activities are also

included.

3.11 Pilot Study

Pilot study was done in September 2010. Ten patients were taken for the pilot

study. The pilot study was conducted to find out the feasibility of the study.

Wong Bakers Faces Pain Rating Scale and selected questions to assess pain

intensity and its relief were used as the tool. After pilot study modifications of

the tool was done.

41

3.12 Data Collection

The data was collected from NeuroSurgery ICU and NeuroSurgery Wards of

Sree Chitra Tirunal Institute for Medical Sciences and Technology. The period

of data collection was from September 2010 to October 2010. Total

craniotomy undergone during that period was seventy-six. Assessment of

patient has been done while they are in the NSICU and NS Wards. The

operation day is counted as '0' day. Most of the patients were shifted to ward

on second or third post operative day. First assessment started after first

twenty-four hours of surgery. Second and third assessments were carried out

on the next days on the same time of first assessment.

3.13 Plan of analysis

The investigator developed a plan of analysis after the pilot study. The data

collected were coded, entered in excel sheet and analyzed using Epi Info

Version 3.5.1.

3.14 Summary

This chapter deals with methodology, study setting, sample and sampling

technique, development and description of the tool, pilot study, data collection

and plan of analysis.

42

CHAPTER-4 ANALYSIS AND INTERPRETATION OF DATA

4.1 Introduction

Analysis is a process of organizing and synthesizing data in such a way that,

project questions can be answered. The overall objective of analysis is to

organize, structure and to elucidate meaning from the collected data.

Interpretation is the process of making sense of the result and examining the

implication of findings within the broad context. This chapter represents

analysis and interpretation of data collected from 40 post operative neuro

surgery patients in the neuro surgery ICU and neuro surgery wards of Sree

Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

The findings of the study were arranged and analyzed under the following

sections.

4.2 Distribution of sample according to demographic data.

4.3 Distribution of sample according to selected variables

4.4 Association between mean post operative pain score and selected

variables.

52

4.4 Association between mean post operative pain score and selected variables

Table 4.10

Mean, Standard deviation and p value of pain score in first

post operative day by age category

Age group Mean Standard deviation p value

Less than 42.5 8.8- 2.04

0.81

Greater than 42.5 8.65 1.87

The maximum obtainable pain score was 19. The median was used to divide

the group into younger and older age groups. Table 4.10 shows that the pain

score of younger patients ranged from 5-13 with a mean pain score of 8.8 ±

2.04 and that of older patients ranged from 6-13 with a mean pain score of

8.65 ± 1.87. Students 't' test showed that there was no statistically significant

difference in the mean pain score of patients who had younger and older age

group (p=0.81).

53

Table 4.11

Mean, Standard deviation and p value of pain score in first post operative d~y by sex

Sex Mean Standard deviation p value

Male 8.56 1.99 0.5

Female 8.94 1.89

The maximum obtainable score was 19. Table 4.11 shows that male patients

pain score ranged from 5-13 with a mean pain score of 8.56 ± 1.99 and female

patients pain score ranges from 7- 12 with a mean pain score of 8.94 ± 1.89.

Students 't' test showed that there was no statistically significant difference in

the mean pain score of male and female (p=0.5).

Table 4.12

Mean, Standard deviation and p value of pain score in first post operative day by type of surgery

I

Type of surgery l\iean Standard deviation

Supratentorial approach 8.91 1.99

Infratentorial approach 7.40 0.54

..

54

The maximum obtainable pain score was 19. Table 4.12 shows that the patient

who had undergone surgery in supratentorial approach had a pain score ranges

from 5-13 with a mean pain score of 8.91 ± 1.99 and those who undergone

surgery in infratentorial approach had a pain score ranges from 7-8 with a

mean pain score of7.40 ± 0.54. Students 't' test significance was not done due

to small sample size in the infratentorial group.

Table 4.13

Mean, Standard deviation and p value of pain score of first post operative day and second post operative day

Post operative day Mean Standard deviation p value

First post operative ·day 8.73 1.935 0.000

Second post operative day 6.25 1.104

The maximum obtainable_pain score was 19. Table 4.13 shows that the pain

score in the first post operative day ranges from 5-13 with a mean pain score

of 8. 73 ± 1.935 and the pain score in the second post operative day ranged

from 4-8 with a mean pain score of 6.25 ± 1.104. A paired 't' test showed that

the mean pain score on the second post operative day was significantly lesser

than the mean pain sore of first post operative day {p=O.OOO).

l

55

Table 4.14

Mean, Standard deviation and p value of pain score of second 0 post operative day and third post operative .day

Post operative day Mean Standard deviation p value

Second post operative day 6.25 10104 0.000

Third post operative day 2.93 2.280

The maximum obtainable pain score was 19. Table 4014 shows that the pain

score in the second post operative day ranges from 4-8 with a mean pain score

of 6.25 ± 10104 and the pain score in the third post operative day ranged from

0-8 with a mean pain score of 2093 ± 2.280. A paired 't' test showed that the

mean pain score on the third post operative day was significantly lesser than

the mean pain score of ~econd post operative day {p=O.OOO).

4.5 Summary

This chapter contains distribution of sample according to demographic data,

selected variables and the association between mean post operative pain score

and selected variables.

I

56

CHAPTER-S SUMMARY, CONCLUSION, DISCUSSION AND

RECOMMENDATIONS

5.1 Introduction

This chapter gives a brief account of the present study including conclusions

drawn from the findings and possible applications of the result.

Recommendations for future research and suggestions for improving the

present study are also included.

5.2 Summary

This study was under taken to assess pain and pain relief in craniotomy

patients. The review of related literature helped the investigator to get a clear

concept about the topic, methodology of the study, tool preparation and plan

of analysis. Using Wong Bakers Faces pain rating scale and selected questions

to assess pain intensity, location, nature, aggravating factors and alleviating

factors were assessed. The effectiveness of pain medications also was

assessed. The assessment was done on the first, second and the third post

operative day about the pain experience and the effectiveness of pain

management. Purposive sampling technique was used. Pilot study was done

prior to the main investigations. Ten craniotomy patients were assessed. After

57

pilot study modifications of tool was done. The study was conducted in the

neuro surgery intensive care unit and neuro surgery wards of Sree Chitra

Tirunal Institute for Medical Sciences and Technology, Trivandrum during the

period of September 2010 to October 2010. The sample size for the study was

40. The data obtained from the study were analyzed by using descriptive and

inferential statistics. Both bar and pie diagram were utilized to illustrate the

findings of the study.

5.3 Objectives of the study

The specific objectives of the study were

• To assess the level of pain suffered by the patient after craniotomy

during hospitalization.

• To find out the association between pam score of patients after

craniotomy and selected variables.

5.4 Limitations

);> The study was conducted m single group patients who have

undergone craniotomy.

);> The study was limited to neurosurgery intensive care unit and neuro

surgery wards of Sree Chitra Tirunal Institute for Medical Sciences

and Technology, Trivandrum.

"\{ ..

58

~ The study was limited to patients who could understand Malayalam

and English, who were conscious and co-operative and were not on

ventilator.

5.5 Major findings of the study

~ Sixty-eight percentage of the patients had increased pain intensity on

the first post operative day compared with other post operative days.

~ Most of the patients had pain intensity high at the time of dressing.

~ There was no gender difference on pain perception.

~ The sample was less to found out the significant difference between

the intensity of pain in patients who undergone supratentorial tumor

excision and infratentorial tumor excision.

~ Most of the patients got pain relief from pain medications and it was

adequate.

~ The mean score of patients in first, second and third post operative

day was 8.73, 6.25 and 2.93.

~ Most of the patients pain score decreased from first post operative

day to third post operative day.

~ The usage of analgesics also decreased from first to third post

operative day.

59

5.6 Discussion

There are many studies related to the different aspect of pain. The present

study emphasized to assess pain and its relief in craniotomy patients using

Wong Bakers Faces Pain Rating Scale. The aim of the study were to assess the

patients craniotomy pain and effectiveness of pain management in craniotomy

within the first three days after surgery and to find out the relationship

between pain score and selected variables. Daily pain assessment by using

pain scale was feasible and valuable. In this study almost all the patients were

able to give a pain score and majority was positive about daily pain

assessment. Vranic et al. (2010) study concluded that the implementation of

the Nonverbal Pain Scale in a critical care setting improved patients' ratings of

their pain experience, improved documentation by nurses, and increased

nurses' confidence in assessing pain in nonverbal patients. Christine et al.

(2010) suggested that majority of patient's experienced pain after craniotomy,

despite conventional pain management, emphasizing the necessity for

improved and individualized pain management in this special group of

patients. Kincaid and Lam (2007) revealed that most patients undergoing

elective major intracranial surgery would experience moderate to severe pain

for the first 2 days after surgery and that this pain was often inadequately

treated. The present study got similar result and found out that there was no

60

gender and age difference on pain perception. The patient's pain gradually

decreased from first post operative day to third post operative day.

5. 7 Recommendations

• Using a large sample size the same study,can be repeated.

• Same study can be done in another intensive care unit or in another

institution.

• Comparative study of pain in supratentorial and infratentorial surgery

can be done.

5.8 Conclusion

Education about safe pain management will help, to prevent under treatment

of pain and the resulting harmful effects. Safety includes the use of appropriate

tools for assessing pain. Use of analgesics, particularly opioids, is the

foundation of treatment for most types of pain. Based on the findings of the

study, the following conclusions were drawn. The Wong Bakers Faces Pain

rating scale is a valid tool to assess the intensity of pain. Patients self report of

pain along with assessment using pain scale were helpful for effective

management of pain. Most of the patient's pain gradually decreased from first

post operative day to third post operative day and pain relief from pain

61

medications was adequate The study found out that there was no gender and

age difference on pain perception. Further research using a large sample is

needed to evaluate and validate the findings.

l

62

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. APPENDIX.

i .

Informed Consent

I hereby agree to participate in the research study "A study to assess the post

operative pain and its management among patients undergoing craniotomy"

conducted by Ms. Rikku Mathew Ist year Diploma in Neuro Nursing of

SCTIMST , Trivandrum. I understand that there will not be any change in the

nature of care that I receive and the data given by me will be kept confidential,

and will be used only for research purpose.

Signature of the patient:

Name of the patient:

Place:

Date:

Questionnaire About Patients' Postoperative Pain And Its Relief After Craniotomy

Section A:

Demographic data:

Name

Age

Sex

Hospital No

Surgery

Fost operative day

Date

Analgesics received :

Frequency

Section B:

(l)Did you experience pain after surgery. if so, how much?

( first day, second day, third day)

(a)No (b) Mild (c) Moderate (d) Severe

(2)What was the frequency of the pain?

(a) No pain (b) Occasionally (c) Frequently (d) Continuously

(3)Does the pain restrict your activity?

(a) No restriction (b) Mild restriction

(c) Moderate restriction (d) Severe restriction

( 4) Which of the following picture mentioned below is most

similar to your pain ?

Pain Scale:-

l 4 5 S lU 0 Hurm Hurts Hurts l'h.Jrts Hurts

No Hurt Littlt~ Bit I.Jttfe Mt>re Even More Whole Let Worst

(5)Where was the pain?

(a) Head (b) Eyes (c) Neck (d) Extremities (e) Any other area

( 6) Can you point out the site of pain ?

(a) Forehead (b) Surgical site (c) Any other area in the head

(d) Any other area in the body part

(7) Does the pain radiate to any direction ?

(a) No (b) Side (c) Back and. shoulder (d) Any other area

(8) During which activities did you suffer more pain?

(a) Position changing (b) At the time of dressing removal

(c) Suctioning (d) Chest physiotherapy (e) Any other activity

(8) What have you tried to relieve the pain ?

(a) Tell the doctor /sister for medications (b) Assume certain

positions (c) Tolerate the pain (d) Any other measures

(10) Was the pain medications effective?

(a) Complete pain relief(b) Moderate pain relief

(c) Mild pain relief (d) No pain relief

(11) What all self care activities can you do with out pain?

(a) Eat I drink (b) Dress changing

(c) Walk in the room I toilet (d) All of the above

(12) In which postoperative day you felt more pain?

(a) On the day of surgery (b) First day

(c) Second day (d) Third day

(13) What are the difficulties you faced in the ICU after craniotomy?

Thank you for taking the time to fill out the questionnaire

I I Wong Bakers Faces Pain Scale:-

The given scale measures the experience of pain ranging from '0' which

means no pain 'I 0' refers to severe pain. The client is requested to choose a

figure from 0 to 10 indicating the pain experienced by, the patient after

craniotomy.

Verbal descriptor Scale:-

Pain score interpretation:

~ 0- No pain

~ 1-2 Mild pain

~ 3-4 Moderate pain

~ 5-6 Severe pain

~ 7-8 Very severe pain

~ 8-10 Worst possible pain

4 6 0

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