I”, , pnnrcd
V”rx. .s,“d.. Vol. ZY. No. 4. PD. 381-392. I” meat Brmlll.
ax~‘48Y ‘92 SI.aJ - 0.m 5‘ IYYZ Pcrgamon Prcv Ltd
IYE
Patients’ night-time pain, analgesic provision and sleep after surgery S. JO?& CLOSS Nursing Research Unit, Department of Nursing Studies, University of Edinburgh, 12 Buccleuch Place, Edinburgh EH8 9L W, L’.K.
hundred patients were interviewed about their experiences of pain and sleep following abdominal surgery. This information was supplemented by data on analgesic provision which were gathered from medication charts. Pain was the most commonly reported cause of night-time sleep disturbance and analgesics helped more patients to get back to sleep.‘than any other intervention. About half of the patients felt that pain was worse at night than during the day. An examination of patterns of analgesic provision revealed that the number of doses given peaked at two points during the 24-hour cycle. The highest numbers of doses were given between 8 a.m. and I2 noon and 8 p.m. and 12 midnight. Fewer doses were given at night, between midnight and 4 a.m. Analgesic provision at night, therefore, did not appear to be explicitly related to need. The assessment and control of post-operative pain at night requires further attention in order to optimize pain control and promote sleep.
Abstract-One
Introduction
Although there is much research into pain control, little of it has addressed the problems specific to the nursing care of patients with post-operative pain at night. It is well established that the pain of post-operative patients is often inadequately controlled (Keeri-Szanto and Heaman, 1972; Cohen, 1980; Donovan et al., 1987; Melzack et al., 1987; Seers, 1987; Car-r, 1990; Kuhn et al., 1990; Owen et al., 1990). It is also well-known that post-operative pain can lead to a wide range of undesirable consequences. These include reduced mobility which may lead to deep vein thrombosis, damage to pressure areas, respiratory difficulties and reluctance to mobilize. Pain may also accelerate tissue breakdown and, following some kinds of surgery, impair bowel and bladder functions and increase the likelihood of longterm pain. In addition, it is clear that post-operative pain at night has a detrimental effect on sleep (Murphy ef al., 1977; Jones ef al., 1979; Seers, 1987; Gloss, 1988). Sleep deprivation 381
382
S. JOSE
C-LOS.5
during the post-operative period may also produce undesirable consequences, such as impaired tissue restoration (Adam and Oswald, 1983) and negative mood states (Horne, 1983; Shaver er al., 1989). The close relationship between pain and sleep means that one cannot be considered without the other when planning night-time nursing care for surgical patients. The research described here is part of a larger study which investigated some aspects of post-operative pain, analgesic provision and sleep (Gloss, 1991).
Method
The aims of the study were: 1. TO assess the extent of sleep disruption due to post-operative pain. 2. To identify differences between day- and night-time experiences of pain and pain control. 3. To examine patterns of analgesic provision over the first three post-operative days and nights. One hundred patients from four wards who had undergone abdominal surgery were included in the study. Each patient was interviewed once only on the third post-operative day. This day was chosen for several reasons. It was felt that patients would generally be well enough to cope with an interview, while still being able to remember their experiences of pain and sleep from the preceding two days. In addition, most patients tended to be weaned off controlled drugs and commenced on milder oral analgesics on about the third post-operative day. By interviewing them at this point it was intended that their experiences while having opioid drugs could be explored. All interviews were conducted at approximately the same time of day (between 4-6 p.m.) for two reasons. First, it would standardize for any circadian fluctuations in pain or factors influencing pain. Second, it was convenient for both patients and ward staff since visiting ended at 4 p.m. and the wards were relatively quiet until supper was served around 6 p.m. Several sorts of nursing documentation were consulted in addition to recording the responses of the patients themselves. The nursing notes provided patients’ demographic data and the patients’ medication charts gave details of analgesic provision. All this information was gathered onto one proforma for each patient.
Results
The first section of the interview dealt with patients’ sleep. First, patients were asked about their usual sleep at home to provide a baseline with which to compare their reports of sleep in hospital. The mean duration of night-time sleep at home was 6.8 f 0.2 (S.E.M.) hours. This was reduced to 5.8 f 0.9 hours for the night in hospital prior to interview. Patients were asked what had woken them up during the night prior to interview (see Table 1). Pain was the most frequent cause of sleep disturbance, with noise coming second. Patients who had woken were asked whether anything or anyone had helped them get back to sleep the previous night. It can be seen (Table 2) that the provision of analgesics helped more patients than any other action. The next question asked what patients’ worst problems with sleeping in hospital had been (see Table 3). A wide variety of reasons were cited, mostly to do with the ward environment or personal discomfort. As expected from earlier research, noise and pain were the two factors considered worst in terms of interfering with patients’ sleep. Although
PAIN.
ANALGESIC Table
PROVISION
AND
SLEEP
1. Causes of night-time
AFTER
awakening
41 21 12 12 4 4 3 3 2 2 5
Pain Noise Needed toilet No reason/don’t know Discomfort Too hot Anxious For nursing care Strange place Plastic bedding Other
115
Total More
than one response possible per patient.
Table What
2. What
helped patients get back to sleep
helped
Given analgesics Made comfortable Used toilet Radio/read/counted Hot/cold drink Given hypnotic Talked to nurse Total
383
No. of patients
Cause
N.B.
SURGERY
No. of patients
in bed sheep
26 7 6 4 3
1 I 48
patients had previously cited pain as being a more frequent cause of night-time wakening than noise, they considered it here almost equally with pain as the worst difficulty with sleeping. This discrepancy may have been due to their expectations about pain and noise, perhaps more readily accepting pain as unavoidable. In order to gain more detail about the effects of pain on sleep, patients were then asked whether pain had interfered with their sleep in any way. Seventy-three said yes, 25 said no and two had not had any pain. This was followed up by an open question about how pain had affected their sleep. In response 44 patients said they had been woken by pain during the night (i.e. three contradicted their earlier response) and 30 had had difficulty either in initiating or getting back to sleep. The sleep of 18 patients was disturbed because of pain as a result of moving in bed and I3 lost sleep because they were unable to lie in a comfortable position. Post-operative pain at night A major emphasis of this study was to investigate night-time experiences of post-operative pain. Patients were asked whether their pain was any different at night compared with during the day (Table 4). The largest group of patients was those who felt that pain was worse at night. Slightly fewer felt that there was no difference between day and night. The four patients who had experienced no pain during the night obviously could not make a comparison.
S. JOSE: CLOSS
384
Table 3. Worst problems sleeping in hospital Problem Noise Pain No problem Strange place/routine Uncomfortable beds Uncomfortable position in bed Constant disturbances Too hot Discomfort Drips and drains Worry No light to read by No drinks available Sore throat Unable to relax Don’t know Total
No. of patients 25 23 10 10 9 5 4 3 2 2 2 1
1 I I 1 100
Table 4. Day-night differences in patients’ experiences of postoperative pain Comment on pain Worse at night Same, day and night Uncertain No nocturnal pain experienced Worse during the day Total
No. of patients 49 38 6 4 3 100
Several patients commented further. Fifteen patients felt that pain actually was worse during the night, while a further 31 felt that pain seemed worse but that this was psychological. Ten felt that pain was worse when they were tired. Another of the questions used to elicit information about day-night differences was: “Would you be more likely to tell the nurses about your pain during the night or during the day?“. Fifty patients said they would be equally likely to tell nurses during the day or night. Of the remaining half of the sample, 33 said they would be more likely to tell nurses about their pain during the night and 17 said during the day. The 50 who had stated a preference were asked what their reasons were. Of those who were more likely to tell nurses about their pain at night, the most common reason was that they felt worse at night, both generally and regarding their pain (n = IS). The second reason for being more likely to tell nurses about pain at night was that they felt it was important to sleep throughout the night (n = 13). The third most common reason was that patients thought that nurses had more time at night (n = 4). Reasons given for being more likely to tell nurses about their pain during the day included there being more nurses on duty during the day (n = 7), or nurses having less time at night (n=2). Two of the patients who had no preference said that they did not want to bother the nurses and two felt that there were plenty of patients worse off than themselves.
P._(I.V, .-I.k’.-lLGESlC
PROVISIOK
Post-operative analgesic provision Prescription of post-operative analgesics.
A.WD SLEEP AFTER
SURGERk
385
Forty of the 100 patients were prescribed continuous analgesics including intravenous (n = 29), interpleural (n = 5) and epidural (n = 6) routes of administration. All three routes of administration were considered together and designated “non-standard analgesia” for the purposes of analysis. These non-standard methods of analgesia included drugs such as morphine, diamorphine and bupivacaine. Ninety-eight patients were prescribed intermittent doses of both opioid and non-opioid analgesics. Intermittent opioids included papaveretum, morphine, diamorphine, cyclimorph and pethidine. The non-opioids included coproxamol, codydramol, paracetamol, dihydrocodeine and ibuprofen. Intermittent analgesics were prescribed in fixed doses to be given 4-hourly or 4-6 hourly. Two had received no intermittent analgesics of any kind and claimed to have experienced no post-operative pain at all. Of these two, one had and one had not received non-standard analgesics. There was a considerable overlap of the various categories of analgesics given. While over one-third of the sample were prescribed non-standard analgesics, a much smaller proportion of those receiving non-standard analgesics were prescribed intermittent nonopioid drugs than those not receiving non-standard analgesics. Patterns of administration of post-operative analgesics. In order to observe patterns of post-operative analgesic provision, the period for which data had been collected was divided into &hour time blocks. These began at midnight following surgery and continued for 64 hours, producing eight consecutive periods of eight hours each, finishing at 4 p.m. on the third post-operative day. For each of the two groups (opioids or non-opioids), a Friedman analysis of variance using the raw data indicated that there were significant changes within each of the groups according to time. For the opioid drugs, x’= 50.5, 7 d.f., P < 0.001. For the non-opioid analgesics, x’ = 16.9, 7 d.f., P < 0.02. This means that for both types of analgesic drug, there were significant variations in the numbers of doses given according to time. This result did not indicate where these differences lay, so further analysis was necessary to clarify this. Having established that there were significant differences in the numbers of doses of analgesics given over 64 hours, visual representations of these patterns of intermittent analgesic provision were produced in order to see whether any obvious patterns existed. These are shown in Figs 1 and 2. The number of doses of opioid analgesics given gradually diminished over the three days while, as might be expected, the number of doses of nonopioid analgesics tended to increase over the three days. In fact, two different effects are visible in the pattern of analgesic provision. Superimposed on the general downward trend for opioid provision is a diurnal fluctuation in the number of doses given. Fewest doses were given at night, more were given in the afternoon and most were given during mornings. This diurnal effect was then separated out from the general downward trend. This was done by adding a regression line (line of best fit), indicating the downward trend over time (see Fig. 3). The values on this plot were then subtracted from the actual number of doses given for each &hour time block, leaving a clear diurnal pattern of provision (Fig. 4). The values on the vertical axis indicate the number of doses deviating from the regression line. A Friedman analysis of variance showed that the data presented in Fig. 4 still varied according to time (x2= 82.7, d.f. 7, P c 0.0001). This confirmed the significance of the diurnal fluctuations in the provision of post-operative opioids. Given that only three values
386
S. JOSr; CLOSS
00
V”rx. .s,“d.. Vol. ZY. No. 4. PD. 381-392. I” meat Brmlll.
ax~‘48Y ‘92 SI.aJ - 0.m 5‘ IYYZ Pcrgamon Prcv Ltd
IYE
Patients’ night-time pain, analgesic provision and sleep after surgery S. JO?& CLOSS Nursing Research Unit, Department of Nursing Studies, University of Edinburgh, 12 Buccleuch Place, Edinburgh EH8 9L W, L’.K.
hundred patients were interviewed about their experiences of pain and sleep following abdominal surgery. This information was supplemented by data on analgesic provision which were gathered from medication charts. Pain was the most commonly reported cause of night-time sleep disturbance and analgesics helped more patients to get back to sleep.‘than any other intervention. About half of the patients felt that pain was worse at night than during the day. An examination of patterns of analgesic provision revealed that the number of doses given peaked at two points during the 24-hour cycle. The highest numbers of doses were given between 8 a.m. and I2 noon and 8 p.m. and 12 midnight. Fewer doses were given at night, between midnight and 4 a.m. Analgesic provision at night, therefore, did not appear to be explicitly related to need. The assessment and control of post-operative pain at night requires further attention in order to optimize pain control and promote sleep.
Abstract-One
Introduction
Although there is much research into pain control, little of it has addressed the problems specific to the nursing care of patients with post-operative pain at night. It is well established that the pain of post-operative patients is often inadequately controlled (Keeri-Szanto and Heaman, 1972; Cohen, 1980; Donovan et al., 1987; Melzack et al., 1987; Seers, 1987; Car-r, 1990; Kuhn et al., 1990; Owen et al., 1990). It is also well-known that post-operative pain can lead to a wide range of undesirable consequences. These include reduced mobility which may lead to deep vein thrombosis, damage to pressure areas, respiratory difficulties and reluctance to mobilize. Pain may also accelerate tissue breakdown and, following some kinds of surgery, impair bowel and bladder functions and increase the likelihood of longterm pain. In addition, it is clear that post-operative pain at night has a detrimental effect on sleep (Murphy ef al., 1977; Jones ef al., 1979; Seers, 1987; Gloss, 1988). Sleep deprivation 381
382
S. JOSE
C-LOS.5
during the post-operative period may also produce undesirable consequences, such as impaired tissue restoration (Adam and Oswald, 1983) and negative mood states (Horne, 1983; Shaver er al., 1989). The close relationship between pain and sleep means that one cannot be considered without the other when planning night-time nursing care for surgical patients. The research described here is part of a larger study which investigated some aspects of post-operative pain, analgesic provision and sleep (Gloss, 1991).
Method
The aims of the study were: 1. TO assess the extent of sleep disruption due to post-operative pain. 2. To identify differences between day- and night-time experiences of pain and pain control. 3. To examine patterns of analgesic provision over the first three post-operative days and nights. One hundred patients from four wards who had undergone abdominal surgery were included in the study. Each patient was interviewed once only on the third post-operative day. This day was chosen for several reasons. It was felt that patients would generally be well enough to cope with an interview, while still being able to remember their experiences of pain and sleep from the preceding two days. In addition, most patients tended to be weaned off controlled drugs and commenced on milder oral analgesics on about the third post-operative day. By interviewing them at this point it was intended that their experiences while having opioid drugs could be explored. All interviews were conducted at approximately the same time of day (between 4-6 p.m.) for two reasons. First, it would standardize for any circadian fluctuations in pain or factors influencing pain. Second, it was convenient for both patients and ward staff since visiting ended at 4 p.m. and the wards were relatively quiet until supper was served around 6 p.m. Several sorts of nursing documentation were consulted in addition to recording the responses of the patients themselves. The nursing notes provided patients’ demographic data and the patients’ medication charts gave details of analgesic provision. All this information was gathered onto one proforma for each patient.
Results
The first section of the interview dealt with patients’ sleep. First, patients were asked about their usual sleep at home to provide a baseline with which to compare their reports of sleep in hospital. The mean duration of night-time sleep at home was 6.8 f 0.2 (S.E.M.) hours. This was reduced to 5.8 f 0.9 hours for the night in hospital prior to interview. Patients were asked what had woken them up during the night prior to interview (see Table 1). Pain was the most frequent cause of sleep disturbance, with noise coming second. Patients who had woken were asked whether anything or anyone had helped them get back to sleep the previous night. It can be seen (Table 2) that the provision of analgesics helped more patients than any other action. The next question asked what patients’ worst problems with sleeping in hospital had been (see Table 3). A wide variety of reasons were cited, mostly to do with the ward environment or personal discomfort. As expected from earlier research, noise and pain were the two factors considered worst in terms of interfering with patients’ sleep. Although
PAIN.
ANALGESIC Table
PROVISION
AND
SLEEP
1. Causes of night-time
AFTER
awakening
41 21 12 12 4 4 3 3 2 2 5
Pain Noise Needed toilet No reason/don’t know Discomfort Too hot Anxious For nursing care Strange place Plastic bedding Other
115
Total More
than one response possible per patient.
Table What
2. What
helped patients get back to sleep
helped
Given analgesics Made comfortable Used toilet Radio/read/counted Hot/cold drink Given hypnotic Talked to nurse Total
383
No. of patients
Cause
N.B.
SURGERY
No. of patients
in bed sheep
26 7 6 4 3
1 I 48
patients had previously cited pain as being a more frequent cause of night-time wakening than noise, they considered it here almost equally with pain as the worst difficulty with sleeping. This discrepancy may have been due to their expectations about pain and noise, perhaps more readily accepting pain as unavoidable. In order to gain more detail about the effects of pain on sleep, patients were then asked whether pain had interfered with their sleep in any way. Seventy-three said yes, 25 said no and two had not had any pain. This was followed up by an open question about how pain had affected their sleep. In response 44 patients said they had been woken by pain during the night (i.e. three contradicted their earlier response) and 30 had had difficulty either in initiating or getting back to sleep. The sleep of 18 patients was disturbed because of pain as a result of moving in bed and I3 lost sleep because they were unable to lie in a comfortable position. Post-operative pain at night A major emphasis of this study was to investigate night-time experiences of post-operative pain. Patients were asked whether their pain was any different at night compared with during the day (Table 4). The largest group of patients was those who felt that pain was worse at night. Slightly fewer felt that there was no difference between day and night. The four patients who had experienced no pain during the night obviously could not make a comparison.
S. JOSE: CLOSS
384
Table 3. Worst problems sleeping in hospital Problem Noise Pain No problem Strange place/routine Uncomfortable beds Uncomfortable position in bed Constant disturbances Too hot Discomfort Drips and drains Worry No light to read by No drinks available Sore throat Unable to relax Don’t know Total
No. of patients 25 23 10 10 9 5 4 3 2 2 2 1
1 I I 1 100
Table 4. Day-night differences in patients’ experiences of postoperative pain Comment on pain Worse at night Same, day and night Uncertain No nocturnal pain experienced Worse during the day Total
No. of patients 49 38 6 4 3 100
Several patients commented further. Fifteen patients felt that pain actually was worse during the night, while a further 31 felt that pain seemed worse but that this was psychological. Ten felt that pain was worse when they were tired. Another of the questions used to elicit information about day-night differences was: “Would you be more likely to tell the nurses about your pain during the night or during the day?“. Fifty patients said they would be equally likely to tell nurses during the day or night. Of the remaining half of the sample, 33 said they would be more likely to tell nurses about their pain during the night and 17 said during the day. The 50 who had stated a preference were asked what their reasons were. Of those who were more likely to tell nurses about their pain at night, the most common reason was that they felt worse at night, both generally and regarding their pain (n = IS). The second reason for being more likely to tell nurses about pain at night was that they felt it was important to sleep throughout the night (n = 13). The third most common reason was that patients thought that nurses had more time at night (n = 4). Reasons given for being more likely to tell nurses about their pain during the day included there being more nurses on duty during the day (n = 7), or nurses having less time at night (n=2). Two of the patients who had no preference said that they did not want to bother the nurses and two felt that there were plenty of patients worse off than themselves.
P._(I.V, .-I.k’.-lLGESlC
PROVISIOK
Post-operative analgesic provision Prescription of post-operative analgesics.
A.WD SLEEP AFTER
SURGERk
385
Forty of the 100 patients were prescribed continuous analgesics including intravenous (n = 29), interpleural (n = 5) and epidural (n = 6) routes of administration. All three routes of administration were considered together and designated “non-standard analgesia” for the purposes of analysis. These non-standard methods of analgesia included drugs such as morphine, diamorphine and bupivacaine. Ninety-eight patients were prescribed intermittent doses of both opioid and non-opioid analgesics. Intermittent opioids included papaveretum, morphine, diamorphine, cyclimorph and pethidine. The non-opioids included coproxamol, codydramol, paracetamol, dihydrocodeine and ibuprofen. Intermittent analgesics were prescribed in fixed doses to be given 4-hourly or 4-6 hourly. Two had received no intermittent analgesics of any kind and claimed to have experienced no post-operative pain at all. Of these two, one had and one had not received non-standard analgesics. There was a considerable overlap of the various categories of analgesics given. While over one-third of the sample were prescribed non-standard analgesics, a much smaller proportion of those receiving non-standard analgesics were prescribed intermittent nonopioid drugs than those not receiving non-standard analgesics. Patterns of administration of post-operative analgesics. In order to observe patterns of post-operative analgesic provision, the period for which data had been collected was divided into &hour time blocks. These began at midnight following surgery and continued for 64 hours, producing eight consecutive periods of eight hours each, finishing at 4 p.m. on the third post-operative day. For each of the two groups (opioids or non-opioids), a Friedman analysis of variance using the raw data indicated that there were significant changes within each of the groups according to time. For the opioid drugs, x’= 50.5, 7 d.f., P < 0.001. For the non-opioid analgesics, x’ = 16.9, 7 d.f., P < 0.02. This means that for both types of analgesic drug, there were significant variations in the numbers of doses given according to time. This result did not indicate where these differences lay, so further analysis was necessary to clarify this. Having established that there were significant differences in the numbers of doses of analgesics given over 64 hours, visual representations of these patterns of intermittent analgesic provision were produced in order to see whether any obvious patterns existed. These are shown in Figs 1 and 2. The number of doses of opioid analgesics given gradually diminished over the three days while, as might be expected, the number of doses of nonopioid analgesics tended to increase over the three days. In fact, two different effects are visible in the pattern of analgesic provision. Superimposed on the general downward trend for opioid provision is a diurnal fluctuation in the number of doses given. Fewest doses were given at night, more were given in the afternoon and most were given during mornings. This diurnal effect was then separated out from the general downward trend. This was done by adding a regression line (line of best fit), indicating the downward trend over time (see Fig. 3). The values on this plot were then subtracted from the actual number of doses given for each &hour time block, leaving a clear diurnal pattern of provision (Fig. 4). The values on the vertical axis indicate the number of doses deviating from the regression line. A Friedman analysis of variance showed that the data presented in Fig. 4 still varied according to time (x2= 82.7, d.f. 7, P c 0.0001). This confirmed the significance of the diurnal fluctuations in the provision of post-operative opioids. Given that only three values
386
S. JOSr; CLOSS
00
