Postoperative Pain Characteristics in Turkish Orthopedic Patients

Methods 

The research was planned as a descriptive study to make postoperative pain assessments of patients who have undergone major orthopedic surgery.

Results 

The mean age of the 150 patients studied was 54.13 ± 18.12 (range 19-93) years. Of the sample, 67.3% were women, 59.3% were married, and 72.7% had previously had surgery. In addition, 43.3% had had hip prosthesis surgery and 70.7% were taking nonopioid analgesic medications when needed (PRN) (Table 1). The majority (81.3%; n = 122) of the patients had “external” pain at the surgical site (e.g., hip, knee, vertebra) and in areas of pressure (e.g., back, breast, buttocks), and 78.7% (n = 118) had “intermittent” pain (Figure 1, Figure 2). The words most commonly used to describe their pain were as follows: “throbbing” (78.0%), “jumping” (12.7%), “drilling” (22.7%), “cutting” (26.7%), “cramping” (40.7%), “tugging” (14.7%), “hot” (28.0%), “tingling” (24.7%) “stinging” (52.7%), “aching” (46.0%), and “tender” (42.0%) in the sensory section; “tiring” (69.3%), “sickening” (8.0%), “fearful” (18.0), “grueling” (29.3%), “wretched” (2.7%) in the affective section; “troublesome” (61.3%) in the evaluation section; and “spreading” (40.7%), “tight” (56.0%), “cold” (6.0%), and “nagging” (74%) in the miscellaneous section (Table 2). The majority of the patients (95.3%) stated that their pain was decreased with analgesic medication administration, and 78.7% stated that position change and physical therapy (69.3%) increased their pain (Table 3). In the assessment of pain severity on the third postoperative day, the PPI was determined to be a mean of 1.75 ± 1.02. In addition, worst/severest pain was determined to be a mean of 4.55 ± 0.70 (especially during movement/physical therapy) on the third postoperative day. Statistically significant differences were found between patients’ pain severity at the moment and the worst/severest pain (p ≤ .001) (Table 4).

Table 1. Distribution of Patients’ Personal Characteristics

	Characteristic	n	%
	Gender
	Female	101	67.3
	Male	49	32.7
	Marital status
	Married	89	59.3
	Divorced	38	25.3
	Single	23	15.4
	Type of surgery
	Hip prosthesis	65	43.3
	Knee prosthesis	37	24.7
	Hemiarthroplasty	28	18.7
	Tumor resection	11	7.3
	Vertebra reconstruction	9	6.0
	Type of analgesic medication
	Nonopioid	106	70.7
	Opioid + nonopioid	41	27.3
	Opioid	3	2.0
	Past surgical history
	No	41	27.3
	Yes	109	72.7

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Figure 1 Distribution of patients’ pain location.

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Figure 2 Distribution of patients’ duration of pain. n = 150. More than one descriptor of the duration of pain may have been used.

Table 2. Distribution of Patients’ Words Descriptors of Postoperative Pain

	No.	Words	n	%	No.	Words	n	%
	1	Flickering	4	2.7	11	Tiring	104	69.3
		Quivering	7	4.7		Exhausting	6	4.0
		Pulsing	2	1.3
		Throbbing	117	78.0
		Beating	2	1.3
		Pounding	0	0.0
	2	Jumping	19	12.7	12	Sickening	12	8.0
		Flashing	18	12.0		Suffocating	5	3.3
		Shooting	5	3.3
	3	Pricking	14	9.3	13	Fearful	27	18.0
		Boring	32	21.3		Frightful	2	1.3
		Drilling	34	22.7		Terrifying	2	1.3
		Stabbing	11	7.3
		Lancinating	4	2.7
	4	Sharp	32	21.3	14	Punishing	1	0.7
		Cutting	40	26.7		Grueling	44	29.3
		Lacerating	13	8.7		Cruel	3	2.0
						Vicious	32	21.3
						Killing	0	0.0
	5	Pinching	1	0.7	15	Wretched	4	2.7
		Pressing	1	0.7		Blinding	1	0.7
		Gnawing	7	4.7
		Cramping	61	40.7
		Crushing	3	2.0
	6	Tugging	22	14.7	16	Annoying	9	6.0
		Pulling	4	2.7		Troublesome	92	61.3
		Wrenching	2	1.3		Miserable	3	2.0
						Intense	24	16.0
						Unbearable	8	5.3
	7	Hot	42	28.0	17	Spreading	61	40.7
		Burning	23	15.3		Radiating	2	1.3
		Scalding	2	1.3		Penetrating	10	6.7
		Searing	0	0.0		Piercing	2	1.3
	8	Tingling	37	24.7	18	Tight	84	56.0
		Itching	2	1.3		Numb	17	11.3
		Smarting	11	7.3		Drawing	1	0.7
		Stinging	79	52.7		Squeezing	5	3.3
						Tearing	0	0.0
	9	Dull	43	28.7	19	Cool	5	3.3
		Sore	5	3.3		Cold	9	6.0
		Hurting	0	0.0		Freezing	1	0.7
		Aching	69	46.0
		Heavy	7	4.7
	10	Tender	63	42.0	20	Nagging	111	74.0
		Taut	24	16.0		Nauseating	4	2.7
		Rasping	1	0.7		Agonizing	6	4.0
		Splitting	0	0.0		Dreadful	5	3.3
						Torturing	7	4.7

Table 3. Distribution of Patients’ Decreasing and Increasing Factors of Pain (n = 150)∗

	Factor	n	%
	Decreasing
	Analgesic medication	143	95.3
	Patient-control analgesia	77	51.3
	Hot/cold pads	48	32.0
	Imagery positive	34	22.7
	Stay on same position	12	8.0
	Another implementations (alternative medicine, sand pads)	11	7.3
	Physical therapy	10	6.7
	Change of attention another way	9	6.0
	Massage	3	2.0
	Increasing
	Changing position	118	78.7
	Physical therapy	104	69.3
	Sleeplessness	92	61.3
	Anxiety	83	55.3
	Changing wound/drain dress	39	26.0
	Stay on same position	34	22.7
	Leaving their family	30	20.0
	Living in hospital	20	13.3
	Leaving their job	11	7.3
	Constipation	7	4.7

∗ More than one factor could be reported.

Table 4. Distribution of Mean Scores for Pain Severity

	Pain Severity	Scale	Min-Max	Mean ± SD	t and p Values
	PPI (at the moment)	0.00-5.00	0.00-5.00	1.75 ± 1.02	t = −29.633
	PPI (worst/severest)	0.00-5.00	2.00-5.00	4.55 ± 0.70	p = .000∗

∗ p ≤ .001.

Discussion 

This study showed the third postoperative day pain characteristics and differences in pain severity results of patients on an orthopedic ward who had had a major surgical procedure. Schoen (2007) determined that pain is most common in orthopedics and must be evaluated closely. The critical features of pain are type, location, severity, duration, and precipitating factors.

In the literature, it has been determined that postoperative pain begins as a result of the surgical incision and gradually decreases with wound healing (Eti-Aslan, 2006, Kanan, 1998). In addition, pain is localized to an extremity and sudden, as with lifting/twisting/bending with arthritis or other disease processes. After the postoperative period, many patients express that the pain increases over the surgical/incisional area. For this reason, pain control for orthopedic surgical patients is essential, because they experience extensive tissue and bone trauma (Harvey, 2005). Pasero and McCaffery (2007) found in a study in parallel with our findings that pain is experienced at the primary surgical site.

The finding of pain's association with time in this study was similar to that found in studies by Kuğuoğlu, et al. (1998) and Özer (1998). In addition, in the literature it has been determined that postoperative pain duration decreases following the recovery process (Erdine, 2000). Therefore, pain duration decreased in “intermittent” time.

The majority of the patients’ pain descriptors were “throbbing” (78.0%), “tiring” (69.3%), “troublesome” (61.3%), and “nagging” (74%) (Table 2). Closs and Briggs (2002) observed that patients’ verbal descriptors of pain after orthopedic surgery were “throbbing, sharp, burning, aching, tight, nagging.” In addition, studies by Dahlen, Zimmerman, and Barron (2006) determined that orthopedic patients marked on words descriptors such as “sharp, aching, tender, tiring-exhausting” on the third postoperative day. Mentioned in the same article was a study by Kuğuoğlu, et al. (1998) and Özer (1998) in which the words “throbbing, ripping, stabbing, exhausting, burning, sharp” were used as descriptors of pain in Turkish surgical patients.

The administration of analgesic pain medication is the most important pharmacologic intervention for decreasing the severity of pain (Erdine, 2000). In studies by Özer (1998) and Yıldız (1999), analgesic pain medication was determined to be the most important intervention for decreasing pain. This finding is similar to those of other research studies. Despite advances in pain management, pain continues to be undertreated. Nonpharmacologic measures may effectively manage pain but often are overlooked or underused. Nurses who are familiar with simple, noninvasive, nonpharmacologic measures, such as patient positioning, thermal measures, massage therapy, aromatherapy, and mind-body therapies, can identify and educate patients who may benefit from nonpharmacologic interventions (Gatlin, 2007). In addition, studies by Antall and Kresevic, 2004, Good et al., 2005, and Pellino et al. (2005) showed that nonpharmacologic pain interventions reduced pain intensity and patients used fewer opioids. For this reason, nurses should implement nonpharmacologic pain interventions with patient attendance. Also, nurses should encourage patients and their families to use nonpharmacologic pain intervention.

In the examination of the distribution of patients’ statements about situations that increased their pain, the overwhelming majority of the patients stated that changing position and physical therapy exercises increased patients’ pain (Table 3). This finding can be explained by the fact that in this period (on the third postoperative day) patients’ physical therapy programs (range of motion exercises, ambulation, etc.) had just started, their strict bedrest had ended, and their level of independence had increased. In similar studies with orthopedic patients by Closs and Briggs (2002) and Hall-Lord, Larsson, Baath, and Johansson (2004), movement and restricted position accounted for the highest percentage for factors causing pain and discomfort. The findings in other studies are similar to those found in this study. For this reason, nurses and physicians should plan to administer analgesic medications and nonpharmacologic interventions before physical therapy and changing patients’ position.

In the present study of the assessment of pain severity on the third postoperative day, PPI was determined to be a mean of 1.75 ± 1.02. In addition, worst/severest pain was determined to be a mean of 4.55 ± 0.70 (especially during movement/physical therapy) on the third postoperative day, and analgesic medications were taken on a PRN basis (Table 4). In the study by Yavuz (2000), the patients’ postoperative worst/severest pain score of 3.70 ± 0.41 (0-5 scale) was determined before pharmacologic and nonpharmacologic interventions. In the study by Berge, Dolin, Williams, and Harman (2004) as well, the most severe state of pain was a mean score of 5.19 ± 1.49 (0-10 scale). In a study by Sjöling, Nordahl, Olofsson, and Asplund (2003), approximately 83% of the patients were reported to experience a level of severity of ≥4 in the postoperative period. Özer (1998) determined that orthopedic and trauma patients had a pain severity of 1.64 ± 0.79 at the surgical site and at pressure points on the third postoperative day. And Wang and Keck (2004) determined that surgical patients’ pain at its worst scores was 8.90 ± 2.02 (0-10 scale) on the first day. The findings from the present study were similar to this research. Doctors should plan to administer pharmacologics, and nurses should implement nonpharmacologic interventions to decrease pain severity.

There was a statistically significant difference in postoperative third day scores and worst/severest pain scores (Table 4). Although the pain severity scores were decreased at the moment in time, pain increased during movement. And it was thought that pharmacologic and nonpharmacologic interventions were not administered effectively on the third postoperative day (especially before movement and physical therapy). The findings in the studies by Hall-Lord et al. (2004) and Dahlen (2006) agree with the present pain severity scores. Those studies determined that pain severity was decreased following the postoperative days in hip and knee arthroplasty patients. Likewise, in the study by Özer (1998), patients’ pain severity decreased following the postoperative days in Turkish surgical patients. In the literature, there are many reasons why a patient feels reluctant to move. If the patient is experiencing pain, it must be managed effectively and reduced to a level acceptable to the patient. Frequently, the patient is afraid that moving will cause further pain, damage, or harm. A knowledgeable, confident, and reassuring nursing approach is required to encourage and support the patient at these times (Davis, 2005).

Conclusions 

The present research findings determined pain characteristics on the third postoperative day in Turkish orthopedic patients. After an evaluation of the conclusions, nurses must learn the postoperative pain characteristics of orthopedic patients to implement safe and effective postoperative pain management. Furthermore, nurses should assess orthopedic patients’ pain severity on the third day as on the first and second days. We think that this study is a key measure of postoperative pain. Pain Management Nursing’s primary readers are nurses in clinical practice. If nurses understand pain characteristics (location, duration, verbal descriptors, increasing-decreasing factors, and severity) in their patients, they can plan and implement nursing care effectively.