first step towards adequate pain relief

first step towards adequate pain relief. It has two major problems: first, the subjective nature of the pain experience; and second, the lack of quantifiable measurements (McGuire 1992, Watt-Watson et al. 2000). Most prostatectomy patients are old, and as such may need more time to assess their pain (Simons & Malabar 1995, Melzack & Wall 1996). Older patients may receive more attention and pain interventions than younger patients, and evidence suggests that men might be given more medication than women (Simons & Malabar 1995, Yorke et al. 2004).

Information and other support may help patients evaluate their experiences of pain, but the main difficulty is that different people respond to pain in different ways. Hence, direct comparisons are therefore impossible, even where the underlying cause of pain is the same. Verbal assessments may also be misinterpreted (McGuire 1992, Ferguson et al. 1997).

Pain measurement tools

The use of a simple, valid and reliable pain assessment tool in the clinical practice would standardize assessment and contribute to more effective management and evaluation of pain (Taylor 1997). The most common tools are the visual analogue scale (VAS) and 0–10 numeric rating scale (NRS) (Jensen et al. 1986, Carpenter & Brockopp 1995, Coll et al. 2004b), as well as the verbal rating scale (VRS) or verbal descriptor scale (VDS) (Bondestam et al. 1987). The quantitative analysis of the results from these scales is problematic, because it yields a classification where pain is slotted into given categories that are defined in advance. However, the boundary lines between the different categories have not been verified, which complicates the task of interpreting the results (Chapman et al. 1985, Bondestam et al. 1987).

Although VAS provides only a unidimensional measure of pain, its construct validity is good and it can adequately distinguish between minimal, regular and maximal pain (Price et al. 1983). Carpenter and Brockopp (1995) concluded that patients have a tendency to use the middle parts or the ends of the scales. The VAS is easy to complete: it has limited use if the patient is too ill to point at the line, if he or she is unable to conceptualize pain in an abstract fashion along a line, or if the patient is visually, cognitively or physically impaired (Kremer et al. 1981, Chapman et al. 1985, Paice & Cohen 1997). The VAS may also be designed as a red wedge that increases in size towards the right. This has been found to simplify and clarify the use of the tool (Zalon 1993).

Problems have also been reported in the use of NRS, but it is still a useful tool for the purposes of assessing the intensity of acute pain (Bondestam et al. 1987, Scott 1994, Heid & Jage 2002). The NRS offers more alternatives than VDS, but less than VAS (Paice & Cohen 1997). The problem with NRS is that some people have difficulty describing the intensity of pain by reference to numbers (Scott 1994, Ferguson et al. 1997, De Rond et al. 1999).

Several studies on cancer patients have proven VAS, NRS and VRS as valid tools (De Conno et al. 1994, Paice & Cohen 1997), but it was also found that patients did not rate their pain in a mathematically equivalent way – VAS ratings were lower than NRS ratings. On the other hand, many studies in cancer patients have reported positive correlations between estimations based on VAS and NRS (Carpenter & Brockopp 1995, Paice & Cohen 1997).

The reliability of VAS and NRS has not been widely tested in surgical patients, and there are no earlier studies set in a recovery room context. The NRS has been used in an

Australian intensive care unit to measure pain intensity and pain distress (Ferguson et al. 1997), as well as in the clinical area of an emergency department (Puntillo et al. 1999). Sjo¨stro¨m et al. (2000) investigated the pain assessments of critical care nurses (n ¼ 30), physicians (n ¼ 30) and postsurgical patients (n ¼ 180) using VAS. Patients’ expressions seem to be associated with the fact that nurses have underestimated their pain.

In the recovery room, where patients are often tired and unwell, it is important that pain assessment is a quick and easy process with simple and sensitive measures (Jenkinson et al. 1995), especially with the elderly (Closs 1996). Analgesics and anaesthetics may influence patients’ awareness and their ability to assess pain after operation (Bowman 1994). With VAS and NRS pain assessment can easily be repeated, allowing for accurate estimates of the effectiveness of pain management (Scott 1994).

Nurses’ assessments

Nurses are especially inclined to underestimate severe pain (Ketovuori 1987, Zalon 1993, Dalpra & Zampieron 1998, Puntillo et al. 1999) or to overestimate mild pain (Zalon 1993). Nurses have difficulty estimating patients’ pain adequately; mistakes can also occur if patients are asleep (Schaufheuthle et al. 2001). Nurses draw their conclusions on the basis of observations and measurements of physiological features such as blood pressure or pulse (McGuire 1992, Salantera¨ et al. 1999), which, however, are unreliable indicators of pain because they are influenced by a large number of other factors (Closs 1996). Nurses’ overestimations tend to increase if a patient has a rising blood pressure and pulse (Teske et al. 1983, Bondestam et al. 1987).

The study


The aim of the study was to explore the congruency of patients’ and nurses’ pain assessments and the possibility of measuring pain using a pain tool in the recovery room.


A descriptive comparative cross-sectional study design was used. A convenience sample of 45 consecutive prostatectomy patients was chosen and then pain was evaluated six times consecutively.

Premedication and anaesthesia were standardized, and the surgical procedure was performed under general and epidural anaesthesia, which effectively reduce dynamic pain (Heid & Jage 2002). These were based on the following criteria:

• Intervertebral epidural anaesthesia Th 12 L1.

• Start dose was bupivacaine 12Æ5 mg epidurally.

• After 1 h from the start of the procedure epidural infusion was started: fentanyl 0Æ5 mg, bupivacaine 50 mg and physiological saline 20 mL.

• The same pain medication continuing at 3–5 mL/h during and after procedure.

• Combined anaesthesia was induced using: fentanyl 2 mg/ kg, propofol 2 mg/kg, rocuronium 1 mg/kg, nitrous oxide and desflurane.

• Minimum alveolar concentration (MAC) was kept over one and patients received no further relaxants (during the procedure). As the epidural analgesia was effective patients were given only 0Æ6 mg fentanyl, on average, during the operation.


A convenience sample of 45 consecutive prostatectomy patients during the year 2001 was enrolled. Power analysis was not carried out because there are no previous studies conducted in the recovery room. The mean age of patients was 62 years, range 47–73 years. The criteria of the American Society of Anaesthesiologists (ASA) were used in classifying patients into groups according to their physical condition. In this classification, a healthy patient is ASA I, one with mild systemic disease is ASA II and one with severe systemic disease is ASA III. ASA IV refers to a patient with life-threatening severe systemic disease and ASA V to a moribund patient. The majority of patients in this study were in ASA class 2 (f ¼ 40); a few were in class 3 (f ¼ 4) or 4 (f ¼ 1). The operation lasted from 2 to 4 h.

Data collection

Postoperative pain was studied with three pain intensity scales being used by patients: a red-wedge version of VAS; NRS scale (0–10); and the patients’ verbal expressions, VRS. On the VAS scale, the two anchor points represented ‘no pain’ and ‘worst imaginable pain’. Patients’ verbal descriptions were classified into four categories: no pain, moderate pain, intense pain and intolerable 

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