Pain Assessment in Pediatric Trauma Patients: A Chart Review

Abstract

A retrospective chart review was done on 63 pediatric trauma patients in three hospitals in a Central Washington community. A survey tool was developed for the review. Demographic, injury, trauma, and assessment data were gathered, with a special focus on pain management. Descriptive statistics were used to analyze data. Overall, the charts reviewed reflected national pediatric injury admissions and 86% ofthe patients did receive some pain medication during their emergency-department stay. However, data demonstrated that there was no documented use of pain assessment scales nor were narrative descriptions of pain charted in any of the reviewed cases. Also, there was no documented re-assessment or re-evaluation. There was no evidence that pain was adequately controlled. Without proper assessment and documentation, appropriate treatment ofpain is definitely an unknown. The role of the nurse practitioner is identifying the barriers, aiding in the elimination of barriers, through proper education of both the caregivers and the patients, and insisting on accountability of the medical institution to the clinicians.