Date of Graduation
Spring 5-17-2024
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
MSN project
First Advisor
Jennifer Zesati, MSN, RN
Abstract
Problem Pain management is essential when providing quality care, and adequate documentation of pain assessment and reassessment with administration of opioid pain medications by nurses is necessary for patient safety and satisfaction. Context Nurses play a pivotal role in providing safe and effective administration of opioid pain medication and documentation of pain assessments. This quality improvement (QI) project aimed to increase opioid medication administration assessment and documentation compliance rate for nurses to 90% or greater in two medical-surgical units. Intervention A knowledge check survey was utilized to assess nurse understanding of required data needed to document, and timing for documentation to meet compliance. Interventions included visual reminders, informational posters, and instructions on how to access individual compliance reports. Measures A post-intervention survey was used to collect nurse feedback on effectiveness of interventions and to gather further suggestions. Quarterly compliance rate data was obtained to identify if improvements in compliance rates were achieved. Results Unit A scored 62% for pre-assessment compliance, and 90% for reassessment compliance. Unit B scored 77% for pre-assessment compliance and 89% for reassessment compliance. Conclusions Providing visual aids as reminders for completing pain assessment and reassessment documentation and expanding nurse education on current self-compliance rates are useful for increasing nurse documentation compliance rates in medical-surgical units. Further evaluation of pain assessment and reassessment documentation compliance rates are required to identify sustainability and opportunities for greater improvements.
Recommended Citation
Espinoza, Alicia, "Pain Assessment and Reassessment Documentation Improvements in Medical-Surgical Units" (2024). Master's Projects and Capstones. 1673.
https://repository.usfca.edu/capstone/1673
