American Journal of Critical Care. 2004;13: 116-125
Copyright © 2004 by the American Association of Critical-Care Nurses.
Pain Levels Experienced With Activities After Cardiac Surgery
By
Lesley B. Milgrom, RN, MSN,
Jo Ann Brooks, RN, DNS,
Rong Qi, MS,
Karen Bunnell, MSN, NP-C,
Susie Wuestefeld, RN, MBA and
Daniel Beckman, MD.
From the School of Nursing (LBM) and School of Medicine (JAB, RQ, KB), Indiana University; Methodist Medical Research Institute (SW); CorVasc MD’s, PC, and Clarian Health, Methodist Hospital (DB), Indianapolis, Ind.
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Abstract
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• Background Acute pain is common after cardiac surgery and can keep patients from participating in activities that prevent postoperative complications. Accurate assessment and understanding of pain are vital for providing satisfactory pain control and optimizing recovery.
• Objectives To describe pain levels for 5 activities expected of patients after cardiac surgery on postoperative days 1 to 6 and changes in pain levels after chest tube removal and extubation.
• Methods Adults who underwent cardiac surgery were asked to rate the pain associated with various types of activities on postoperative days 1 to 6. Pain levels were compared by postoperative day, activity, and type of cardiac surgery. Pain scores before and after chest tube removal and extubation also were analyzed.
• Results Pain scores were higher on earlier postoperative days. The order of overall pain scores among activities (P < .01) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. Changes in pain reported with coughing (P=.03) and deep breathing or using the incentive spirometer (P = .005) differed significantly over time between surgery groups. After chest tubes were discontinued, patients had lower pain levels at rest (P = .01), with coughing (P=.05), and when getting up (P=.03).
• Conclusions Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain.
Patients often experience acute pain after cardiac surgery.1–3 Postoperative pain can keep patients from participating in expected activities such as deep breathing exercises and getting out of bed, which foster wellness and prevent postoperative complications. Adequate pain assessment and understanding of pain are essential components for providing satisfactory pain control and optimizing postoperative recovery.4
Pain is a completely subjective and multidimensional phenomenon.5,6 Postoperative pain is influenced by physical, environmental, psychological, social, cultural, and individual factors.7 The multiple facets assimilated in the personal experience of pain warrant close attention to the pain level specified by each patient. Examination of the adverse effects of pain that may undermine the desired outcomes of cardiac surgery reaffirms the importance of patients’ postoperative pain rating.
Unrelieved pain has physiological consequences8–10 that may adversely affect recovery after cardiac surgery.11 The sympathetic response to pain adds to cardiac work, and hemodynamic stability may be compromised. Cardiac surgery patients become more susceptible to cardiac irritability because of the sympathetic response, potential for myocardial ischemia, electrolyte imbalances, and anxiety related to pain.12 Pain from the cardiac procedure and chest tubes may result in inadequate lung expansion, retention of secretions due to an ineffective cough force, and immobility promoting hypoxemia, atelectasis, and pneumonia.13–15 Patients with higher pain scores had an increased incidence of atelectasis in a study by Puntillo and Weiss.1 Studies on improved pain management through advanced methods of analgesia have indicated decreases in postoperative atelectasis and pulmonary infections.16,17 Gastrointestinal effects of pain such as nausea, vomiting, and a poor appetite perpetuate the feeling of decreased well-being. Vomiting and decreased nutrition can lead to fluid and electrolyte imbalances and may impede healing. Immune activity may be compromised by the stress response to pain.14
The psychological reaction to pain may involve anxiety, fear, and irritability.7,18 A diminished capacity to concentrate when experiencing pain can interfere with learning, self-care, and activities that promote wellness and prevent complications. Psychological and physiological factors interact with one another and intensify the adverse effects of pain.
| To promote postoperative activity, assessing pain only during rest is insufficient.
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Literature Review
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Studies have revealed that more intense pain levels occur during the first 2 days following cardiac surgery.2,3 Patients described their pain after coronary artery bypass graft (CABG) surgery with terms such as sore, aching, tender, tiring, and annoying more often on postoperative days 2 and 3 in a study by Pozehl et al.19 Pain decreased significantly from postoperative day 2 to day 3, and pain was significantly lower by day 7.
Immobility, a tendency to maintain a supine position, and reduced ambulation are behavioral effects of pain that may adversely influence postoperative outcomes.14,20 Reduced mobility was the most commonly reported effect of pain in a study of acute care patients.21 Participants also reported that pain affected sleep and made them feel worried and exhausted. Some descriptive characteristics defining the nursing diagnosis of pain were immobility, sleep disturbance, and guarding behavior.20 Patients have conveyed that surgical pain worsened with movements or coughing.22 Significantly higher pain intensity after turning was described in a study of traumatically injured adults.23
Endotracheal tube suctioning, coughing, and chest tube removal have been described as painful.22,24 Patients have stated that chest tube discomfort interferes with movement in bed, mobility, and sleep.25 Mueller et al26 reported that patients who had a chest tube in place on postoperative day 2 had significantly higher pain levels than did patients who had their chest tubes removed on day 1. These authors26 suggested that early removal of chest tubes after cardiac surgery limits the pain sensation.
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Purpose
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The belief that pain should normally occur after surgery ignores the significance of self-reported pain and can obstruct effective pain management. The adverse effects of pain can compromise patients’ conditions. Endotracheal tubes, chest tubes, and postoperative activities can cause increased levels of pain. Treating pain levels assessed solely with patients at rest may not be adequate because of the rapid upsurge of activities to prevent postoperative complications. Previous studies did not sufficiently address pain levels experienced with the expected activities that are emphasized postoperatively. Therefore, the purpose of this study was to describe self-reported pain levels for particular activities expected of patients after cardiac surgery, on postoperative days 1 through 6. In addition, pain levels before and after extubation and chest tube removal were examined.
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Research Questions
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The 5 research questions were as follows:
- What pain levels do cardiac surgery patients report on postoperative days 1 through 6 for pain at rest while lying in bed, when coughing, with deep breathing or using an incentive spirometer, with movement or turning in bed, and when getting up to a chair or to walk?
- Do the pain levels reported on postoperative days 1 through 6 differ significantly according to the type of postoperative activity?
- Do the pain levels reported on postoperative days 1 through 6 differ significantly according to the type of cardiac surgical procedure performed?
- Do pain levels decrease significantly after chest tubes are discontinued?
- Do pain levels decrease significantly after extubation?
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Methods
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This study was part of a larger clinical investigation evaluating predictors of postoperative pulmonary complications in patients who had abdominal, cardiac, or thoracic surgery. A secondary, descriptive analysis design was used for the cardiac surgery subset.
The convenience sample selected from 3 urban hospitals in the Midwest consisted of 711 adult patients who underwent cardiac surgery. Inclusion criteria were as follows: age 18 years or older; ability to provide informed consent; and during the hospitalization, no general anesthesia or mechanical ventilation before the current surgery.
The cardiac surgery subset was further differentiated according to the type of cardiac surgery performed. Group 1 consisted of patients who had undergone single (aortic or mitral) valve replacement. Group 2 included patients who had CABG surgery with cardiopulmonary bypass. Patients in group 3 had off-pump coronary artery bypass (OPCAB) surgery. Patients who had undergone multiple cardiac surgeries that included valve replacements, CABG, repair of atrial septal defect, and repair of the ascending or transverse aorta were clustered into group 4. Six patients were not included in the analysis because their surgery type did not fit any of these 4 categories.
Full approval to conduct the primary study was obtained from the appropriate institutional review board. Research assistants identified potential participants who met the inclusion criteria from a daily review of surgical schedules, fully explained and obtained informed consent from the participants before enrolling them in the study, and collected the data. Interrater reliability during training was assessed, with a requirement of 95% agreement on data collection.
Patients were visited daily from postoperative day 1 through postoperative day 6 for a brief interview and examination. A sedation scale was used, and pain levels were assessed only if the sedation level was 1 (awake) or 2 (drowsy). Patients were not questioned if the sedation scale rating was 3 (extremely sleepy or sedated). A horizontal, numerical rating scale from 0 to 10 was the measurement tool used for self-reporting of postoperative pain. Zero was defined as no pain, and 10 referred to "pain as bad as I can imagine." Patients were asked to rate their pain at a random time each postoperative day for 5 levels of activity
- at rest, while lying in bed or sitting in a chair;
- when coughing;
- with deep breathing or using the incentive spirometer;
- with movement or turning in bed; and
- when getting up to a chair or walking.
Data on demographics, medical history, comorbid conditions, smoking history, cognitive status, mobility status, and initial postoperative pain management also were collected.
Data were analyzed with SAS 8.2 statistical software (SAS Institute Inc, Cary, NC). Descriptive statistics (percentages for categorical variables and means with SDs for continuous variables) by cardiac surgery subgroup were computed for all demographic variables for 705 participants. Chi-square tests were used to test for differences between the 4 groups for categorical variables: age, sex, education, mobility, cognitive status, and history of smoking, heart surgery, acute myocardial infarction, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, cerebral vascular accident, and renal disease. Fisher exact tests, as alternatives for small frequencies, were computed for race, asthma history, and initial pain management variables. The Kruskal-Wallis test was used for the continuous variables: total length of stay, length of stay before surgery, and duration of intubation. Statistical significance was set a priori at P
.05.
Descriptive statistics (means, SDs, and ranges) were computed to evaluate the pain scores reported on postoperative days 1 through 6 for the 5 separate activities. A mixed-model analysis of variance (ANOVA) with repeated measurement was used to analyze the pain score with postoperative day, activity, and the interaction between day and activity to determine if pain scores differed between activities. Five separate mixed-model ANOVAs with repeated measurement were used to evaluate the impact of type of cardiac surgery on the pain scores for each activity. Similar mixed-model ANOVAs were used to determine if pain scores decreased significantly after chest tube discontinuation and extubation. If the P value was significant, a Tukey test for multiple comparisons was performed.
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Results
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Data on 705 cardiac surgery patients, 484 men and 221 women, were analyzed. Age ranged from 25 years to 97 years (mean 65 years; SD 11.3). The single valve replacement group consisted of 39 participants (5.5%). The group undergoing CABG surgery with cardiopulmonary bypass had 480 participants (68.1%). A total of 83 patients (11.8%) had undergone OPCAB surgery. The multiple surgery group had 103 patients (14.6%). Demographic data for the patients by surgical group are presented in Table 1
. The multiple surgery group included significantly older patients, fewer smokers, and a greater percentage of patients with a history of CHF than did any other group. The CABG group had fewer patients with a history of CHF than did the multiple surgery and single valve replacement groups. The OPCAB group had more smokers, more patients with a history of heart surgery, but fewer patients with a history of CHF than did the other groups. The single valve replacement group consisted of relatively more women, patients with mobility limitations, and nonsmokers. The single valve replacement group had relatively fewer patients with a history of heart surgery and acute myocardial infarction. Additionally, the CABG and OPCAB groups had shorter mean total lengths of stay and intubation times than did the other groups. The 4 groups did not differ significantly in race; education level; cognitive status; or history of asthma, chronic obstructive pulmonary disease, hypertension, cerebral vascular accident, or renal disease.
| Greatest pain levels occurred during coughing; lowest levels, at rest.
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The 4 groups did differ significantly (P = .007) in the type of initial postoperative pain management used (Table 2). The majority of patients in all subgroups (616 patients) were treated with a reactive approach to pain management, with medications administered intravenously or intramuscularly as needed. The multiple surgery group had the highest percentage of patients receiving intravenous/intramuscular medication (93.2%), and the single valve replacement group had the lowest percentage (82.1%). A very small percentage of patients in the CABG, OPCAB, and single valve replacement groups had epidurals for initial pain control. Patient-controlled analgesia was used for 82 patients as the initial pain management, with the highest percentage in the single valve replacement group (15.4%) and the lowest in the OPCAB group (4.8%).
Table 3 contains the descriptive statistics of the self-reported pain scores for each activity during every postoperative day. Missing values were excluded when these unadjusted means were calculated. On postoperative day 1, the mean pain score was lowest for activity at rest at 3.26 (SD 2.70) and highest for coughing at 6.45 (SD 2.96). On postoperative day 6, the mean pain score at rest had decreased to 1.82 (SD 2.40) and the mean score for coughing was 4.33 (SD 2.73). Multiple comparison of pairs of activity within each day, based on adjusted means because of missing data, indicated that pain scores for the patients were higher on earlier postoperative days than on later postoperative days. Pain score ratings for each postoperative day by activity are shown in Figure 1. Overall, self-reported pain scores differed significantly among activities (P < .01). Adjusted by time, the order of pain levels for each activity from highest to lowest was coughing; movement or turning in bed; getting up to a chair or to walk; deep breathing or using the incentive spirometer; and at rest, while lying in bed or sitting in a chair.
For resting, moving or turning in bed, and getting out of bed, the type of cardiac surgery was not related to pain scores. However, pain levels reported for coughing and for deep breathing or using the incentive spirometer between groups were inconsistent over time (P = .03 and .005, respectively). Figure 2 shows that the OPCAB group had a large decrease in pain level with coughing from postoperative day 3 to day 4, whereas the single valve replacement group had increased pain scores for the same period. Figure 3 reveals a similar pattern for the OPCAB group versus the single valve replacement group for deep breathing or using the incentive spirometer between postoperative days 3 and 4.
A total of 66% of patients had chest tubes solely during the day of surgery and postoperative day 1. Seven patients still had chest tubes at postoperative day 6. After adjustment for time, patients had lower pain levels after the chest tubes were discontinued while at rest (P = .01), when coughing (P = .05), and when getting up to a chair or walking (P = .03). For deep breathing or using the incentive spirometer and with movement or turning in bed, chest tubes were not a significant factor affecting pain scores.
Of the 705 cardiac patients, 608 (86.2%) had mechanical ventilation solely on the day of surgery. Eight patients remained intubated on postoperative day 6. After the data were adjusted for time, we found no significant difference in reported pain level for any activity after the patients were extubated.
| Removing chest tubes significantly decreases pain associated with activity.
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Discussion
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The Agency for Health Care Policy and Research27 (now the Agency for Healthcare Research and Quality) and the American Pain Society28 have provided guidelines for improved assessment and management to reduce acute postoperative pain. Although mean pain scores for individual activities decreased each postoperative day in the current study, the data revealed that patients had pain throughout the 6-day period despite the availability of pain medication and alternative methods for pain relief by nurses. The finding that pain levels were higher on earlier postoperative days than on later postoperative days is consistent with previous research.2,3,19 However, patients continued to have pain on postoperative days 5 and 6. Mean pain ratings (Table 3
) were approximately 3 to 4 (range 0–10) for all activities except rest at a point when cardiac surgery patients are typically discharged from the hospital and their activities continue to increase. With interventions for pain management available, should patients be experiencing pain on postoperative day 6? Results of some studies suggested that patients are usually satisfied with their overall pain management despite reports of moderate or severe pain.29–32 The expression of satisfaction with pain relief, even when postoperative patients are experiencing pain, may be influenced by their view of pain. Patients may minimize their pain experience by perceptions that it is normal to have pain after surgery, pain builds character, and pain is purposeful in recovery. Fear of addiction to the medication or of experiencing adverse effects, cultural stoicism, patients’ perceived lack of power, and not knowing what pain relief measures are available may also influence their attitude toward pain and general satisfaction with pain relief.31,32 If the 3 levels of pain severity derived from interference with patients’ function defined by Serlin et al33 were used, the mean pain scores for all activities on postoperative days 5 and 6 presented in Table 3 would be rated as mild. However, the actual pain levels even on postoperative day 6 ranged from no pain to the highest severity of pain, reaffirming the need to assess and treat each patient’s pain level on an individual basis. Nurses should also consider if patients self-limit postoperative activities that cause pain, specifically those activities that prevent postoperative complications.
Coughing elicited the highest level of pain; next, in order, were movement or turning in bed, moving out of bed to a chair or walking, deep breathing or using an incentive spirometer, and at rest. It is not surprising that coughing was associated with the most pain for patients with a sternotomy incision. Previous investigators22,23 reported that coughing, movement, and turning elicit pain, although none compared levels of pain for each activity. Patients reported reduced mobility as the most common effect of pain in a study by Yates et al.21 Patients are less likely to adequately perform activities that reduce postoperative complications, such as deep breathing and getting out of bed, if these interventions cause more pain. Therefore, pain should not be assessed solely while patients are at rest. Pain assessment should occur during expected postoperative activities. Also, some patients in our study had an extended period of hospitalization (range 2–98 days). Did the adverse effects of pain contribute to postoperative complications that led to extended lengths of stay? A comprehensive assessment of pain followed by adequate pain management optimizes activity performance and a timely recovery.
The single valve replacement group had increased pain levels from postoperative day 3 to 4 with coughing and deep breathing or using the incentive spirometer, whereas the OPCAB group had a decrease in the level of pain on the same 2 consecutive days for these activities (Figures 2 and 3). The significant demographic and pain management differences between these 2 groups may have influenced the disparity in reported pain levels. The single valve replacement group included more women. In a study by Yates et al,21 women reported significantly higher pain scores and described pain that was distressing to excruciating more frequently than men did. Women reportedly have a lower threshold and tolerance than do men to certain types of pain, influenced by biological and psychosocial gender differences.34–37 Sex-related differences in response to analgesic medications36 and potential gender bias in pain assessment and treatment37 have also been reported. The number of patients with mobility limitations and the number of patients with a history of CHF were also higher in the single valve replacement group. More intense exertion with activity may have been required for patients with mobility limitations that caused increased pain. The patients with a history of CHF may have had a greater concentration of respiratory maneuvers such as deep breathing because of the pulmonary sensitivity to increased fluid volumes. Although differences between the 4 groups in cognitive status were not significant, a greater percentage of patients in the single valve replacement group had moderate to severe cognitive impairment, a situation that may have influenced their rating of pain. The OPCAB group had shorter intubation times, and shorter length of stay, but surprisingly was composed of more smokers. Smokers would be expected to have increased secretions requiring coughing, resulting in higher pain levels. The OPCAB group also had more patients with a history of heart surgery. Their previous experience with pain control, knowing what pain management interventions were available and what worked for them, may have allowed for better pain control within this group.
The level of pain at rest, when coughing, and when getting up to a chair or walking decreased significantly from the day before to the day after chest tube removal. Although Fox et al25 also reported that chest tubes hampered movement in bed, our results support the significant decrease in pain level after chest tube removal reported by Mueller et al.26 Chest tubes are invasive and rigid, extending into the surgical area. Healthcare professionals should be responsive to pain levels reported by patients with chest tubes so that postoperative activities are not limited because of pain.
Pain levels did not differ significantly before and after extubation. Endotracheal tube suctioning has been described as painful.22,24 Most patients in our study were extubated before the first postoperative day, when data collection on pain was initiated. The analysis of data for patients who remained intubated after postoperative day 1 may have been influenced by the tendency of intubated patients to be less mobile and perhaps better medicated because of the decreased risk of respiratory depression while receiving mechanical ventilation.
| Pain management should be individualized according to self-reported pain levels during postoperative activities.
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The generalizability of our findings are limited to the experience at 3 institutions and by the missing data for patients who were unable to rate their pain because of sedation, altered mental status, or early discharge. Only the initial intervention for managing postoperative pain was viewed in this study. The type, amount, and frequency of pain management used for each patient was not considered in relation to pain levels assessed on postoperative days 1 through 6, although these findings may have affected patients’ pain ratings. Also, the timing of the daily assessment of pain levels was random. Experiencing pain at the time of assessment or conversely, having been adequately medicated for pain during questioning may have influenced the patients’ responses. The sample represents a variety of cardiac surgeries and an acceptable size. However, differences between groups in the type of cardiac surgery performed were significant.
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Implications
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Pain is subjective and unpleasant. Multiple factors shape an individual’s expression of pain, and adverse effects can compromise a patient’s well-being. Pain relief indicates effective pain management and is an important outcome of care on the postoperative path to recovery. The tendency to manage patients within a similar group in the same way, for example, using standardized pain interventions for postoperative cardiac surgery patients, should be avoided. Patients are expected to perform activities that prevent postoperative complications, yet pain may be rated solely when patients are at rest and not adequately treated. Our findings revealed that pain levels at rest are significantly lower than at other times. Postoperative activities and the presence of chest tubes intensified pain levels. Researchers have identified postoperative complications associated with increased pain levels.13,14,17 Close attention to patients’ self-reported pain levels during expected activities after cardiac surgery may curtail the adverse effects of pain and complications, and promote postoperative recovery.38 Further research is needed on pain levels with various postoperative interventions, investigating the adequacy of pain management and associated postoperative complications.
Exploring patients’ perceptions of pain may benefit pain assessment and management. The level of pain acceptable to each patient should be assessed and should serve as the patient’s standard for effective pain management39 only after misconceptions are addressed and the patient is informed about the pain interventions available. Preemptive medication,40 multimodal regimens,41 and alternative therapies should be considered for individualized management of pain based on self-rated pain assessments leveled for activities.
| Avoid the tendency to use standard pain interventions to manage all cardiac surgery patients.
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Research continues to indicate that many patients still experience moderate to severe postoperative pain despite the guidelines identifying pain control as a priority in patients’ care. Therefore, evidence-based education for healthcare professionals on the phenomenon, assessment, and treatment of pain should be a priority. Effective pain assessment and management after cardiac surgery can be achieved through a collaborative process in implementing and advancing clinical practice guidelines that emphasize an individualized approach for alleviating postoperative pain.
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ACKNOWLEDGMENTS
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We thank Phyllis Dexter, PhD, and Marsha Ellett, DNS, for editorial assistance with the manuscript. Funding for this study was provided by National Institute of Nursing Research grant NR0-4192, the Showalter Cardiovascular Foundation at Methodist Hospital, and the American Lung Association of Indiana.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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Abstract
Literature Review
