Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Respondent Number: __________
Ward: ______________________
Instructions: Please answer the following questions as honestly as a you can.
Research Objectives
1. To determine the profile of the
respondents in terms of the
following:
1.1 age;
1.2 sex;
1.3 marital status;
1.4 highest educational attainment;
1.5 religion;
1.6 type of operation;
1.7 type of anesthesia used;
1.8 length of surgery; and
1.9 date of operation;
Research Objectives
2. To determine the patients level
of post-operative pain threshold.
Naval, Biliran
Date: _________ Time: __________
Survey Questions
SECTION 1: PATIENTS PROFILE
1. What is your age? Please specify
2. Are you a male or female? 1 Male 2 Female
3. What is your marital status?
1 Single 2 Married 3 Others, please specify
4. What is your highest educational attainment?
1 Elementary level 2 Highschool level
3 College level 4 Others, please specify
5. What is your religion? 1 Catholic 2 Non-Catholic
6. What type of operation did you have?
1 Minor 2 Major
7. What type of anesthesia was used in your operation?
1 Spinal/Epidural/Regional/Local 2 General 3 Both
8. How long did the operation take? Please specify
9. How many days ago your operation was done? Please
specify
Survey Questions
SECTION 2. PAIN THRESHOLD AND PAIN ASSESSMENT
10. In a scale of 0-10, where 0 is no pain, 5 is moderate pain,
and 10 is worst pain. What is your pain score now? Please
specify.
3. To determine the frequency of
assessment of patients post-
operative pain.
Research Objectives
4. To determine the non -
pharmacologic
therapies used in
managing the patients
post-operative pain.
Research Objectives
5. To determine the patients level
of satisfaction with the non-
pharmacologic therapies used in
managing the post-operative
pain.
11. How frequent does the nursing staff assess your pain?
1 Every 30 minutes
2 Every hour
3 Every 2 hours
4 Every 4 hours
5 Once every shift
6 Whenever they like
Survey Questions
SECTION 3. NON-PHARMACOLOGIC PAIN MANAGEMENT
THERAPIES
12. Which of the following non-pharmacologic pain
management therapies you can consider to be the MOST
EFFECTIVE in managing your pain? Choose ONLY ONE
answer.
1 Aromatherapy
2 Comfort touch e.g. massage/cuddles/stroking/rocking
3 Conversation with family or other patients to distract
self from focusing on the pain
4 Guided imagery (imagining a picture in your mind) e.g.
eating chocolates in the beach
5 Listening to music
6 Reading
7 Relaxation techniques e.g. meditation, praying, deep
breathing
8 Positioning, restriction of movement/resting
9 Use of cold compress
10 Use of heat pack
11 Watching video/movies on TV or cellphone
12 Others, please specify
Survey Questions
SECTION 4: LEVEL OF SATISFACTION
13. What is your overall level of satisfaction with the non-
pharmacologic pain management therapies you used to
manage your pain?
1 Not satisfied
2 Slightly satisfied
3 Moderately satisfied
4 Highly satisfied