AJCC
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

American Journal of Critical Care. 2004;13: 126-136
Copyright © 2004 by the American Association of Critical-Care Nurses.
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Right arrow Take the CE Test
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gélinas, C.
Right arrow Articles by Puntillo, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gélinas, C.
Right arrow Articles by Puntillo, K.

Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study

By Céline Gélinas, RN, MSc, Martine Fortier, BA, Chantal Viens, RN, PhD, Lise Fillion, RN, PhD and Kathleen Puntillo, RN, DNSc. From Faculty of Nursing, University Laval, Quebec City, Quebec (CG, MF, CV, LF), and Department of Physiological Nursing, University of California, San Francisco, Calif (KP).


   Abstract
Top
 Abstract
Theoretical Framework
 Study Aim
 Methods
 Results
 Discussion
 Conclusion
 References
 
• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally.

• Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated.

• Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories.

• Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (<25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time.

• Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.

Pain is an important stressor for critical care patients.1–6 Many sources of pain have been identified, such as acute illness, surgery, trauma, invasive equipment, nursing and medical interventions, and immobility.7–10 Moderate to severe pain is experienced by patients in critical care, a finding that reinforces the importance of this stressor.4,5,11–18

The concepts of pain and discomfort are often used interchangeably in research.19–23 The standard definition of pain is an unpleasant sensory and emotional experience associated with actual or potential damage.24 Discomfort is defined as a negative affective and/or physical state subject to variation in magnitude in response to internal or environmental conditions.25 In both definitions, physical and affective components are highlighted. These 2 concepts are subjective and have many components. For instance, pain has been associated with sensory, affective, cognitive, physiological, and behavioral components.26–29 Some authors21 describe discomfort as part of pain. Indeed, pain can be viewed as a point on a continuum from mild discomfort to severe pain.20 In this article, we specifically address pain.

Because pain is an important problem in critical care, its management is a priority. The first step in providing adequate pain relief for patients is appropriate assessment. The Agency for Health Care Policy and Research (now Agency for Healthcare Research and Quality)30 proposed guidelines and recommendations for the assessment of acute pain. As often as possible, patients’ self-reports of pain should be obtained because these reports are the most valid measure of pain.31 Unfortunately, especially in critical care, many factors may alter verbal communication with patients, such as administration of sedative agents, mechanical ventilation, and patients’ changes in level of consciousness.7,10,32

Nevertheless, although they cannot speak, many intubated patients can communicate by using facial expressions or hand motions or by seeking attention with other movements.4 Tools for assessing pain, such as a 0-to–10 pain intensity scale and the short-form McGill Pain Questionnaire33 were used in some studies5,13,14 to document intubated patients’ self-reports of pain. When patients cannot express themselves in any way, observable indicators, clustered into physiological and behavioral categories, become unique indices for the assessment of pain.4,7,8,10,29,34–36 The Agency for Health Care Policy and Research30 strongly recommended that these indicators become part of pain assessment when patients cannot express themselves. Moreover, pain should be assessed and reassessed to further document pain relief after a pain intervention.

Little research has been done on the documentation of pain assessment in critical care. Much of this research, based on review of medical files, surveys, or interviews, described the administration of analgesics to acute and critical care patients18,37–40 or the documentation of pain assessment in patients who could verbalize their pain.41–43 Most of these studies highlighted the lack of documentation on pain assessment and the undertreatment of pain. As a solution to this situation, implementation of a pain flowsheet has been recommended.8,18,41,44,45 Further research on pain in critical care is needed, especially in nonverbal patients. Our study was designed to explore documentation of pain assessment and management in critically ill intubated patients.


   Theoretical Framework
Top
 Abstract
 Theoretical Framework
Study Aim
 Methods
 Results
 Discussion
 Conclusion
 References
 
As a theoretical framework, the multidimensional pain theory developed by Melzack28 provides an appropriate model for pain assessment. In this model, pain indicators can be clustered into nonobservable/subjective and observable/objective categories. Nonobservable indicators constitute subjective information, patients’ self-reports of pain, including the sensory, emotional, and cognitive components of pain. The sensory component refers to characteristics of pain experienced by the patient, such as intensity, location, quality, aggravating or relieving factors, and onset. The emotional component refers to feelings or emotions associated with the experience of pain, and the cognitive component refers to the meaning given to pain.26–28

Observable indicators include those of the physiological and behavioral components of pain. These indicators can be used by healthcare professionals for pain assessment. Indeed, physiological indicators can be easily documented in critical care settings because of continuous monitoring. For instance, increased blood pressure and increased cardiac rate are common signs related to acute pain.46,47 Behavioral indicators, such as facial expression, body movements, rigid posture, and compliance with the ventilator, which have been related to acute pain,46–49 can be documented by nurses through observation of patients. Melzack’s theory was used as a guide to develop a data collection instrument for this study.


   Study Aim
Top
 Abstract
 Theoretical Framework
 Study Aim
Methods
 Results
 Discussion
 Conclusion
 References
 
The primary aim of this study was to determine, from a review of medical files, potential indicators of pain assessment and reassessment of critically ill intubated patients. To achieve this aim, 3 objectives were pursued:

  1. to describe pain indicators used by nurses and physicians for pain assessment,
  2. to describe pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and
  3. to describe pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management.


   Methods
Top
 Abstract
 Theoretical Framework
 Study Aim
 Methods
Results
 Discussion
 Conclusion
 References
 
Design
A descriptive design was used for this exploratory quantitative study. Because data were collected from patients’ medical files of past hospitalizations, the study was retrospective.

Settings
In order to provide documentation on a variety of critically ill intubated patients, data from the files of 2 specialized healthcare centers in Quebec City, Quebec, a cardiology/pneumology center and a neurosurgery/traumatology center, were reviewed.

Sample
After the study was approved by the human research committee of each institution, 52 medical files were reviewed: 24 from the cardiology/pneumology center and 28 from the neurosurgery/traumatology center. Patients’ medical files were included in the study if the patients met the following criteria: (1) age 18 years or older, (2) intubation for at least 24 hours in the intensive care unit during the period 1999 to 2001 inclusively, (3) intubation occurred after surgery, trauma, or a medical complication or because of a pulmonary disease, and (4) documentation of pain episodes in the medical record.

The size of the sample was determined by the saturation of information.50 Thus, data collection stopped when the absence of new information was noted. Identification codes were used to ensure confidentiality of the patients’ medical files.

Instrument
The instrument used for data collection was organized to collect 2 types of data: (1) general and medical information and (2) physicians’ and nurses’ notes on patients’ pain. The instrument was developed on the basis of some existing validated instruments51,52 and, especially, the conceptual framework of Melzack28 described earlier. The content of the instrument was verified by 3 experts in nursing and measurement. Corrections to the instrument were made according to the experts’ comments.

In the first section, sex and age were included as general information. Diagnosis, type of surgery, type of trauma, and complications were included as medical information.

In the second section, physicians’ and nurses’ notes on pain were organized differently. For physicians’ notes, any information on pain was collected. For nurses’ notes, a form (see FigureGo) was designed to record information on pain assessment, management, and reassessment.



View larger version (20K):
[in this window]
[in a new window]
  		Data collection form for pain documentation in nurses’ notes. Abbreviations: BP, blood pressure; HR, heart rate; RR, respiratory rate; SaO2, arterial oxygen saturation.

 
Procedure
Two of us, the principal researcher (C.G.) and a research assistant (M.F.), reviewed the files to select pain episodes. The episodes were selected on the basis of the notation of acute pain indicators, as defined in the description of the theoretical framework, in the physicians’ or nurses’ notes and/or notations of the administration of an analgesic and/or a sedative agent. Data were recorded on the instrument created for this study.

From each medical file, data on pain episodes that occurred in the first 72 hours after the patients were intubated were collected from the nurses’ notes. Data collection of pain episodes stopped at the end of that 72-hour period or at saturation of information. Data on a total of 2 to 6 pain episodes in chronological order were collected from nurses’ notes in each medical file. Data on pain assessment from physicians’ notes were collected for the same 72-hour interval.

Data Analysis
Frequencies and percentages were calculated for each pain-related indicator in assessment and reassessment and in pain management. SPSS 10.0 software (SPSS Inc, Chicago, Ill) was used for data analysis.


   Results
Top
 Abstract
 Theoretical Framework
 Study Aim
 Methods
 Results
Discussion
 Conclusion
 References
 
Characteristics of the Sample
The sample consisted of 21 women and 31 men. The mean age was 55.55 years (SD 16.45 years). Patients had been hospitalized because of a heart condition (27%), cerebral hemorrhage (23%), head injury (19%), other trauma (10%), cancer (10%), pulmonary disease (4%), or other causes (7%). In most instances (79%), they had undergone surgery; the most common types were neurosurgery (40%), cardiac surgery (23%), and thoracic surgery (10%). A total of 29% of the sample had been hospitalized after head injury or other trauma caused by incidents such as a fall (40%), motor vehicle accident (27%), being hit by a car (13%), or other causes (20%).

Pain Assessment
  Physicians.   Although physicians were not at the patients’ bedsides on a continuous basis, results are presented in terms of the number of medical files (n = 52) in which pain assessment was documented by physicians. A large proportion of the physicians (42%) did not record any information about pain assessment in the 52 medical files selected. Pain-related indicators that were recorded were clustered into 3 categories (Table 1Go): nonobservable indicators, observable indicators, and responses to treatment.


View this table:
[in this window]
[in a new window]
  		Table 1 Pain assessment in physicians’ notes

 
The nonobservable indicators were patients’ self-reports of pain. In general, physicians did not record information about patients’ self-reports, and it was once recorded that a patient had reported no pain.


In most cases, physicians did not document any pain assessment.

 

Observable indicators that could imply pain were classified into 6 subcategories: body movements, compliance with the ventilator, neuromuscular signs, means of communication, facial expressions, and reactions to physical examination. Body movements, almost exclusively agitation, were often recorded by physicians. In a few files, the physicians mentioned information about a patient’s compliance with the ventilator, such as "coughs against ventilator" or "bites endotracheal tube." Neuromuscular signs were rarely mentioned. For instance, a physician wrote once that a patient was spastic. Information on means of communication such as patients’ trying to speak or acknowledging not being in pain and data on facial expressions such as grimacing were again rarely recorded. Patients’ reactions to the physical examination were often documented. Notes related to the patients’ reactions to pain, such as withdrawal, localization of pain, and the absence of reaction to pain stimuli, were the most recorded indicators. For physicians, these data seemed to constitute important information in pain assessment.

In addition, responses to treatment were documented in the physicians’ notes. Information about the effectiveness of medication was provided in some files, such as "sedated," "not sedated," or "not relieved."

  Nurses.   Data on 183 pain episodes were collected from nurses’ notes. Nurses’ data on pain assessment were classified into 2 main categories (Table 2Go): nonobservable indicators and observable indicators.


View this table:
[in this window]
[in a new window]
  		Table 2 Pain assessment in nurses’ notes

 
The nonobservable indicators included patients’ self-reports of pain. The methods used to obtain the self-reports from intubated patients were not specified. The notes usually stated, "Patient expresses pain" or "Patient says he has pain or is uncomfortable." In the 183 pain episodes documented, the use of a pain scale was mentioned in only 3 (1.6%).


Nurses documented pain behaviors much more often than physiological indicators.

 

Observable indicators included physiological and behavioral indicators. Potential physiological indicators, documented in 44 (24%) of the 183 pain episodes, were clustered into 3 subcategories: cardiovascular, respiratory, and cerebral responses. Cardiovascular indicators associated with pain were increased blood pressure, increased or altered cardiac rate or rhythm (tachycardia or arrhythmia), decreased cardiac output (or contractility), increased afterload (systemic resistances), and elevated preload (increased central venous pressure and/or pulmonary capillary wedge pressure). Increased respiratory frequency (or tachypnea), decreased oxygen saturation and respiratory volume, and deterioration of arterial blood gas results constituted respiratory indicators associated with pain. Pain-related cerebral responses were increased intracranial pressure and decreased cerebral perfusion.

In most of the files, the nurses recorded information on behavioral indicators that could be related to pain. These potential pain indicators, documented in 133 (73%) of the 183 pain episodes, were clustered into 7 subcategories: body movements, compliance with the ventilator, neuromuscular signs, means of communication, facial expressions, rest quality, and neurological state. Body movements were clearly the most recorded behaviors. Agitation was mentioned for more than half of the pain episodes. In reference to body movements, nurses recorded information such as "tries to sit," "movements directed towards the endotracheal tube," "pulls restraints," and "touches the pain site." Notes on patients’ compliance with the ventilator included comments on patients’ biting the endotracheal tube, coughing, activating alarms, and not being "well ventilated." Neuromuscular signs noted were muscular rigidity and shivers. Means of communication were described as patients trying to communicate with the nurses, such as making head signs, punching the bed to make noise, pointing to something, or gesticulating. Facial expressions recorded included wincing, opened eyes, red and tensed face, and frowning. Information on rest quality ("not being able to sleep," "abruptly waking up") was also documented. Finally, the neurological state, which refers to patients’ collaboration, their reaction to pain, and their orientation, were rarely noted by nurses in a pain context.

Pain Management
Pain management provided by nurses to patients was clustered into pharmacological and nonpharmacological interventions (Table 3Go). Pharmacological pain interventions were noted in 163 (89%) of the 183 episodes. These included administration of analgesics, sedatives, and other agents. When used alone, sedatives were administered a little more often than were analgesics. However, analgesics and sedatives were often administered concomitantly. Codeine, morphine, and fentanyl were the analgesics used most often. Acetaminophen, hydromorphone, and meperidine were used less often. Midazolam was, by far, the sedative administered most often. Lorazepam and propofol were also used. Other therapies used included epidural perfusion and administration of methotrimeprazine and haloperidol. A small proportion of patients were receiving continuous perfusion of analgesic or sedative.


View this table:
[in this window]
[in a new window]
  		Table 3 Pain management in nurses’ notes

 
Nonpharmacological pain interventions were noted in 41 (22%) of the 183 episodes. Positioning and endotracheal suctioning were often used to promote patients’ comfort. In addition, safety-oriented interventions (obtaining a blood sample for determination of arterial blood gas, adjusting the ventilator or postponing extubation, using restraints, or inserting an oropharyngeal airway) and other comfort measures (massage, oral care, wound care, reassurance, providing information) were recorded. In 73 (40%) of the 183 episodes, physicians were advised about the situation by telephone or were in the unit and wrote prescriptions.

Pain Reassessment
Almost 40% of pain episodes were not reassessed by nurses after pain interventions to verify the effectiveness of the intervention. Nurses’ notes on pain reassessment, up to an hour after the intervention, were classified into the same 2 categories as those for initial assessment (Table 4Go): nonobservable indicators and observable indicators.


View this table:
[in this window]
[in a new window]
  		Table 4 Pain reassessment in nurses’ notes

 
Among the patients’ self-reports, expressions of persistent pain were documented in 7 episodes and of relieved pain in 7 episodes. A pain intensity scale was used only once.

Potential physiological and behavioral indicators were also documented as observable indicators. Physiological indicators were clustered into 4 subcategories, the 3 identified for initial pain assessment and an additional global category. In general, some of these indicators were associated with pain relief, whereas for others we assumed that they signified that no change had occurred in the pain situation. Cardiovascular indicators, specifically decreased blood pressure, were recorded and could be associated with pain relief. Respiratory indicators, such as an improvement in oxygen saturation and decreased respiratory rate, were recorded for 4 pain episodes and could also be associated with pain relief. On the other hand, a decrease in oxygen saturation was recorded for 6 pain episodes and could suggest the persistence of pain. In the category of cerebral responses, decreased intracranial pressure was recorded. This indicator could be associated with pain relief. A global evaluation, such as stable state or vital signs, was reported a few times.


Effectiveness of pain intervention was documented in most cases (60%).

 

Behavioral indicators were also clustered in the same subcategories as those identified for initial pain assessment. Again, some indicators were associated with pain relief, whereas others suggested no change in the pain situation. In the category of body movements, agitation was sometimes recorded and could be associated with the persistence of pain. In relation to compliance with the ventilator, coughing, and biting the endotracheal tube were recorded for 2 pain episodes and could be associated with persistence of pain. On the other hand, not fighting the ventilator was recorded for 2 pain episodes and could be associated with pain relief. Neuromuscular signs, such as vigorous muscular strength, rigidity, and persistent shivering, were considered implications of persistent pain or an absence of pain relief. Only decreased shivering, recorded for 1 pain episode, could be associated with pain relief. No information on means of communication and facial expressions was recorded. The most frequent indicator of possible pain relief was rest quality: "patient seems to rest," "rests within intervals," and "calm." Rest quality was documented for several episodes. Finally, the neurological state, meaning no problem with a patient’s cooperation, was recorded a few times.


   Discussion
Top
 Abstract
 Theoretical Framework
 Study Aim
 Methods
 Results
 Discussion
Conclusion
 References
 
Pain Assessment
Nonobservable and observable indicators were both identified in physicians’ and nurses’ notes, as proposed in Melzack’s model for pain assessment.28 In the category of nonobservable indicators, only minimal information on the sensory component was documented about patients’ self-reports of pain, mainly recorded by nurses. This documentation consisted of basic information about the occurrence (presence or absence) of pain and seldom included descriptions of the pain’s intensity. In fact, a pain scale was used for only 3 episodes, which were experienced by patients treated with an epidural perfusion protocol, which includes a pain scale. A previous study53 highlighted that patients receiving patient-controlled analgesia or epidural infusions of analgesics received formal pain assessment, whereas other patients did not. Other investigators18,41,42,54 reported that a pain intensity scale was used less than 25% of the time in current practice. Yet, in previous studies5,13,14 of intubated patients, pain tools were used. For pain assessment in critically ill patients, both occurrence and intensity of pain should at least be reported.8

None of the affective and cognitive components of pain were documented. These components do not seem to be documented in current practice in intensive care units. A possible explanation is that intubated patients might not be able to provide much information while they are sedated.

In the category of observable indicators, both physiological and behavioral components were reported, as proposed by Melzack.28 These indicators were considered potential indicators of pain. Physiological indicators, recorded by nurses but not by physicians, appeared to be relevant cues for pain assessment even though the indicators were less frequently identified than were behavioral indicators. This situation can be explained, in part, by the fact that nurses record vital signs on a sheet separate from their notes. Thus, they may consider it irrelevant to duplicate this information in their notes.

Nevertheless, cardiovascular and respiratory indicators can be easily documented in critical care settings. Some of these indicators are commonly monitored, such as blood pressure, cardiac rate, respiratory rate, and oxygen saturation. Others, such as some cardiovascular indicators (cardiac output, systemic resistance) and cerebral responses (intracranial pressure and cerebral perfusion), are specific to certain specialized healthcare centers; obtaining these indicators requires specialized hemodynamic monitoring equipment. Vital signs seem to be relevant to nurses in assessing pain18 and are recommended in the documentation of pain assessment.8 In addition, increased blood pressure and increased cardiac rate have been related to acute pain.8,46,47 However, the relevance of physiological indicators for pain assessment needs to be further explored.

Many subcategories of behavioral indicators were identified in both the physicians’ and the nurses’ notes. Body movements were the most frequent. They are also considered important cues for pain assessment.18,37,46–49 Another behavioral indicator was compliance with the ventilator, which Payen et al46 consider a relevant pain indicator in intubated patients. Neuromuscular signs, mainly referring to muscular tension, were also documented. In contrast to other researchers who confuse neuromuscular signs with body movements,46 we considered this indicator a type of information distinct from body movements. Means of communication was created as a subcategory of behavioral indicators in agreement with Puntillo’s results.4 In that study, intubated patients used movements to communicate pain. Even though facial expressions may be recognized as an important indicator for pain,18,37,46–49,55 they were less often recorded by nurses and physicians.

In general, more information about pain assessment was reported in nurses’ notes than in physicians’ notes. This finding is not surprising because physicians are not at patients’ bedsides as often as nurses are. In addition, physicians rely on nurses’ pain assessments of patients to orient the practice in pain control.18

Some behavioral indicators were documented by either physicians or nurses but not by both. Physicians use physical examinations and related indicators to diagnose pain.18 Reactions to physical examinations appeared to be important information documented by physicians in relation to pain assessment. Nurses, because they are always present at patients’ bedsides, documented rest quality. This indicator is commonly used in pain assessment for neonates and infants56–58 and is also used for adults.35 In addition, neurological state was seldom considered complementary information in nurses’ notes.


Pain documentation is incomplete.

 

In this study, both physicians and nurses used observable indicators more often than they used patients’ self-reports of pain. This finding is consistent with the results of previous studies.37,59,60 The availability of physiological indicators as a result of invasive technology and continuous monitoring in critical care can support the use of these indicators in pain assessment.32 In addition, perhaps communication is viewed as a barrier to pain assessment in intubated patients. However, although intubated patients cannot speak, they can use other means of communication.29 Only a few such means of communication were documented in the medical files in our study.

However, because pain is a subjective experience, patients’ self-reports should be the first information on which clinicians should rely.30 In addition, the absence of pain behaviors does not mean the absence of pain.47 For this reason, observable indicators are not considered the most reliable measures for pain assessment and should not replace patients’ self-reports of pain whenever the self-reports can be obtained.30 Moreover, these observable indicators are not specific to pain; some of them have also been associated with anxiety.61,62

Pain Management
Both pharmacological and nonpharmacological interventions were documented as means of pain management. In pharmacological interventions, analgesic and sedative agents were more often used concomitantly than individually. However, when the agents were used individually, sedatives were administered a little more often than were analgesics. This practice may explain why nurses could not come to a definite conclusion about a pain situation and why sedatives appeared to be one of the best solutions for providing comfort to patients. Also, agitation was often recorded in the nurses’ notes. This behavior may also indicate anxiety,61,62 which could have motivated nurses to use a sedative rather than an analgesic agent. In addition, the fact that the patients were intubated may have influenced the practice of administration of such medications. Intubation may have contributed to the use of both analgesia and sedation to ensure patients’ comfort.

Nonpharmacological interventions were not often used. This finding is consistent with the results of other studies,37,45 in which nonpharmacological interventions were used with less than 35% of patients. Nonpharmacological interventions could be further developed and used to enhance patients’ comfort. When used in conjunction with pharmacological interventions, they can increase pain relief.37

Pain Reassessment
Reassessment of pain after interventions to relieve pain were documented solely in nurses’ notes, and only a few notes included such information. This finding means that for most pain episodes, we could not come to a conclusion about the effectiveness or ineffectiveness of the pain intervention because documentation was lacking. At first glance, this result reinforces the relevance of using a pain flowsheet. Indeed, in previous studies,45,63,64 documentation on pain assessment improved with implementation of a pain flowsheet.

In 60% of the pain episodes involving reassessment, patients self-reports of pain relief were seldom recorded. Again, observable indicators were documented more often than were nonobservable indicators. Some indicators were associated with a certain level of pain relief, whereas others most likely signified that the pain intervention used was ineffective. Rest quality appeared to be an important indicator for assessing the effectiveness of pain interventions.

Of interest, no information on facial expressions was recorded. We assume that the nurses recorded none because facial expressions did not occur. However, because the absence of facial expressions was not recorded, we cannot state with certainty that none occurred.

Most likely, pain was not sufficiently relieved in most pain episodes documented. We cannot comment on the quality of pain relief because data on pain relief were not available in the medical files. In many studies,* investigators concluded that pain control in acute and critical care is inadequate. Underestimation of patients’ pain, incomplete assessments, and difficulty in pain assessment are contributing factors to this situation.{dagger}

Limitations of the Study
An important limitation of this study is its design. With retrospective collection of data, pain assessment cannot be investigated with depth and precision from health professionals’ and patients’ points of view. In addition, the data collection instrument was developed for this study, so it was being used for the first time. Also, the indicators reported are not specific to pain; they can be related to other signs of discomfort or anxiety62 experienced by critically ill patients. As mentioned earlier, pain, discomfort, and anxiety are interrelated, making them difficult to differentiate, especially when verbal communication is altered, as in intubated patients.

Because pain assessment in intubated patients has not been extensively studied, the information collected in this preliminary study is important because it provides a starting point for improving pain assessment in critical care. In addition, this study was an exploratory study. Moreover, critical care settings involve many sources of pain. We must assume that patients can experience pain and that they deserve to have their pain assessed and relieved.30 Finally, the observable indicators addressed in this study were identified as potential pain-related indicators.

Future Recommendations
In studies with a descriptive design, interviews could be conducted with physicians, nurses, and patients to compare the 3 groups’ experiences of pain assessment. Using the data collection instrument we developed in other studies would help verify its content validity. To our knowledge, observable indicators are not specific to pain and can underlie other symptoms. On the basis of this knowledge, a pain assessment tool that includes observable indicators could be developed and used as a complement to patients’ self-reports of pain to enhance pain assessment and documentation, especially with intubated or noncommunicative patients. This tool could take the form of a pain flowsheet, as recommended in the literature,8,18,41,44 to allow ongoing assessment before and after a pain intervention is undertaken.


   Conclusion
Top
 Abstract
 Theoretical Framework
 Study Aim
 Methods
 Results
 Discussion
 Conclusion
References
 
Pain is a real problem in critically ill patients. In order to be accurately managed, it must first be adequately assessed. Our results indicate that many potential indicators of pain are documented in patients’ medical files. However, this documentation is often incomplete or inadequate. Nurses and physicians may systematically evaluate pain but not document all their observations in the medical files. On the other hand, the lack of a pain assessment tool may contribute to this incomplete documentation in medical files. Research is needed to develop tools to enhance pain assessment and management and to improve the quality of care for critically ill intubated patients. Finally, as a theoretical framework for research, the model for pain assessment provided in Melzack’s theory appears to be relevant.


   ACKNOWLEDGMENTS
 
This work was supported by a nursing fellowship research grant from the Heart and Stroke Foundation of Canada.

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.

* 5,11,12,14,16–18,39–41,45,54,61,65,66 Back

{dagger} 12,17,18,41–43,45,60,61 Back


   REFERENCES
Top
 Abstract
 Theoretical Framework
 Study Aim
 Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Cochran J, Ganong LH. A comparison of nurses’ and patients’ perceptions of intensive care unit stressors. J Adv Nurs. 1989;14:1038–1043.[Medline]
  2. Wilson VS. Identification of stressors related to patients’ psychologic response to the surgical intensive care unit. Heart Lung. 1987;16:267–273.[Medline]
  3. Hallenberg B, Bergbom-Engberg I, Haljamäe H. Patients’ experiences of postoperative respirator treatment: influence of anaesthetic and pain treatment regimens. Acta Anaesthesiol Scand. 1990;34:557–562.[Medline]
  4. Puntillo KA. Pain experience of intensive care unit patients. Heart Lung. 1990;19:526–533.[Medline]
  5. Puntillo KA. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Am J Crit Care. 1994;3:116–122.[Abstract]
  6. Turner JS, Briggs SJ, Springhorn HE, Potgieter PD. Patients’ recollection of intensive care unit experience. Crit Care Med. 1990;18:966–968.[Medline]
  7. Christoph SB. Pain assessment: the problem of pain in the critically ill patient. Crit Care Nurs Clin North Am. 1991;3:11–16.[Medline]
  8. Kwekkeboom KL, Herr K. Assessment of pain in the critically ill. Crit Care Nurs Clin North Am. 2001;13:181–194.[Medline]
  9. Murray MJ. Pain problems in the ICU. Crit Care Clin. 1990;6:235–253.[Medline]
  10. Hamill-Ruth RJ, Marohn L. Evaluation of pain in the critically ill patient. Crit Care Clin. 1999;15:35–54.[Medline]
  11. Desbiens NA, Wu AW, Broste SK, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Crit Care Med. 1996;24:1953–1961.[Medline]
  12. Ferguson J, Gilroy D, Puntillo K. Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Australian intensive care unit. J Adv Nurs. 1997;26:1065–1072.[Medline]
  13. Puntillo KA, Weiss SJ. Pain: mediators and associated morbidity in critically ill cardiovascular surgical patients. Nurs Res. 1994;43:31–36.[Medline]
  14. Puntillo KA. Patients’ perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care. 2001;10:238–251.[Abstract]
  15. Stanik-Hutt J, Soeken KL, Fontaine DK, Gift AG. Pain experiences of traumatically injured patients in a critical care setting. Am J Crit Care. 2001;10:252–259.[Abstract]
  16. Valdix SW, Puntillo KA. Pain, pain relief and accuracy of their recall after cardiac surgery. Prog Cardiovasc Nurs. Summer 1995;10:3–11.[Medline]
  17. Watt-Watson J, Stevens B, Garfinkel P, Streiner D, Gallop R. Relationship between nurses’ pain knowledge and pain management outcomes for their postoperative cardiac patients. J Adv Nurs. 2001;36:535–545.[Medline]
  18. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmacotherapy. 1995;15:592–599.[Medline]
  19. Hall-Lord ML, Larsson G, Steen B. Pain and distress among elderly intensive care unit patients: comparison of patients’ experiences and nurses’ assessments. Heart Lung. 1998;27:123–132.[Medline]
  20. Heye ML. Pain and discomfort after coronary artery bypass surgery. Cardiovasc Nurs. July–August 1991;27:19–24.[Medline]
  21. Montes-Sandoval L. An analysis of the concept of pain. J Adv Nurs. 1999;29:935–941.[Medline]
  22. Morrison RS, Ahronheim JC, Morrison GR, et al. Pain and discomfort associated with common hospital procedures and experiences. J Pain Symptom Manage. 1998;15:91–101.[Medline]
  23. Stevens BJ, Johnston C, Grumau RVE. Issues of assessment of pain and discomfort in neonates. J Obstet Gynecol Neonatal Nurs. 1995;24:849–855.[Medline]
  24. International Association for the Study of Pain Subcommittee on Taxonomy. Pain terms: a list with definitions and notes on usage. Pain. 1979;6:249–252.[Medline]
  25. Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health. 1992; 15:369–377.[Medline]
  26. Loeser JD, Cousins MJ. Contemporary pain management. Med J Aust. 1990;153:208–212, 216.[Medline]
  27. McGuire DB. Comprehensive and multidimensional assessment and measurement of pain. J Pain Symptom Manage. 1992;7:312–319.[Medline]
  28. Melzack R. From the gate to the neuromatrix. Pain. 1999;6(suppl): S121–S126.[Medline]
  29. Puntillo KA, ed. Pain in the Critically Ill: Assessment and Management. Frederick, Md: Aspen Publishers Inc; 1991. Aspen Series in Critical Care Nursing.
  30. Agency for Health Care Policy and Research. Acute pain management: operative or medical procedures and trauma, part 1. Clin Pharm. 1992;11:309–331.[Medline]
  31. McCaffery M. Nursing Management of the Patient With Pain. 2nd ed. Philadelphia, Pa: Lippincott; 1979.
  32. Shannon K, Bucknall T. Pain assessment in critical care: what have we learnt from research. Intensive Crit Care Nurs. 2003;19:154–162.[Medline]
  33. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987; 30:191–197.[Medline]
  34. Kaiser KS. Assessment and management of pain in the critically ill trauma patient. Crit Care Nurs Q. August 1992;15:14–34.[Medline]
  35. Mlynczak B. Assessment and management of the trauma patient in pain. Crit Care Nurs Clin North Am. 1989;1:55–65.[Medline]
  36. Solomon P. The clinical utility of pain behavior measures. Phys Rehabil Med. 2000;12:193–211.
  37. Ferrell BR, Eberts MT, McCaffery M, Grant M. Clinical decision making and pain. Cancer Nurs. 1991;14:289–297.[Medline]
  38. Paice JA, Mahon SM, Faut-Callahan M. Factors associated with adequate pain control in hospitalized postsurgical patients diagnosed with cancer. Cancer Nurs. 1991;14:298–305.[Medline]
  39. Lay TD, Puntillo KA, Miaskowski CA, Wallhagen MI. Analgesics prescribed and administered to intensive care cardiac surgery patients: does patient age make a difference? Prog Cardiovasc Nurs. Fall 1996;11:17–24.[Medline]
  40. Maxam-Moore VA, Wilkie DJ, Woods SL. Analgesics for cardiac surgery patients in critical care: describing current practice. Am J Crit Care. 1994;3:31–39.[Abstract]
  41. Tittle M, McMillan SC. Pain and pain-related side effects in an ICU and on a surgical unit: nurses’ management. Am J Crit Care. 1994;3:25–30.[Abstract]
  42. Camp LD, O’Sullivan PS. Comparison of medical, surgical and oncology patients’ descriptions of pain and nurses’ documentation of pain assessments. J Adv Nurs. 1987;12:593–598.[Medline]
  43. Idvall E, Ehrenberg A. Nursing documentation of postoperative pain management. J Clin Nurs. 2002;11:734–742.[Medline]
  44. Leisifer D. Monitoring pain control and charting. Crit Care Clin. 1990;6:283–294.[Medline]
  45. Carroll KC, Atkins PJ, Herold GR, et al. Pain assessment and management in critically ill postoperative and trauma patients: a multisite study. Am J Crit Care. 1999;8:105–117.[Abstract]
  46. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–2263.[Medline]
  47. Puntillo KA, Miaskowski C, Kehrle K, Stannard D, Gleeson S, Nye P. Relationship between behavioral and physiological indicators of pain, critical care self-reports of pain, and opioid administration. Crit Care Med. 1997;25:1159–1166.[Medline]
  48. Mateo OM, Krenzischek DA. A pilot study to assess the relationship between behavioral manifestations and self-report of pain in postanesthesia care unit patients. J Post Anesth Nurs. 1992;7:15–21.[Medline]
  49. Webb MR, Kennedy MG. Behavioral responses and self-reported pain in postoperative patients. J Post Anesth Nurs. 1994;9:91–95.[Medline]
  50. Huberman AM, Miles MB. Analyse des Données Qualitatives: Recueil de Nouvelles Méthodes [Analysis of Qualitative Data: Collection of New Methods]. Brussels, Belgium: De Boeck University; 1991.
  51. Bell M. Postoperative pain management for the cognitively impaired older adult. Semin Perioper Nurs. 1997;6:37–41.[Medline]
  52. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage. 1995;10:591–598.[Medline]
  53. Mackrodt K, White M. Nurses’ knowledge within the context of pain management. J Orthop Nurs. 2001;5:15–21.
  54. Celia B. Age and gender differences in pain management following coronary artery bypass surgery. J Gerontol Nurs. 2000;26:7–13.[Medline]
  55. Prkachin KM. The consistency of facial expressions of pain: a comparison across modalities. Pain. 1992;51:297–306.[Medline]
  56. Attia J, Mayer MN, Shnider SM, Barrier G. Correlation of a clinical pain score with catecholamine and endorphin levels in small infants [abstract]. Intensive Care Med. 1987;13:459.
  57. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5:53–61.[Medline]
  58. Schade JG, Joyce BA, Gerkensmeyer J, Keck JF. Comparison of three preverbal scales for postoperative pain assessment in a diverse pediatric sample. J Pain Symptom Manage. 1996;12:348–359.[Medline]
  59. Hurlock-Chorostecki C. Management of pain during weaning from mechanical ventilation: the nature of nurse decision-making. Can J Nurs Res. 2002;34:33–47.[Medline]
  60. Manias E, Botti M, Bucknall T. Observation of pain assessment and management: the complexities of clinical practice. J Clin Nurs. 2002;11:724–733.[Medline]
  61. Stannard D, Puntillo KA, Miaskowski C, Gleeson S, Kehrle K, Nye P. Clinical judgment and management of postoperative pain in critical care patients. Am J Crit Care. 1996;5:433–441.[Abstract]
  62. Frazier SK, Moser DK, Riegel B, et al. Critical care nurses’ assessment of patients’ anxiety: reliance on physiological and behavioral parameters. Am J Crit Care. 2002;11:57–64.[Abstract/Free Full Text]
  63. Faries JE, Mills DS, Goldsmith KW, Philips KD, Orr J. Systematic pain records and their impact on pain control. Cancer Nurs. 1991;14:306–313.[Medline]
  64. Voigt L, Paice JA, Pouliot J. Standardized pain flowsheet: impact on patient-reported pain experiences after cardiovascular surgery. Am J Crit Care. 1995;4:308–313.[Abstract]
  65. Carr ECJ, Thomas VJ. Anticipating and experiencing post-operative pain: the patients’ perspective. J Clin Nurs. 1997;6:191–201.[Medline]
  66. Puntillo KA, Wild LR, Morris AB, Stanik-Hutt J, Thompson CL, White C. Practices and predictors of analgesic interventions for adults undergoing painful procedures. Am J Crit Care. 2002;11:415–429.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Crit Care NurseHome page
A. M. Kabes, J. K. Graves, and J. Norris
Further Validation of the Nonverbal Pain Scale in Intensive Care Patients
Crit. Care Nurse, February 1, 2009; 29(1): 59 - 66.
[Full Text] [PDF]

Home page
 Crit Care NurseHome page
J. E. Helms and C. P. Barone
Physiology and Treatment of Pain
Crit. Care Nurse, December 1, 2008; 28(6): 38 - 49.
[Full Text] [PDF]

Home page
 Am J Crit CareHome page
C. Gelinas, L. Fillion, K. A. Puntillo, C. Viens, and M. Fortier
Validation of the critical-care pain observation tool in adult patients.
Am. J. Crit. Care., July 1, 2006; 15(4): 420 - 427.
[Abstract] [Full Text] [PDF]

Home page
 Crit Care NurseHome page
D. Li and K. Puntillo
What is the current evidence on pain and sedation assessment in nonresponsive patients in the intensive care unit?
Crit. Care Nurse, October 1, 2004; 24(5): 68 - 3.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Respond to This Article
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Right arrow Take the CE Test
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gélinas, C.
Right arrow Articles by Puntillo, K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gélinas, C.
Right arrow Articles by Puntillo, K.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS