Pain Assessment in Sedated and Ventilated Patients
Introduction
Nursing refers to the functions and duties carried out by persons who have had formal education and training in the art and science of nursing. To promote the restoration and maintenance of health in their clients, nurses become more particular in enhancing their knowledge through integration with health and biological sciences ( 1993). As an applied discipline, the vocation of nursing evolves within a dynamic body of knowledge. The quality of nursing practice is dependent on the knowledge of individual practitioners as well as their willingness to engage in professional relationships and behaviors.
Nurses are required to have the skills and know-how to explore, confirm, and direct the progress of nursing practice. Five value concepts uphold professional development: the (1) knowledge base, which is the foundation knowledge base upon which clinical practice decisions are made, (2) continuing education which comprise of the continuing learning activities that are crafted to benefit the individual and the profession, (3) mentoring and networking which are the professional relationships that are instituted with the intent of supportive growth for the individual as well as the profession, (4) research which is the qualitative and/or quantitative investigation of the factors which affects the professional nursing practice, and lastly (5) career development which are purposeful, planned strategies that are designed to boost short and long term professional goals ( 1998).
It has not been long since nurses have had specialized training especially on patient management; these specialized trainings include the situation in which they are more likely to find themselves, thus affecting how they will react to the situations presented before them. The differences of their actions mean very much to the patients, and thus they must learn how to distinguish the different factors and be able to help their patients in achieving the best method of improving their health and returning to their vigorous states. This paper discusses the pertinent issues related to pain assessment among sedated and ventilated patients critically analyzing the current concerns in the nursing practice to present the applications and implications of the issues and provide sound recommendations.
Issues on Pain Assessment among Sedated and Ventilated Patients
Nurses are advocates and health educators for patients, families, and communities. When providing direct patient care, they observe, assess, and record symptoms, reactions, and progress in patients; assist physicians during surgeries, treatments, and examinations; administer medications; and assist in convalescence and rehabilitation. Nurses also develop and manage nursing care plans, instruct patients and their families in proper care, and help individuals and groups take steps to improve or maintain their health. While state laws govern the tasks that the nurse may perform, it is usually the work setting that determines their daily job duties.
Pain assessment is a key aspect in the nursing management and delivery of care within the clinical environment in which nurses utilize many aspects of knowledge including that of the underlying Pathophsiology, pharmacological knowledge of the drugs available for use, and knowledge of the patient being assessed. Such use of the wide range of knowledge is important when caring for a variety of patients to ensure accurate pain assessment based on sound judgment to achieve a pain-free status whenever possible and ensure that the patient achieves the best possible treatment (2003).
According to (2000) there are several advantages of monitoring the patients’ sedation outcomes. These include (a) reductions in intensive care unit (ICU) stay, (b) duration of mechanical ventilator support, and (c) some diagnostic tests that will assess the function of the central nervous system. However, there are issues that are in need of attention so as to address the proper and accurate procedures of assessing pain among sedated and ventilated patients. These include the difficulties encountered in assessing pain and the accuracy of pain assessment tools and methods.
Several studies have been conducted in the discipline of medicine and care giving in order to improve the condition of the patients who are suffering from discomfort due to their physical condition before or after undergoing medical procedures. These studies were conducted so as to determine the accuracy of the tools and measures of determining the discomfort levels of the patients in order to help the patient recover easily and immediately from the illness that he or she is experiencing as well as to contribute to the ways of overcoming the difficulties of pain assessment. Some of these studies which investigated the cases of sedated and ventilated patients are briefly presented below.
Pain and theories on pain. Pain is one of the most common human experiences, as no one is spared from such suffering, whether such to the physical or emotional. Yet for the longest time, pain has never been fully considered as a medical problem. It may be due to the fact that it is a subjective and a highly personal experience. For centuries, people have been puzzled by pain and its nature. Hence, several theories have been formulated to describe the mechanisms of pain.
Though pain can be measured you, it can not be diagnosed, felt (unless it’s your own), imagined or proved its existence. Pain as a sensation differs from one person to another. Hence no person can exactly feel the same degree of pain at the same time. But pain is as real as the symptoms it shows, it is the reason why approximately 70 million visits were made by people to health care professionals every year. Pain is the body’s natural way of sending a warning to the brain that something is amiss. Aches are felt when pain is being transmitted, carried by chemicals called neurotransmitters, which travel from the nerves, along the spinal cord to the brain. In the brain, pain messages are combined with thoughts, emotions and expectations that mold our interpretation and response to the pain (2004). Early theories on the psychology of pain were primarily based on global factors such as age, gender, personality and culture.
Little was known about the psychology of pain for specific age groups. It was believed that women were more likely to experience more frequent pain and higher risks of disability after the pain than do men. Those who were not exposed to hardships would have less tolerance of pain and would be more complaining on pain (2001). Theories have noted that pain is related to various psychological aspects. Several psychological mechanisms are involved in the manifestation of pain. Through sensation, nerves within the body are stimulated. This sensation travels to the brain, resulting to the perception of pain. As this causes unpleasant sensations, pain is commonly related to illness (1992). Indeed, the gate control theory as well as the study on cognitive coping and upload blockade has shown that psychological factors affect the development of pain ( 2003).
One theory that provides a variable link between injury and pain is the gate control theory of ( 1999). This theory suggests that the gates or the nerve fibers found in the nerve pathway should be open so as to let pain sensation travel to the brain. The theory then supports the concept that the gates is capable of closing when there is an absence of sufficient stimulus, resulting to the prevention of more pain sensations. (2001) supported this by stating that pain is dependent on physiological, affective, behavioral and socio-cultural dimensions. (1996) conducted a study which claimed that psychological or cognitive coping of pain is capable of decreasing the perception of pain. When upload receptors are pharmacologically blocked, the benefits of cognitive coping become enhanced. Thus, the study concluded that psychological coping does not depend on endogenous uploads alone and that coping is based on situational and stimulus characteristics.
Every year there have been several researches done concerning the removal of pain, whether temporarily or permanently (King, 1991) and recent studies have shown that nursing knowledge has continued to increase when it comes to the nurses’ identification of pain (1997). This highlights the significant role of health professionals particularly nurses when it comes to pain assessment.
Difficulties in pain assessment. Assessment of pain for the sedated patient is often complicated by the patient’s inability to report pain levels. As such the sedated patient undergoing painful procedures depends on the nurse to interpret physical signs to quantify his or her distress both on the physiological and behavioral responses to pain for assessment when the patient’s self-report is absent. Even though an individual’s self-report of pain intensity and distress is the most accurate assessment measurement, the validity of a sedated patient’s elicited response about pain is questionable that the nurse attempts to assess through observation.
(2003) claimed that the accurate assessment of pain in nonverbal patients is difficult because nurses often rely on different methods of determining medication impact. Moreover, commonly used indicators of pain may not effectively measure the true extent of distress in patients as on going studies continue their initiatives to provide more accurate measures of assessing pain to benefit patients who are not in the condition to communicate their sufferings. (2005) on the other hand stated that understanding the Pathophsiology of pain facilitates the assessment of the objective components of pain.
According to (2001) careful thought and planning may allow the nurse to adapt usual assessment tools for use by patients who have difficulty in communicating. This includes (1) using all means possible to document the patient’s self-report of the pain experience, (2) supplementing ratings with behavioral and physiologic indicators of pain status, and (3) documenting findings to communicate the patient’s pain to concerned individuals. But the study conducted by (2004) which described (1) the pain indicators used by nurses and physicians for pain assessment, (2) the pain management, including pharmacological and no pharmacological interventions undertaken by nurses to relieve pain, and (3) the pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are incubated concluded that pain documentation in medical files is incomplete or inadequate due to the lack of a pain assessment tool.
Accuracy of pain assessment tools and methods. In the last few years, experiments and other forms of studies have been designed in the medical arena to evaluate the validity and reliability of the different agitation and sedation scales including the Sedation-Agitation Scale and the Motor Activity Assessment Scale. Other assessment tools have been developed from the results and observations made among patients that helped clinicians in the area of patient care. Such studies recommended further investigation on the impact of these monitoring techniques in relation to the aim of improving patient comfort, minimizing adverse events, and reducing resource consumption as well as more accurate pain assessment methods.
Assessing pain and sedation in no responsive patients is a challenge primarily because of the confounding effect of sedation on objective indicators of pain. As such, clinicians might interpret incorrectly because the behavioral responses to pain and anxiety/agitation have many similarities. Hence, additional research is needed to establish the validity, sensitivity, and specificity of pain indicators in sedated patients. Moreover, in the case of no responsive sedated patients, clinicians should integrate actual or potential risks of pain and risks of pain-related functional impairment into their pain assessment (2004). According to (2003) pain assessment and management for critical care patients, present challenges to clinicians and researchers as pain assessment methods and clinical trials of pharmacological interventions continue to investigate procedural pain assessment methods. There have been studies that investigated the validity and reliability of pain assessment tools that medical practitioners are currently using.
(2002) conducted a study on estimating the comfort levels of sedated patients who undergone gastrointestinal examination in order to determine the validity and reliability of the Colorado Behavioral Numerical Pain Scale in which interpreter reliability showed 82% agreement on the observations made on the patients. The study likewise included the participation of nurses from other hospitals and a medical person from an ambulatory facility which illustrated a 92% agreement that the words described what they observed during a gastrointestinal examination and 94% felt it was a better descriptor of pain than a patient self-report numerical scale.
Meanwhile, (2001) tried to establish the validity and reliability of a new behavioral pain scale (BPS) for critically ill sedated adult patients for prospective evaluation among ten-bed trauma and surgical intensive care units in a university teaching hospital. The results of the study indicated that the expression of pain can be scored validly and reliably by using the BPS in sedated, mechanically ventilated patients providing warranty on the utility of the BPS in making clinical decisions about the use of analgesic drugs in the intensive care unit.
(2002) on the other hand conducted a study which (1) described the Pain Assessment and Intervention Notation (P.A.I.N.) tool, (2) detailed critical care nurse participants’ evaluations of the P.A.I.N. intervention tool when used during care of postoperative patients in pain, and (3) evaluated the tool’s usefulness in practice and education. the results of the study indicated that P.A.I.N. tool provides a consistent, systematic method of quantifying their assessment of patient pain and analgesic responsiveness and that it improves practice with regard to pain and sedation assessment. However, the usefulness of the tool presented limitations since it is too detailed to be used routinely when caring for critically ill patients.
(2005) reviewed available researches which investigated the three commonly used pain rating scales: (1) the Visual Analogue Scale, (2) the Verbal Rating Scale, and (3) the Numerical Rating Scale to provide information for the understanding of the main properties of the scales. Their investigation indicated that all three pain-rating scales are valid, reliable and appropriate for use in clinical practice, although the Visual Analogue Scale has more practical difficulties than the Verbal Rating Scale or the Numerical Rating Scale. The Numerical Rating Scale generally has good sensitivity and generates data that can be statistically analyzed for audit purposes as preferred by patients who seek a sensitive pain-rating scale would. Meanwhile, patients prefer the Verbal Rating Scale because of its simplicity despite the fact that it lacks sensitivity which could result to misunderstood data.
However, mere evaluation of existing pain assessment tools seem inadequate as (2002) addressed the need for a systematic, objective pain assessment tool development among adult intensive care units. The pain assessment tool consist a numerical and verbal rating scale to facilitate documentation and audit through ongoing adjustment and evaluation. The tool scores the patient’s pain by incorporating behavioral and physiological indicators and is used in conjunction with the Glasgow Coma Score and the modified Sheffield Sedation Scale to achieve a comprehensive neurological assessment wherein assessment is carried out at rest and during procedures such as suctioning and manual handling introducing a flow chart and a clinical guideline. Preliminary evaluation established the effectiveness of the tool as a means of estimating and recording pain levels in individual patients.
Skills and knowledge of nurses. Other studies have been performed to investigate other areas of pain assessment among critically ill patients particularly with an interest in the nursing practices in the medical field. The study performed by (1998) highlighted that the patients’ experiences of pain and distress do not fully agree with nurses’ and assistant nurses’ assessments; nor was there consistency between the views of nurses and those of assistant nurses. Nurses overestimated patients’ breathing and intellectual problems while assistant nurses assessed that patients received more assistance to relieve physical pain, physical discomfort, fatigue, and fear than patients reported. Furthermore, compared with nurses’ assessments, assistant nurses also perceived patients to suffer less from physical discomfort, breathing problems, and fatigue. As such, they concluded that nurses need more systematic procedures to assess patients’ distress and pain experiences and that organization of care should optimize the possibilities for the caregivers to carry out the desired assessments and interventions with a high degree of continuity and communication among staff to reduce the discrepancies observed between nurses and assistant nurses. On the other hand, (2003) examined strategies for changing pain management practices in critical care by reviewing documentation practices, the utilization of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. They recommended that pain assessment be given a higher priority within the clinical context, since inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care.
Meanwhile, studies that focused on the indications of pain among patients were also undertaken which are relevant to the need for accurate pain assessment tools to improve health care services among critically ill patients. (2001) characterized the symptoms experienced of intensive care unit (ICU) patients at high risk for hospital death. Patients’ self-reports of symptoms using the Edmonton Symptom Assessment Scale (ESAS), and ratings of pain or discomforts associated with ICU diagnostic/therapeutic procedures and of stress associated with conditions in the ICU were used as tools to measure the symptoms of the cancer patients. The results indicated that hospital mortality for the group was 56% as fifty patients had the capacity to respond to the ESAS, among whom 100% provided symptom reports. Between 55% and 75% of ESAS responders reported experiencing pain, discomfort, anxiety, sleep disturbance, or unsatisfied hunger or thirst that they rated as moderate or severe, whereas depression and dyspnea at these levels were reported by approximately 40% and 33% of responders, respectively. Moreover, significant pain, discomfort, or both were associated with common ICU procedures, but most procedure-related symptoms were controlled adequately for a majority of patients. The patients’ inability to communicate, sleep disruption, and limitations on visiting were particularly stressful among ICU conditions studied.
Conclusion
Nursing is a helping profession, one that has sworn to protect and help those who are in need, and thus they must live to that promise and continue to give priority to their patients. The reduction of pain that their patients are having through proper methods and accurate means of assessing pain particularly among sedated and ventilated patients is a sure sign of their success and enough reason for their glory.
Nurses should do more than administer methods or means to control and manage pain. It is first important for nurses to be able to assess the pain of their patients. As care providers, they should be able to accurately determine the levels of pain that their patients endure for them to act according to their needs and comfort. This perhaps implies the important correlation of theories and the role of nurses to pain assessment as well as the success of the initiatives that were undertaken to improve and develop ways of providing better facilities through honing specific skills among nurses to assess pain.
Nurses must learn how to quickly assess the painful sufferings of their patients, and thus must be able to give sound judgments based on their nursing knowledge, techniques, and most of all experience in order to ensure the improvement of health (either physically or emotionally) of the patient. They must be able to judge how the patient will fare during the next few days or if immediate actions should be undertaken. By these quick assessments that are deemed true and follows their knowledge and competence, they may be able to give judgments that will say much about their capabilities. Most importantly, nurses should serve as the patients’ pillar of strength and their motivator towards immediate recovery. They must also know how to assess the psychological conditions of the patients and attempt to put them into some ease in order to better perform the medical profession.
Recommendations
In order to use pain-rating scales well clinicians need to appreciate the potential for error within the tools, and the potential they have to provide the required information. Since interpretation of the data from a pain-rating scale is not as straightforward as it might first appear, critical care nurses need not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future. Early exposure to learning experiences among student nurses would be relevant to introduce them to the complexities of caring particularly pain assessment. Guidance and monitoring responsibilities among medical professionals should be provided to facilitate improved caring practices as well as to minimize cases of errors that might lead to grave consequences both on the part of the patient as well as the nurse.
More initiatives for research and development should be realized not just in the academe but most importantly among practitioners of medical professions to support the continuous improvement and development in the current medical environment. Participation and cooperation among patients in research initiatives as well as pioneer studies in the medical files will be also necessary to carry out investigations that will highly contribute to public health care. Support of the medial institutions, government, academe and the public in general will be helpful in motivating members of the medical discipline to enhance and provide better medical services to the public
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