Pain in Unresponsive Patients - Essay Example

Pain in unresponsive patients Aims The word pain likely originated from the Latin word poena, meaning punishment. Pain is very common in several pathological conditions including, but not restricted to, trauma, surgery, malignancy, and end of life. Pain management is a major challenge, and especially complicated in patients who are unable to communicate verbally or effectively e.g., pediatric, intubated, sedated, critically ill or end-of-life patients. Studies are lacking on pain assessment in such patients and, therefore, pain often remains inadequately treated in unresponsive patients. A contributing factor for this could be that the various pain scales available for noncommunicative patients generally are subjective and, therefore, lacking in inter-rater reliability. Besides, research in pain assessment tools has not been adequate. The major aims of this study are (1) to compare the Numerical Rating Scale and the Behavioral Pain Scale for measuring pain in unresponsive patients, and (2) to evaluate pain scores produced by the attending nurse vis a vis assessment according to family members. Background and Significance Background Pain is an important problem in critical care and accurate assessment of pain in the unresponsive patient is indeed a challenge. The unresponsive patients include pediatric, trauma, surgery, cancer, and critically ill, end-of- life cases. The attending nurses are generally accountable for pain management in the patient. It is estimated that critically ill patients dying in the ICU account for nearly 20% of the hospital deaths (Rocker & Curtis, 2003). Hence, nursing care decisions made at the end of life are crucial for the comfort of the patient. Palliative care has been defined by the World Health Organization as "the total care of patients and families whose disease is not responsive to curative treatment" (WHO, 1990, p.11). Assessment and management of pain in the palliative care is a very difficult process especially in the case of a non-verbal patient (Gambrell, 2005). Health-care providers play an active role in managing pain and providing comfort to such patients. But unmitigated pain in the absence of adequate use of analgesics and sedatives can lead to enhanced morbidity and mortality in patients in the ICU (Ahlers et al., 2008). The tools available for pain assessment in noncommunicative patients are mostly subjective which is a great drawback. Ideally, an objective tool for quantification of pain intensity capable of providing a quick feedback would be needed to provide comfort to the unresponsive patient (Gambrell, 2005). Critically ill patients show a variety of hormonal changes and neurogenic blockade and analgesia with local anaesthetics can prevent a major part of the stress-response to surgery (Kehlet, 2008). Studies have shown that postoperative pain is a factor involved in the stress response consequent to surgery (Rutberg et al., 1984). A detailed understanding of pain mechanisms has come about through basic science research while clinical science has provided basic knowledge required for pain measurement and management (Puntillo, 2003). A new subject of research “that represents an advanced step from conventional pain research” is molecular pain dealing with “physiological and pathological pain at the cellular, subcellular and molecular levels” (Gu et al., 2005). It is a rapidly expanding field of research in recent years that combines pain research with modern biomedical technologies viz., molecular biology, genomics, proteomics, modern electrophysiology and neurobiology. However, no specific neurobiological parameter is currently available to evaluate pain (Dimopoulou, 2005). According to Puntillo (2003), when the patients face problems in making known their pain to nurses it begets them conservative medication. A study of patients after abdominal surgery showed that the patients did not derive any pain relief during the first 3 days after surgery probably because of the small amount of analgesics the patients received overall (Puntillo, 1994). The study further showed that morbidity was increased also in patients with higher pain scores. Accurate pain assessment in infants is also complex and here too nurses play a critical role in the assessment and management of infant pain. Significance Nurses’ judgment of pain is important for clinical decision making vis a vis patient comfort and safely. Pain assessment being essentially a cognitive and intuitive process, the pain assessment tool should be specific enough so that clinicians and caregivers feel confident of their judgment (Puntillo, 2003). In the opinion of experts, a patient’s self-report of pain intensity is the most valid measure (Aïssaoui et al., 2005). However, in the absence of self-reports, as is essentially the case in non-verbal patients, observable indicators including behaviors and physiological signs of pain will have to be judged. It has been reported that whatever their level of consciousness, critically ill adult patients react to an unpleasant stimulus by expressing different behaviors that may be associated with pain (Gélinas et al., 2006). Pain behaviors can signal the existence, intensity, and causes of pain (Aïssaoui et al., 2005). The pain assessment tools basically depend upon subjective/objective measurements of key variables such as body/upper limb movements, muscle rigidity, rest quality, vocalization and facial expression to represent behavioral factors, and hemodynamic measurements such as mean arterial blood pressure and heart rate as physiological markers. Payen et al. (2001) have developed a pain scale based on behavioral indicators for use in ICU patients. A validation of this tool as a measure of pain was conducted using psychometric methods by Aïssaoui et al. (2005) in critically ill patients who were sedated and mechanically ventilated. In the case of pediatric cases, the pain measurement tool should have applicability for premature and newborn infant populations as well. Behavioral and physiological indicators of pain, sleep-wake states, and development are important factors in pain assessment in infants (Beacham, 2003). The behavioral indicators in infants include sleep/wake states, facial actions and hand actions (Holsti & Grunau , 2007). A systematic evaluation of pain in unresponsive critically ill patients will help immensely in pain management through a proper approach e.g., an analgesia-based approach. Some of the available pain scales are the Numerical Rating Scale (NRS) and the Behavioral Pain Scale (BPS). The attending nurse is involved closely with the daily care of the patient. However, the perception of pain in the patient according to the nurse can be very different from that of the family members of the patient. Hence, the current study is designed to validate the different pain scales such as NRS (1 to 10) and BPS in unresponsive patients. Also, the study will compare pain scores of different observers (nurses and family members) to determine inter-user reliability of the scoring systems. The study will be restricted to unresponsive adult patients and will not consider pediatric cases in the first instance. The Theoretical Framework Critically ill patients are prone to experience pain owing as much to their pathophysiology (Blakely & Page, 2001) as to the therapies and procedures they undergo (Gacouin et al., 2004). Patient report is usually the most reliable measure of pain. Nonresponsive patients are those who cannot report pain verbally, in writing, or through signals such as finger span or answer specific questions on pain through blinking of eyes to indicate yes or no (Herr et al., 2006). Any condition that causes pain in a cognitively capable person is likely to cause a similar degree of pain in the cognitively impaired, sedated, immobilized, comatose or demented person (Herr et al., 2006). Therefore, when the patients are unable to reliably report their pain, special techniques of pain assessment will have to be employed. According to Prkachin (1992), there exists a universal facial language of pain. He enumerates lowering of the brow, tightening and closing of the eyelids, wrinkling of the nose, and raising the upper lip as the four facial actions that convey most of the facial information about pain. Usually adult patients who are the most difficult to assess are also those who are grievously ill and experience great pain. Inadequate pain assessment puts them at risk of increased morbidity and even mortality on account of unrecognized and under-treated pain. In the absence of a standardized process of evaluating pain e.g., in the case of unresponsive patients, efforts should be made to validate the tools that are available for use in the general domain. Furthermore, perception of pain in the patients might greatly differ between various observers. Hence pain scores of the clinician are likely to be different from those of the attendant nurse which will differ from those of close family members of the patient. According to the recommendations of ASPMN, the American Society for Pain Management Nursing, behavioral signs are useful surrogate indicators of both acute and persistent pain which need to be validated in the appropriate patient population (Herr et al., 2006). Furthermore, family members are said to be able to provide valuable inputs about behaviors that may be indicative of pain. Different pain measuring tools such as the BPS and the NRS and have been tested widely among critically ill patients who were sedated or unconscious ( Payen et al., 2001; Aissaoui et al., 2005; Young et al., 2006). The tests differ in their inherent utility. For instance, the BPS reflects the objective visible behavior at one specific time point, and the NRS represents a global impression of pain, including several background factors integrated over a period of time. Statistical evaluations of the results will be made in order to improve the validity of the tests. The factor structure of each of the tests will be extracted by performing exploratory principal components factor analysis. This is a statistical procedure that enables the underlying dimensions of a scale to be determined. Responsiveness to each test will be determined by the ability of the tests to detect important changes over time in the concept, i.e., pain, being measured, even very small changes being considered. The coefficient of response will be calculated by dividing the difference between the mean scores of each test at rest and during painful procedures by the standard deviation of the mean scores at rest. The proposed study is expected to produce useful, statistically valid information on objective pain measures for use with critically ill patients unable to self-report. A Conceptual Model of the proposed study Aims Activities Outcome 1. Comparison of pain scales NRS, VAS, and BPS in unresponsive patients 2. Comparative evaluation of nurse & family members scores References Ahlers S.J., van Gulik L., van der Veen, A.M., et al., 2008 Comparison of different pain scoring systems in critically ill patients in general ICU. Critical Care, 12(1): R15. Aïssaoui, Y., Zeggwagh, A.A., Zekraoui, A. et al. 2005. Validation of a Behavioral Pain Scale in Critically Ill, Sedated, and Mechanically Ventilated Patients. Anesthesia & Analgesia, 101:1470-1476. Beacham, P.S. 2003. Behavioral and physiological indicators of procedural and postoperative pain in high-risk infants, J Obstetric Gynecologic & Neonatal Nursing, 33(2): 246-255. Blakely, W.P. and Page, G.G. 2001. 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