Nursing Essay: Pain Assessment In Intubated Patients In ICU.

Discuss about the Nursing practice for the assessment of pain.

Intubation refers to the medical procedure that in false insertion of a tube inside the body of a patient. Management of the airways is a commonly performed process in Intensive Care Unit (ICU), which results in emergency and planned intubation in critically ill patients (Griesdale et al., 2012). Moderate to severe pain is a common health disturbance experienced by most patients in the ICU. Inadequate assessment and management of pain among these patients increases the rates of mortality and morbidity (Alderson & Mckechnie, 2013). Therefore, this topic has been selected for analysis in order to identify the best nursing practices that can reduce pain among intubated patients, thereby improving their health outcomes.

The study conducted by Ayasrah et al., (2014) focused on identifying the pain indicators and their effectiveness. One major advantage is that it considered patients who were adults and were placed under mechanical ventilation for a minimum time period of 72 hours, to prevent misleading results. Owing to the fact that critically ill patients are often unable to decide for themselves and lose the power of speech, the researchers demonstrated a correct step in obtaining consent from their family members, who acted as the decision makers (Schenker et al., 2012). Furthermore, categorization of the collected medical records on the basis of non observable, and observable indicators and response to pain treatment was an accurate step. Using SPSS software package gave exact percentage and frequencies for all pain related indicators (Kanda, 2013). It suggested that use of recognised pain scale is the most essential nursing practice that needs to be implemented in ICU. However, major limitations were associated with consideration of only three hospitals, which might have contributed to a selection bias (Elwert & Winship, 2014). In addition, failure to include information on the methods that are implemented for obtaining self reports of pain was another drawback.

On the other hand another systematic review conducted by Varndell, Fry & Elliott (2017) examined suitability and psychometric properties of pain instruments for using non verbal critically ill patients. Use of key search terms and inclusion of 26 studies for the review was also adequate. Using the critical appraisal skills program (CASP) helped in systematically examining the reliability, trustworthiness and relevance of the articles (Zeng et al., 2015). Inclusion of studies conducted across various countries assisted in eliminating selection or population bias (Mangin et al., 2012). Furthermore, assessing the reliability and validity of all instruments mentioned in this study provided comprehensive results. 1 major advantage of the review can be related to identification of 5 observational pain assessment tools, namely, CPOT, BPS, PAINAD, FLACC and NVPS (Stites, 2013). Furthermore, it also emphasized on use of appropriate observational pain assessment tools to improve its management for intubated adult patients in ICU. Strongest evidence for the use of CPOT increases its importance in nursing practice (Herr et al., 2012).  However, some drawbacks were associated with data extraction being carried out by one author, variation in detail and quality of description of the instruments, and exclusion of un-reported researches.

Critical Evaluation

Additionally, a cohort study conducted by Rijkenberg et al., (2015) compared the validity and reliability of the CPOT (Critical-Care Pain Observation Tool) and BPS (Behavioral Pain Scale) pain observation tools up on mechanically ventilated patients in ICU. Inclusion of adult patients who had been in ICU for more than 12 hours, under mechanical ventilation and inability to self report the pain status was a correct method owing to previous findings with suggested success of CPOT and BPS in assessing pain (Keane, 2013). Data extraction using patient clinical information helped in providing accurate medical records. Training the ICU nurses to use the 2 pain assessment tools helped them to gain a sound understanding of the procedure. Using SPSS software and Cronbach’s coefficient was also an accurate step (Bonett & Wright, 2015). The results suggested that CPOT is a more preferable tool. However some limitations are associated with failure to blind the nurses to the study, completion of BPS first that could affect data, small number of patients in final analysis and failure to translate and validate the two instruments in Dutch, which might have contributed to misleading results (Hróbjartsson et al., 2012) (Marshall et al., 2013). 

Health assessment is usually regarded as the first phase in nursing practice where nurses are expected to use their clinical expertise and knowledge to express care for their clients (Shehabi et al., 2012). Pain is a common experience among intubated patients in the ICU, and gets aggravated by factors such as invasive procedure, stage of health disorder and surgical intervention (Herr et al., 2012). It acts as a source of suffering and creates a long-term imprint on such patients. During my clinical placement, I had been selected to work with post -operative patients on intubation, in the ICU.  Most of the patients were under continuous infusion of analgesics and sedatives. There were 2 patients in ICU, following an operation for intestinal obstruction. Nasogastric intubation was administered to the patients for nutritional support and aspiration of the stomach contents.

However, I found them to be extremely restless and demonstrated non-compliance with the intubation tube. This significantly increased their pressure. The patients were found to move to their extremities restlessly and also showed facial grimaces. Initially, with the help of a co-worker I tried to reassure the patients by talking to them. However, their gestures suggested that they were facing physical discomfort due to severe abdominal pain. I immediately notified it to the ICU doctor and raised my concern that absence of adequate pain management techniques could be the reason for their restlessness and agitation. The doctor agreed on the possibility and instructed the nurse-in-charge to assess their pain. Extensive study of literature, has worked towards establishing the reliability of CPOT on assessing pain in ICU patients (Buttes et al., 2014). The nurse was found to use the CPOT tool and she began observing their facial expressions and body movements. She also recorded their compliance with the intubation and scored it as per the scale provided. I observed the nurse to move the patient's arms and recorded the level of resistance that was displayed, following the advice by the senior RN.

Critical Observation

Furthermore, the body and facial indicators of pain were also recorded, while turning the patients on their sites.  This was followed by adding up all the scores which helped the nurse to determine the total score for both the patients. While in one patient had a score of 6, the other had a total score of 8. High scores in both the patients indicated that they were suffering from severe pain and needed immediate pharmacological or non pharmacological intervention. Thus, my critical observation suggests that the nurse demonstrated an accurate practice as CPOT tool has been recommended by research studies, for the assessment of pain severity among non-verbal and critically ill patients (Linde et al., 2013). Adherence of the concerned nurse to the best practice can be further illustrated by the fact that evaluation of muscle tension, body movement, facial expression and compliance has been identified as the best parameters that can determine severity of pain, according to international clinical guidelines (Buttes et al., 2014).  Thus, the placement helped in establishing the fact that pain assessment and its measurement is major vital sign that needs to be recorded in nursing practice in order to improve health outcomes of patients.

Conclusion

To conclude, it can be stated that pain assessment is crucial to implementation of optimal pain management interventions. Critical evaluation of the three articles and the reflection during clinical placement emphasizes on the use of CPOT tool in assessing pain among critically ill patients, under incubation in Intensive Care units.  This will help in measuring the severity of the ear pain and administer appropriate pharmacological or non pharmacological interventions. 

References

Alderson, S. M., & Mckechnie, S. R. (2013). Unrecognised, undertreated, pain in ICU—causes, effects, and how to do better. Open Journal of Nursing, 3(01), 108.

Ayasrah, S. M., O’Neill, T. M., Abdalrahim, M. S., Sutary, M. M., & Kharabsheh, M. S. (2014). Pain assessment and management in critically ill intubated patients in Jordan: a prospective study. International journal of health sciences, 8(3), 287

Bonett, D. G., & Wright, T. A. (2015). Cronbach's alpha reliability: Interval estimation, hypothesis testing, and sample size planning. Journal of Organizational Behavior, 36(1), 3-15.

Buttes, P., Keal, G., Cronin, S. N., Stocks, L., & Stout, C. (2014). Validation of the Critical-Care Pain Observation Tool in adult critically ill patients. Dimensions of Critical Care Nursing, 33(2), 78-81.

Elwert, F., & Winship, C. (2014). Endogenous selection bias: The problem of conditioning on a collider variable. Annual Review of Sociology, 40, 31-53.

Conclusion

Griesdale, D. E., Liu, D., McKinney, J., & Choi, P. T. (2012). Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 59(1), 41-52.

Herr, K., Bursch, H., Ersek, M., Miller, L. L., & Swafford, K. (2012). Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice. Journal of gerontological nursing, 36(3), 18-29.

Hróbjartsson, A., Thomsen, A. S. S., Emanuelsson, F., Tendal, B., Hilden, J., Boutron, I., ... & Brorson, S. (2012). Observer bias in randomised clinical trials with binary outcomes: systematic review of trials with both blinded and non-blinded outcome assessors. Bmj, 344, e1119.

Kanda, Y. (2013). Investigation of the freely available easy-to-use software ‘EZR’for medical statistics. Bone marrow transplantation, 48(3), 452.

Keane, K. M. (2013). Validity and reliability of the critical care pain observation tool: a replication study. Pain Management Nursing, 14(4), e216-e225.

Linde, S. M., Badger, J. M., Machan, J. T., Beaudry, J., Brucker, A., Martin, K., ... & Roy, R. D. N. (2013). Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery. American Journal of Critical Care, 22(6), 491-497.

Mangin, B., Siberchicot, A., Nicolas, S., Doligez, A., This, P., & Cierco-Ayrolles, C. (2012). Novel measures of linkage disequilibrium that correct the bias due to population structure and relatedness. Heredity, 108(3), 285-291.

Marshall, B., Cardon, P., Poddar, A., & Fontenot, R. (2013). Does sample size matter in qualitative research?: A review of qualitative interviews in IS research. Journal of Computer Information Systems, 54(1), 11-22.

Rijkenberg, S., Stilma, W., Endeman, H., Bosman, R. J., & Oudemans-van Straaten, H. M. (2015). Pain measurement in mechanically ventilated critically ill patients: behavioral pain scale versus critical-care pain observation tool. Journal of critical care, 30(1), 167-172.

Rose, L., Haslam, L., Dale, C., Knechtel, L., & McGillion, M. (2013). Behavioral pain assessment tool for critically ill adults unable to self-report pain. American Journal of Critical Care, 22(3), 246-255.

Schenker, Y., Crowley-Matoka, M., Dohan, D., Tiver, G. A., Arnold, R. M., & White, D. B. (2012). I don’t want to be the one saying ‘we should just let him die’: intrapersonal tensions experienced by surrogate decision makers in the ICU. Journal of general internal medicine, 27(12), 1657-1665.

Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., ... & Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators and the ANZICS Clinical Trials Group. (2012). Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. American journal of respiratory and critical care medicine, 186(8), 724-731.

Stites, M. (2013). Observational pain scales in critically ill adults. Critical care nurse, 33(3), 68-78.

Varndell, W., Fry, M., & Elliott, D. (2017). A systematic review of observational pain assessment instruments for use with nonverbal intubated critically ill adult patients in the emergency department: an assessment of their suitability and psychometric properties. Journal of clinical nursing, 26(1-2), 7-32.

Zeng, X., Zhang, Y., Kwong, J. S., Zhang, C., Li, S., Sun, F., ... & Du, L. (2015). The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta?analysis, and clinical practice guideline: a systematic review. Journal of evidence-based medicine, 8(1), 2-10.