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Expected Nursing Practice 1. Assess and document pain in all critically ill

adult patients using appropriate and validated tools. [level B]

a. Attempt to obtain the patient’s self-report of pain using validated pain assessment tools or simple questions.

b. Teach patients to use self-report pain scales and communicate in verbal and nonverbal ways, such as numerical rating scales, point- ing, and head nodding.

c. Perform and document pain assessments routinely, including a baseline evaluation at the beginning of shifts, evaluations

AACN Practice Alert

Scope and Impact of the Problem Many critically ill adult patients experience signifi-

cant pain as indicated by a score on a numeric rating scale greater than 4.1 Furthermore, more than 50% have significant pain during procedures or routine care (eg, chest tube removal, endotracheal suctioning, wound care, turning/repositioning).2,3 Even a dressing change can cause pain.4

Untreated pain can result in negative consequences, including adverse events (eg, tachycardia/bradycardia, hypertension/hypotension, desaturation, bradypnea)5 and the development of chronic pain.6,7 Conversely, treating pain first, before sedative use (analgosedation) can significantly decrease pain scores, duration of mechanical ventilation, and length of stay in the inten- sive care unit (ICU).8

Because pain is multidimensional and subjective,9 the patient’s self-report is the gold standard for assess- ment. However, many adult patients in the ICU cannot self-report pain as a result of an altered level of conscious- ness, mechanical ventilation, and/or the administration of sedative agents. The lack of self-reporting makes assess- ing pain in critically ill patients a challenge for nurses, who should consider use of alternatives such as behav- ioral pain assessment tools.1,10

©2018 American Association of Critical-Care Nurses doi: https://doi.org/10.4037/ccn2018781

Assessing Pain in Critically Ill Adults

AACN Levels of Evidence Level A Meta-analysis of quantitative studies or metasyn-

thesis of qualita tive studies with results that consis tently support a specific action, intervention, or treatment (including systematic review of randomized controlled trials)

Level B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment

Level C Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

Level D Peer-reviewed professional and organizational standards with the support of clinical study recommen- dations

Level E Multiple case reports, theory- based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations

Level M Manufacturer’s recommendations only

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during activities or procedures known to be painful, and before and after adminis- tration of analgesics.

d. Communicate pain assessment findings during patient handoffs. If possible, assess pain jointly during handoffs to ensure inter- rater reliability with tools or questions.

2. Assess and document pain for critically ill adults who are unable to self-report, using a validated behavioral pain scale, such as the Behavioral Pain Scale in intubated (BPS) and nonintubated (BPS-NI) patients, or the Critical-Care Pain Obser- vation Tool (CPOT). [level B]

a. Perform and document pain assessments routinely, including a baseline evaluation at the beginning of shifts, evaluations during activities or procedures known to be painful, and before and after adminis- tration of analgesics.

b. Communicate pain assessment findings during patient handoffs; if possible, assess pain jointly during handoffs to ensure inter- rater reliability with tools.

3. Avoid referring primarily to vital signs for pain assessment of critically ill adult patients. [level C]

a. Use changes in vital signs as cues that the patient might be having pain and assess using validated pain tools.1

b. Consider significant changes in vital signs (ie, tachycardia/bradycardia, hypertension/ hypotension, desaturation, and bradypnea) as possible adverse events of severe pain.5

4. Consider asking someone who knows the patient well to identify behaviors that may indicate pain.11,12 [level C]

Supporting Evidence Attempt to Obtain the Patient’s Self-Report Using Valid Tools

The patient’s self-report remains the gold standard for pain assessment based on the universal definition of pain.9 Obtaining a patient’s self-report should be based on current practice guidelines from the American Society for Pain Management Nursing10 and the Society of Criti- cal Care Medicine.1

Use of validated pain assessment tools should be standard practice when caring for critically ill adult patients. Among pain intensity scales, patients prefer the 0 to 10 numeric rating scale in a visual format; it is usually the best discriminative tool for use in the adult ICU.13

When a patient cannot concentrate on a pain inten- sity scale, ask a simple question about the presence of pain. A “yes” or “no” answer, indicated by head nodding, head shaking, or other signs, should be considered a valid self-report of pain.10 In more unstable, critically ill adults, a self-report on the presence of pain is easier to obtain than a self-report on the intensity of pain.14

Use Valid Behavioral Scales for Patients Unable to Self-Report

Behavioral pain scales should be used routinely to assess pain in critically ill adults who are unable to self-report and with motor capacity to express behaviors.1 The BPS15 and the BPS-NI16 (scales of 3-12) and the CPOT17 (scale of 0-8) are considered the most valid and reliable tools for use with adults in medical, surgical, and trauma ICUs.14,18 Both scales were tested in hundreds of adults in the ICU, including delirious patients,19,20 with good interrater reliability and construct validity. BPS/BPS-NI and CPOT scores consistently increased during painful procedures compared with nonpainful procedures, and their scores positively correlated with patients’ self-reports of pain, the gold standard measure of pain.14,18 Cutoff scores for the presence of pain were established for the BPS (>5)5 and the CPOT (>2).21

An earlier study showed that the behavioral cutoff score (with the CPOT) was effective in detecting mod- erate-to-severe pain, but it could not detect mild lev- els of pain.21 Therefore, a behavioral score should not be considered equivalent to a self-reported pain inten- sity score.10,14

Studies using the BPS/BPS-NI and the CPOT in ICUs showed improved routine assessments of pain and better use of analgesic and sedative agents, as well as positive patient outcomes (ie, decreased mechanical ventilation duration, fewer adverse events).5,8,22-25 These behavioral pain scales can be implemented with minimal standard- ized training.

The Behavior Pain Assessment Tool is a newly devel- oped tool that underwent validation at the international

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level with its translation into 12 languages and testing in 3851 ICU patients from 28 countries.26 The Behavior Pain Assessment Tool showed construct validity and robust interrater reliability among thousands of ICU clinicians. These findings support its ability to discrimi- nate between painful procedures and rest and to cor- relate positively with the patient’s self-reports of pain. Implementation research is necessary to investigate its feasibility of use in clinical practice and its impact on patient outcomes.

Avoid the Use of Vital Signs as a Primary Assessment for Pain

Vital signs (eg, blood pressure, heart rate, respiratory rate) should never be used as the sole indicator of pain; rather, they should be considered cues to begin further pain assessment and avoid potential adverse effects of untreated pain.1,10

Vital signs are easily accessible in ICUs, and nurses consider them important in pain assessment. A large Canadian survey showed that more than 70% of ICU nurses used vital signs to assess pain.27 However, current evidence does not support the validity of vital signs for detecting pain in critically ill adults. Values of vital signs were found to increase, decrease, or remain stable during painful procedures.14 Moreover, correlations of vital sign fluctuations with behavioral pain scores and self-reports of pain were weak or absent.14 Significant fluctuations in vital signs should be considered as pain-related adverse events instead of as indicators for pain assessment.5

Ask Someone Who Knows the Patient Well About Pain Behavior

Proxy reports by someone who knows a patient well can assist nurses in identifying less obvious changes in behavior that may indicate the presence of pain.11 In a recent qualitative study, family members could describe common behaviors included in validated scales but also unique behaviors they believed were indicative of pain in their loved one.12 However, when asked to rate the pain intensity of their loved one, family members tend to overestimate intensity when compared with patients’ self-reports.11 Proxy assess- ments of pain should be combined with other evi- dence, including direct observation with the support of validated behavioral pain scales, and the presence of known or potentially painful conditions.10

Implementation/Organizational Support for Practice

Ensure that your unit has implemented a pain assess- ment policy for all critically ill adults, using validated tools that are appropriate to each patient’s capacity to communicate.

Make sure your unit provides education and clinical support on the use of behavioral pain scales and interpre- tation of the scores.

Develop an assessment-driven pain management protocol that includes appropriate use of validated tools, and consider use of pharmacologic and nonpharmaco- logic strategies according to pain assessment findings.14

Encourage comprehensive pain assessments that com- bine different strategies, such as behavioral pain scales and proxy reporting by family members or caregivers.10-12

Need More Information or Help? 1. Go to www.aacn.org, click Clinical Resources,

and scroll down to select AACN Practice Resource Network.

2. View the Society of Critical Care Medicine’s webi- nar “Successfully Overcoming Assessment and Treatment Challenges for ICU Pain.”

3. Access a free educational video to learn more about using the CPOT in the ICU on Kaiser Permanente Nursing’s website at http://kpnursing .org/professionaldevelopment/index.html or on the ICU Liberation SCCM website, where educational material of the BPS/BPS-NI is also available: http://www.iculiberation.org/Bundles /Pages/Pain.aspx.

4. Read the American Society of Pain Management Nursing position statement on pain assessment in patients who cannot self-report: Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-re- port: position statement with clinical practice recommendations. Pain Manage Nurs. 2011; 12(4):230-250.

5. Gélinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the critical- care pain observation tool on pain assessment/ management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study. Int J Nurs Stud. 2011;

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48(12):1495-1504. Appendix A contains a description of and directives on the use of the CPOT.

6. De Jong A, Molinari N, De Lattre S, et al. Decreas- ing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project). Crit Care. 2013;17(2):R74. http://ccforum.com /content/17/2/R74. Click on links to access elec- tronic supplemental material.

Original Author: Céline Gélinas, PhD, RN Date: May 2013

Contributing Authors: Céline Gélinas, PhD, RN, Kathleen Puntillo, PhD, RN, FAAN, FCCM

Approved by the Clinical Resources Task Force; May 2018.

Financial Disclosures None reported.

References 1. Barr J, Fraser GL, Puntillo KA, et al. Clinical practice guidelines for the

management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

2. Puntillo KA, Max A, Timsit JF, et al. Determinants of procedural pain intensity in the intensive care unit. The Europain study. Am J Respir Crit Care Med. 2014;189(1):39-47.

3. Al Sutari MM, Abdalrahim MS, Hamdan-Mansour AM, Ayasrah SM. Pain among mechanically ventilated patients in critical care units. J Res Med Sci. 2014;19(8):726-732.

4. Chanques G, DeLay J, Garnier O, et al. Is there a single non-painful procedure in the intensive care unit? It depends. Intensive Care Med. 2018;44:528-530.

5. De Jong A, Molinari N, De Lattre S, et al. Decreasing severe pain and serious adverse events while moving intensive care unit patients: a prospective interventional study (the NURSE-DO project). Crit Care. 2013;17(2):R74.

6. Baumbach P, Götz T, Günther A, Weiss T, Meissner W. Prevalence and characteristics of chronic intensive care-related pain: the role of severe sepsis and septic shock. Crit Care Med. 2016;44(6):1129-1137.

7. Choinière M, Watt-Watson J, Victor JC, et al. Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study. CMAJ. 2014;186(7):E213-E223.

8. Faust AC, Rajan P, Sheperd LA, Alvarez CA, McCorstin P, Doebele RL. Impact of an analgesia-based sedation protocol on mechanically ventilated patients in a medical intensive care unit. Anesth Analg. 2016;123:903-909.

9. International Association for the Study of Pain. IASP Taxonomy. 2014. http://www.iasp-pain.org/education/content.aspx?itemnumber=1698. Accessed September 4, 2018.

10. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manage Nurs. 2011;12(4):230-250.

11. Puntillo KA, Neuhaus J, Arai S, et al. Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help? Crit Care Med. 2012;40(10):2760-2767.

12. Vanderbyl B, Gélinas C. Family perspectives of traumatically brain injured patient pain behaviors in the intensive care unit. Pain Manage Nurs. 2017; 18(4):202-213.

13. Chanques G, Viel E, Constantin JM, et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain. 2010;151(3):711-721.

14. Gélinas C. Pain assessment in the critically ill adult: recent evidence and new trends. Intensive Crit Care Nurs. 2016;34:1-11.

15. 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(12): 2258-2263.

16. Chanques G, Payen J-F, Mercier G, et al. Assessing pain in non-intubated critically ill patients unable to self-report: an adaptation of the Behavioral Pain Scale. Intensive Care Med. 2009;35(12):2060-2067.

17. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006;15(4):420-427.

18. Gélinas C, Puntillo KA, Joffe A, Barr JA. A validated approach to evaluating psychometric properties of pain assessment tools for use in nonverbal critically ill adults. Semin Respir Crit Care Med. 2013;34(2):153-168.

19. Chanques G, Payen J-F, Mercier G, et al. Assessing pain in non-intubated critically ill patients unable to self-report: an adaptation of the Behavioral Pain Scale. Intensive Care Med. 2009;35(12):2060-2067.

20. Kanji S, MacPhee H, Singh A, et al. Validation of the Critical-Care Pain Observation Tool in critically ill patients with delirium: a prospective cohort study. Crit Care Med. 2016;44:943-947.

21. Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009;37(1):58-67.

22. Chanques G, Jaber S, Barbotte E, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34(6): 1691-1699.

23. Rose L, Haslam L, Dale C, Knechtel L, McGillion M. Behavioral pain assessment tool for critically ill adults unable to self-report pain. Am J Crit Care. 2013;22(3):246-255.

24. Gélinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the critical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study. Int J Nurs Stud. 2011;48(12):1495-1504.

25. Georgiou E, Hadjibalassi M, Lambrinou E, Andreou P, Papathanas- soglou EDE. The impact of pain assessment on critically ill patients’ outcomes: a systematic review. Biomed Res Int. 2015;2015:503830.

26. Gélinas C, Puntillo KA, Levin P, Azoulay E. The Behavior Pain Assessment Tool for critically ill adults: a validation study in 28 countries. Pain. 2017; 158:811-821.

27. Rose L, Smith O, Gélinas C, et al. Critical care nurses’ pain assessment and management practices: a survey in Canada. Am J Crit Care. 2012; 21(4):251-259.

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