By Karen Long
While all nurses evaluate the four vital signs of temperature, pulse, blood pressure and respiratory rate, Ellen Cunningham, RN, MSN, is among many RNs who assess a fifth: pain.
"Every patient has the right not to suffer in pain," said Cunningham, nurse manager at the Interventional Pain Center at North Shore-LIJ Health System’s Syosset (N.Y.) Hospital.
But assessing the pain of patients in the critical care setting can be difficult, especially if they have cognitive impairments or can’t speak.
"Inability to provide a reliable report about pain leaves the patient vulnerable to under-recognition and under- or over-treatment," the American Society for Pain Management Nursing stated in a July 2011 position paper about pain assessments in patients unable to self-report. "Nurses are integral to ensuring assessment and treatment of these vulnerable populations."
How to assess a critically ill patient
Determining a nonverbal patient’s pain is "definitely like unpeeling an onion," Cunningham said. Many nurses follow a hierarchy for pain assessment to evaluate the pain of a patient who cannot self-report, said Barbara St. Marie, ANP, PhD, GNP, ACHPN, pain specialist and former member of the American Society for Pain Management Nursing’s board of directors. The ASPMN outlines the steps in its position paper as follows:
Try to have the patient self-report pain. It often is difficult with critically ill patients, Cunningham said. Obtaining that information "may be hampered by delirium, cognitive and communication limitations, altered level of consciousness, presence of endotrachael tube, sedatives and neuromuscular-blocking agents," according to the position paper. Those patients might not be able to rate pain on a scale of one to 10, but could use a gesture such as grasping the nurse’s hand or blinking their eyes to indicate pain, St. Marie said.
Identify potential causes of pain. That could include surgery, trauma, catheter removals, wound care or constipation, Cunningham said.
Observe patient behavior. Several tools also exist to help nurses assess pain in patients who are unable to speak, said Donna Gorglione, RN, BSN, clinical nurse manager of the ICU and progressive care unit at Hudson Valley Hospital Center in Cortlandt Manor, N.Y. For patients who are aware but not able to voice their pain, nurses can use the Wong-Baker FACES Pain Rating Scale, said Maggie Adler, RN, MSN, WCC, associate director of standards and quality at HVHC.
The Pain Assessment in Advanced Dementia Scale measures behaviors such as restlessness, agitation, moaning and grimacing that can indicate pain. Nurses observe the patient and score a zero, one or two in five areas — breathing independent of vocalization, negative vocalization, facial expression, body language and consolability — then add up the score. Zero equates to no pain while 10 means severe pain. Nurses then treat the patients based on the pain score, Adler said. For example, a two might indicate the patient’s pain could be eased with Tylenol, while a seven would dictate a more serious intervention, such as narcotics.
The critical care pain observation tool and Face, Legs, Activity, Cry, Consolability tool also are useful, St. Marie said. Changes in blood pressure, heart rate or respiration could be indicators of pain. "I always say that if someone has a physiologic indicator, that’s the point where you start investigating more," she said.
Obtain a proxy report. Parents of young children or caregivers and family members of the elderly can provide vital information about what is causing patients’ pain, Cunningham said. "Credible information can be obtained from family members who know the patient well and may be a very consistent caregiver throughout their illnesses," St. Marie said.
Try an analgesic trial. If the other methods to determine pain yield inconclusive results, a trial could help, St. Marie said. Nurses administer low doses of any number of opioids and look for the patient to settle down, change facial expression or otherwise indicate a decrease in pain. According to Cunningham, any of those would indicate the patient had pain and not distress.
Pain management treatments
After assessing the patients’ pain, level of consciousness and respiratory status, nurses look at other indicators such as comorbidities, kidney and liver function, estimated blood loss from surgery and amount of opioids received in the OR and PACU. Nurses can use a variety of treatments to block pain through multiple receptors and pathways, St. Marie said.
Medications — such as nonsteroidal anti-inflammatory drugs, opioids, acetaminophen, local anesthetic agents and antiepileptics — through various pathways are common ways to treat pain. "Pain mechanisms involve our entire body, so it’s not just one pathway" that pain is transmitted through, St. Marie said. Nurses can now help block pain at many of those pathways.
Not all pain can be eliminated, Gorglione said. In some cases, a patient’s goal is to reduce pain to a tolerable level. "That’s an important piece of pain management," she said. "Sometimes we can’t get your pain to zero. If you can tolerate a level of three or four, we can get your pain there, and you can perform your activities of daily living."
Besides medications, patients can benefit from holistic therapies including music, massage or even hand-holding or warm blankets, Gorglione said.
"The tendency with medicine is to run right to the medicine cabinet," Adler said, noting other therapies can be effective. For some patients at HVHC, music has made a difference. "We’ve had patients and patients’ families thank us for the special attention and how relieved they were and how much it helped," Gorglione said. An integral part of pain management is reassessment after treatment. Nurses should use the same tool they used for assessments to determine whether the patient has a lower level of pain, St. Marie said.
Challenges in treating pain
Along with determining the right treatment, nurses face a variety of challenges in pain management. For example, some patients think pain is a normal part of their illnesses and refuse pain medication, Adler said. Elderly patients often have anxiety about becoming dependent on medications, Gorglione said. In those cases, educating the patient about pain management can help.
In other situations, the challenges come from providers. Patients who arrive in the ICU and have addiction issues often are stigmatized or marginalized because providers blame the victim, St. Marie said. But a patient going through withdrawal needs "serious pain control," she said.
Nurses have to overcome the challenges to be able to assess, treat and reassess patients’ pain, Cunningham said.
"No matter how old someone is, no matter how cognitively impaired they might be, it never takes away that they might be in pain," she said.