Pain was elevated to the status of a vital sign more than a decade ago to raise awareness about the importance of pain assessment and management, yet critical care nurses like Joanna Zanko, RN, MS, CCRN, face the reality every day that many patients still suffer from significant pain. Even more disturbing is that in many cases these critically ill patients cannot verbalize their pain.
Every once in a while these nonverbal patients are given a voice. In July, the New York Times published a story about a patient who also was an RN in an ICU in Fort Worth, Texas. She was gravely ill due to abdominal infections and surgeries and had been sedated and intubated. The woman recovered physically, but her stay in the ICU was so traumatic that she was tormented by it several years later. She experienced short-term memory loss and had trouble sleeping after she recovered.
This article caught Zankos attention, and it confirmed her decision to implement a new program aimed at reducing pain among critically ill patients at New York Methodist Hospital, where she is director of nursing for critical care services. If patients are in pain, they are not able to do deep breathing or expand their lungs well enough to get off the ventilator, Zanko said. If they are in pain, they also cant perform passive range of motion exercises, which interferes with the next steps toward mobility, clearing secretions and improved respiratory status. Pain also has physiological effects, such as elevating the heart rate and blood pressure and putting a strain on the heart.
The American Association of Critical-Care Nurses highlighted the importance of standardizing the assessment of critically ill patients in a practice alert issued in August. According to studies reviewed in the alert, more than 30% of patients in the ICU have significant pain at rest and more than 50% have significant pain during routine care, such as turning, endotracheal suctioning and wound care. Those are definitely high numbers, but I am not all that surprised, Zanko said. I think as nurses in critical care, a lot of activities we do with patients are painful.
The push for preemptive relief
Although reducing pain may seem like an overwhelming task, Zanko is focusing on minimizing discomfort for patients during routine activities. Zanko was challenged by recommendations from the Society of Critical Care Medicine that suggested an innovative approach: administering pain medications for any patient before routine care such as suctioning and dressing changes or before repositioning patients.
Zanko met with a critical care physician who supported the innovative approach and the duo outlined the details for a new protocol. Upon admission, nurses would assess patients tolerable pain levels, or the level of pain that is acceptable to each patient before he or she requests pain medication. Once a physician has activated an admission order set that includes routine pain management, a nurse could use his or her clinical judgment to determine whether routine care is causing the patient to experience pain above the tolerable level and if pain medication is needed before routine activities. If patients are able to tell us verbally that they have some degree of pain, that is ideal, but if they cant tell us, we use nonverbal cues such as twitching, stiffness or rigidity of muscles, agitation or facial grimacing, Zanko said.
The new program started in the spring, and although outcome data is not yet available, the rewards seem to be outweighing the challenges. It definitely has been very challenging, Zanko said. From the staff perspective, nurses get nervous about patients being overmedicated and oversedated, especially because they are trying to get patients to participate in their care. The physicians also had some concerns about why we should give medication preemptively before there is even pain, but in time they could see it was having a positive effect on the patient.
Positive effects included weaning a patient from a ventilator sooner and a shorter stay in the ICU, according to Zanko. Patients appreciated not having pain during routine care, were able to progress in their mobility programs more quickly and were able to tolerate coughing and deep breathing exercises.
Nurses with high pain IQ
Although Roger Blanza, RN, BSN, a nurse in the cardiac surgical ICU at Brigham and Womens Hospital in Boston, may not have the luxury of a formal policy for preemptive medication administration, he has discovered ways to offer a similar form of care for his patients.
Blanza waits for patients to receive the regularly scheduled pain medication before he performs routine activities. I know they usually become drowsy, so I tell them that five minutes after I administer intravenous pain medication, I will have to wake them up to do my planned activities, such as deep breathing exercises, CPT or getting [them] out of bed, he said. This is the time when the medication will have its peak effect, so it is important to be proactive and not wait until they wake up on their own.
Blanza also believes whether a patient is verbal or not, it is critical to set expectations before an activity. I warn them ahead of time that they may have some pain, and I explain what we will be doing and why.
Like Blanza, Michele Zucconi, RN, MSN, CCRN, administrative director of cardiac care at Inspira Medical Center Vineland (N.J.), believes critical thinking skills are a nurses best defense against untreated pain. One area for improvement she sees is assessment of pain when it is not directly related to a patients reason for being admitted.
If someone comes in with respiratory distress and is put on a ventilator in the ICU, something like back pain may not be treated as aggressively as the acute, life-threatening condition, Zucconi said. However, this should not negate the fact that they are in pain at baseline and maybe even more so now that they are immobile in a bed.
Zucconi said life-threatening injuries often are coupled with other painful secondary injuries. Within the last year, her facility implemented a new electronic alert system that signals nurses to perform a pain assessment every four hours using the Wong-Baker FACES Pain Rating Scale. If nurses administer pain medication, an additional alert signals them to reassess the patient for pain within 60 minutes, though most RNs check on patients sooner if the medication was given intravenously, Zucconi explained.
We are documenting a lot more about pain when doing the assessment and the reassessment after administering medication, Zucconi said. Now we are looking at the frequency, location and intensity of the pain on a regular basis. The assessment alerts are a reminder to think critically about everything that is happening with our patients.
Although pain assessment and treatment has improved over time, nurses acknowledge one of the significant challenges is that it is subjective, unlike the other four vital signs. We have these scales that measure pain, but one person may see grimacing and I may not, and it is so subjective that it impacts the quality of pain care, said Martin Schiavenato, RN, PhD, an associate professor at Washington State University College of Nursing in Spokane. My greatest wish is that we can make the pain assessment process more objective, and I think technology can help us. By no means do we want to take nurses out of the equation, but if nurses have more objective information, they can better assess pain.
Schiavenatos passion for more accurate pain assessments motivated him to invent a device that uses a computer chip to interpret a patients pain signals. The device is designed for measuring pain in infants in the NICU, but it has applications for adults who cannot verbalize pain. The device uses leads to measure heart rate variability and sensors that monitor facial and hand responses to pain. Whenever I tell a nurse what it is we are doing, they seem very encouraged because they know that pain is a prevalent and disconcerting problem, he said. This could tell us the patients pain level at any moment and in real time.
Although Schiavenatos device is in the development stage, he believes proper pain assessment is so critical that it has become the focus of his career in nursing. His hope is the healthcare community will recognize pain care cannot be ignored. The chemicals secreted in the bodys pain response are like poison to the brain development of preemies, he said. Unlike preemies, adults are not growing or developing their brains, but we now know that acute pain left untreated can predispose people to chronic pain. I believe the solution starts with acknowledging that pain is complex and much more than simply a fifth vital sign.