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Ashkenazy S, Weissman C, DeKeyser Ganz F. Measuring pain or discomfort during routine nursing care in lightly sedated mechanically ventilated intensive care patients: A prospective preliminary cohort study. Heart Lung 2024; 67:169-175. [PMID: 38810529 DOI: 10.1016/j.hrtlng.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/26/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Pain is routinely measured on mechanically ventilated ICU patients. However, the tools used are not designed to discriminate between pain and non-pain discomfort, a distinction with therapeutic implications. OBJECTIVES To evaluate whether clinical measurement tools can discern both pain and non-pain discomfort. METHODS A prospective observational cohort study was conducted in a General ICU at a tertiary Medical Center in Israel. The Behavior Pain Scale (BPS) and Visual Analog Scale (VAS) of Discomfort were simultaneously assessed by a researcher and bedside nurse on thirteen lightly sedated patients during 71 routine nursing interventions in lightly sedated, mechanically ventilated, adult patients. Patients were asked whether they were in pain due to these interventions. RESULTS Statistically significant increases from baseline during interventions were observed [median change: 1.00 (-1-5), 1.5(-4-8.5), p < 0.001] as measured by BPS and VAS Discomfort Scale, respectively. BPS scores ranged between 4 and 6 when the majority (53 %) of the patients replied that they had no pain but were interpreted by the clinicians as discomfort. Endotracheal suctioning caused the greatest increase in BPS and VAS, with no statistically significant differences in BPS and VAS Discomfort Scale scores whether patients reported or did not report pain. A BPS>6 had a higher sensitivity and specificity to reported pain (accuracy of 76 %) compared to a BPS of 4-6. CONCLUSIONS Standard assessments are sensitive to pain caused by routine nursing care interventions. However, this study presents evidence that among lightly sedated ICU patients, moderate BPS scores could also measure non-pain discomfort. ICU nurses should be aware that signs of unpleasantness measured by a pain scale could reflect non-pain discomfort.
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Affiliation(s)
- Shelly Ashkenazy
- Hadassah Hebrew University School of Nursing, Hadassah Medical Center, Kiryat Hadassah, POB 12000, Jerusalem, 91120, Israel.
| | - Charles Weissman
- Hebrew University of Jerusalem, Faculty of Medicine, Hospital Administration, Hadassah-Hebrew University Medical Center Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Freda DeKeyser Ganz
- Center for Nursing Research and Professor Emeritus, Hadassah Hebrew University School of Nursing, Hadassah Medical Center, Kiryat Hadassah, POB 12000, Jerusalem, 91120, Israel
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Ashkenazy S, Weissman C, DeKeyser Ganz F. Perception of discomfort by mechanical ventilation patients in the Intensive Care Unit: A qualitative study. Intensive Crit Care Nurs 2021; 64:103016. [PMID: 33676810 DOI: 10.1016/j.iccn.2021.103016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Routine care in intensive care units (ICU) results in patient pain and discomfort. While pain is treated with analgesics, discomfort is generally not well characterised or addressed. Since many ICU patients communicate only non-verbally, practitioners often cannot discern between pain or discomfort when treating such patients, potentially leading to inappropriate analgesic administration. A first step in discriminating between pain and discomfort is understanding how patients perceive their discomfort. OBJECTIVE To describe mechanically ventilated ICU patients' perceptions of discomfort and how they differentiate discomfort from pain. METHOD A qualitative descriptive study using semi-structured interviews conducted with 13 patients in a Medical and General ICU who survived mechanical ventilation. Transcripts were analysed using content analysis. FINDINGS Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychological feelings. Each theme was further divided into subcategories. Most patients did not describe high levels of pain and did not associate physical discomfort with pain. CONCLUSIONS Discomfort, as described by patients, stems from both physical sensations and psychological feelings. Pain was less often described as a negative ICU experience, while other non-pain sources of discomfort were more likely to be recalled. Therefore, practitioners should not only focus on treating pain but also on treating overall comfort to improve the quality of the ICU experience and potentially decrease post-ICU psychological sequela.
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Affiliation(s)
- Shelly Ashkenazy
- Hebrew University of Jerusalem, Hadassah Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel.
| | - Charles Weissman
- Hebrew University of Jerusalem, Hadassah Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Freda DeKeyser Ganz
- Hebrew University of Jerusalem, Hadassah Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel; Jerusalem College of Technology, 11 Beit Hadfus, Jerusalem 9548311, Israel
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Arimon MP, Llobet MP, Roldán-Merino J, Moreno-Arroyo C, Blanco MÁH, Lluch-Canut T. A Communicative Intervention to Improve the Psychoemotional State of Critical Care Patients Transported by Ambulance. Am J Crit Care 2021; 30:45-54. [PMID: 33385200 DOI: 10.4037/ajcc2021619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Communication is key to understanding the emotional state of critical care patients. OBJECTIVE To analyze the effectiveness of the communicative intervention known as CONECTEM, which incorporates basic communication skills and augmentative alternative communication, in improving pain, anxiety, and posttraumatic stress disorder symptoms in critical care patients transported by ambulance. METHODS This study had a quasi-experimental design with intervention and control groups. It was carried out at 4 emergency medical centers in northern Spain. One of the centers served as the intervention unit, with the other 3 serving as control units. The nurses at the intervention center underwent training in CONECTEM. Pretest and posttest measurements were obtained using a visual analog scale to measure pain, the short-version State-Trait Anxiety Inventory to measure anxiety, and the Impact of Event Scale to measure posttraumatic stress disorder symptoms. RESULTS In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of the intervention group (Pillai multivariate, F2,110 = 57.973, P < .001). The intervention was associated with improvements in pain (mean visual analog scale score, 3.3 pretest vs 1.1 posttest; P < .001) and posttraumatic stress disorder symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the percentage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001). CONCLUSION The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport.
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Affiliation(s)
- Marta Prats Arimon
- Marta Prats Arimon is an associate professor, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; a collaborating professor, School of Nursing, Faculty of Medicine and Health Sciences, University Ramon Llull, Barcelona, Spain; and a registered nurse, Emergency Department, Hospital Transfronterer de Cerdanya, Puigcerdà (Girona), Spain
| | - Montserrat Puig Llobet
- Montserrat Puig Llobet is a professor and director of the Mental and Public Health Department and director of the master’s program in nursing interventions in complex chronic patients, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona and a researcher in the CARINGCF Research Group, Tarragona, Spain and the GIRISAME Research Group, Madrid, Spain
| | - Juan Roldán-Merino
- Juan Roldán-Merino is a professor, Campus Docent, Sant Joan de Déu-Fundació Privada, School of Nursing, University of Barcelona; a researcher in the GIESS Research Group and the GEIMAC Research Group, Barcelona, Spain; and coordinator of the GIRISAME Research Group and the REICESMA Research Group, Madrid, Spain
| | - Carmen Moreno-Arroyo
- Carmen Moreno-Arroyo is a professor in the Department of Fundamental and Medical-Surgical Nursing and a director of the master’s program in critical care nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona
| | - Miguel Ángel Hidalgo Blanco
- Miguel Ángel Hidalgo Blanco is a professor in the Department of Fundamental and Medical-Surgical Nursing and a director of the master’s program in critical care nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona
| | - Teresa Lluch-Canut
- Teresa Lluch-Canut is a professor of psychosocial and mental health, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona; and a researcher in the GEIMAC Research Group, Barcelona, Spain
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van Dijk JFM, Schuurmans MJ, Alblas EE, Kalkman CJ, van Wijck AJM. Postoperative pain: knowledge and beliefs of patients and nurses. J Clin Nurs 2017; 26:3500-3510. [DOI: 10.1111/jocn.13714] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jacqueline FM van Dijk
- Department of Anesthesiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Marieke J Schuurmans
- Department of Nursing Science; University Medical Center Utrecht; Utrecht The Netherlands
| | - Eva E Alblas
- Department of Communication Science; Radboud University Nijmegen; Nijmegen The Netherlands
| | - Cor J Kalkman
- Department of Anesthesiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Albert JM van Wijck
- Department of Anesthesiology; University Medical Center Utrecht; Utrecht The Netherlands
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Aktaş YY, Karabulut N. A Turkish Version of the Critical-Care Pain Observation Tool: Reliability and Validity Assessment. J Perianesth Nurs 2016; 32:341-351. [PMID: 28739066 DOI: 10.1016/j.jopan.2015.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 10/20/2022]
Abstract
PURPOSE The study aim was to evaluate the validity and reliability of the Critical-Care Pain Observation Tool in critically ill patients. DESIGN A repeated measures design was used for the study. METHODS A convenience sample of 66 patients who had undergone open-heart surgery in the cardiovascular surgery intensive care unit in Ordu, Turkey, was recruited for the study. The patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (suctioning), and 20 minutes after the procedure while they were conscious and intubated after surgery. FINDING The Turkish version of the Critical-Care Pain Observation Tool has shown statistically acceptable levels of validity and reliability. Inter-rater reliability was supported by moderate-to-high-weighted κ coefficients (weighted κ coefficient = 0.55 to 1.00). For concurrent validity, significant associations were found between the scores on the Critical-Care Pain Observation Tool and the Behavioral Pain Scale scores. Discriminant validity was also supported by higher scores during suctioning (a nociceptive procedure) versus non-nociceptive procedures. The internal consistency of the Critical-Care Pain Observation Tool was 0.72 during a nociceptive procedure and 0.71 during a non-nociceptive procedure. CONCLUSIONS The validity and reliability of the Turkish version of the Critical-Care Pain Observation Tool was determined to be acceptable for pain assessment in critical care, especially for patients who cannot communicate verbally.
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Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. [Nursing team knowledge on behavioral assessment of pain in critical care patients]. ACTA ACUST UNITED AC 2014; 34:55-63. [PMID: 24344585 DOI: 10.1590/s1983-14472013000300007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This investigation consisted on a prospective cross-sectional study that aimed to describe the nursing team knowledge on behavioral assessment of pain. The study was conducted in a private hospital in the city of Sao Paulo, Brazil in November 2011, with nursing professionals from a general adult intensive care unit. They answered a questionnaire that contained sociodemographic data and questions related to knowledge about a behavioral assessment of pain. Descriptive data analysis was carried out and the average positive score was compared among categories using the Mann-Whitney test. Out of the 113 participants, over 70% have demonstrated knowledge of the main aspects of this assessment and there was no statistical significant difference among the professional categories. It was concluded that the knowledge of the professionals was satisfactory, but it can be improved.
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Grap MJ, Munro CL, Wetzel PA, Ketchum JM, Hamilton VA, Sessler CN. Responses to noxious stimuli in sedated mechanically ventilated adults. Heart Lung 2014; 43:6-12. [PMID: 24239298 PMCID: PMC3907191 DOI: 10.1016/j.hrtlng.2013.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the effect of sedation on physiologic responses and comfort before, during and after a noxious stimulus (endotracheal tube suctioning). METHODS The sample was a subset of a larger, longitudinal descriptive study, blood for endorphins and saliva for alpha-amylase were obtained before and after suctioning. Heart rate (HR), respiration rate (RR), oxygen saturation (SPO2), and arm and leg actigraphy were continuously recorded. RESULTS 67 subjects from medical and surgical ICUs were primarily deeply (37%) or mildly sedated (54%) prior to suctioning. Alpha-amylase increased post suctioning (p = 0.04); endorphins did not change (p = 0.58). Neither were modified by sedation. There were no changes in HR, RR or SPO2 post suctioning. Arm (p = 0.007) and leg actigraphy (p = 0.057) changed from baseline and depended on sedation level (p = 0.0005). CONCLUSIONS While a stress marker did increase during suctioning, only the measure of patient arm movement was significantly affected by sedation level.
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Affiliation(s)
- Mary Jo Grap
- Adult Health and Nursing Systems Department, School of Nursing, Virginia Commonwealth University, Box 980567, Richmond, VA 23298-0567, USA.
| | | | - Paul A Wetzel
- Department of Biomedical Engineering, School of Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica M Ketchum
- Department of Biostatistics, School of Medicine, VCU Center for Rehabilitation Science and Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - V Anne Hamilton
- Adult Health and Nursing Systems Department, School of Nursing, Virginia Commonwealth University, Box 980567, Richmond, VA 23298-0567, USA
| | - Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Changes in the Bispectral Index in Response to Experimental Noxious Stimuli in Adults under General Anesthesia. ISRN PAIN 2013; 2013:583920. [PMID: 27335878 PMCID: PMC4893395 DOI: 10.1155/2013/583920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/25/2013] [Indexed: 11/18/2022]
Abstract
Objective. Pain assessment is a major challenge in nonverbal patients in the intensive care unit (ICU). Recent studies suggest a relationship between the Bispectral Index (BIS) and nociceptive stimuli. This study was designed to examine changes in BIS in response to experimental noxious stimuli. Methods. Thirty participants under general anesthesia were in this quasiexperimental, within subject, pre- and poststudy. In the operating room (OR), BIS was monitored during moderate and severe noxious stimuli, induced by a thermal probe on the participants' forearm, after induction of general anesthesia, prior to surgery. Results. Significant increases in BIS occurred during moderate (increase from 35.00 to 40.00, P = 0.003) and severe noxious stimuli (increase from 37.67 to 40.00, P = 0.007). ROC showed a sensitivity (Se) of 40.0% and a specificity (Sp) of 73.3% at a BIS value > 45, in distinguishing a moderate from a severe noxious stimuli. Conclusion. BIS increased in response to moderate and severe noxious stimuli. The Se and Sp of the BIS did not support the use of the BIS for distinction of different pain intensities in the context of deep sedation in the OR. However, the results justify further studies in more lightly sedated patients such as those in the ICU.
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Gélinas C, Arbour C, Michaud C, Robar L, Côté J. Patients and ICU nurses' perspectives of non-pharmacological interventions for pain management. Nurs Crit Care 2012; 18:307-18. [PMID: 24165072 DOI: 10.1111/j.1478-5153.2012.00531.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pain is a major stressor for critically ill patients. To maximize pain relief, non-pharmacological interventions are an interesting avenue to explore. AIMS AND OBJECTIVES The study aim was to describe the perspectives of patients/family members and nurses about the usefulness, relevance and feasibility of non-pharmacological interventions for pain management in the intensive care unit (ICU). DESIGN A qualitative descriptive design was used. METHODS Patients/family members (n = 6) with a previous experience of ICU hospitalization and ICU nurses (n = 32) were recruited. Using a semi-structured discussion guide, participants were asked to share their perspective about non-pharmacological interventions that they found useful, relevant and feasible for pain management in the ICU. Interventions were clustered into five categories: a) cognitive-behavioural, b) physical, c) emotional support, d) helping with activities of daily living and, e) creating a comfortable environment. RESULTS A total of eight focus groups (FGs) with patients/family members (two FGs) and ICU nurses (six FGs) were conducted. Overall, 33 non-pharmacological interventions were discussed. The top four non-pharmacological interventions found to be useful, relevant and feasible in at least half of the FGs were music therapy and distraction (cognitive-behavioural category), simple massage (physical category) and family presence facilitation (emotional support category). Interestingly, patients/family members and nurses showed different interests towards some interventions. For instance, patients discussed more about active listening/reality orientation, while nurses talked mostly about teaching/positioning. CONCLUSIONS Four non-pharmacological interventions reached consensus in patients and nurses' FGs to be useful, relevant and feasible for pain management in the ICU. Other interventions seemed to be influenced by personal experience or professional role of the participants. RELEVANCE TO CLINICAL PRACTICE While more evidence is required to conclude to their effectiveness, ICU nurses can use non-pharmacological interventions complementary to pharmacological treatment of pain as they are low cost and safe.
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Affiliation(s)
- Céline Gélinas
- C Gélinas, RN, PhD, Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada, The Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada, Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, CanadaC Arbour, RN, BSc, PhD (c), Ingram School of Nursing, McGill University, Montreal, Quebec, Canada, Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada, The Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada, Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, CanadaC Michaud, RN, PhD, School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada, Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, CanadaL Robar, BSc, Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Québec, CanadaJ Côté, RN, PhD, Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada, Quebec Nursing Intervention Research Network (RRISIQ), MOntréal, Québec, Canada
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Rowbotham S, Holler J, Lloyd D, Wearden A. How Do We Communicate About Pain? A Systematic Analysis of the Semantic Contribution of Co-speech Gestures in Pain-focused Conversations. JOURNAL OF NONVERBAL BEHAVIOR 2011. [DOI: 10.1007/s10919-011-0122-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chen YY, Lai YH, Shun SC, Chi NH, Tsai PS, Liao YM. The Chinese Behavior Pain Scale for critically ill patients: Translation and psychometric testing. Int J Nurs Stud 2011; 48:438-48. [DOI: 10.1016/j.ijnurstu.2010.07.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 07/26/2010] [Accepted: 07/26/2010] [Indexed: 11/27/2022]
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Latorre Marco I, Solís Muñoz M, Falero Ruiz T, Larrasquitu Sánchez A, Romay Pérez A, Millán Santos I. Validación de la Escala de Conductas Indicadoras de Dolor para valorar el dolor en pacientes críticos, no comunicativos y sometidos a ventilación mecánica: resultados del proyecto ESCID. ENFERMERIA INTENSIVA 2011; 22:3-12. [PMID: 21333576 DOI: 10.1016/j.enfi.2010.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 09/17/2010] [Indexed: 10/18/2022]
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Delgado-Guay MO, Parsons HA, Li Z, Palmer LJ, Bruera E. Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 2008; 115:437-45. [DOI: 10.1002/cncr.24017] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Varga K, Diószeghy C, Fritúz G. Suggestive communication with the ventilated patient. EUROPEAN JOURNAL OF MENTAL HEALTH 2008. [DOI: 10.1556/ejmh.2.2007.2.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Carroll SM. Silent, slow lifeworld: the communication experience of nonvocal ventilated patients. QUALITATIVE HEALTH RESEARCH 2007; 17:1165-1177. [PMID: 17968034 DOI: 10.1177/1049732307307334] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The author explored communication experience of nonvocal ventilated individuals in rehabilitation settings with an aim to understand the reality of being voiceless using interpersonal relations theory as the theoretical study framework. Nineteen participants of varied ages and with varied ventilator courses shared their experiences while they were still nonvocal. The author used an interpretive phenomenological approach and analyzed the data using thematic analysis. Participants described the meaning of their nonvocal experience as "Being trapped in a silent world makes me feel frustrated and incomplete," "Days pass in slow motion while the rest of the world speeds by," "Making and preserving connections is of paramount importance," and "The powerlessness of being nonvocal was ameliorated by developing coping strategies and by consistent and reliable nursing care." In the discussion, the author provides an expanded understanding of the complexities of living in a silent, slow world.
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Gélinas C. Management of pain in cardiac surgery ICU patients: Have we improved over time? Intensive Crit Care Nurs 2007; 23:298-303. [PMID: 17448662 DOI: 10.1016/j.iccn.2007.03.002] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 02/23/2007] [Accepted: 03/04/2007] [Indexed: 10/23/2022]
Abstract
This study described the pain experience of cardiac surgery ICU patients. After their transfer to the surgical unit, 93 patients were interviewed using a questionnaire about their pain experience while they were in the ICU. Sixty-one patients (65.6%) recalled being ventilated and 72 patients (77.4%) recalled having pain. Turning was the most frequent source of pain experienced by the patients. A large proportion of the patients (47.3%) identified the thorax as the location of their pain. All patients had a sternal incision. Pain was mild for 16 patients, moderate for 21, and severe for 25 of them. While ventilated, head nodding and movements of the upper limbs were the most frequent means of communication used by the patients. Despite advances in pain management, the study's findings are disturbingly similar to those of 17 years ago [Puntillo KA. Pain experiences of intensive care unit patients. Heart Lung 1990;19:526-33]. Evidence from research about clinical guidelines for pain management needs to be applied to the care of cardiac surgery patients in order to reduce patient suffering.
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Affiliation(s)
- Céline Gélinas
- School of Nursing, McGill University, 3506 University Street, Wilson Hall, Room 420, Montréal, Québec, Canada H3A 2A7.
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Curtis JR, Engelberg RA. Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit. Crit Care Med 2007; 34:S341-7. [PMID: 17057596 DOI: 10.1097/01.ccm.0000237048.30032.29] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Because of the severity of illness, the intensive care unit (ICU) is a setting where death is common. Although optimal palliative care should prevent many terminal ICU admissions, the ICU will always remain an important setting for end-of-life care because of the severity of illness of patients in the ICU and because many patients with chronic, life-limiting diseases and their families opt for a trial of intensive care. Therefore, improving the quality of end-of-life care in the ICU is an important endeavor. Furthermore, there are data to suggest that current quality of end-of-life care in the ICU is often poor and that this is an important target for quality improvement. However, as interventions are designed to improve the quality of end-of-life care in the ICU, researchers, clinicians, and quality improvement personnel will need reliable and valid measures to determine whether these interventions do improve the quality of care. In this article, we examine some of the data supporting potential process and outcome measures that could be used to evaluate the success of interventions designed to improve end-of-life care in the ICU.
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Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
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Engelberg RA. Measuring the quality of dying and death: methodological considerations and recent findings. Curr Opin Crit Care 2007; 12:381-7. [PMID: 16943713 DOI: 10.1097/01.ccx.0000244114.24000.bc] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW While the need to improve the quality of dying and death in critical settings has been well accepted, there is less agreement on which measures and criteria are best used to assess it. In this article, we present methodological considerations and recent findings that pertain to the measurement of the quality of dying and death. RECENT FINDINGS Research evaluating the quality of dying and death employs measures based on professionally determined criteria as well as measures relying on patient and family-centered standards. Professionally determined measures include assessments of resource consumption (e.g., length of stay, costs of care, technology utilization) and processes of care (e.g., do-not-resuscitate orders, family conferences). Studies of interventions designed to improve end-of-life care have shown positive changes in these outcomes. Patient and family-centered measures (e.g., quality of dying and death questionnaires, quality of end-of-life care questionnaires) have been used less often in intervention studies but, in descriptive studies, have shown important associations with factors related to a 'good death'. SUMMARY These findings suggest a need to integrate both types of measures in research on the quality of end-of-life experiences. This integration, with attention to important methodological issues, may represent a significant step toward improving patients' experiences at the end-of-life.
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Affiliation(s)
- Ruth A Engelberg
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA.
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Nursing care of the mechanically ventilated patient: what does the evidence say? Part two. Intensive Crit Care Nurs 2006; 23:71-80. [PMID: 17074484 DOI: 10.1016/j.iccn.2006.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 08/14/2006] [Accepted: 08/16/2006] [Indexed: 10/24/2022]
Abstract
The care of the mechanically ventilated patient is a fundamental component of a nurse's clinical practice in the intensive care unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly, yet is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient was explored with specific focus on patient safety: particularly patient and equipment assessment. This article, part two, examines the evidence related to the mechanically ventilated patient's comfort: patient position, hygiene, management of stressors (such as communication, sleep disturbance and isolation), pain management and sedation.
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Ramelet AS, Abu-Saad HH, Bulsara MK, Rees N, McDonald S. Capturing postoperative pain responses in critically ill infants aged 0 to 9 months. Pediatr Crit Care Med 2006; 7:19-26. [PMID: 16395069 DOI: 10.1097/01.pcc.0000192336.50286.8e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time. DESIGN This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist. PATIENTS A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery. MEASUREMENTS AND MAIN RESULTS There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli. CONCLUSIONS Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool for this group of infants.
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Affiliation(s)
- Anne-Sylvie Ramelet
- Nursing Services, Women's and Children's Health Service, Princess Margaret Hospital for Children, Western Australia, Australia.
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Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a Behavioral Pain Scale in Critically Ill, Sedated, and Mechanically Ventilated Patients. Anesth Analg 2005; 101:1470-1476. [PMID: 16244013 DOI: 10.1213/01.ane.0000182331.68722.ff] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessing pain in critically ill patients, particularly in nonverbal patients, is a great challenge. In this study, we validated a behavioral pain scale (BPS) in critically ill, sedated, and mechanically ventilated patients. The BPS score was the sum of 3 subscales that have a range score of 1-4: facial expression, upper limb movements, and compliance with mechanical ventilation. Two assessors observed and scored pain simultaneously with the BPS at rest and during painful procedures. The psychometric properties of the BPS that were studied were reliability, validity, and responsiveness. We achieved 360 observations in 30 patients. The BPS was internally reliable (Cronbach alpha = 0.72). The intraclass correlation coefficient to evaluate inter-rater reliability was high (0.95). Validity was demonstrated by the change in BPS scores, which were significantly higher during painful procedures, with averages of 3.9 +/- 1.1 at rest and 6.8 +/- 1.9 during procedures (P < 0.001), and by the principal components factor analysis, which revealed a large first-factor accounting for 65% of the variance in pain expression. The BPS exhibited excellent responsiveness, with an effect size ranging from 2.2 to 3.4. This study demonstrated that the BPS can be valid and reliable for measuring pain in noncommunicative intensive care unit patients.
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Affiliation(s)
- Younès Aïssaoui
- *Service de Réanimation Médicale et de Toxicologie Clinique, Hôpital Ibn Sina; and †Laboratoire de Biostatistiques, de Recherche Clinique et Epidémiologique, Faculté de Médecine et de Pharmacie, Rabat, Morocco
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