Controlling Pain in the ICU

When asked how common significant pain is in critically-ill adult patients in the ICU, Eileen F. Sollars, RN, special care unit nurse at Scottsdale Healthcare-Osborn, responded, “In a word: very.”

She’s right. Moderate to severe pain during an ICU stay is reported in up to 50% of medical as well as surgical patients.

“In the trauma ICU, pain can be a constant companion to our patients,” Sollars said.

Pain in critically ill adult patients can be due to many causes related to their underlying illness, surgery or from noxious stimuli related to routine care that is provided in the ICU setting, noted Nancy Christiansen, MSN, RN, CCRN, CNS, clinical nurse specialist for Critical Care and the Definitive Step-Down Unit at St. Joseph Hospital in Orange, Calif.

Pain is a source of significant stress for patients as assessment and evaluation remain a leading challenge. Long considered the “gold standard” for assessment, patients’ self-report of pain is not always accurate.

“The difficulty in the ICU setting is that many patients are unable to communicate their needs and the nursing attentiveness to assessing pain becomes a very important part of the nursing care,” said Christiansen.

Effects of Untreated ICU Pain

An article published in Critical Care Medicine, “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult,” reported that at times “ensuring that critically ill patients are free from pain may conflict with other clinical management goals, such as maintaining cardiopulmonary stability.”

However, if left untreated, pain in the ICU can lead to physiologic responses, such as tachycardia with increased oxygen consumption, hypermetabolism and alterations in immune function.

Patients who are unable to communicate will often exhibit restlessness and anxiety, noted Megan Liego, DNP(c), APRN, ACNP-C, CNS, acute care nurse practitioner with the cardiac surgery and critical care teams at St. Joseph Hospital.

“In surgical patients, such as our cardiac surgery population, pain can cause decreased activity and alterations in breathing. This has been associated with increased rate of atrial fibrillation and other complications, such as pneumonia,” explained Liego.

The psychological impact of untreated pain can be significant and may affect the patient’s ability to recover and their wellbeing.

Similar to soldiers in the military, post-traumatic stress disorder (PTSD) has also been found in a number of critical care patients long after their discharge home due to untreated pain.

Complications of Self-Assessment

Christiansen noted that it is essential for all patients to be assessed for pain to avoid negative physiological and psychological consequences if left untreated.

In addition, it is possible for untreated pain to lead to the development of chronic disabling pain.

Complications and longer hospital stays can also be contributed to untreated pain, she said. However, self-assessment isn’t as straightforward as it may sound, particularly because pain is a very individualized experience.

“Pain is multidimensional and patients’ perception and reporting of pain is influenced by many factors, including their cultural norms and beliefs, gender roles and life experiences,” said Liego.

Language and culture can get in the way of pain assessment and discomfort or pain can be difficult for some patients to describe.

“In some cultures, admitting pain is considered a weakness. So some assessment parameters may tell us a patient is in pain when she or he denies it,” remarked Mary Pat Aust, MS, RN, clinical practice specialist, American Association of Critical-Care Nurses.

Linda Bell, MSN, RN, clinical practice specialist, American Association of Critical-Care Nurses, concurred.

“Hearing and visual changes associated with aging and the inability to understand directions when asked to identify pain – whether it’s because the patient and nurse speak different languages or they’re using unfamiliar words – can interfere with accurate self-assessment,” she said.

Right Tools for the Challenge

Liego remarked that it is important to have validated, standardized pain assessment tools.

The most common verbal scale for adult ICU patients is the Verbal Numerical Rating Scale (VNRS), where pain is rated on a scale from zero to 10-10 being severe and zero being no pain at all.

Some non-verbal scales consist of having the patient point to a number on a board or paper, asking the patient to shake their head yes or no to pain, and following their facial expressions and vital signs for indications of pain.

Assessing pain in a non-verbal patient or in a patient who is unable to communicate can be challenging for nurses, acknowledged Christiansen. That is why it is important to use a validated tool that takes into account other physiological criteria for pain. She said one of the more helpful tools for assessing pain is the mnemonic OLDCART:

Many pain assessments incorporate the items from this mnemonic, Christiansen explained.

As for assessing pain in patients who cannot communicate, Christiansen noted that in St. Joseph Hospital’s ICU, nurses use a non-verbal pain assessment that includes facial expression, patient movement, signs of guarding, vital sign criteria, changes in respiratory rate and pulse oximetry, and verbal cues.

“Each of these criteria contributes to an overall pain score for the patient, and pain medication is then administered according to the pain score,” she said.

Mary Stahl, MSN, RN, ACNS-BC, CCNS-CMC, CCRN, clinical practice specialist, American Association of Critical-Care Nurses, noted that “sedation or paralytic drugs can mask non-verbal behaviors associated with pain but they do nothing to alleviate pain.”

Aust added that both the Critical Care Pain Observation Tool and the Behavioral Pain Scale are examples of valid and reliable pain assessment tools when a patient can’t self-report.

“We used to think changes in heart rate or blood pressure would tell us someone was in pain. These can be cues to pain, but they can signal other things,” she concluded.

Resources for this article can be accessed here.
Beth Puliti is a freelance writer.