الفهرس 
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Abstract
Patients admitted to Intensive Care Units (ICUs) frequently experience pain and discomfort during their stay. Procedures performed during care, underlying health condition or disease, catheters or tubes inserted into the patients and being unable to change position are some of the many reasons for this pain. Most patients in the ICU are under sedation, on mechanical ventilation, having altered consciousness or cognitive problems and hence are not able to communicate verbally. Being unable to communicate pain is a major barrier to having adequate pain assessment and management and, consequently leads to a great risk of underrated and undertreated pain.
Procedural pain, as a type of acute pain, can be a threat to tissue integrity, initiating a series of psychological, physiologic, and inflammatory stress responses. In fact, procedural pain in ICU patients has been identified as a negative physiologic and psychological stressor which necessitates the importance of identifying the determinants of procedural pain intensity in non-verbally communicating critically ill patients. So, the current study was conducted to assess the determinants of procedural pain intensity in non-verbally communicating critically ill patients.
Aim of the study
This study aimed to assess determinants of procedural pain intensity in non-verbally communicating critically ill patients.
Research design
A prospective descriptive correlational research design was used.
Materials and method
The study was conducted in the intensive care units of the Alexandria Main University Hospital namely: Unit I, Unit II and Unit III.
A convenience sample of 50 adult patients with age ranging from 18 to 60 years old, non-verbally communicating critically ill patients, and with a Glasgow coma Scale of ≤ 8 was included. This estimation was based on the power analysis using Epi Info V7 program. Patients were excluded from this study if they were hemodynamically unstable, having a condition likely to interfere with behavioral pain assessment (receiving neuromuscular blockers, quadriplegic patients, having polyneuropathy, or Guillain-Barré syndrome) in addition to delirious patients.
Tools of the study
Two tools were used in this study.
- Tool one, the Richmond Agitation-Sedation Scale (RASS) was used to assess the agitation or sedation level of the non-verbally communicating critically ill patients. The RASS scoring system ranges from restless to combative scored (+1 up to +4),
alert-and-calm scored (0) and drowsy to unarousable, scored (-1 up to -5). This tool is proved to be reliable (r= 0.956).
Patient’s demographic and clinical data were also recorded such as patient’s age, sex, date of admission, length of ICU stay, current diagnosis, presence of co-morbidities, days on mechanical ventilator, time of the last sedative agent, the presence of invasive devices, the Glasgow coma scale was used to assess the level of consciousness, and the Acute Physiology and chronic Health Evaluation (APACHE II) was used to measure the severity of illness on patient’s admission to the study.
- Tool two, the Revised Non-verbal Pain Scale (RNVPS) was used to assess pain intensity in non-verbally communicating critically ill patients. This tool includes assessment of patient’s behavioral and physiological pain intensity responses, using items such as: facial expression, activity (movement), guarding, physiologic pain response such as vital signs (heart rate, blood pressure, respiratory rate) and respiratory response (complaint/synchronization with ventilator). This tool is proved to be reliable (Cronbach α value = 0.71).
Assessment of patient’s behavioral and physiological pain intensity responses was done for the following procedures; artificial airway suctioning, vascular puncture and repositioning. The behavioral and physiological responses, for each item, are scored from 0 to 2, where 0 means absence of pain, 1 mild pain and 2 severe pain. The total overall pain measurement for all the items are interpreted as follow; 0 means no pain, 1 to 4 means mild pain, 5 to 6 moderate pain and 7 to 10 severe pain.
Procedure of data collection
Approval of the ethics committee of the Faculty of Nursing was obtained. An official letter from the Faculty of Nursing was delivered to the Alexandria Main University Hospital’s authorities to obtain the approval to conduct the study.
The tools used in this study (Tool I & II) were adopted from (Sessler et al, 2002) and (Kabes et al., 2009).
A pilot study was conducted on 5 patients (10% of the subjects), whom were excluded from the study sample in order to assess the clarity, feasibility and applicability of the tools. . The pilot study revealed that further modifications were not needed.
All patients admitted to the previously mentioned ICUs who met the inclusion criteria were enrolled in the study. Patients’ demographic and clinical data were recorded. Patients’ level of sedation was assessed before each procedure to obtain a baseline data using Tool one. Patients’ pain intensity was assessed by the researcher for the following procedures, suctioning (endotracheal and tracheal), arterial puncture and positioning (supine, lateral decubitus and semi Fowler), using the Revised Non-verbal Pain Scale (Tool two). The researcher performed real time observations at the patients’ bedside when the ICU nurses were performing the procedures to capture all patients’ behaviors. Each procedure took approximately 2 minutes to complete, except patient repositioning, which lasted longer, up to 5 minutes. The researcher observed patients earlier in the morning (to cover part of the night and the morning shift) when most of the nursing care procedures are done.
Each patient was assessed 3 times for pain intensity in one of the previously mentioned procedures using Tool II. The 1st time immediately before each procedure, an initial assessment was done at rest to obtain a baseline data; the 2nd time during each procedure an assessment was performed and the 3rd time immediately 2 to10 minutes after each procedure, a follow up assessment was done.
Ethical consideration
A written informed consent was obtained for non-verbally communicating critically ill patients from their surrogates at the time of data collection, after providing a clear explanation of the aim of the study, the potential benefits, the risks and discomfort from participation in his study. Patients’ privacy and confidentiality of responses, voluntary participation and right to withdraw from the study were ascertained before inclusion in the study sample.
Statistical analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS version 20 Chicago, IL, USA). Categorical variables were described using frequency and percent. Comparison between pain intensity using Revised Non-Verbal Pain Scale at 3 time points (before, during and after the procedure) was done using Friedman test. Multivariate Linear regression was used for predictors affecting pain intensity. Spearman correlation test was used to assess correlation between scores and quantitative parameters. In all statistical tests, the level of significance of .05 or less was used.
Results
The main findings of the current study revealed that more than half of the studied patients were males (54%) and 46% were Females. The mean age of the studied patients was 50 years old, Patients’ mean length of ICU stay was 32 days. More than three quarter of them had medical diagnosis (76%), and 12% were surgical and trauma patients respectively. The majority of the patients had urethral catheter (98%) and central venous catheter (92%) in place. More than three quarter (76%) had an endotracheal tube inserted while only 2% had a peripheral intravenous cannula inserted. The majority of the studied patients (88%) did not receive sedatives prior, during or after the procedure. While 10% had a sedative/analgesic infusion running at the time of the procedure, and 2% were given the sedative/analgesic in the last 4 hours before the procedure. The mean Richmond Agitation Sedation Scale score on the day of the procedure was 7. Patients mean level of consciousness was almost 8 as measured by the Glasgow Coma Scale, and patients’ severity of illness was 24 on APACHE II score.
Significant differences were found between the median pain intensity score and the 3 phases of each of the following procedures: endotracheal suctioning, arterial puncture, supine position, lateral decubitus position, using the Revised Non-Verbal Pain Scale (P≤ 0.001), in that pain intensity score was mild, 2 (0-5) before the procedure and increased to 7 (1-10) during the procedure, then it decreased again to 2 (0-2) after the procedure, where Z= 19.6, P 0.000, Z=24.174, P 0.000, Z=11.565, P 0.003, and Z= 26.533, P 0.000 respectively.
Multivariate regression analysis models revealed that patients’ characteristics, the past and present medical history, and the presence of invasive devices were not considered predictors of procedural pain intensity.
A positive correlation was found between the Richmond Agitation Sedation Scale and the Revised Non-Verbal Pain Scale on the second and third phases of the procedure (during and after the procedure) r = 0.301, p (0.034) and r = 0.341, p (0.015) respectively, denoting that the more the patient is sedated, the less the patient experiences pain.
Conclusion
It can be concluded from this study that non-verbally communicating critically ill patients experience mild pain before the procedures. Pain intensity increases with the procedures and can be severe. After the procedure, these patients still experience mild pain. The types of procedure were related to significant pain experience before, during and after the procedure. There are other factors such as the presence of infection, endotracheal tube, tracheostomy tube and peripheral line which are not significant with procedural pain intensity, but are associated with relatively high risk of experiencing pain before, during and after the procedures.
Recommendations
Based on the findings of the current study, the following are recommended:
• To integrate pain determinants in pain assessment tool of non-verbally communicating critically ill patient
• To encourage critical care nurses participation in conferences and workshops dedicated to pain assessment and management in the intensive care unit
• To provide ICU healthcare workers with pain related policies and protocols
• To assess nurses’ knowledge in relation to pain determinants in non-verbally communicating critically ill patients
• To replicate this study on a larger sample size.