Evidence-Based Measurement of Pain in Nonverbal Critically Ill Adults
Deborah Wegman, RN, BSN1, Nancy Freeland, RN, MS2, Margaret Odhner, RN2, and Gail L. Ingersoll, EdD, FAAN3. (1) Critical Care, University of Rochester Medical Center, Rochester, NY, USA, (2) Critical Care Nursing, University of Rochester Medical Center, Rochester, NY, USA, (3) Nursing Practice, University of Rochester Medical Center, Rochester, NY, USA
The management of pain is essential to the delivery of high quality care. Inherent in this process is the ability to accurately assess level of pain and whether or not treatment measures are successfully relieving its presence, intensity and duration. One of the most difficult situations in the pain management process is the determination of level of pain in persons unable to communicate their needs or discomfort.
Patients intubated because of critical illness or injury often are sedated to assist in the management of their ventilation needs. Many of these individuals are unable to respond to verbal commands or to indicate when they are in pain. Nurses working in a Burn/Trauma ICU of one large hospital undertook an initiative to develop an evidence-based pain assessment tool for use with their nonverbal critically ill patients. Recommendations to use an instrument developed for use with nonverbal children was considered unreliable and invalid for use with nonverbal adults. As a result, they conducted a comprehensive review of the literature for measurement approaches and factors indicative of the presence of pain and identified several assessment dimensions not included in child-focused tools.
An initial instrument development testing of the proposed scale determined it was much more reliable and valid for use with adults than the existing child-focused scale. One of the dimensions of the newly-developed scale, however, was less robust than the others and was subsequently revised. A second study comparing the revised tool to the original one determined that the change in assessment approach resulted in more consistent assessment findings. In all cases, the newly-developed adult-focused scale was superior to the child-focused one. Currently, over 30 hospitals in the U.S, Canada, Europe and Australia are testing the scale and have reported satisfaction with its usefulness for measuring pain in nonverbal adults.