Egyptian Nursing Journal

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 14  |  Issue : 3  |  Page : 211--216

Assessment of pain during turning procedures in patients on mechanical ventilation


Hend M Allam 
 Department of Medical Surgical Nursing, Faculty of Nursing, Benha University, Benha, Egypt

Correspondence Address:
Hend M Allam
Department of Medical Surgical Nursing, Faculty of Nursing, Benha University, Benha, 13511
Egypt

Abstract

Background Pain is a significant problem for critically ill patients throughout their stay in the ICU, especially those who are mechanically ventilated. A turning procedure is one of the most common procedure that may cause pain for critically ill patients. Aim The aim of this study was to assess pain during turning procedures in patients on mechanical ventilation. Research question What are the characteristics of pain caused by turning procedures in patients on mechanical ventilation? Patients and methods A descriptive research design was used in the present study. A convenient sample of adult men and women on mechanical ventilation and unconscious patients in ICUs at Benha University Hospital were included in the study. Those above 65 years of age, receiving neuromuscular blocking agents, and with peripheral neuropathy were excluded. The following tools were used for data collection: (a) data collection sheet (developed by the researcher) included (i) sociodemographic data, (ii) medical-related data, and (iii) physiological parameters); (b) Critical Care Pain Observation Tool; and (c) facial pain scale. The duration of the study was 6 months, from May 2015 to October 2015. Results In our study sample (92 men and women patients), 87% had severe pain during turning procedures, which decreased to 4.3% 10 min after the procedure. There was no statistically significant difference between the level of pain for both men and women, as well comorbid diseases. There was a highly statistically significant difference between behavior indicators and physiological parameters before, during, and 10 min after the turning procedure. Recommendations Pain assessment should be a part of the overall management for mechanically ventilated patients and must be routinely documented in the patient’s record and nursing notes and regularly updated. In addition, the results of our study highlight the need to administer additional analgesia before turning procedures, particularly in mechanically ventilated patients unable to self-report or those with cognitive impairment.



How to cite this article:
Allam HM. Assessment of pain during turning procedures in patients on mechanical ventilation.Egypt Nurs J 2017;14:211-216


How to cite this URL:
Allam HM. Assessment of pain during turning procedures in patients on mechanical ventilation. Egypt Nurs J [serial online] 2017 [cited 2018 Oct 21 ];14:211-216
Available from: http://www.enj.eg.net/text.asp?2017/14/3/211/233667


Full Text



 Introduction



Mechanical ventilation is a basic life therapeutic and supportive intervention used in critically ill patients. It is indicated in patients requiring support to maintain oxygenation or eliminate carbon dioxide, and it is typically applied to patients as a supportive treatment modality for acute respiratory failure with hypercarbia or hypoxemia (Larson et al., 2014).

Pain is a symptom common to almost every illness, disease, traumatic injury, or any painful procedures regardless of the person’s age, sex, or socioeconomic status. It is pain that alerts an individual to an injury and encourages guarding off the injury to prevent further damage. Pain is a reminder of the activity that caused it. For most people diagnosing the source of pain leads to successful treatment and resolution of pain within a relatively short period of time (Greifzu, 2014).

Pain decreases patient cooperation with various care procedures designed to promote healing, such as turning and physical therapy. These factors and many more may delay patients’ recovery time as the physiologic responses to pain inhibit the body’s ability to react positively during the healing process. Heart rate and blood pressure increase, tissue perfusion is impaired, therefore decreasing oxygen delivery, hyperventilation occurs, and other compensatory mechanisms kick in as the body is stressed because of pain (Sohn, 2010).

Turning is one of the general kinds of nursing actions during care of patients. Patients who move themselves will automatically shift position, but in ICU patients who cannot move themselves depend upon the nursing staff to do this for them. Patients should be turned and their position changed every 1–2 h. This should be reinforced continuously through nursing care plans and the nurse’s notes (Avent, 2010). Therefore, the aim of the current study was to assess pain during turning procedures in patients on mechanical ventilation.

Significance of the study

Many critically ill adult patients experience significant pain during hospitalization. In the ICU, for example, more than 30% have significant pain at rest, and more than 50% have significant pain during routine care such as turning procedures; moreover, there might be an increased risk for developing a chronic pain syndrome if high-intensity pain events are repeated while in the ICU (Chanques et al., 2014).

Untreated pain can result in negative consequences, including multisystemic complications and the development of chronic disabling pain. These results, in turn, may seriously impact the patient’s functioning, quality of life, and well-being. Furthermore, the absence of pain assessment or an incomplete assessment has been associated with death in the ICU (Dunwoody et al., 2014).

 Aim



The aim of this study was to assess pain during turning procedures in patients on mechanical ventilation.

Research question

What are the characteristics of pain caused by turning procedures in patients on mechanical ventilation?

 Patients and methods



Design

A descriptive exploratory research design was used in this study.

Setting

The current study was conducted in ICUs at Benha University Hospital.

Patients

All mechanically ventilated patients (both males and females) or those in unconscious state in ICU at Benha University Hospital during a period of 6 months (from May 2015 to October 2015) (total number=92 patients) were included in the study. We excluded patients with quadriplegia, peripheral neuropathy, or those receiving neuromuscular blocking agents, and also patients above 65 years of age.

Data collection tools

First tool

Developed by the investigator, the first tool included three parts: (a) sociodemographic data for patients, such as age, sex, marital status, and residency; (b) medical record sheet, which included data such as diagnosis, drugs, duration of mechanical ventilation, and comorbid diseases (heart disease, respiratory disease, diabetes mellitus, hypertension, cancer, etc.); and (c) physiological parameters sheet, which included physiological data such as blood pressure, heart rate, respiratory rate, and arterial oxygen saturation.

Second tool

Critical Care Pain Observation Tool (CPOT), adopted from Gelinas et al. (2009), was used as the second tool. (It was originally developed in French.) It contains four sections, each dealing with different behavioral categories. The first section is facial expressions (relaxed or natural, tense, grimacing); the second section is body movements (absence of movement, protection, restlessness); the third section is muscle tension (relaxed, rigid, very tense), and the fourth section is compliance with the ventilator (tolerating ventilator, coughing but tolerating, fighting ventilator). Items in each section are scored from 0 to 2, with a possible total score ranging from 0 to 8; pain is described according to the score (no pain, 0; mild pain, 1–3; moderate pain, 4–6; and severe pain, ≥6).

Third tool

The third tool used was the facial pain scale, adopted from the National Institute of Clinical Studies (2011). It provides the majority of pain information that includes a wide range of facial expression descriptors such as no facial response, relaxed, smile to most extreme wince, and grimacing (brow lowering, orbit tightening, nose wrinkling, and eye closure). In addition, pain is described according to the score (no pain, 0; mild pain, 1–3; moderate pain, 4–6; and severe pain, 7–10).

Validity and reliability of the tools

The tools were revised by a panel of five experts from the faculties of nursing, Cairo University, Benha University, and Menoufia University to evaluate the validity of the tools and necessary modifications were done accordingly.

Procedure

A formal approval was taken from the Dean of Faculty of Nursing, Benha University, and submitted to the directors and matrons of Benha University Hospital, and an official permission was obtained from the administrative directors to start data collection.

A pilot study was carried out on 10% of the patient in ICUs to assess patients’ pain during turning procedures and to estimate the proper time required for collecting data. This pilot study was carried out to test the clarity and practicality of the tools. The results of the data obtained from the pilot study helped in the modification of the tools; items were corrected or added as needed, and the final form was developed. The results from the pilot study were not included in the main statistical sample.

A field study was conducted during the period from May 2015 to October 2015 (6 months). The estimated time spent with each patient for collecting data lasted between 20 and 30 min; a total number of patients 94 were recruited. An informed oral consent was obtained from patients’ relatives for participation in the study. The investigator visited the ICU 3 days/week. Each patient’s demographic data were obtained from patient’s hospital record, and patients’ blood pressure, heart rate, respiratory rate, and, also, oxygen saturation before, during, and 10 min after turning procedures were recorded. The investigator assessed patients’ pain levels using the critical care pain observational tool, which includes facial expressions, body movements, muscle tension, and compliance with the ventilator, and observed the patients’ pain by using the face pain scale, before and during the turning procedure. In addition, the investigator assessed patients’ pain levels 10 min after the turning procedure using the same scale.

Ethical consideration

The aim of this study was explained to patients’ relatives and they were reassured that all information would be kept confidential and would be used only for patients’ benefit and for research purposes and would not be harmful for the patients.

 Results



The presentation and analysis of data obtained in the current study was divided into four parts: (a) sociodemographic characteristics, (b) physiological parameters and pain score, (c) behavior indicators, and (d) relation between level of pain and taking analgesic.

[Table 1] illustrates that more than half (52.2%) of the studied patients were above the age of 50 years, 60.9% were men, 59.8% were married, and 66.3% were living in rural areas.{Table 1}

[Table 2] illustrates that there was a highly statistical significant difference between physiological parameters and pain score before, during, and 10 min after the turning procedure in the studied patients.{Table 2}

[Table 3] clarifies that 59.8% of the studied patients had grimacing facial expression, 56.5% showed restlessness, 46.6% had very tense muscles, and 50% were fighting the ventilator during the turning procedure.{Table 3}

[Table 4] illustrates that 65.2% of the studied patients had moderate pain before the turning procedure (for patients not taking analgesic) and 83.7% had severe pain during the turning procedure.{Table 4}

 Discussion



This study aimed at assessing pain during turning procedures in patients on invasive mechanical ventilation. The present study revealed that more than half of the studied patients were aged 50 years and above, which was supported by the studies by AlSutari et al. (2014), Ibrahem (2012), and Mohammed (2008) who studied mechanically ventilated patients in critical care units and found that the sample age was 50 years and above. On the other hand, Hassan (2007)] who studied nutritional status for ventilation-dependent patients at ICU Shebin El-Kom University Hospital, Faculty of Nursing, Menoufia University, found that the majority of studied patients were around the 35 years of age.

The current study revealed that more than half of the studied patients were males and most of them were smokers; this result was supported by AlSutari et al. (2014) and Ibrahem (2012) who found that more than half of the studied patients were males. Moreover, the British Association of Critical Care Nurses (2011)], which studied pain in nonverbal patients, found that more than half of sample (57.3%) were males and 42.7% were females. Furthermore, these findings were in agreement with Serag (2008) who studied ventilator-associated pneumonia in ICU, Benha University Hospital, and found that the majority of the sample were males.

Regarding taking analgesic, it was surprising in the current study that the majority of the studied patients did not receive any analgesic during assessment; this could be attributed to the fact that all the studied patients were unconscious, and thus could not express or self-report feeling pain; this result was in agreement with AlSutari et al. (2014), as well as with Puntillo et al. (2012), who found that near two-thirds of studied patients did not received any analgesia during assessment. This result was in contrast to that of Vázquez et al. (2011), who studied pain assessment during turning procedures in patients on invasive mechanical ventilation and found that the majority of the patients received analgesia as continuous infusion an hour before the turning procedure.

Regarding the critical care pain observational tool (behavior indicators) before, during, and 10 min after the turning procedure, the present study revealed that approximately more than half of the studied patient were have grimacing facial expressions and were tolerating the ventilator before the turning procedure, whereas less than half of the studied patient were very tense during the turning procedure, and that more than half of the studied patient were relaxed 10 min after the turning procedure. These findings display symptoms of pain during turning procedures, which can be seen in the important variations for each of the indicators on the CPOT scale. The facial expression indicators showed the greatest increase and this occurred in more than half of the studied patients. The next behavior indicators were body movements, which increased by more than half, from protection (slow, cautious movements, touching or rubbing the site of the pain, and seeking attention through movements) to restlessness (pulling the tube, moving limbs, and attempting to sit up), and finally, lack of compliance with the ventilator, which was presented by half of the studied sample. These results were in agreement with Vázquez et al. (2011) and American Association of Critical-Care Nurses (2015) who found that during turning procedures patients display symptoms of pain, which can be seen in the important variations for each of the indicators on the CPOT scale. Facial expressions such as frowning, brow lowering, orbit tightening, contraction, and lowering eyelids tightly, were the indicators that showed the greatest increase, and this occurred in more than half of the observations. Next were the body movements, which increased by more than one-third, from protection (slow, cautious movements, touching or rubbing the site of the pain, and seeking attention through movements) to restlessness (pulling the tube, moving limbs, and attempting to sit up), and finally, lack of compliance with the ventilator, which rose by 31%. Finally, muscle tension increased in nearly one-quarter of the observations.

 Conclusion



On the basis of the findings of the current study, it can be concluded that there was an increased pain intensity during turning procedures in patients on mechanical ventilation, which increased still more 10 min later, as did their physiological parameters (heart rate, respiration, blood pressure, oxygen saturation).

Recommendations

The assessment of pain is particularly difficult in critical patients unable to self-report or those with cognitive impairment. Clinical guidance for the assessment of pain for these kinds of patients is recommended. In addition, the use of physiological parameters and behavioral indicators is a must.Written schedule for pain assessment should be available in each ICU of the hospitals.The results obtained in the current study highlight the need to administer additional analgesia before turning procedures, particularly in critically ill patients unable to self-report or those with cognitive impairment.Further studies should include qualitative approaches to provide an in-depth description of nurses and healthcare professionals’ perception toward pain management in critically ill mechanically ventilated patients in critical care settings.[16]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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