The aim of this study was to explore factors influencing emergency department (ED) clinicians' use of opioids in treating selected patients. Patients who either received or did not receive opioids in ...the ED, as well as their nurses and physicians, were interviewed before patient discharge. We found that the decrease in patients' mean (SD) pain intensity from the time of admission to the ED (7.3 +/- 2.4 on a 0 to 10 numeric rating scale) to discharge (5.0 +/- 2.9) was statistically significant (t93 = 8.4, p < 0.001, 95 percent CI = 1.7, 2.8) for all groups except those with trauma-related pain. The factor that most frequently led physicians of patients with abdominal pain and nurses in general to administer no opioids was that the patient was "not in that much pain." However, the patients in question had self-reported pain scores that indicated moderate pain. Our findings lead us to conclude that clinicians inaccurately infer severity of patient pain. This in turn can influence the prescription of opioids and the patient's decrease in pain.
Critical care clinicians frequently manage patient pain and agitation and promote ventilator stability through use of opioids and benzodiazepines. Often, doses of these drugs must be increased ...considerably over time as they lose their effectiveness—an indication of drug tolerance. Furthermore, patients can experience negative physiologic responses to withdrawal of these drugs—an indication of drug dependence. Withdrawal symptoms due to abrupt discontinuation of drug therapy can be profound and dangerous. It is important that clinicians understand the mechanisms of drug therapies and their potential negative sequelae. The purpose of this article is to present physiologic theories of opioid and benzodiazepine actions, as well as drug tolerance and dependence, as a basis of knowledge for clinical practice. A clinical scenario of an intensive care unit patient is presented, and a care plan is offered, to provide guidance to practitioners who care for patients experiencing the consequences of long-term opioid and benzodiazepine use.
Patients who are hospitalized for treatment of cardiac problems are at risk from life‐threatening cardiovascular changes related to autonomic nervous system (ANS) arousal. Physical care during ...hospitalization can increase ANS arousal, yet caregiving is an essential feature of patient treatment. The purpose of this study was to identify the degree to which a patient’s vulnerability to sensory stimuli, perceptions of previous caregiving and stressful events during hospitalization may contribute to ANS arousal during caregiving. Fifty‐nine patients, who were hospitalized for treatment of coronary artery or valvular disease, received a standardized protocol designed to simulate aspects of physical caregiving. Heart rate, incidence of arrhythmias, blood pressure and state anxiety were measured during the protocol to determine ANS arousal. Regression analyses provided evidence that sensory vulnerability was the most consistent predictor across all indices of arousal during caregiving. Previous caregiving experiences that were perceived as ‘negative’ by the patient also contributed to higher blood pressure and anxiety. Stressful hospital events involving the family predicted higher blood pressure during caregiving.
Acute pain is a significant problem in critical care patients. Although many barriers to successful assessment and management of pain in critical care patients have been noted, little is known about ...how critical care nurses make clinical judgments when assessing and managing patients' pain.
This qualitative analysis is part of a pilot study evaluating nurses' use of a pain assessment and intervention notation algorithm in patients in critical care areas who have limited communication abilities after abdominal or thoracic surgery.
Transcribed audiotapes of nurse participants' "thinking aloud" while using the pain assessment and intervention notation algorithm were analyzed by using interpretive phenomenology. The interpretive account is based on 31 tape recordings of 14 nurses caring for 41 patients (12 patients in the ICU and 29 patients in the postanesthesia care unit).
The two domains of clinical judgment found were (1) assessing the patient and (2) balancing interventions.
Many nurses' reports showed that they accurately assessed their patients' needs for analgesics. Through testing of and learning from their patients' responses, nurses were able to give amounts of analgesics that diminished patients' postoperative pain. Additionally, nurses had to balance analgesic administration against the patients' hemodynamic and respiratory conditions, medical plan and prescriptions, and the desires of the patients and the patients' families.
The Intensive Care Unit McAdam, Jennifer; Puntillo, Kathleen
Structure and Processes of Care,
01/2015
Book Chapter
The intensive care unit (ICU) environment has represented one of the areas of greatest need for palliative care services, yet also one of the most challenging. The culture of the ICU, with a focus on ...cure and recovery for critical care patients, often creates barriers to implementing palliative care, whose aim is to provide comfort. Yet models have been developed that demonstrate very effective integration of palliative ICU care for patients across many acute and chronic illnesses. Processes such as withdrawal of life support, family conferencing, and collaboration between palliative care clinicians and intensivists are being successfully implemented. This chapter provides a review of both progress and continuing needs in the ICU.
As part of a major study on procedural pain, perceptions of pain and responses to various procedures in younger and older adults were examined. Procedures included wound care, wound drain removal, ...tracheal suctioning, turning, femoral sheath removal and central line insertion. Pharmacological treatments of pain and procedural distress by age were also examined.
Prospective, descriptive-correlational.
Critical and acute care units in acute care hospitals.
Acute and critically ill adults undergoing a procedure (wound care, wound drain removal, tracheal suctioning, turning, femoral sheath removal and central line insertion). There were 5957 participants in the sample, 3126 younger (18–64 years) and 2831 older adults (+65 years).
Pain intensity, behaviours and quality were measured prior, during and after the procedure.
Data showed pain intensity was greatest during the procedure, but did not differ according to age. More younger than older patients received analgesics; however, use of analgesics in both was minimal. Pain quality words and pain behaviours observed were similar in both groups. Procedural distress was mild but significantly greater in younger than older patients.
These data show pain is greatest for both groups during the procedure. In addition, more persons in the younger group receive analgesics, although the mean dosage is not significantly different. Younger patients report greater distress during procedures than older ones, even though their pain intensity, words and behaviours are not different. Further attention needs to be given to understand these differences.
Pain is a significant stressor for critically ill patients. Yet the nature of their pain remains poorly understood. To address this problem, dimensions of post-surgical and procedural pain in ...critical care patients were studied. Also investigated were predictors of pain and relationships of pain to morbidity factors. The sample consisted of 74 cardiovascular surgical patients. Tonic post-surgical pain was measured over three immediate postoperative days. Procedural pain from chest tube removal and endotracheal suctioning was also measured. Dimensions of pain examined were its intensity and extent as well as its sensory (e.g. throbbing or sharp) and affective qualities. Pain measures included the McGill Pain Questionnaire-Short Form and pain intensity scales. Predictors included personality adjustment measured by the California Q-Set, age, gender, and amount of analgesics. Morbidity factors were also determined through chart review. Results indicated that patient tonic pain intensity was moderate but did not diminish over three days. Patient pain was quite localized. Patients used few sensory and affective pain descriptors, indicating that physical sensations and emotional tension associated with pain caused little distress. Vascular surgery patients reported significantly more pain than cardiac surgery patients, and chest tube pain was significantly more intense than endotracheal suctioning or tonic pain. The more pain intensity associated with chest tube removal, the less pain relief obtained from analgesics. Overall, patients received very little analgesics. However, analgesic amount was a primary and significant pain predictor. Gender was a significant predictor of degree of sensory pain, suggesting that women may be more bothered by physical sensations of pain than men. Personality factors did not predict any pain dimension. The longer a patient needed to be intubated, the less s/he was bothered by physical sensations of pain, suggesting that severity of illness might influence pain perception. Patients with higher pain intensity were significantly more likely to have atelectasis. However, other morbidity factors, such as length of critical care stay and psychological disturbances, were not associated with patient pain. Research results demonstrated that pain can be assessed comprehensively with critically ill patients even when they are intubated. Findings suggest the need to develop and test more effective interventions for critical care patient pain relief.
