MU Sinclair School of Nursing University of Missouri MASTER ’ S EXAMINATION

Pain is a common and distressing symptom in critically ill patients. Critically ill patients experiencing high levels of pain are at risk for a plethora of negative psychological and physiological consequences, some of which may be life-threatening. A systematic assessment of pain is difficult in intensive care units due to the high percentage of patients who are noncommunicative and unable to self-report pain. Although several tools have been developed to identify objective measures of pain, there are currently no recommendations that identify which assessment tool is most appropriate for this patient population. A comprehensive literature search was completed to identify relevant evidence pertaining to the reliability and validity of available observational pain scales. The evidence was evaluated and synthesized to identify the ideal instrument for assessing pain in the non-communicative critically ill patient. While the Critical Care Pain Observation Tool (CPOT) instrument has demonstrated superiority in reliably identifying pain in this patient population, pain assessment for those individuals incapable of spontaneous neuromuscular movements or in those individuals with concurrent conditions, such as chronic pain or delirium, remains an enigma. PAIN ASSESSMENT IN THE CRITICALLY ILL ADULT 3 Pain Assessment in the Non-Communicative Critically Ill Adult Clinical Implications of Pain Pain is a significant problem in the intensive care unit (ICU), and inadequate pain assessment and management has been linked to increased morbidity and mortality (Shannon & Bucknall, 2003). The physiologic response to pain is almost universally negative, causing potentially fatal hemodynamic instability, alterations in immune system functioning, hyperglycemia, and increased release of catecholamine, cortisol, and antidiuretic hormone secretions (Puntillo et al., 2004). Moreover, uncontrolled pain has been implicated in a variety of psychosocial effects including depression, anxiety, delirium, post traumatic stress disorder, and disorientation (Jacobi et al., 2002). Despite the acknowledgement in the literature that pain is a common stressor in the ICU, high rates of uncontrolled pain remain common in the critically ill (Campbell & Happ, 2010). This can be attributed to the presence of circumstances, such as mechanical ventilation or hemodynamic instability, that preclude the assessment of pain by selfreport. Despite the availability of strong evidence that documentation of pain assessment improves pain management and decreases patients’ pain, there has been no universally recommended pain assessment instrument for use in critically ill patients incapable of self-report (Shannon & Bucknall, 2003). Background and Significance McCaffery, in 1968, provided the salient definition of pain, that is, “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery & Pasero, 1999, p. 24). In 1994, the International Association for the Study of Pain (IASP), refined and expanded this definition, reporting “pain is an unpleasant sensory and PAIN ASSESSMENT IN THE CRITICALLY ILL ADULT 4 emotional experience in association with actual or potential tissue damage, or described in terms of such damage” (IASP, 1994, p. 209). Pain can be classified as acute or chronic, depending on duration, and as peripheral or central, depending on location. Further classifications are used to describe the pain source, such as from injury to the skin (cutaneous), nerves (neuropathic), muscles and bones (somatic), or organs (visceral) (Siedlecki, 2009). Nearly five million people are admitted to the intensive care unit annually (Pronovost & Goeschel, 2005) and an estimated 71% of those patients remember experiencing pain during their stay (Klein, Dumpe, Katz, & Bena, 2010). Pain is one of the most common symptoms present in the critically ill and is experienced by each patient in a unique manner (Puntillo, Smith, Arai, & Stotts, 2008). Critically ill patients are predisposed to experiencing pain both by nature of their pathophysiologic process (Blakely & Page, 2001) and by the high frequency of therapies and procedures that they undergo (Summer & Puntillo, 2001). Painful procedures, such as turning, tracheal suctioning, catheter insertion and sheath removal, are performed commonly in the intensive care unit, and precipitate acute pain (Cade, 2008). In addition, many critically ill patients have a history of chronic pain, which complicates assessment and treatment (Curtiss & Haylock, 2001). Furthermore, when pain is present in the critically ill patient it is more likely to be of moderate to severe intensity and multidimensional in nature (Puntillo et al.,