The following case study will focus on a discussion around pain assessment and complexity of care delivered to individuals, who are mechanically ventilated, with altered levels of consciousness. The pathophysiology of ventilation and its associated consequences and symptoms for a patient’s care will be thoroughly examined. Aspects of pain assessment in individuals, who are sedated on ventilation support, and nursing interventions to identify levels of pain will be critically analysed and justified. Finally, the complexity of patient’s care will be argued and critically evaluated and the wider context of care management will be conscientiously discussed.
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The International Association for the Study of Pain (IASP) outlines the definition of pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 2017). In accordance to Chanques et al (2007) pain is one of the most occurring complications associated with intensive care stay with an occurrence of moderate to severe level of pain experienced by almost 50 % of medical and surgical patients. Bertollini et al (2002) reported that approximately 80 % of patients on critical care units, amongst Europe, have experienced pain during nursing interventions and have not received adequate analgesia. In multicentre studies 50 – 65% of patients complained that they suffered severe pain in ICU; 15% were unhappy with the pain management they received.
To maintain confidentiality and to protect the identity of an individual, the name of the patient will be changed to Mr Kenneth Smith (pseudonym), in line with Nursing and Midwifery Council (NMC,2015). Kenneth is an 74 year old male admitted to cardiac intensive care unit (day 10) following coronary artery bypass graft surgery. Kenneth was previously diagnosed with triple vessel coronary artery disease, following myocardial infarction four weeks prior to surgery. Currently, he cannot maintain his own breathing, therefore, to promote haemodynamic stability Ken is ventilated with a use of synchronised intermittent mandatory ventilation (SIMV) mode. To facilitate Ken’s ventilation, he is also sedated however, it has been found that Ken reacts to voice and occasionally opens his eyes. The possibility of delirium also emerged as the patient’s wife deems, that Kenneth appears disorientated and agitated at times (Kings & Grattixs, 2009). As Ken requires respiratory and cardiovascular support, he requires level 3 care, due to the complexity of his needs as defined by Intensive Care Society Document, Levels of Critical Care for Adult Patients (2009). In accordance to Marjorie (pseudonym), Kenneth’s wife, they live in the family home. Upon nursing assessment, the high complexity level is presented as Kenneth cannot communicate his pain verbally, nor physically, and due to minimal non-verbal cues, nursing staff find it challenging to interpret signs, that could possibly indicate pain. Therefore, it could impose the risk of untreated pain and prolong Kenneth’s stay on intensive care unit; compromising successful post-operative recovery (Rakel and Herr, 2004). Twycross (2002) argues that pain appears to be a problem in acute settings, yet the knowledge and understanding of its management is limited amongst nursing staff; which breaches the principles of effective practice in line with the best available evidence (NMC, 2015).
Awareness of causes and interactions of pain, agitation and delirium in Kenneth’s case is essential, to promote quicker recovery by managing pain effectively and weaning patient off the ventilation support (Stein-Parbury and Mckinley, 2000). Endotracheal tube combined with sternal wound and chest drains contributes to nociceptor activation and sensitization at various levels (Dahl and Kehlet, 2006). Hence, Kenneth is experiencing ongoing pain at rest, that increases with movements. Although, pain analgesia is administered on regular basis to control discomfort levels (WHO, 2015); Koppert et al (2003) argues that increased pain sensitivity in surgical patients to stimuli is commonly recognised as an effect of opioids. The thesis is strongly supported by Wilder Smith (2006) who acknowledge, that hyperalgesia has a major effect on the way brain processes pain signals. There several mediators that contributes to nociceptor activation: prostaglandins, interleukins, cytokine and neutrophils (Brennan, 2017). Peripheral neutrophilic granulocytes (NG’s) also have an impact on peripheral sensitivity and contribute to pain where the incision was made (Carreira et al, 2013).
The intensity of pain is amplified by nociceptive neurones that send electrical signals to central nervous system along axons, which again depends on many factors, including surgical site and discomfort caused by endotracheal tube or Kenneth position (Steeds, 2016).
Recent Kenneth’s arterial blood gas reading revealed, decreased tissue pH and increased lactate concentration, which in accordance to Brennan (2011) could also influence the intensity of pain and spontaneous pain behaviour. Initially, Kenneth was commenced on mechanical ventilation post operatively to maintain his haemodynamic stability, decrease cardiac workload and provide optimum for gaseous exchange (Goldsworthy and Graham, 2014). Upon physician assessment, Kenneth receives SIMV, which delivers set amount of breath and encourages patient to take spontaneous breaths (Wiesen et al, 2013). SIMV mode helps to reduce Kenneth’s cardiac output, although it has been proved that it prolongs ventilation dependency. Due to persistent episodes of hypoxemia, weaning from ventilation is delayed, which put Kenneth at risk of further complications (Chlan, 2011). Pillbeam and Cairo (2006) conducted a study which shown that prolonged ventilation increases the mortality rate. Challenges faced by nursing staff in pain management influences the process of weaning, hence it affects Kenneth’s quality of life (Baazm et al, 2014). Nelson et al, 2010 argues that patients who struggle to wean of ventilation support are at greater risk of infection, delirium, pain and they are often experiencing anxiety. Therefore, it could be questioned whether, unmanaged pain is a leading cause of prolonged ventilation or vice versa. Whitehouse et al (2014) reports that pain can trigger stress response which can have detrimental effect on patient’s health and wellbeing. Increased levels of catecholamines can cause arteriolar vasoconstriction, impair tissue perfusion and decrease tissue oxygen partial pressure which would impact on delayed weaning of ventilation support and increased oxygen consumption (Barr et al 2013). Catabolic disturbances and hypoxemia caused by pain can also impair wound healing process and lead to wound infection; pain decreases natural killer cell activity, cytotoxic T cell and neutrophils which are pivotal for immune system (Woolf, 1989). Wagner et al 1998 emphasises that other factors such as sleep disturbances and anxiety can aggravate pain perceptions.
Royal College of Nursing (2003) concludes that nurses have duty of care to minimise distress and suffering from pain. The “gold standard” in pain assessment by nurses is self-reporting by the patient, providing necessary information, that helps to identify source, intensity and underlying condition so that appropriate analgesia can be administered (Chanques and Constantin, 2010). but Kenneth cannot give sufficient response due to endotracheal tube and sedation level (Craig and Schlavenato, 2010). Pain is difficult to measure as it is an individual experience and everyone perceive it on their own way. It encompasses wide spectrum of physiological and psychological responses; therefore, it is pivotal for nurses to provide holistic approach when looking after critically ill patients (Woodrow and Moore, 2004). Kenneth during morning activities, whilst being assisted with personal hygiene needs appeared to be in discomfort, especially during moving and handling manoeuvres. Bird (2003) argues that there is no specific pain assessment tool for ICU patients and should evaluate effectiveness of tools used, to manage pain effectively. Chanques and colleagues (2010) have manifested that visually enlarged numeric rating scale (NRS) from 0 (minimal discomfort) to 10 severe pain, is the most successful and valid across other pain assessment tools available. Jensen (2003) has reviewed 164 journals and demonstrated that NRS tool is the most reliable indicator of pain intensity. Although Kenneth can blink his eyes occasionally when asked about pain levels, it is difficult to determine the accuracy of patient’s perception due to level of sedation and cognition state. Kenneth’s effort to express and communicate pain is respected and adequate pain analgesia is provided. The evidence shows that the belief of patient’ report creates trust relationship between patient and healthcare professional, therefore pain management is more successful and effective (D’Arcy, 2011). Pain can increase with activity and it is revealed as dynamic process, therefore Kenneth is reassessed on a regular basis to maintain comfort and minimise distress (Dahl and Kehlet, 2006). Barr (2013) emphasises that pain in intensive care unit patients’ needs to be assessed frequently and repetitively in an effective manner to maintain high quality of care and promote healing. Puntillo (2009) stresses that healthcare professionals must use “structured, valid and reliable tools” due to complexity of patients’ needs.
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Upon Kenneth pain assessment, it was found that Behavioural Pain Scale was the most effective. Nurses observed that Kenneth is becoming restless and agitated and facial grimacing is present, which resolves with appropriate analgesia (Feldt, 2000). These behaviours fit into criteria of pain indication as per Checklist of Nonverbal Pain Indicators (CNPI) (Young, 2006). Nurses derived the total BPS score of 8-10, which indicated that Kenneth was experiencing severe pain on assessment. D’arcy (2011) speculates that the use BPS is not as effective and developed as current tools that have been in use for years. Li and colleagues (2008) also argue that there is some evidence about BPS, an updated revision in regards to validity and effectiveness is needed, so that it can be applicable for ICU patients. However, Payen (2008) and Arbour et al (2011) dispute with the opinion of his colleagues and demonstrate that there are recent studies which show that BPS improve pain management and successful recovery, followed by shorter duration of mechanical ventilation. Implementation of Payen BPS appeared to be extremely useful, when repositioning Kenneth in bed, as it assesses compliance with ventilation, detecting specific pain behaviours (Puntillo et al., 2001). In addition to respiratory support, pain is also triggered by sternal wound and both chest drains which increase the intensity of pain experienced by Kenneth. The study carried out by Payen (2001) demonstrated that 63% of ICU patients could remember pain and 40% patients post cardiac surgery experienced the worst pain due to chest drains and surgical wounds.
In addition to BPS, there are other assessment tools for critically ill patients, like Kenneth, such as Gelinas Critical Care Pain Observation Tool (CPOT) which is also based on behavioural observations (Gelinas et al, 2006). Its effectiveness was again reported during moving and handling manoeuvres, where ventilation machine was observed for alarms, which displayed that Kenneth stopped breathing spontaneously. Slight resistance was also felt by nursing staff; which indicated muscle tension that potentially resulted from pain (Li et al 2008).
Marjorie, Kenneth’s wife, was also asked to provide information in regards to Kenneth’s usual behaviours which could be then compared with those gathered during specific assessments. Nursing staff found difficulties in interpreting Kenneth behaviours at times, as they represented numerous things amongst various periods of time (Garteth and Williams, 2017). Olding et al (2015) suggest that family involvement in nursing care positively influences patients care despite its complexity; therefore, behaviour changes were written down over a shift duration, with Marjorie’s active involvement, and clear picture of Kenneth’s behaviours created. It also facilitated implementation, care planning and evaluation that promote holistic and family centric model of care (World Health Organisation, 2007). Surrogate designation of Marjorie to help with pain assessment, represents Kenneth’s wishes and needs; effective communication and good relationship between relatives and nursing professionals protects Kenneth’s autonomy (Sprung and Azoulay, 2004). Marjorie, visits Kenneth daily, hence, nursing staff could go through the pain assessment tool together, improving its effectiveness and recognising new changes. It has been reported that, when Marjorie is present, Kenneth is more settled and less agitated, therefore, social contact with beloved ones maximises quality of care and recovery (Aust, 2013). Family interaction in basic nursing care and patient psychological and emotional support is a way of demonstrating love and care, a unique aspect of care that can be only provided by them (Engstrom and Soderberg, 2007). Dowling and Wang (2005) conclude that family support has a positive impact on patient’s outcome and recovery rate. Close contact with family gives them strength to overcome struggles related to their condition and enables them to regain orientation within the environment (Magarey and McCutcheon, 2005).
Kenneth’s physiologic parameters are monitored regularly to maintain patient’s stability and to provide nurses with information about Ken’s physiologic status so that, they can react fast upon any changes (National Institute for Health and Care Excellence [CG50], 2017). During personal hygiene and moving and handling manoeuvres, it has been noted that Kenneth’s blood pressure (BP), heart rate (HR) and respiratory rate (RR) increased with visible behavioural changes and became stable once the painful stimuli was removed. Although, vital signs are widely used by nurses in pain assessment, they are not validated and supported by clinical evidence (Donaldson et al., 2003). Kenneth’s is also receiving inotropic therapy in terms of cardiovascular support and sedative agent are also used, therefore, his vital signs are likely to fluctuate (Imal et al., 2011); however, they have not been discussed further in this discussion. Payen et al. (2001) with Gelinas and Johnston (2007) found that BP and mean blood pressure (MAP) increased in patients with altered level of consciousness, when exposed to nociceptive stimuli. However, Frazier et al (2002) argued that alteration of vital signs could result from activation of autonomic nervous system as a stress response and anxiety indication from performed procedures. Barr et al. (2013) in Clinical Practice Guidelines do not recommend that vital signs should be used when performing pain assessment, although they can be used as a suggestion and cue to conduct further assessment.
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