analgesia and sedation assessment in the intensive care unit · analgesia and sedation assessment...

Sydney Local Health District CRG_PG2015_9095 Date Issued: August 2015

Compliance with this Procedural Guideline is highly recommended. This Guideline may contain mandatory components of 15

Procedural Guideline

Analgesia and sedation assessment in the Intensive Care Unit

Document No: CRG_PG2015_9095 Functional Sub-Group: Clinical Governance Summary: This guideline supports staff in the assessment of pain

and agitation and sedation in the Intensive Care Setting. Approved by: Clinical Policy Committee Consultation: Intensive Care Publication (Issue) Date: August 2015 Next Review Date: August 2018 Replaces Existing Document: N/A Previous Review Dates: N/A Note: Sydney Local Health District (SLHD) was established on 1 July 2011 following amendments to the Health Services Act 1997 which included renaming the former Sydney Local Health Network (SLHN). The former SLHN was established 1 January 2011, with the dissolution of the former Sydney South West Area Health Service (SSWAHS).



Content: Introduction

Purpose

Principles / Standards / Practices

Use of the Guide

Definitions

References & Links

Custodian

Associated Procedures



Analgesia and sedation assessment in the Intensive Care Unit

1. Introduction Pain is identified as an unpleasant sensory and emotional experience related with actual or potential tissue damage. Pain is inherently subjective, unobservable and varies from individual to individual. Effective management of pain is humane and is fundamental to patient care.

The risks addressed by this guideline: Inaccurate assessment and documentation of pain experienced by the patient in the Intensive Care Unit (ICU).

The aims / expected outcome of this Guideline Assessment of pain in the ICU is difficult. The most important index of pain is the patient’s own subjective experience, but it is frequently impossible to quantify this because of the presence of an endotracheal tube, or decreased conscious state due to illness or co administered sedative agents.

2. Procedural Guideline Statement

Many patients in the ICU experience pain, however due to clinical condition and/or ongoing treatment, they experience difficulty in, or are unable to vocalise their level of pain. It is important for clinicians to be cognisant that this inability to effectively communicate a pain experience does not indicate the individual is not experiencing pain, it is instead reflective of the difficult situation, a significant barrier that critical care clinicians experience when ensuring effective assessment of pain.

Such situations highlight the need for a range of tools to be available to allow the clinician to select an appropriate tool that meets the individual needs of the patient, resulting in accurate pain assessment.

Pain should be routinely monitored, assessed, reassessed and documented clearly to ensure effective communication between all health professionals.

3. Principles / Standards / Practices 3.1 Richmond Agitation and Sedation Score

The use of a formal agitation assessment in conjunction with a pain assessment is associated with decreased incidence overall of pain. In the ICU the agitation tool of choice is the Richmond Agitation and Sedation Score (RASS). The RASS tool is a validated sedation scale that assesses the agitation and sedation of patients. It is a 10 point scale, with four levels of anxiety or agitation (+1 to +4), one level to denote a patient being calm and alert (0) and 5 levels of sedation (-1 to -5) with -5 being unrousable. The total score is quickly calculated in a three step process:



Step 1: Observe patient alert restless or agitated

Step 2: If no response to step 1, that is, the patients is not alert, see patient’s response to verbal command.

Step 3: If no response to step 2, central stimuli is applied to ascertain a response.

See the RASS tool below for more information regarding the three steps.

The target RASS is for light sedation which is a range of: –2 Light sedation to +1 Restless, unless otherwise medically prescribed. RASS assessments should be performed routinely at 2-4 hourly assessment intervals or more frequently if clinically indicated

3.2 Pain assessment

Pain assessment should be tailored to the individual. There is not one assessment tool that will be suitable for all patients.



In the ICU, best practice for pain assessment is direct reporting from the patient as pain is a subjective experience, however the clinical condition of the ICU patient can prevent direct reporting of pain and behavioural assessment tools maybe required. In the ICU three different pain assessment tools are available. It is imperative that the pain assessment tool chosen should be appropriate to the individual patient to allow for accurate pain assessment. It is important to consider the developmental, cognitive, language and cultural needs of the patient are considered when selecting the tool.

The tools include:

1. Numerical rating scale (NRS) 2. Critical Care Pain Observation Tool (CCPOT) 3. Pain Assessment in Advanced Dementia (PAINAD)

Pain should be regularly assessed, reassessed and interventions clearly documented. Ongoing assessment and evaluation of interventions allow for optimising interventions designed to reduce pain for the patient. Evidence reveals that exposure to high levels of uncontrolled pain can have both a negative affect physically and psychologically.

Ongoing assessment and evaluation of pain allows for optimising interventions designed to reduce pain.

• Pain should always be treated before administration of additional sedative agents • Scoring for patients with opain management modalities such as Patient Controlled

Analgesia (PCA), Epidurals, Continuous local Anaesthetic infusion, should be carried out as per hospital and state form guidelines

• Increased scoring time frames maybe required if an intervention has been required, or any change in patients condition, or if ordered by a medical officer

3.2.1 Numerical rating scale (NRS)

The NRS is point scale where the end points are the extremes of no pain and pain. The pain assessment tool can be applied in both written and verbal forms. Patients self report their level of pain and effectiveness of analgesia administered utilising the scale of 0 to 10 where 0 represents ‘no pain’ and 10 represents ‘worst pain imaginable’. Clinicians directly apply the NRS by typically articulating the question:

‘On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain you could imagine, where would you rate the pain you are experiencing right now?’

A visual form of the 11-point NRS can also be shown to the patient with tick marks on a line or boxes with numbers may also be used

Pain assessments should be performed routinely at 2-4hourly assessment intervals or more frequently if clinically indicated.



It is important that NRS is applied consistently, with no pain being a score of zero and the worst pain imaginable being ten. The goal is to have a pain score of less than or equal to 3. A value of 4 requires a clinical intervention.

The NRS tool is the preferred tool for pain assessment for the patient who is able to articulate or indicate their level of pain using the 0-10 scoring system, however, whilst a simple and quick to use tool, this may not be appropriate for all types of patients. The NRS is not appropriate to use for the patients who are not able to communicate in any form (verbal or physical) their level of pain using the 0-10 scoring system. If this is the clinical situation, a behavioural tool for pain assessment will need to be employed, see 3.2.2 and 3.2.3.

3.2.2 Critical Care Pain Observation Tool (CCPOT)

For the non-verbal patient, traditional subjective pain scales such as the NRS are often not applicable. ICU patients who are sedated, unresponsive or due to their critical condition, may be unable to physically indicate/communicate pain experienced. It has been well established in the literature that through observing patients behaviour, facial expressions and physiological indicators the clinician is able to assess the presence of pain. The CCPOT is a validated behavioural pain assessment tool designed for use in both intubated and non-intubated critical care patients. This tool is to be utilised in the patients who are not able to self report pain. This tool has four domains of assessment, they include:

1. Facial expressions 2. Movement 3. Muscle tension 4. Ventilator compliance

Each response is scored from 0 to 2 with the total scores ranging from 0 (no pain) to 8 (most pain).

TARGET PAIN LEVEL 0-2, score >3 indicates the presence of pain.



Gélinas et al., 2006, pg 1

Directions for use of the CCPOT

1. The patient must be observed at rest for one minute to obtain a baseline value of the CCPOT

2. The patient should be observed during nociceptive procedures (e.g., turning, endotracheal suctioning, wound dressing) to detect any changes in the patient’s behaviours to pain

3. The patient should be evaluated before and at the peak effect of an analgesic agent to assess if the treatment was effective in relieving pain

4. For the rating of the CCPOT, the patient should be attributed the highest score observed during the observation period

5. The patient should be attributed a score for each behaviour included in the CPOT and muscle tension should be evaluated last, especially when the patient is at rest because just the stimulation of touch (passive flexion and extension of the arm) may lead to behavioural reactions.



The presence of pain is assumed when the CCPOT score is greater than 2 or when the CCPOT score increases by 2 points or more. Such scores should trigger an intervention for pain management. Accordingly, a decrease of 2 points or more in the CCPOT score would indicate that the intervention was effective in relieving pain. It is important to remember, the CCPOT does not provide the clinician with the actual severity of pain, it detects the presence or absence of pain.

3.2.3 Pain Assessment in Advanced Dementia PAINAD

Another population of non-verbal patients includes individuals with dementia. PAINAD is a simple, reliable and validated five-item observational assessment tool developed for patients who are unable to self-report and communicate pain. PAINAD assists clinicians in identifying pain and evaluate the effectiveness of interventions. PAINAD examines five specific indicators:

1. Breathing 2. Vocalisation 3. Facial expression 4. Body language 5. Consolability

Total scores range from 0 to 10, with higher scores indicating more severe pain.



3.2.4 Tool selection

Pain and sedation assessment should be performed routinely at 2-4hourly assessment intervals or more frequently if clinically indicated.

Ensure results are documented on flow sheet and in clinical notes; indicating tool used and the derived score of any intervention.

Patient assessment

Numerical Rating Scale

CCPOT

PAINAD

Where appropriate, clinicians should endeavour to use the self reporting

NRS tool

Pt alert and able to self report pain

experienced?

E.g.: GCS>10 RASS>-3

Or able to indicate

YES

NO

Is the patient intubated?

No

YES

Consider other sources of potential pain for nonverbal and unresponsive

patients.



3.2.5 Non-pharmacological Interventions Non-pharmacological interventions include strategies that do not involve consumption of medicines. These interventions aim to compliment traditional pharmacological interventions in managing pain. Along with acute pain management, a clinical history should be obtained regarding any pre-existing painful or chronic conditions and, where possible, the usual pain management strategies should be implemented. Non-pharmacologic strategies can be grouped into five categories: cognitive-behavioural, physical, emotional support, assistance with activities of everyday living and creating a comfortable environment. These are rarely stand-alone interventions, as elements of each may form a single intervention, examples include: Cognitive- Behavioural therapy

• Music therapy • Distraction- For example, Television • Simple relaxation therapy- For example deep breathing • Preparedness for procedure or treatment- allows a patient to be mentally prepared for

a potentially painful experience Physical

• Positioning/repositioning • Comfortable fixation of invasive devices • Care in the management of secretions and excretions • Exercise therapy • Touch • Hot/Cold packs • Simple massage

Emotional support

• Emotional support • Active listening • Reorientation • Facilitation of family presence • Promotion of family involvement

Assistance with activities of everyday living

• Ensuring basic hygiene is attended to e.g. teeth cleaning, mouth care, body wash, skin care and hair washing

Comfortable environment

• Establishing a method non-verbal communication eg: use of a board, nodding/shaking, blinking

• Minimisation of noise from spurious alarms and unnecessary equipment • Ensuring patients surrounds promote optimal comfort e.g. proximity of bedside table, • Maintenance of a day/night routine (lighting and activity) is thought to aid sleep quality

Along with assessment of pain, clinicians should also regularly consider other sources of potential pain for nonverbal and unresponsive patients. Employment of some of the above



mentioned strategies can potentially assist in the reduction of other sources of painful stimuli.

4. Use of the guide

5. Definitions CCPOT Critical Care Pain Observation tool- behavioural pain assessment tool

Nociceptive Causing pain

NRS Numerical Rating Score, scoring system of pain for patients, score is from 0-10

RASS Richmond Agitation and Sedation Score, behavioural sedation and agitation score

PAINAD Behavioural tool for patients with dementia

6. References and links Arbour, C. and Gelinas, C. 2011. Setting goals for pain management with using a behavioural scale4: Example with the Critical -Care pain Observational Tool. Critical Care Nurse, 31,6, 66-68. Aitken, L. and Elliot, R. 2007. Chapter 7 Psychological Care. In Elliott, D., Aitken, L.M. and Chaboyer, W. (eds) ACCCN’s Critical Care Nursing. Elsevier, Marrickville. Gelinas, et al. 2006. The Critical Care Pain Observation Tool (CPOT). Herr, K., Coyne, P.J., Key, T., Manworren, R., McCaffery, M., Merkel, S., Pelosi-Kelly, J. and Wild, L. 2006. Pain Assessment in the Nonverbal Patient: Position statement with Clinical Practice Recommendations, Pain Management Nursing, 7, 2, 44-52. Gelinas, C., Arbour, A., Michaud, C. and Cote, J. 2014. Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management. Nursing in Critical Care, 18, 6, 307-318. Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2010), Acute Pain Management: Scientific Evidence (3rd edition), ANZCA & FPM, Melbourne. Paulson-Conger, M., Leske, J., Maidl, C.,Hanson, A. and Dziadulewicz, L.2011. Comparison of Two Pain Assessment Tools in Nonverbal Critical Care Patients. Pain Management Nursing, 12, 4, 218-224. Warden V, Hurley AC, VolicerL. 2003. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc,4,9-15. Williamson, A., Hoggart, B. (2005)Pain: a review of three commonly used pain rating scales, Journal of Clinical Nursing, (14) 7, 798 – 804.

Wibbenmeyer et al 2011).



7. Custodian Intensive Care Unit Clinical Nurse Consultant

8. Associated Procedures Title Entity/ Department Custodian /

Author Document Number

Appendix

Appendix 1. RASS tool

Appendix 2. NRS



Appendix 3. CCPOT tool



Appendix 4. PAINAD tool

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