ORIGINAL ARTICLE
Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients

https://doi.org/10.1016/j.iccn.2005.04.004Get rights and content

Summary

Current empirical evidence supports claims that pain in sedated, unconscious Intensive Care Unit (ICU) patients is underrated and under-treated. Given the severity of ICU patients’ illness pain management, whilst important, may not be considered a priority and therefore can be easily overlooked. The aim of this study was to validate the Behavioural Pain Scale (BPS) for the assessment of pain in critically ill patients by evaluating facial expressions, upper limb movements and compliance with mechanical ventilation.

Methods

A prospective, descriptive repeated measures study design was used to assess the validity and reliability of the BPS for assessing pain in critically ill patients undergoing routine painful (repositioning) and non-painful (eye care) procedures.

Results

An average of 73% of BPS scores increased (indicating pain) after patients were repositioned, as opposed to 14% after eye care. This increase was statistically significant for repositioning (p < 0.003) but not for eye care (p > 0.3). The odds of an increase in BPS between pre- and post-procedure assessments was more than 25 times higher for repositioning compared with eye care (p < 0.0001), after controlling for analgesics and sedatives.

Conclusion

The BPS was found to be a valid and reliable tool in the assessment of pain in the unconscious sedated patient. Results also highlighted that traditional pain indicators, such as fluctuations in haemodynamic parameters, are not always an accurate measure for the assessment of pain in unconscious patients and as such more objective pain assessment measures are essential. Finally, further validation of the BPS and identification of other painful routine procedures is needed to enhance pain management delivery for unconscious patients.

Section snippets

Introduction and background

The ICU is designed to manage the care of patients suffering from a range of complex and life threatening conditions. Critically ill patients undergo many routine procedures and treatments, which are often associated with considerable discomfort and pain (Payen et al., 2001, Stanik-Hutt et al., 2001, Tittle and McMillan, 1994, Kinney et al., 1995, Puntillo, 1990, Turner et al., 1990). In a small study by Puntillo (1990), although seven patients (29%) had no recall of their pain, 71% (n = 17) of

Objectives

  • To determine the validity and reliability of the BPS instrument in assessing pain in ICU patients undergoing two routine procedures.

  • To determine inter-rater reliability of the BPS instrument with ICU nursing staff.

  • To determine factors that may influence BPS scores.

Research design

Using a repeated measures design, patients were assessed twice for pain with eye care and twice for pain with repositioning. Specifically, patients were assessed immediately prior to their routine procedure being conducted and then assessed during the course of the procedure using the BPS tool.

Sample and setting

This study was conducted in an 18 bed medical, surgical, neurological and emergency Intensive Care Unit at a Western Australian adult teaching hospital. Forty-four patients were recruited for this study

Ethics

The Hospital's Human Research Ethics Committee and the Nursing Research Scientific Sub-Committee approved this study. All next of kin were given written information to explain the study prior to signing their consent. All patients were assigned a code number to ensure confidentiality.

Results

Forty-four patients were recruited for this study. A higher proportion of participants were male (59%; n = 26) and the median age was 64 years (range = 16–82 years). The majority (70%; n = 31) were medical patients, with only 13 patients having undergone a surgical procedure. Diagnoses varied greatly from pneumonia and asthma to multi trauma and coronary artery bypass grafting. Intubation via an endotracheal tube was used in the majority of cases (84%; n = 37) with the remainder intubated via a

Discussion

Numerous studies have reported the under-treatment of pain in the critically ill conscious patient (Puntillo et al., 2001, Carroll et al., 1999, Hall-Lord et al., 1998, Puntillo et al., 1997, Tittle and McMillan, 1994, Puntillo, 1990). Yet, very few studies have actually researched how best to assess pain in the unconscious, ventilated ICU patient. Interestingly, a review of the literature found only one study by Payen et al. (2001) which evaluated the use of a pain management tool in this

Acknowledgments

This project was made possible with funding from the SCGH Nursing Research Scholarship. Special thanks to Ms. Rebecca Lee for data collection, the ICU management and team for supporting this study and to Mrs. Janice Low for administrative support.

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