Patients

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Patients Perceptions and Responses to Procedural
PainResults From the Thunder Project? II
The American Association of Critical-Care Nurses
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Thunder Project II Research Question

• What are the perceptions and responses of
  acutely/critically ill patients to procedural
  pain?

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Study Aims

• Describe patients perceptions of and responses
  to pain associated with six study procedures.
• Compare the pain perceptions and responses across
  procedures.
• Examine relationships between patients pain
  perceptions and responses and pre-procedural
  analgesic administration.

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Procedures Studied

• Turning
• Central Line Insertion
• Wound Drain Removal
• Non-burn Wound Dressing Change
• Tracheal Suctioning
• Femoral Sheath Removal

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Criteria For Choosing Procedures

• Frequency
• Breadth of patient population
• Significance of procedure
• Nurse involvement
• Feasibility

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Pain Dimensions

• Pain Intensity
• Pain Quality
• Pain Location
• Pain Behaviors
• Physiological Responses (HR and BP)

results reported in this presentation
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Pain MeasuresChildren Ages 3-7
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Pain MeasuresChildren Ages 8-12
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Pain MeasuresAges 13-17
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Pain MeasuresAges 18 and up
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Other Information

• Procedural distress (ages 13 and up)
• Debriefing question (ages 13 and up)
• Analgesic and sedative profile
• Use of non-pharmacological interventions
• Procedure specific variables
• Generic procedure variables
• Demographic variables

results reported in this presentation
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Data Collection Times

• TIME 1 Pre-Procedure
• TIME 2 Intra-Procedure
• most painful part of procedure
• TIME 3 Post-Procedure
• 10 minutes after end of procedure

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Thunder Project? II Research Sites

• Data Collection Sites 169
• Sites reporting demographic info 153
  (90.5)
• Research Associates avg 6/site (? 4.8)
• Dedicated Childrens Hospital 17 (26.1)

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Participating Sites Regions
Northwest 7
Midwest 36
Northeast 24
Southwest 14
South 17
International Sites 3
Total sites reporting geographic location 152
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Size of Participating Hospitals Beds
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Type Of Units Participating In Thunder Project?
II
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Sample Age by Procedure
Overall age range 4-97 years mean 60.6 years
(? 16.3)
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Thunder Project? II Sample
of Patients
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Mean Pain Intensity by Procedures (adults only)
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Differences in Mean Pain Intensity(by procedure)
? non-significant ? significant
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Mean Pain Intensity by Age GroupTurning, Wound
Drain Removal, Wound Care Tracheal Suctioning
Mean Pain Reported
Scale modified from 0-100
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Pain Quality Word List
Sensory
Affective

• Sharp
• Tender
• Aching
• Stinging
• Heavy
• Stabbing
• Shooting
• Cramping

• Tiring-exhausting
• Sickening
• Fearful-frightening
• Punishing-cruel
• Awful
• Bad

• Dull
• Throbbing
• Hot-burning
• Gnawing
• Numb
• Splitting

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Pain Quality WordsDecreased from Baseline
of Patients Reporting
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Pain Quality WordsIncreased from Baseline
of Patients Reporting
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Procedural Distress
On a scale where 0 means no distress and 10
means worst possible distress, how distressing or
how bothersome was this procedure to you?
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Degree of Distress (by age group procedure)
Mean Distress Reported
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Differences in Distress(by procedure, adults
only)
? non-significant ? significant
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Opioids Prior to Procedure
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Patients who received preprocedure opioids Was
pain present at baseline?
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Sedatives Prior to Procedure
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Local Anesthetic Prior to Procedure
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Age

• Patients in the 13-17 year age group had greater
  pain intensity across four procedures than adults
• Wound care highest pain and distress
• Relative length of the procedure may be more of a
  factor for adolescents
• Body image issues and developmental level may
  also play a role

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Turning and Suctioning

• Turning most painful and most distressing
  procedure for adults
• moderate level of pain
• higher than with previous studies
• Suctioning
• mild level of pain reported in this study
• lower level than reported in previous studies
• Few patients received pre-medication for
  procedure
• Repetitive nature of these procedures
• What is cumulative effect?

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Femoral Sheath andCentral Line Placement

• Least painful
• Least distressing
• Patients received more medications overall and
  especially sedatives
• Lidocaine use more likely
• Procedures more likely to be protocol driven

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Pain Quality

• Extent of language used to describe procedural
  pain is broad
• Physiologic basis for quality words used
• Baseline pain
• aching, dull, gnawing
• characteristics of slower, C-fiber transmission
• Procedural pain
• sharp, stinging, stabbing, shooting
• characteristics of rapid, A-delta fiber
  transmission

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Limitations

• Sampling
• convenience sample
• no heavily sedated patients--experiences may
  differ
• No standardization of specific interventions for
  procedural pain
• Generalizability across age groups is limited due
  to small numbers of children yet is largest
  study to date to include children

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Wound Care Summary
Sensory/Affective Words Tender (58) Sharp (44) S
tinging (36) Aching (30)
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Wound Drain Removal Summary
Sensory/Affective Words Sharp (52) Stinging
(38) Tender (32)
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Tracheal Suctioning Summary
Sensory/Affective Words Tender (36) Sharp (34) A
ching (30)
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Turning Summary
Sensory/Affective Words Sharp (47) Aching
(47) Tender (38) Bad (32) Tiring-
(32) exhaustive
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Femoral Sheath Removal Summary
Sensory/Affective Words Aching
(34) Tender (31)
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Central Line Insertion Summary
Sensory/Affective Words Sharp (38) Stinging
(38) Stabbing (36)
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Conclusions

• Pain intensity and distress vary considerably
  across procedures and age groups
• Incisive quality of procedural pain
• Be attentive to repetitive procedures and the
  potential need for analgesia
• Patient preparation may be very important
• Inclusion of sensory descriptions when preparing
  patients for procedures may help

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Future Work

• Medications
• Pain Behaviors
• Procedure-specific information
• location, procedure-related variables
• Age span
• pediatric
• elderly
• Instrumentation
• Managing multisite research