Patients’ Perceptions and Responses to Procedural Pain: Results From the Thunder Project  II

1. Patients’ Perceptions and Responses to Procedural Pain:Results From the Thunder Project II The American Association of Critical-Care Nurses

2. Thunder Project II Research Question: What are the perceptions and responses of acutely/critically ill patients to procedural pain?

3. 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.

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

5. Pain Dimensions • Pain Intensity* • Pain Quality* • Pain Location • Pain Behaviors • Physiological Responses (HR and BP) * results reported in this presentation

6. Pain MeasuresChildren Ages 3-7

7. Pain MeasuresChildren Ages 8-12

8. Pain MeasuresAges 13-17

9. Pain MeasuresAges 18 and up

10. 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

11. 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

12. Thunder Project II Research Sites • Data Collection Sites: 169 • Sites reporting demographic info: 153 (90.5%) • Research Associates: avg 6/site ( 4.8) • Dedicated Children’s Hospital 17 (26.1%)

13. Participating Sites: Regions Northwest 7% Midwest 36% Northeast 24% Southwest 14% South 17% International Sites 3% Total # sites reporting geographic location: 152

14. Size of Participating Hospitals: # Beds

15. Type Of Units Participating In Thunder Project II

16. Sample: Age by Procedure Overall: age range 4-97 years; mean 60.6 years ( 16.3)

17. Thunder Project IISample % of Patients

18. Mean Pain Intensity by Procedures (adults only)

19. Differences in Mean Pain Intensity(by procedure)  = non-significant = significant

20. Mean Pain Intensity by Age Group:Turning, Wound Drain Removal, Wound Care & Tracheal Suctioning Mean Pain Reported * Scale modified from 0-100

21. Sharp Tender Aching Stinging Heavy Stabbing Shooting Cramping Tiring-exhausting Sickening Fearful-frightening Punishing-cruel Awful Bad Pain Quality Word List Sensory Affective • Dull • Throbbing • Hot-burning • Gnawing • Numb • Splitting

22. Pain Quality Words:Decreased from Baseline % of Patients Reporting

23. Pain Quality Words:Increased from Baseline % of Patients Reporting

24. 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?”

25. Degree of Distress (by age group & procedure) Mean Distress Reported

26. Differences in Distress(by procedure, adults only)  = non-significant = significant

27. Opioids Prior to Procedure

28. Patients who received preprocedure opioids: Was pain present at baseline?

29. Sedatives Prior to Procedure

30. Local Anesthetic Prior to Procedure

31. 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

32. 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?

33. 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

34. 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

35. 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

36. Wound Care: Summary Sensory/Affective Words Tender (58%) Sharp (44%) Stinging (36%) Aching (30%)

37. Wound Drain Removal: Summary Sensory/Affective Words Sharp (52%) Stinging (38%) Tender (32%)

38. Tracheal Suctioning: Summary Sensory/Affective Words Tender (36%) Sharp (34%) Aching (30%)

39. Turning: Summary Sensory/Affective Words Sharp (47%) Aching (47%) Tender (38%) Bad (32%) Tiring- (32%) exhaustive

40. Femoral Sheath Removal: Summary Sensory/Affective Words Aching (34%) Tender (31%)

41. Central Line Insertion: Summary Sensory/Affective Words Sharp (38%) Stinging (38%) Stabbing (36%)

42. 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

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