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

UNLABELLED: 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.

Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery.

The aim of this study was to describe bowel problems, self-care practices, and information needs of patients who have recovered from the acute effects of sphincter-saving surgery for colorectal cancer. A retrospective, descriptive survey was conducted using a structured telephone interview and mailed questionnaires. The sample consisted of 101 patients who had undergone sphincter-saving surgery for colorectal cancer in the last 6 to 24 months. Most participants (71.3%) reported a change in bowel habits after surgery. The 6 most frequently reported gastrointestinal problems were incomplete evacuation (75.2%), excessive flatus (75.2%), urgency (73.3%), straining (61.4%), perianal soreness or itching (49.5%), and bloating (43.6%). Incontinence of feces (varying from smears to complete bowel action) was reported by 37.6% of participants. The most frequently reported information needs were related to diet (50.5%) and managing conditions such as diarrhea (31.7%), bloating/wind/gas (28.7%), pain (21.8%), and incomplete emptying of the bowel (18.8%). Patients who had recovered from the acute effects of sphincter-saving surgery for colorectal cancer reported a wide range of bowel problems and ongoing concerns about managing symptoms. Findings from this study provide valuable information to guide the development of educational resources to prevent or better manage bowel problems after surgery.

Patients' self-report of procedural pain in the intensive care unit.

AIM: To determine which routine nursing procedures performed on conscious intensive care unit (ICU) patients were painful and which routine procedures were not painful. BACKGROUND: Current empirical evidence supports that routine procedures are often not viewed in the context of causing pain to the critically ill patient. Given the complexity of illness and the need to prioritize care in ICU patients, clinicians may not consider routine procedures as causing pain. With patients in intensive care undergoing frequent routine procedures, greater understanding of which procedures inflict pain is warranted to improve patient care and inform and shape nursing practice. DESIGN: A prospective, descriptive study using a convenience sample of ICU patients was used. METHODS: Sixty-one patients were asked to rate pain intensity experienced prior to and during a routine nursing procedure using a verbal numeric rating scale. The procedures observed were turning, tracheal suctioning, line removal, deep breathing and coughing exercises, simple dressings and drain removal. RESULTS: Results showed that certain routine procedures cause pain with significant differences observed between pre- and postprocedure pain scores for drain removal (p = 0.042), deep breathing and coughing exercises (p = 0.003), suctioning (p = 0.025), positional change (p = 0.000) and line removal (p = 0.010). A higher proportion of morphine was administered to those patients undergoing drain removal (50%), deep breathing and coughing exercises (38.5%) and turns (32.6%) but results show that <50% of patients actually received analgesia. Heart rate, systolic and diastolic blood pressure all increased slightly postprocedure but were not found to be statistically significant. CONCLUSION: Haemodynamic measures are not suitable indicators for the presence of pain. Nurses need to recognise that certain routine procedures can cause pain and should therefore plan patient care with this in mind. RELEVANCE TO CLINICAL PRACTICE: Nurses need to recognise of the fact that routine procedures can cause pain and to use analgesia appropriately to minimize this pain. Practice guidelines should recommend that pain relieving measures be considered as part of routine procedural instructions. Analgesic prescription and administration could be improved for this patient group.

Getting on with life: accepting the permanency of an implantable cardioverter defibrillator.

Increasing numbers of people with cardiovascular disease are requiring the insertion of Implantable Cardioverter Defibrillators (ICDs). Although these devices are an effective life-saving treatment, psychological distress sometimes accompanies their insertion. A qualitative approach was used to explore the experiences, concerns and needs of recipients of the device in Western Australia. Twenty-two tape-recorded interviews were carried out and transcribed verbatim. This paper focuses on the physical and psychological adjustments following the insertion of the device. A central theme of 'getting on with it' used to cope with the permanency of the device was identified. This was an approach to life in which the presence of the device was accepted and then put aside while life was continued and optimized. This study provides directions for the identification of persons who might be experiencing difficulties adjusting, or who are taking extended amounts of time to accept the permanency of the device.

Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil.

AIMS AND OBJECTIVES: The study aimed to compare the use of plain ice, flavoured ice and standard care, to evaluate the effect on mucositis and to determine patients' perceptions of the two forms of oral cryotherapy. BACKGROUND: Despite evidence that oral cryotherapy is useful in preventing mucositis in patients receiving 5-fluorouracil, concerns have been expressed about its clinical utility, due to potential side effects and negative perceptions. DESIGN: A randomized, controlled, crossover trial was conducted in the outpatient chemotherapy department of an acute care teaching hospital in Perth, Western Australia. Patients were randomized to receive each of three interventions across three cycles of chemotherapy: standard care alone; standard care plus plain ice; and standard care plus flavoured ice. METHODS: Oral mucositis was assessed by nurses prior to each of the three chemotherapy cycles and 15 days after each intervention. Two assessment tools were used, the Oral Assessment Guide, and the Western Consortium Cancer Nursing Research Scale. Participants completed a questionnaire to determine their comfort and satisfaction with oral cryotherapy, as well as factors affecting compliance. RESULTS: Findings from 67 patients revealed that when participants used standard care alone, they were significantly more likely to experience symptoms of mucositis than when they used either plain or flavoured ice. Odds ratios were at least threefold higher for standard care alone, varying according to the instrument used. The two main concerns reported were the taste of flavoured ice and the time required to complete the cryotherapy interventions. Side effects such as nausea, sensitivity and headache were reported more frequently for flavoured ice (n = 11) compared with plain ice (n = 5) and standard care (n = 1). CONCLUSIONS: Both forms of oral cryotherapy were effective in reducing the severity of oral mucositis after chemotherapy and were more effective than standard care alone. Flavoured ice was associated with the highest frequency of side effects. RELEVANCE TO CLINICAL PRACTICE: The benefits of cryotherapy appear to outweigh the problems in this sample of patients. The intervention should be tailored to individual patients, based on preferences for plain versus flavoured ice and small chips vs. larger blocks. Unsweetened frozen fruit juices should be evaluated. Time constraints could be addressed by providing transportable containers of ice.

Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls.

A prospective cohort study was used to determine the reliability and validity of two fall risk assessment tools and nurses' clinical judgement in predicting patient falls. The study wards comprised two aged care and rehabilitation wards within a 570 bed acute care tertiary teaching hospital in Western Australia. Instrument testing included test-retest reliability and calculations of sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The test retest reliability of all methods was good. In this setting, the three methods of assessing fall risk showed good sensitivity but poor specificity. Also, all methods had limited accuracy, and overall, exhibited an inability to adequately discriminate between patient populations at risk of falling and those not at risk of falling. Consequently, neither nurses' clinical judgement nor the fall risk assessment tools could be recommended for assessing fall risk in this clinical setting.

Evaluation of an electronic monitoring device for urinary incontinence in elderly patients in an acute care setting.

AIM: The primary aim of this study was to determine whether the use of habit training with an electronic monitoring device is better than standard habit training in the assessment and management of urinary incontinence in elderly patients in acute care hospitals. The second aim was to describe nurses' perceptions of continence management in acute care settings. DESIGN: A randomized controlled trial was conducted for an 18-month period. SAMPLE AND SETTING: The sample consisted of 41 elderly incontinent patients who resided on the acute care rehabilitation wards of 2 western Australian hospitals. INSTRUMENTS: A continence assessment form was used to document self-reported or carer-reported frequency and severity of incontinence. A continence monitoring chart was used to record voiding patterns and continence outcomes. A semi-structured interview guide was developed to elicit nurses' perceptions of continence management. RESULTS: Findings revealed no significant improvements in the self-reported or carer-reported frequency of incontinence from baseline to follow-up of in-patients and at 1 month after discharge, although there was a trend toward improvement in both the experimental and the control groups at the posttest time points. A significant reduction in self-reported or carer-reported severity of incontinence was demonstrated in the experimental group at 1 month follow-up (P = 5.025).Nurses' perceptions of continence management of elderly patients in acute care settings ranged from positive to extremely negative. Even those with positive perceptions were challenged by problems with device malfunction, perceptions of lack of time, lack of support from other staff, and lack of knowledge about how best to meet the continence management needs of this complex group of patients. CONCLUSION: The potential value of an electronic monitoring device for reducing incontinence could not be adequately assessed because of the small sample size and problems with the device and with implementing the study protocol. Although it was possible to determine a pattern in voiding times using the electronic device, compliance with the toileting regimen was difficult to achieve.Researchers and clinicians planning future studies with this device should be aware of the practical limitations associated with habit-training regimens for elderly patients in the acute care setting.

Reasons for attending and not attending a support group for recipients of implantable cardioverter defibrillators and their carers.

There is evidence to suggest that people who have an implantable cardioverter defibrillator and their caregivers experience psychological distress. This qualitative descriptive study explored the experiences, concerns and needs of recipients of implantable cardioverter defibrillators and their caregivers who attended or did not attend a support group organized by a public hospital located in Perth, Western Australia, Australia. Eleven recipients of implantable cardioverter defibrillators and their caregivers participated in this study. Among those who attended the support group, four major themes were identified: providing information, connecting with others, helping others and attendance. Explanations for non-attendance included difficulties attending because of the location, not wanting to be reminded about the implantable cardioverter defibrillator, and a perception, among younger recipients, that the support group was comprised of mainly older recipients with whom they had little in common.

Evaluating the impact of a new high dependency unit.

The impact of a new high dependency unit (HDU) that was developed from an adjoining ward was evaluated from both an organizational and consumer perspective. Satisfaction of patients and relatives with nursing care on the ward of origin was measured before and after the development of the HDU, and nurses were surveyed regarding the impact of the change on nursing practices. Patients' perceptions of pain and pain management was compared between patients admitted to the ward prior to the development of the HDU, and a later group admitted to the HDU. Results showed that despite high satisfaction prior to the development of the HDU, satisfaction of patients and relatives improved on the ward after the development of the HDU. Nurses in both areas also described higher satisfaction levels after the change. Patients admitted to the HDU expressed higher levels of satisfaction with nurses' response to analgesia requests and clinical data showed a trend toward lower pain scores in this group compared with pre-HDU patients. The HDU was found to be effective in providing high level care and monitoring for a group of patients at risk of postoperative complications. It was also associated with additional benefits in the running of the adjacent ward.

Risk factors associated with pressure ulcer development at a major western Australian teaching hospital from 1998 to 2000: secondary data analysis.

OBJECTIVE: The purpose of this study was to identify risk factors associated with the presence of pressure ulcer development in adult patients at an acute care teaching hospital. DESIGN: The database was established by combining the results from 3 annual cross-sectional pressure ulcer prevalence studies conducted between 1998 and 2000. SETTING AND SAMPLE: The sample consisted of all medical and surgical patients who were inpatients on the day of the pressure ulcer surveys. The sample includes a total of 1394 patients. METHODS: This study undertook secondary data analysis with use of logistic regression and descriptive statistics. RESULTS: Overall pressure ulcer prevalence was calculated at 15.9%, with this figure decreasing slightly to 12.7% when pressure ulcers present on admission were excluded. Initial analysis identified several variables as significant risk factors for pressure ulcer development (age, Braden Scale risk category, and admission type and specialty). However, when entered into a final multivariate model, only 2 factors, age and Braden Scale risk category, were found to be significant. The odds ratio matrix revealed a consistent trend toward increasing odds ratios with increasing Braden Scale risk category within each age group. The magnitude of this trend was more pronounced in the younger age groups, highlighting the importance of undertaking Braden Scale assessments of younger patients, some of whom may be at greater risk of having a pressure ulcer develop than would otherwise be expected. CONCLUSION: Pressure ulcer prevalence in this acute care setting is high when compared with other Australian data. However, comparisons of pressure ulcer prevalence across studies are difficult to interpret because of different reporting methods. Although predictor variables for pressure ulcers have been identified in a number of studies, longitudinal studies are needed to identify the cause-and-effect relationships for potential predictor variables. In addition, more sophisticated statistical analyses such as the use of the odds ratio matrix may help guide further research into interaction effects between predictor variables and how these might affect the psychometric properties of risk assessment tools such as the Braden Scale. Pressure ulcer interventions should be targeted at the sacrum and heel, because these appear to be the most frequently observed locations for pressure ulcers.