title: Pain descriptors for critically ill patients unable to self-report.
abstract: OBJECTIVE
  To examine descriptors used by nurses in two Canadian intensive care units to document pain presence for critically ill patients unable to self-report.
  
  
  BACKGROUND
  Systematic documentation of pain assessment is essential for communication and continuity of pain management, thereby enabling better pain control, maximizing recovery and reducing physical and psychological sequelae.
  
  
  METHODS
  A retrospective, mixed method, having observational design in two Level-III intensive care units of a quaternary academic centre in Toronto, Canada. During 2008-2009, data were abstracted via chart review guided by a reference compendium of potential behavioural descriptors compiled from existing behavioural pain assessment tools.
  
  
  RESULTS
  A total of 679 narrative descriptions were extracted. Behavioural descriptors (232, 34%), physiological descriptors (93, 14%), and descriptors indicating the patient was pain free (117, 17%) were used to describe pain presence or absence. Narratives also described analgesia administered without descriptors of pain assessment (117, 17%) and assessment and analgesic administration prior to a known painful procedure (30, 4%). Emerging themes included life-threatening treatment interference, decisional uncertainty and a wakefulness continuum.
  
  
  CONCLUSIONS
  Inconsistent or ambiguous documentation was problematic in this sample. This may reflect confounding behaviours and concomitant safety priorities. Developing a lexicon of pain assessment descriptors of critically ill patients unable to self-report for use in combination with valid and reliable measures may improve documentation facilitating appropriate analgesic management. Protocols or unit guidelines that prioritize a trial of analgesia before administration of sedatives may decrease decisional uncertainty when patients exhibit ambiguous behaviours such as agitation or restlessness.
authors.affiliation: Department of Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. lynn.haslam@sunnybrook.ca
authors.forename: Lynn
authors.initials: L
authors.lastname: Haslam
authors.forename: Craig
authors.initials: C
authors.lastname: Dale
authors.forename: Leasa
authors.initials: L
authors.lastname: Knechtel
authors.forename: Louise
authors.initials: L
authors.lastname: Rose
mesh_terms: D000328:Adult; D000368:Aged; D000698:Analgesia / Q000379:methods; D002170:Canada; D015400:Clinical Nursing Research; D016638:Critical Illness / Q000451:nursing*; D004282:Documentation; D005149:Facial Expression; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units; D007697:Kinesics; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment / Q000379:methods*; D009737:Nursing Records; D010146:Pain / Q000175:diagnosis* / Q000188:drug therapy; D010147:Pain Measurement / Q000379:methods* / Q000451:nursing; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D012189:Retrospective Studies; D057566:Self Report; D009626:Terminology as Topic; D035501:Uncertainty
chemical_list: D006993:Hypnotics and Sedatives