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BACKGROUND: Little is known about the painfulness of procedures commonly performed in acute and critical care settings. OBJECTIVE: To describe pain associated with turning, wound drain removal, tracheal suctioning, femoral catheter removal, placement of a central venous catheter, and nonburn wound dressing change and frequency of use of analgesics during procedures. METHODS: A comparative, descriptive design was used. Numeric rating scales were used to measure pain intensity and procedural distress; word lists, to measure pain quality. RESULTS: Data were obtained from 6201 patients: 176 younger than 18 years and 5957 adults. Mean pain intensity scores for turning and tracheal suctioning were 2.80 and 3.00, respectively (scale, 0-5), for 4- to 7-year-olds and 52.0 and 28.1 (scale, 0-100) for 8- to 12-year-olds. For adolescents, mean pain intensity scores for wound dressing change, turning, tracheal suctioning, and wound drain removal were 5 to 7 (scale, 0-10); mean procedural distress scores were 4.83 to 6.00 (scale, 0-10). In adults, mean pain intensity scores for all procedures were 2.65 to 4.93 (scale, 0-10); mean procedural distress scores were 1.89 to 3.47 (scale, 0-10). The most painful and distressing procedures were turning for adults and wound care for adolescents. Procedural pain was often described as sharp, stinging, stabbing, shooting, and awful. Less than 20% of patients received opiates before procedures. CONCLUSIONS: Procedural pain varies considerably and is procedure specific. Because procedures are performed so often, more individualized attention to preparation for and control of procedural pain is warranted.

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To sustain optimal pain-relieving care for acutely and critically ill patients, organizations must have systems in place to support evidence-based interventions, facilitate expert practice in the area of pain management, and encourage ongoing communication among patients, families, and providers. The key to success may be to create an organizational culture that is supportive of all practitioners to use effectively the many therapeutic options available to manage pain. Although redesigning structures to support pain management care can be done with relative ease, altering the culture of the practice environment and the behavior of care providers may prove more challenging. Cultural changes occur slowly, but as the practice changes do take hold, so do the results. The steps to change an organizational culture around pain management include understanding the existing system and involving key formal and informal leaders. Most experts recommend not attacking the existing culture head-on but living the culture you are trying to create and understanding that the transformation is not going to take place overnight. The use of evidence-based collaborative practice and quality improvement models may be a key to improving the practice environment for pain management. Evidenced-based pain management practice combined with an organizational commitment to optimal pain management for all patients helps to create and sustain the environment to effect the change.

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The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.

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As the practice of medicine grows in complexity and the public calls for demonstrated value at decreased cost, the need for increasing effectiveness of both providing care and evaluating patient outcomes becomes paramount. This paper will demonstrate the success of utilizing a standardized taxonomy within an automated patient record to provide cues to clinicians regarding individual, patient-focused outcomes as well as timely evaluation of aggregated patient outcomes data. A case study will be used to illustrate dynamic evaluation of clinical outcomes following cardiac surgery.

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This study explores how an organization, as the context of care, influences nursing practice and a nursing-sensitive, quality health outcome-pain management. The results provide important insights into organizational patterns associated with favorable pain management-related outcomes as well as the congruence between and among subunits within the organization. Outcomes were most favorable on units where nurses had attitudes supportive of aggressive pain management and higher levels of coordination and discretion.

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With the cost of prescription drugs rising at three times the rate of other products, nurses can play a principal role in assisting clients and communities to ask critical questions regarding the costs and benefits of pharmacologic therapies. Building on an expanded view of client and environment, this article applies the process and concepts of critical social theory to critique the ideologic, social, political, and economic conditions contributing to tensions between quality and costs using pain-relieving drugs as a clinical example. Implications and strategies for nursing in the research and practice arenas are also proposed.

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Although neuromuscular blocking agents (NMBAs), such as pancuronium bromide and succinylcholine, are widely used in the management of critically ill patients, many misconceptions regarding the agents' clinical effects and indications persist. This article will discuss these misconceptions and review the indications for the use of NMBAs in the critically ill patient, how these potent agents work, and strategies to effectively manage critically ill patients who are receiving NMBAs as a part of their treatment regimen.

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Epidural narcotics are finding increasing favor in management of postcesarean birth pain. Effective pain relief coupled with minimal side effects often make this technique the method of choice. To provide comprehensive and safe nursing care for the mother using epidural narcotics, nurses must be knowledgeable about the technique, drugs, and associated patient responses. Nursing management using a care plan with nursing diagnosis and expected patient outcomes will help nurses plan their care of these patients.

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