10 American Nurse Today Volume 8, Number 3 www.AmericanNurseToday.com
T
O MEET THE NEEDSof patientsand their families, healthcare prac-tice must be based on current re-search and the best evidence. Many definitions of evidence-based prac-tice (EBP) exist. All share similar el-ements—critical review of current research and examination of other forms of evidence, including na-tional and local guidelines for prac-tice, practice consensus documents, benchmark data, quality improve-ment studies, and population or pa-tient perspectives.
To embrace EBP, nurses must crit-ically examine multiple forms of evi-dence. No longer is it acceptable to resist changing a practice simply be-cause the task or skill in question “has always been done that way.” To move nursing practice forward, we must question practices and con-tinually review available evidence to ensure a given practice benefits pa-tients. By doing this, nurses can lead healthcare reform through embrac-ing EBP that results in better care. This article discusses the evidence on several common nursing prac-tices and makes recommendations to help improve outcomes.
Assessing pain in nonverbal
adults
Pain is a subjective experience, de-fined by whatever the patient says it is and existing whenever the pa-tient says it exists. It’s best assessed by patient self-report, which clini-cians should elicit routinely and
re-peatedly, and then implement ap-propriate interventions.
Assessing and managing pain is a nursing care priority for all pa-tients—even those who can’t com-municate verbally. Obvious chal-lenges arise when a patient can’t give a self-report due to severe ill-ness, altered cognition, or use of equipment (such as a mechanical ventilator) that inhibits communica-tion. We now have a large
body of evidence to guide nursing manage-ment of pain, includ-ing pain in nonver-bal adults. To meet the pain-manage-ment needs of nonverbal adults, assess frequently for behavioral changes, anticipate pain after certain proce-dures, use patient surrogate reporting, and administer anal-gesic trials (and evaluate the pa-tient’s response).
Current evidence shows the most effective way to assess nonverbal adults for pain is to follow an eval-uation hierarchy. (See Hierarchy of pain assessment techniques). In nonverbal patients, pain assessment relies less on vital-sign assessment and more on observing behaviors, checking for potential causes of pain, and eliciting information from the patient’s surrogates. Vital-sign changes are misleading as a
pri-mary indicator of pain because they may stem from underlying physio-logic conditions, hemodynamic changes, and medications. Only limited evidence suggests vital-sign assessment alone should be used to gauge pain. Nonetheless, vital-sign changes may suggest the need for further assessment for pain or other stressors. More importantly, absence of vital-sign changes doesn’t
indi-cate absenceof pain. You can use several valid and reliable
ob-servational and be-havioral scales to
aid pain assess-ment in nonverbal patients. But be aware that these scales don’t evalu-ate pain intensity, especially in patients receiving sedatives. Patients with advanced dementia require additional be-havioral observation. As dementia progresses, self-reporting ability decreases. EBP suggests nurses should assess for pain and inter-vene appropriately in patients (in-cluding dementia patients) with conditions that typically cause pain, such as chronic arthritis, low back pain, and neuropathies. Parelat-ed behaviors or indicators may in-clude changes in facial expression, verbalizations and vocalizations, changes in activity patterns or rou-tines, rubbing a body part, and
al-Questioning common nursing practices:
What does the
evidence
show?
To improve patient outcomes,
nurses need to challenge practice traditions.
By Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN; Carol A. Rauen, MS, RN, CCNS, CCRN; and Kathryn T. VonRueden, MS, RN, FCCM
www.AmericanNurseToday.com March 2013 American Nurse Today 11 tered interpersonal interactions
(such as agitation, restlessness, and combativeness). The City of Hope Pain and Palliative Care Resource Center offers a comprehensive list of resources and valid, reliable tools for assessing pain in elderly patients with cognitive impairment. (Visit http://prc.coh.org/pain_ assessment.asp.)
Implications for practice
The potential for unrelieved, unrec-ognized pain is greatest in patients who can’t verbalize their discom-fort. No patient’s pain should go untreated during an acute hospital-ization. To meet patients’ needs, nurses should use valid, reliable pain assessment tools. Current best evidence suggests that when pro-viding care to patients who can’t self-report pain, clinicians should assess pain frequently using a be-havioral pain scale and information obtained from surrogates, assess for subtle changes in observed behav-iors, and initiate an analgesic trial.
Assessing gastric residual
volume
Why do nurses assess gastric resid-ual volume (GRV)? Many believe the purpose is to gauge the pa-tient’s tolerance of tube feeding and risk for aspiration. But the evidence shows that checking GRV doesn’t provide reliable information on tube-feeding tolerance, aspiration risk, or gastric emptying. In fact, it may lead to patient underfeeding. Studies show the most common reasons for stopping enteral feeding include high GRV, supine patient positioning for procedures or nurs-ing care, diarrhea, and preproce-dural protocols. Little evidence sup-ports stopping or withholding tube feeding to reposition patients.
Similarly, the value of assessing GRV in evaluating tube-feeding toler-ance isn’t well defined, and scant evi-dence exists to guide nurses in ob-taining an accurate GRV. Most guidelines suggest using a
large-volume syringe (60 mL) to aspirate fluid effectively, as smaller-volume syringes may collapse the tube. Like-wise, it’s easier to obtain GRV from larger-bore tubes (14 to 16 French) than smaller-bore tubes (8 to 12 French). Also, placing a tube near the gastroesophageal junction promotes aspiration of contents. Evidence also questions the accuracy of GRV ob-tained from postpyloric tubes as these tubes have a small diameter, and in this part of the GI system, contents are propelled forward, making accu-rate GRV measurement difficult.
What’s more, we have little evi-dence to define how much volume constitutes a high GRV. Typically, at
any given time the stomach con-tains approximately 180 mL of fluid (such as saliva and gastric secre-tions). When assessing GRV, clini-cians should include this native volume in interpreting the volume extracted from the gastric tube. Current evidence shows high GRV ranges from 150 to 500 mL of as-pirate. But a single elevated GRV requires no action—only ongoing monitoring. Caregivers shouldn’t stop enteral nutrition on the basis of a single high GRV, although serial high GRVs may warrant ad-ditional interventions, such as con-sideration of prokinetic agents to promote gastric motility.
Hierarchy of pain assessment techniques
This diagram shows the progression of techniques to use when assessing a patient for pain, starting with patient self-report at the base of the pyramid. For patient self-report, use a 1-to-10 pain scale or elicit a simple “yes/no” answer. In nonverbal patients, assume pain is present and search for a potential cause (second pyramid segment from bot-tom). Be aware that certain pathologic conditions (such as some cancers and neu-ropathies), postsurgical status, constipation, patient repositioning and turning, and some procedures (such as wound care and blood withdrawals) are likely to cause pain but may not trigger a behavioral response.
When observing patient behaviors (third segment), know that pain-related behav-iors may not accurately reflect pain intensity. If relying on behavbehav-iors for pain assess-ment, evaluate the context of the behavior.
Surrogate reporting of the patient’s pain and behavior or activity changes by family members or other loved ones (second segment from top) can help you assess pain in nonverbal patients. Ask someone who knows the patient well to identify subtle behav-ioral changes that may indicate he or she in pain. In nonverbal patients, a clinician’s judgment may not accurately reflect pain severity; combining this judgment with sur-rogate reporting can lead to more accurate pain assessment.
Finally, an analgesic trial (top segment) should be initiated when pain is anticipated or patient behaviors suggest pain is present. If such behaviors subside with analgesic administration, assume pain was the cause and establish an analgesic regimen.
Attempt analgesic
trial. Elicit surrogate reporting of pain and behavior/activity changes. Observe patient behaviors. Assess for potential causes of pain.
Using an evidence-based nutri-tional protocol can minimize unnec-essary withholding of enteral feedings and help meet patients’ nutritional needs more reliably. If serial GRV measurements are high, explore the cause of enteral-feeding intolerance (such as bloating, abdominal pain, or changes in patient condition). To avoid underfeeding, once the patient can tolerate tube feedings, question the need to keep checking GRV.
Likewise, using GRV to assess as-piration risk isn’t evidence based. Research has found patients may aspirate with a GRV of 5 to 500 mL, and in many cases aspiration is clinically silent. Patient characteris-tics, not GRV assessment, increase the aspiration risk. The risk rises with an altered level of conscious-ness, critical illconscious-ness, and mechanical ventilation. Interventions to reduce risk include keeping the head of bed above 30 degrees, evaluating the need for agents that increase
gastric motility, and considering postpyloric enteral feeding if intol-erance persists.
On the other hand, GRV moni-toring can be used to assess gastric tube location. After radiography confirms accurate gastric-tube placement, GRV assessment (includ-ing evaluation of aspirate appear-ance and changes) may aid ongo-ing tube-placement assessment.
Implications for practice
GRV assessment isn’t a reliable way to assess tube-feeding tolerance or aspiration risk. Maximizing nutrition is essential to patient health. Meeting patients’ nutritional needs hinges on
using evidence-based enteral feeding protocols that guide GRV assessment frequency, prokinetic agents, and other variables of intolerance. Assess-ing aspiration risk should be driven by severity of illness and interven-tions that compromise the gag reflex.
Nurses must challenge the cur-rent practice of using GRV as a pri-mary assessment variable to deter-mine tube-feeding tolerance and aspiration risk. EBP suggests that relying on GRV alone may adverse-ly affect patient outcomes.
Using the Trendelenburg
position to treat hypotensive
episodes
In the late 1800s, Friedrich Adolf Trendelenburg placed patients supine with the head of the bed tilted 45 degrees downward to aid visualization of abdominal organs for surgical procedures. Today, some clinicians use this position, now called the Trendelenburg
posi-T
he
trendelenburg
position
has little,
if any, positive effect
on cardiac output and
blood pressure.
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tion, to treat hypotensive episodes. They believe this position shifts in-travascular volume from the lower extremities and abdomen to the up-per thorax, heart, and brain, im-proving perfusion to these areas.
But as far back as the 1960s, re-searchers found undesirable effects of the Trendelenburg position, in-cluding decreased blood pressure, engorged head and neck veins, im-paired oxygenation and ventilation, increased aspiration risk, and greater risk of retinal detachment and cerebral edema. Evidence shows that while this position shifts fluid, it adversely engorges the right ventricle, causing it to become di-lated, which further reduces cardiac output and blood pressure. It also impairs lung function by compro-mising pulmonary gas exchange. Abdominal contents shift upward, increasing pressure on and limiting movement of the diaphragm and reducing lung expansion. Lung
compliance, vital capacity, and tidal volumes decrease while the work of breathing increases. The result is impaired gas exchange—hypercar-bia and hypoxemia. Evidence also suggests that when obese patients are placed in Trendelenburg posi-tion, lung resistance increases sig-nificantly and pulmonary gas ex-change worsens.
Implications for practice
The Trendelenburg position has little, if any, positive effect on car-diac output and blood pressure. It impairs pulmonary gas exchange and increases the aspiration risk. The evidence doesn’t support its use to treat hypotension. However, evi-dence-based practice does support elevating the lower extremities— without using a head-down tilt posi-tion—to mobilize fluid from the lower extremities to the core during hypotensive episodes. Sometimes called a modified Trendelenburg
po-sition, this position has been found to support blood pressure without the negative consequences of the traditional Trendelenburg position.
Ensuring that healthcare prac-tices are based on the best evi-dence can improve patient safety. To safely and effectively manage acutely ill patients, clinicians must evaluate traditional practices and
systems. O
Visit www.AmericanNurseToday.com/ Archives.aspx for a list of selected references and observational and behavioral pain assess-ment tools.
Mary Beth Flynn Makic is a research nurse scientist in critical care and an associate professor (adjoint) at the University of Colorado in Aurora. Carol A. Rauen is an independent Clinical Nurse Specialist and education consultant as well as a staff nurse in the emergency department at the Outer Banks Hospital in Nags Head, North Carolina. Kathryn T. VonRueden is a Clinical Nurse Specialist at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore and an assistant professor at the University of Maryland School of Nursing.
www.AmericanNurseToday.com March 2013 American Nurse Today 14
Online sidebar
Observational and behavioral pain assessment
scales
When patients can’t verbally self-report pain due to communication challenges or an impaired level of consciousness, conduct routine pain assessment by observing patient behaviors and check whether the patient has had interventions that could cause discomfort. No single scale definitively assesses pain in nonverbal patients, but several valid and reliable scales are available, including those below.
Faces, Legs, Activity, Cry, Consolability Observational Tool (FLACC)
http://painconsortium.nih.gov/pain_scales/FLACCScale.pdf
This scale has been validated for measuring pain in children. In each of five cate-gories, the clinician assigns a score from 0 to 2. The total score may range from 0 to 10; the higher the total score, the more pain the child is experiencing.
Behavioral Pain Scale (BPS)
www.consensus-conference.org/data/Upload/Consensus/1/pdf/1670.pdf
Validated in the critical-care practice setting, this scale assesses three items—facial expression, upper limb movement, and compliance with the ventilator. Clinicians assign a score from 0 to 4 for each item. The higher the total, the higher the pain assessment score.
Critical-Care Pain Observation Tool (CPOT)
http://nursingpathways.kp.org/national/learning/webvideo/resources/cpot/ CPOTHandout.pdf
This tool, validated in critically ill patients, has four categories—facial expression, body movements, compliance with the ventilator (in intubated patients) or vocal-izations (in extubated patients), and muscle tension. Clinicians assign a score from 0 to 2 in each category.
Nonverbal Pain Scale (NVPS)
http://ccn.aacnjournals.org/content/29/1/59.full
Based on the FLACC tool, the NVPS has been validated in adults. Its five assessment categories are face (expression/grimacing), activity, guarding, physiologic (vital signs), and respiratory. The clinician scores each category from 0 to 2 and obtains a total score. A higher total score suggests a high pain level.
