Guideline Update: Bundle Up for Pain, Agitation, and Delirium

Abstract

According to the 2018 PADIS (Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption) guidelines, the Behavioral Pain Scale in intubated and nonintubated patients and the Critical-Care Pain Observation Tool have the greatest validity and reliability for monitoring pain in critically ill adults who are unable to self-report. These tools are both well validated for use in this population.In these circumstances, we would still document both the pain level the patient is reporting and their behavior. It is also key to work collaboratively with the patient regarding treatment goals and desire for pain management. For example, you may say, “I see that you are rating your pain very high. Would you like something to manage it or do you feel that you have what you need? If you want some medication, would you like to start with some Tylenol or do you prefer something stronger?” You could also ask the patient what helps lower their pain level.To assess patients with an altered baseline mental status, it is key to know what they could or could not do at baseline. The family/primary caregiver is instrumental in providing this information. I often explain the type of questions in the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) to the family and ask if the patient would normally (when not sick) be able to perform the test. In the intensive care unit (ICU), our key diagnostic feature often is the attention screening. So, I first focus on that quick test (eg, squeeze on letter A). If the family indicates that the patient could do this at baseline, then I proceed with the evaluation as usual. If not, I modify as needed. For example, you may say, “Squeeze on the number 2” and use a number list.Although the hourly neurological checks may be necessary for the patient’s condition, the nurse can work to minimize any other delirium risk factors (especially medications). Also, the nurse can continually monitor for the appropriate time to lengthen the neurological checks and decrease the potential disruption of the patient’s sleep.The PADIS guidelines apply to critically ill adults. Information for the pediatric CAM-ICU can be found at www.icudelirium.org. This website includes resources for delirium assessment for all ages. In addition, the AACN Practice Alert on delirium pertains to patients across the lifespan (https://www.aacn.org/clinical-resources/practice-alerts/assessment-and-management-of-delirium-across-the-life-span).