Patients’ Perceptions and Responses to
Procedural Pain:
Results From the Thunder Project II
The American Association of
Critical-Care Nurses
Thunder Project II
Research Question:
What are the perceptions and
responses of acutely/critically ill
patients to procedural pain?
Study Aims

Describe patients’ perceptions of and responses to
pain associated with six study procedures.

Compare the pain perceptions and responses across
procedures.

Examine relationships between patients’ pain
perceptions and responses and pre-procedural
analgesic administration.
Procedures Studied
 Turning
 Central
Line Insertion
 Wound Drain Removal
 Non-burn Wound Dressing Change
 Tracheal Suctioning
 Femoral Sheath Removal
Pain Dimensions





Pain Intensity*
Pain Quality*
Pain Location
Pain Behaviors
Physiological Responses
(HR and BP)
* results reported in this presentation
Pain Measures
Children Ages 3-7
Pain Response
Measure
Intensity
Oucher 0-5 Faces
Location
Child Body Outline Diagram
Quality
Patient states 3 words
Behaviors
Behavior checklist
Heart rate
Bedside monitor
Blood pressure
Bedside monitor
Pain Measures
Children Ages 8-12
Pain Response
Measure
Intensity
Oucher 0-100 Numeric Rating Scale
Location
Adolescent Body Outline Diagram
Quality
Modified MPQ-SF
Behaviors
Behavior checklist
Heart rate
Bedside monitor
Blood pressure
Bedside monitor
Pain Measures
Ages 13-17
Pain Response
Measure
Intensity
0-10 intensity Numeric Rating Scale
Location
Adolescent Body Outline Diagram
Quality
Modified MPQ-SF
Behaviors
Behavior checklist
Heart rate
Bedside monitor
Blood pressure
Bedside monitor
Pain Measures
Ages 18 and up
Pain Response
Measure
Intensity
0-10 intensity Numeric Rating Scale
Location
Adult Body Outline Diagram
Quality
Modified MPQ-SF
Behaviors
Behavior checklist
Heart rate
Bedside monitor
Blood pressure
Bedside monitor
Other Information
Procedural distress (ages 13 and up)*
 Debriefing question (ages 13 and up)
 Analgesic and sedative profile*
 Use of non-pharmacological interventions
 Procedure specific variables
 Generic procedure variables
 Demographic variables*

* results reported in this presentation
Data Collection Times

TIME #1: Pre-Procedure

TIME #2: Intra-Procedure
– most painful part of procedure

TIME #3: Post-Procedure
– 10 minutes after end of procedure
Thunder Project II Research Sites

Data Collection Sites:
169

Sites reporting demographic info: 153 (90.5%)

Research Associates:

Dedicated Children’s Hospital
avg 6/site ( 4.8)
17 (26.1%)
Participating Sites: Regions
Northwest
7%
Southwest
14%
Midwest
36%
Northeast
24%
South
17%
International Sites 3%
Total # sites reporting geographic location: 152
Size of Participating Hospitals: # Beds
>500
26%
< 50
1%
50-99
3%
100-199
12%
200-299
17%
400-499
16%
300-399
25%
Type Of Units Participating In
Thunder Project II
Med-Surg
Floor
7%
Emerg Dept
1%
Other
Oncology
8%
3%
Cardiac Cath
8%
Prog Care/Tele
14%
Specialty ICU
18%
Med-Surg ICU
41%
Sample: Age by Procedure
Procedure
Ages 4-12 Ages 13-17 Ages 18
Total
Wound Care
2
7
412
421
Wound Drain Removal
1
18
548
567
Tracheal Suctioning
20
17
756
793
Turning
61
85
1395
1541
Femoral Sheath Removal
7
22
2629
2658
Central Line Placement
0
2
219
221
Total
91
151
5959
6201
Overall: age range 4-97 years; mean 60.6 years ( 16.3)
Thunder Project II Sample
80
% of Patients
70
60
50
40
76
59
41
30
20
8 11
10
0
2 2
Gender
Ethnicity
Male
Female
Caucasian
African American
Native American
Hispanic
Asian/Pacific Islander
Mean Pain Intensity by Procedures
(adults only)
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Mean Intensity
Turning
Drain
Removal
Wound
Care
Trach Sx
Central
Line
Fem
Sheath
4.93
4.67
4.42
3.94
2.72
2.65
Differences in Mean Pain Intensity
(by procedure)
Wound
Care
Drain
Removal
Trach
Sx
Turning
Fem
Sheath
Wound
Care
Drain
Removal

Trach
Sx


Turning



Fem
Sheath
Central
Line








 = non-significant
= significant

Central
Line
Mean Pain Intensity by Age Group:
Turning, Wound Drain Removal, Wound Care &
Tracheal Suctioning
10
Mean Pain Reported
9
8
7
6.5 6.3
7
6
Turning
5.2
5
5
4
4.9 4.7
Drain Removal
4.4
3.9
2.7
3
2.8
Wound Care
Trach Suction
2.3
2
1
1
0
4-7 yrs
8-12 yrs*
13-17 yrs
18 yrs & up
* Scale modified from 0-100
Pain Quality Word List
Sensory








Sharp
Tender
Aching
Stinging
Heavy
Stabbing
Shooting
Cramping






Affective
Dull
Throbbing
Hot-burning
Gnawing
Numb
Splitting






Tiring-exhausting
Sickening
Fearful-frightening
Punishing-cruel
Awful
Bad
Pain Quality Words:
Decreased from Baseline
% of Patients Reporting
50%
40%
30%
T1 Baseline
T2 Intraprocedure
20%
10%
0%
Aching
Dull
Gnawing
Pain Quality Words:
Increased from Baseline
% of Patients Reporting
40%
30%
20%
T1 Baseline
T2 Intraprocedure
10%
0%
Sharp
Stinging
Stabbing
Shooting
Procedural Distress
“On a scale where 0 means no distress
and 10 means worst possible distress,
how distressing or how bothersome
was this procedure to you?”
Degree of Distress
Mean Distress Reported
(by age group & procedure)
10
9
8
7
6
5
4
3
2
1
0
6
4.2
3.7
3.5
2.8
2.8
3.2 3.1
2 1.9
1.5
13-17 yrs
18 and up
Wound Care
Turn
Trach Sx
Drain Removal
Fem Sheath
Central Line
Differences in Distress
(by procedure, adults only)
Wound
Care
Drain
Removal
Trach
Sx
Turning
Fem
Sheath
Wound
Care
Drain
Removal

Trach
Sx


Turning



Fem
Sheath
Central
Line








 = non-significant
= significant

Central
Line
Opioids Prior to Procedure
97%
100%
86%
81%
80%
88%
87%
% receiving
opioids
75%
60%
% NOT
receiving
opioids
40%
25%
19%
20%
14%
13%
12%
3%
Su
ct
lL
in
Tr
ac
h
tra
C
en
io
n
e
g
rn
in
Tu
al
R
em
ov
D
ra
in
C
ou
nd
W
Fe
m
Sh
ea
t
ar
e
h
0%
Patients who received preprocedure opioids:
Was pain present at baseline?
100%
88%
85%
76%
80%
% with NO pain
at Time 1
62%
60%
52%
48%
% with pain at
Time 1
38%
40%
24%
15%
20%
12%
Dr
a
in
g
in
rn
Tu
Re
m
ov
al
e
Ca
r
W
ou
nd
at
Sh
e
m
Fe
Ce
n
tra
ll
in
e
h
0%
Sedatives Prior to Procedure
97%
100%
80%
98%
99%
99%
78%
71%
60%
40%
% receiving
sedative
29%
% NOT receiving
sedative
22%
20%
3%
1%
1%
Ce
nt
ra
lL
in
e
Fe
m
Sh
ea
th
W
ou
nd
Ca
Tr
re
ac
h
Su
ct
io
Dr
n
ai
n
Re
m
ov
al
Tu
rn
in
g
0%
2%
Local Anesthetic Prior to Procedure
97%
100%
80%
100%
100%
100%
71%
67%
60%
% receiving LA
40%
29% 33%
% NOT receiving
LA
20%
0%
ov
a
l
0%
in
R
em
ct
io
n
Su
D
ra
Tr
ac
h
C
ar
e
ou
nd
W
Sh
ea
th
Fe
m
C
en
tra
lL
in
e
0%
0%
Tu
rn
in
g
3%
Age
Patients in the 13-17 year age group had greater
pain intensity across four procedures than adults
 Wound care highest pain and distress

– Relative length of the procedure may be more of a
factor for adolescents
– Body image issues and developmental level may also
play a role
Turning and Suctioning

Turning most painful and most distressing
procedure for adults
– moderate level of pain
– higher than with previous studies

Suctioning
– mild level of pain reported in this study
– lower level than reported in previous studies
Few patients received pre-medication for procedure
 Repetitive nature of these procedures

– What is cumulative effect?
Femoral Sheath and
Central Line Placement

Least painful

Least distressing

Patients received more medications overall and
especially sedatives

Lidocaine use more likely

Procedures more likely to be protocol driven
Pain Quality
Extent of language used to describe procedural
pain is broad
 Physiologic basis for quality words used

– Baseline pain
» aching, dull, gnawing
» characteristics of slower, C-fiber transmission
– Procedural pain
» sharp, stinging, stabbing, shooting
» characteristics of rapid, A-delta fiber transmission
Limitations

Sampling
– convenience sample
– no heavily sedated patients--experiences may differ
No standardization of specific interventions for
procedural pain
 Generalizability across age groups is limited due
to small numbers of children; yet is largest study
to date to include children

Wound Care: Summary
10
Sensory/Affective
Words
8
6
4
2
0
Wound Care
Intensity
Distress
4.4
2.8
Tender
(58%)
Sharp
(44%)
Stinging
(36%)
Aching
(30%)
Wound Drain Removal: Summary
10
6
Sensory/Affective
Words
4
Sharp
(52%)
Stinging
(38%)
Tender
(32%)
8
2
0
Drain Removal
Intensity
Distress
4.7
3.1
Tracheal Suctioning: Summary
10
8
6
4
2
0
Trach Suction
Sensory/Affective
Words
Intensity
Distress
3.9
3.2
Tender
(36%)
Sharp
(34%)
Aching
(30%)
Turning: Summary
10
8
6
4
2
0
Turning
Sensory/Affective
Words
Intensity
Distress
4.9
3.5
Sharp
(47%)
Aching
(47%)
Tender
(38%)
Bad
(32%)
Tiring(32%)
exhaustive
Femoral Sheath Removal: Summary
10
8
6
4
2
0
Fem Sheath
Sensory/Affective
Words
Intensity
Distress
2.7
2
Aching
(34%)
Tender
(31%)
Central Line Insertion: Summary
10
8
6
4
2
0
Central Line
Sensory/Affective
Words
Intensity
Distress
2.7
1.9
Sharp
(38%)
Stinging
(38%)
Stabbing
(36%)
Conclusions

Pain intensity and distress vary considerably across
procedures and age groups

Incisive quality of procedural pain

Be attentive to repetitive procedures and the
potential need for analgesia

Patient preparation may be very important
– Inclusion of sensory descriptions when preparing
patients for procedures may help
Future Work
Medications
 Pain Behaviors
 Procedure-specific information

– location, procedure-related variables

Age span
– pediatric
– elderly
Instrumentation
 Managing multisite research
