意識不清重症患者之疼痛評估工具：文獻探討

Tools for measuring the pain of unconscious patients in critically illness: A literature review

重症患者常因疾病或醫療處置而無法表達其疼痛。在無法獲得病患疼痛主述時，醫護人員需要仰賴一套完整且有系統的評估方法，以提供良好的疼痛處置。目前臨床上普遍所使用的疼痛評估工具，並無法確實瞭解意識不清或無法主訴的病人疼痛困擾程度。因此，本文將綜觀近幾年研究文獻，期望找出能協助無法主訴之重症患者具體表達疼痛感受的評估工具，以提供臨床應用。本文蒐集1990年後Medline、CINAHL與Embase 中有關意識不清或使用鎮靜劑的重症患者疼痛評出方法之英文文獻。以關鍵字pain、instrument/questionnaire/scale/Assessment/observation、ventilated/respiration/artificial、unconsciousness/Sedatives 及critica1 care/intensive care/ICU進行相關研究之查證。由13篇研究結果顯示，除了生命徵象，共有四種疼痛行為量表。只有Behavioural Pain Scales （BPS）以及Critical-care Pain Observation Too1（CPOT）在評估意識不清成人重症患者疼痛時，具有適當的信效度。但仍需臨床試驗在更多不同的族群，以具體確立。BPS以及CPOT應該可以是臨床加護單位一套完整而有系統的疼痛評估方法。未來須有更多實驗數據顯示他們的信度與效度，以確立他們可改善因病人無法表達疼痛而造成的錯誤處置。

Background: The accurate assessment of pain in unconscious patients is difficult, with nurses often rely on a variety of methods to determine medication impact. Much of the evidence to date suggests that common use of pain assessments may not effectively measure the true extent of distress in patients who are unable to verbalize their level of discomfort. Aim: This paper aims to review the evidence regarding pain assessment tools for patients unable to self-report and to establish whether the use of a tool can be recommended in practice. Search strategy: In this review, papers published after 1990 that tested pain assessment tools for unconscious or sedated patients with intensive care are discussed. A search of electronic databases (Medline, CINAHL, Embase) combined with cross referencing was performed. The search terms used in this paper were 'pain', 'instrument/questionnaire/scale/assessment/observation', 'ventilated/respiration artificial', 'unconsciousness/sedatives', and 'critical care/intensive care/ICU'. Result: Thirteen of 55 potential papers were chosen for the final analysis in this review. Beside of vital signs, 4 different pain assessment tools were discussed. Only the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) have been tested among the broadest range of adult patients. They were found to be reliable and valid tools. Research is needed to further demonstrate the reliability and validity among different critical care populations, such as Asian or African. Conclusions: The implementation of the BPS and the CPOT can be recommended in intensive care units and may improve the management of pain among unconscious/sedated and ventilated patients by providing a systematic and consistent approach to pain assessment to guide interventions, but first requires further validation. Also, further researches are needed into the effects of pain assessment tools on pain management practices and patient outcomes.