Care of Critically Ill AdultsSymptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research
Introduction
Critically ill, intensive care unit (ICU) patients experience many distressful symptoms associated with complex causes, such as acute illness or injury, critical care treatments and procedures, or pre-existing symptoms from underlying chronic conditions. Although the generally accepted definition of a symptom is the “self-reported perception of an individual's experience of disease or physical disturbance,”1 symptom assessment in the ICU involves unique challenges because many critically ill patients are limited in their ability to provide a self-report. Critical care professional groups (e.g., the Society of Critical Care Medicine) endorse the use of alternative strategies, which primarily are based upon observational measures, when subjective symptom report (i.e., self-report) is unattainable.2, 3
In response to a growing awareness of the importance of promoting patient-centered symptom assessment in the ICU, a group of expert nurse scientists were invited to participate in a scientific symposium titled “Symptom Measurement during Critical Illness” at the American Thoracic Society Annual International Conference in San Diego, California, in 2014. This paper is a synthesis of the respective presentations from the symposium based on the most up-to-date evidence for each topic. First, we introduce strategies to overcome challenges of accurate symptom identification and effective symptom communication with non-vocal ICU patients. Next, we highlight the effect of delirium on symptom communication. In the subsequent sections, we address the challenges and strategies in the clinical identification and measurement of selected symptoms of high prevalence in critically ill patients including pain, dyspnea, weakness and fatigue.4, 5 Moreover, we present implications for clinical practice and research.
Section snippets
Communication with non-vocal ICU patients
Common therapeutics in the ICU, including endotracheal intubation, mechanical ventilation, and sedation, often limit patients' ability to verbalize their symptoms or even minimally participate in symptom assessment. In addition, severe illness and complex therapeutics affect cognitive function and alter a given patient's ability to report the symptoms that he or she is experiencing. Problems with communication can lead to errors in symptom identification,6 missed symptoms, poor symptom
Delirium
Delirium is a complex, acute brain dysfunction syndrome with a prevalence range of 32–87% among ICU patients.15, 16, 17, 18, 19 The causal mechanisms of delirium are complex and remain difficult to determine. Although delirium is associated with poor outcomes in hospitalized patients,20, 21, 22, 23 ICU delirium is related to increased length of stay,24 increased duration of mechanical ventilation,25 and may be related to impaired cognitive recovery following ICU discharge.19 Patients with
Pain
Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.35 Therefore, it is not surprising that critically ill ICU patients experience significant pain either at rest or during procedures that are part of standard of care.36, 37, 38 Under-assessment of pain represents one of the primary barriers to adequate symptom management in ICU patients.39 Perhaps most alarming is the evidence documenting
Dyspnea and respiratory distress
Dyspnea is a prevalent symptom among critically ill patients—particularly those who require mechanical ventilation and can only be known by a patient's self-report.4, 63 In the ICU a numeric report or a visual analog scale are effective means for obtaining the patient's uni-dimensional measure of dyspnea.64 The Multidimensional Dyspnea Profile has potential for use in the ICU and has been validated in acutely ill patients and those being treated in the emergency department.65 When the patient
ICU-acquired weakness and fatigue
Critical illness and its related therapeutics in the ICU, such as mechanical ventilation and sedation, not only lead to prolonged bedrest, but also result in profound decrease in strength and volume of skeletal muscle—a condition called ICU-acquired weakness.73 Reduced skeletal muscle strength and volume can manifest as weakness. Defined as a subjective feeling of physical tiredness and lack of energy,74 fatigue is a vague, under-studied symptom in mechanically ventilated patients, yet this
Implications for clinical practice and research
In daily symptom assessment, the priority of ICU clinicians is to first determine a given patient's ability to communicate and then determine the presence or absence of delirium (Table 4). Communication ability and the presence of delirium are key determinants of symptom assessment. Nevertheless, assessing communication ability and delirium is more challenging when the patient is non-vocal and/or presents a hypoactive type of delirium. During assessment, clinicians need to consider all
Limitations
There are limitations in this report. First, this report is not based upon systematic review of all symptoms or all available symptom assessment strategies targeting non-vocal ICU patients—this report provides a summary of a conference symposium presented by expert nurse scientists with long-standing programs of research on specific symptoms. Therefore, its findings and recommendations should be contextualized as such. Second, although we acknowledge the importance of psychological symptoms
Summary
Optimizing assessment and management of symptoms is an integral part of safe and high quality care for the critically ill. Difficulty with or impairments to vocal communication and cognitive ability, regardless of whether or not these conditions are temporary or pre-existing, pose major challenges to accomplishing effective symptom assessment among ICU patients. In this narrative review, the SPEACS-2 assessment guide was introduced as a useful tool that can help patients, family members, and
Acknowledgement
National Institute of Nursing Research K24-NR010244 (M. Happ); National Institute of Child Health and Human Development 5R01-HD043988 (M. Happ); Robert Wood Johnson Foundation INQRI grant # 66633 (M. Happ); National Institute of Nursing Research R01-NR009295 (L.Chlan); Canadian Institutes of Health Research (CIHR) grant# 258867 and Fonds de Recherche du Québec - Santé (FRQS) grant# 25094 and research career award (C. Gélinas). The authors declare no conflicts of interest.
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