Neuro ICU - "how to test for pain response in comatose individuals

[janwebsa]

Dear all

I am a coma care communications trainer and counselor in a neurosurgery ICU in a large state hospital in Africa. It is an under resourced and highly stressed environment.

We work following minimal signals from people in altered states of consciousness - acknowledging and helping amplify these signals.

Our aim is accompaniment and completion of inner process which will hopefully lead to an easier death process (we have one of the highest global rates of AIDS deaths) or recovery process from TBI.

Many of our patients are inidentified young men and women who have entered ICU through violent attacks. It is important for me that their experience of hospital is not one of secondary violence.

Those that have recovered and can remember their experience say how important it was in their recovery and rising to consciousness that they were treated kindly and positively and that they " distanced themselves" when they were treated harshly.

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.

I want to challenge this practice and would like advice on how this is approached in other hospitals.

With thanks

JW

[CarVsTree]

Don't flame me...

If the nipple twist elicits a pain response and TMJ pressure is painful, how is one more humane than the other. I can see where one is more PC than the other, but pain is pain.

Have pt's that remember the experience said anything in terms of disliking one more than the other.

Thanks!

[gwenith, BSN, RN]

Don't flame me...

If the nipple twist elicits a pain response and TMJ pressure is painful, how is one more humane than the other. I can see where one is more PC than the other, but pain is pain.

Have pt's that remember the experience said anything in terms of disliking one more than the other.

Thanks!

Which would you prefer to have done to you or to your daughter or mother? There is a common dictum in medicine -

FIRST DO NO HARM

Try the noxious stimuli on yourself - how much pressure would you have to exert upon your own nipples to elicit a response? Would the amount of pressure put any danger of causing damage to underlying structure? Underlying the trapezius is muscle - if bruised it will cause an ouchie and usually long before enough damage is done for bruising to occur so - normally no serious sequelae - within the nipple are the ducts and tiny muscles - easy to do damage to. I am unsure of what eventual damage could be caused but since there is NO research supporting this then I suggest other methods be used.

[CarVsTree]

Which would you prefer to have done to you or to your daughter or mother? There is a common dictum in medicine -

FIRST DO NO HARM

Try the noxious stimuli on yourself - how much pressure would you have to exert upon your own nipples to elicit a response? Would the amount of pressure put any danger of causing damage to underlying structure? Underlying the trapezius is muscle - if bruised it will cause an ouchie and usually long before enough damage is done for bruising to occur so - normally no serious sequelae - within the nipple are the ducts and tiny muscles - easy to do damage to. I am unsure of what eventual damage could be caused but since there is NO research supporting this then I suggest other methods be used.

Thanks Gwenith. That makes a lot of sense.

[sanctuary, BSN, MSN, RN]

Sternal rub is my preference as there is no chance of soft tissue damage, and tends to look less distressing to family members. A male nurse was written up for doing a nipple twist on a female patient because the family complained.(And you might have to wait all of a minute before you say that there was no response. An eyelid flicker 40 seconds later counts.)

[gwenith, BSN, RN]

Sorry but sternal rubs are also now considered to be "less than ideal"

This is one of the reasons why

If you have to do stimuli on the sternum it should be pressure only not a rub.

Applying noxious stimuli to the sternum has the added disadvantage of confusing the responses you get for "abnormal flexion" and "localising" - particularly in ventilated patients who, usually are sedated and have diminished responses. To be considered as localising the patient MUST cross a midline of the body. The sternum being at the midline can confuse new staff when a movement is made by the arm.

[gwenith, BSN, RN]

I just went web searching and found this under nyu.edu neurology checking for pain in a comatose state and this is what they're taught:

"Mental status is evaluated by observing the patient's response to visual, auditory and noxious (i.e., painful) stimuli. The three main maneuvers to produce a noxious stimulus in a comatose patient are: 1. press very hard with your thumb under the bony superior roof of the orbital cavity, 2. squeeze the patient's nipple very hard, and 3. press a pen hard on one of the patient's fingernails.":nono:

I contacted the authors and they were very apologetic - the site had not been updated in some time and this section wil be reviewed!!

Sometimes we really can change things for the better:D

[sanctuary, BSN, MSN, RN]

Yeuch, yow, ptui! OK! No sternal rubs, thumps or battering for me, but what does one do? What is OK, accurate, and will do little short or long term damage? All I know now is what not to do...although if one of my patients became even close to comatose, we'd transfer them out, so my question is hypothetical, but serious. What does one do?

[NeuroICURN]

Ok...this thread really struck a cord with me because I too have seen physicians, as well as new nurses, do nipple twists....and it irritates the heck out of me!!! I'm always the first one to speak up and correct ANYONE when I see this behavior....it's inappropriate and it's wrong....it's wrong both morally and clinically.

As Gwenith previously mentioned, there are only three ways to properly assess for a reaction to central stimulation:

1. sternal rub (which is more of a pressure and can be done without leaving those awful bruises and breakdown like in the picture above).

2. trapezius muscle squeeze (this one is usually a little easier for the men to do because of hand strength and it also depends on the size of your patient....easier to do on a little old lady as opposed to a huge guy that was a construction worker).

3. Peri-orbital pressure (***important note: this can cause people to brady down, so be extremely cautious with this one! Granted, it usually reverses itself pretty quickly, but can still be dangerous).

Now, if you want to assess for peripheral response to pain, then you can apply nailbed pressure. There isn't always a need for a pen, just press down with your own finger. It just depends on your patient and what it takes to elicit a response from them...as all of us experienced Neuro ICU nurses will tell ya, everyone is different.

*edited to include* Remember, a peripheral response can come from the brain, but sometimes, it can just be a spinal response.

Originally posted by Gwenith: "To be considered as localising the patient MUST cross a midline of the body." I would love to give you a BIG " thank you" for saying this....I don't know how many new (and some not-so-new) nurses give credit to a patient for localizing, when they don't truly cross midline. This also irritates me because it means their assessment is incorrect, and if I follow them and they don't truly localize, then I suspect a neuro change and can end up going for a CT scan. On more than one occasion, during RN report, when I've been told that a pt. localizes, I'll ask if they TRULY cross midline.

Now, to address the original poster: sometimes a neurologic assessment can be a bit "brutal"...of course, depending on the patient. Despite what I've been told in report (i.e. that the patient never opens eyes or follows commands), I still give them an opportunity to do so. I'll introduce myself, as I always do, then ask them to open their eyes, ask them to squeeze my hands or wiggle their toes, etc. This gives them a chance to do what they can or can't and it also goes from least to more invasive. People can improve and who's to say that it can't happen with your initial assessment???

Now, as for assessing pain in an unresponsive, comatose or even expressively aphasic patient. We use a "Nonverbal pain assessment" scale, which is right on each of our VS screens. It assesses facial expression, HR, BP, RR, movement, etc. Depending on the answer for each, it's assigned a value of "0-2". Then the total determines the patient's probable pain level. For example (and don't quote me, I may not have this exactly right) a total of 0 is obviously no pain, a total of 1-3 indicates mild pain, 4-6 indicates moderate pain and 7-10 indicates severe pain. Then, of course, you can treat the pain accordingly.

I like this scale because I'm sure there were several times when a patient's pain may have been previously unrecognized.

Ok, I've gone on for way too long....hope this helps someone!!

[BlueEyedRN]

I had a neurologist tell me that the best noxious stimulus that isn't painful is to tickle the inside of a nostril with a q-tip. You have to be gentle and careful, but it doesn't cause any damage.

[GrnHonu99, RN]

once I saw a resident take a pair of scissors.. and the back part of the scissors where the loops for your fingers are, he put the pts. fingernail in between and squeezed...kinda hard to explain but it looked incredibly painful.

[Mz Mocha]

I've just begun the neuro rotation as of 1/09/07, and forgive me for not having the knowledge at this time, but wouldn't it make sense to put yourself in the patients shoes? How much pressure would be considered too much pressure? I believe (from my reading materials), that all of these procedures are ligitimate according to the house policy in the environment in which you work, but as a nurse, we all know that there is ( should be)a form of dignity and respect in every aspect of our nursing; therefore any technique used should be deemed appropriate and without harm to the patient.

[LadyNASDAQ]

Dear all

I am a coma care communications trainer and counselor in a neurosurgery ICU in a large state hospital in Africa. It is an under resourced and highly stressed environment.

We work following minimal signals from people in altered states of consciousness - acknowledging and helping amplify these signals.

Our aim is accompaniment and completion of inner process which will hopefully lead to an easier death process (we have one of the highest global rates of AIDS deaths) or recovery process from TBI.

Many of our patients are inidentified young men and women who have entered ICU through violent attacks. It is important for me that their experience of hospital is not one of secondary violence.

Those that have recovered and can remember their experience say how important it was in their recovery and rising to consciousness that they were treated kindly and positively and that they " distanced themselves" when they were treated harshly.

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.

I want to challenge this practice and would like advice on how this is approached in other hospitals.

With thanks

JW

We don't do that in our hospitals. A sternal rub suffices. Also, the feet are stroked with a person's back of a pen. Never the tip and never use a needle to prick someone's skin. Docs use a wet paper towel and carefully tap the eye ball. I won't do this but have seen other Nurses do this in deep comatose patients.