• Lynn Haslam, Craig Dale, Leasa Knechtel, and Louise Rose.
• Department of Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. lynn.haslam@sunnybrook.ca
• J Adv Nurs. 2012 May 1;68(5):1082-9.

Aim  To examine descriptors used by nurses in two Canadian intensive care units to document pain presence for critically ill patients unable to self-report.Background  Systematic documentation of pain assessment is essential for communication and continuity of pain management, thereby enabling better pain control, maximizing recovery and reducing physical and psychological sequelae.Method  A retrospective, mixed method, having observational design in two Level-III intensive care units of a quaternary academic centre in Toronto, Canada. During 2008-2009, data were abstracted via chart review guided by a reference compendium of potential behavioural descriptors compiled from existing behavioural pain assessment tools.Results  A total of 679 narrative descriptions were extracted. Behavioural descriptors (232, 34%), physiological descriptors (93, 14%), and descriptors indicating the patient was pain free (117, 17%) were used to describe pain presence or absence. Narratives also described analgesia administered without descriptors of pain assessment (117, 17%) and assessment and analgesic administration prior to a known painful procedure (30, 4%). Emerging themes included life-threatening treatment interference, decisional uncertainty and a wakefulness continuum.Conclusion  Inconsistent or ambiguous documentation was problematic in this sample. This may reflect confounding behaviours and concomitant safety priorities. Developing a lexicon of pain assessment descriptors of critically ill patients unable to self-report for use in combination with valid and reliable measures may improve documentation facilitating appropriate analgesic management. Protocols or unit guidelines that prioritize a trial of analgesia before administration of sedatives may decrease decisional uncertainty when patients exhibit ambiguous behaviours such as agitation or restlessness.© 2011 Blackwell Publishing Ltd.

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