الفهرس 
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Abstract
The ICU is designed to manage the care of patients suffering from a range of complex and life threatening conditions. Although pain is reported as a major problem and a predominant stressor that can activate many pathophysiological mechanisms in critically ill patients, assessment rates of pain in ICU remain low. Critical care patients commonly have pain and physical discomfort from obvious factors, such as pathophysiology of disease, monitoring and therapies (catheters, drains, noninvasive ventilating devices, and endotracheal tubes), routine nursing care (airway suctioning, physical therapy, dressing changes, and patient mobilization), prolonged immobility, and trauma Exposure to high levels of pain that are uncontrolled have negative physiologic and psychologic consequences. The performance of procedures is a common occurrence in clinical practice, and many of these procedures cause substantial pain.
The aim of this study was to assess perception of procedural pain among unconscious intubated critically ill patients. To achieve this aim, a descriptive cross-sectional research design was used to conduct this study. Which was carried out in general ICUs namely; (unit I, unit II, and unit III) at the Alexandria Main University Hospital (AMUH). A convenience sample of 70 unconscious intubated critically ill patients of both sexes who were admitted to the previously mentioned intensive care units was included in this study. Quadriplegic patient, patients who receive neuromuscular blockade, and haemodynamically unstable patients were excluded from this study.
One tool was used to collect data of this study. This tool named: ―Unconscious patients’ perception of procedural pain assessment record‖. This tool was used by the researcher after extensive review of relevant literature (26, 29, 72, 79, 159-163) to assess perception of procedural pain among unconscious intubated critically ill patients.
Approval of ethics committee of the faculty of nursing was obtained. Permission to conduct the study was obtained from hospital responsible authority after explanation of aim of the study and delivery of an official letter from the Faculty of Nursing. The study tools were tested for content validity by 5 experts in the field of the study. The necessary modifications were done accordingly. Reliability of tool two was tested using Cronbach’s Alpha test and result was 0.8 which is accepted. A pilot study was carried out on 10% of the study sample in order to test the clarity and applicability of the research tools. Data were fed to the computer and analyzed using Statistical Package for Social Sciences (SPSS/ version 20.0) software.
All included patients were assessed for pain intensity during four distinct procedures that are part of the routine care in the ICU: 1) the nociceptive procedures known to be painful (positioning and tracheal suctioning); and 2) non-nociceptive procedures known to be non-painful (Eye care and central venous catheter (CVC) dressing).
The main results of the current study revealed that 62.9% were male, while 37.1% were females and their age ranging between 18 and 60 years with a mean age of 43.29 ± 14.30. It can be noted that (18.6%) of studied patients had more than two admission diagnoses, whereas (81.4) the majority of the studied patients had one or two admission diagnose. Concerning the number of co-morbidities, it was found that the highest percentage of patients had two or less co-morbidities (88.56%). Regarding the presence of co-morbidities, it can be noted that 35.7 % had no co-morbidities; while 64.3% had co-morbidities. Concerning invasive devices, it was noted that the total number of invasive devices were between 4 to 5 devices.
It can be noted that reason for admission of the studied critically ill patient’s admission to ICU was neurological disorders (80%) ,followed by respiratory disorders (54.3%) , and the rest was distributed between (20%) with cardiovascular disorders, (15.7%) with infectious disorders, (15.7%) with gastrointestinal disorders and (14.2%) with other diagnosis.
It can be noted that positioning and suctioning were significantly painful, while eye care and CVC dressing were significantly non painful. On the other hand, it can be noted that the mean pain score of positioning was (8.08±1.76), which indicates that positioning is significantly the most painful procedure, when the difference in mean pain score between phase one and phase two was taken (p=<0.001*).
In relation to positioning, it can noted that, the numbers of co-morbidities, patients who had more than two co-morbidities had higher mean pain scores(8.50± 1.53) than who had less than two co-morbidities(Mean =7.61± 1.90) with significant difference( U = 2.063* ,P=0.039*).In relation to total number of invasive devices, patients who had five devices had higher mean pain scores(9.57±1.13) than who had four devices ( Mean =7.91±1.74) with significant difference (U = 2.660*, P=0.008*).Concerning FOUR score, patients who had score between 5-8 had higher mean pain scores (8.18±1.87) than who had score between 0-4(Mean =7.58±1.0) with significant difference(U = 1.952*, P=0.049*).Regarding RASS score, patients who had score between -1:+5 had higher mean pain scores (8.82±1.13) than who had score between-2: -5 (Mean 7.84±1.87) with significant difference (U = 2.086*, P=0.037*).
In regard to suctioning, it can be noted that total number of invasive devices, patients who had five devices had higher mean pain scores (9.14±1.07) than who had four devices (Mean =7.30±1.32) with significant difference (U = 3.192*, P=0.001*).
When doing multivariate regression analysis of factors increasing pain intensity regarding positioning, it is noted that total number of invasive devices is the most significant factor affecting pain intensity score (t=3.151*, p=0.002*), followed by number of co-morbidities (t=2.027*, p=0.047*), then RASS score (t=1.916, p=0.060), and finally, FOUR score (t=0.451, p= 0.654).
It can concluded that critically ill patients commonly have pain and physical discomfort from obvious factors, such as pathophysiology of disease, monitoring and therapies, routine nursing care, prolonged immobility, and trauma. The performance of procedures is a common occurrence in clinical practice, and many of these procedures cause substantial pain. Moreover, critically ill patients often cannot self-report their level of pain because of changes in cognition or physiological status or the presence of an endotracheal tube. The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment. So, pain and suffering must be considered in all patients with DOCs. Furthermore, total number of invasive devices is the most significant factor that causes pain to unconscious critically ill patients.
The most important recommendations of this study are as follow: Pain assessment tools should be incorporated into daily practice; this will be assist health care professionals in the early identification and efficient management of pain and also optimum use of sedatives and analgesics in the ICU. Clinical and theoretical training on pain assessment should be included in nursing and medical core curriculum. Moreover additional researches are needed to address the barriers of pain assessment and to provide alternative strategies.