In this essay I will reflect about the importance of pain assessment in patients acutely unwell in Emergency Department setting. I’m going to use Tanner’s (2006) clinical judgment model as my reflection guideline, so I can affectively explore the different stages of the situation that I will report and deliver enough foundations to support the reflection. The clinical judgment model, consists in 4 steps, Noticing, it is a function of nurse’s expectation of the situation, that will depend on the background of the nurse, the experience and knowledge. Interpreting and Responding, it’s giving a meaning of the data collected and determining an appropriate course of action. The last step is reflection, reflection-in-action and reflection-on-action, the first one refers to nurse’s ability to “read” the patient, and adjust the interventions based on the assessment. Reflection-on-action is the subsequent clinical learning, completes the cycle, showing what nurses gain from their experience, contributes to their ongoing knowledge development and their capacity for clinical judgment in future situations. (Tanner’s, 2006) Potter and Perry (2017) states critical thinking is a process gained only through experience, commitment and active curiosity toward learning. Nurses who apply critical thinking in their work are able to see the big picture from all possible perspectives. Learning to think critically helps you care for patients as their advocate and make better-informed choices about their care. NMC (2017) considers has an important standard for nurses having a continuous reflective discussions, has a culture of sharing, reflection and improvement. Pain is a universal but individual experience, it is the most common reason that people seek health care, yet is often underrecognized, misunderstood and inadequately treated. A person in pain often feels distress or suffering and seeks relief. (Potter et al, 2017) The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Some pain is protective and acts as an early warning sign to alert the individual that tissue damage is occurring or is about to occur. However, pain can also be experienced when there is no evidence of tissue damage. (Castledine and Close, 2009)Respect people’s right to privacy and confidentiality is part of the NMC Code (2015), because of that the name of the patient that I’m going to describe is fictional to preserve confidentiality. Mr. X came to Emergency Department with LAS (London Ambulance Service) has a blue call, blue calls is when patients need resuscitation or immediate medical attention, this patients went directly to the Resuscitation area. On arrival Mr. X was given a priority 2, very urgent, using the Manchester triage, has patient came with altered conscious level, responding to pain, GCS (Glasgow Coma Scale) 9/15, query head injury, had battle’s sign, also known mastoid ecchymosis. Manchester Triage Group (2014) defines emergency triage has a fundamental part of clinical risk management that promulgates a system that delivers a method of assigning clinical priority in emergency settings, to ensure that those who need care receive it appropriately quickly.Priority 2 is given in patients with head injury when there’s a new neurological deficit more than 24hrs old, significant mechanism of injury, altered consciousness level and scalp haematoma (bruises below the hair line at the front are to the forehead). (Manchester Triage Group, 2014)This patient had multiple haematomas all over his body, had CT scans, x-rays, to rule out any fractures and head injury. Was put out a Trauma call, seen by A&E, Surgical, Intensive Care and Orthopaedics doctors, but none of this teams assess the pain of this patient, me and my nursing colleagues on that shift several times ask the doctors if they could prescribe analgesia for this patient, but only thing that was prescribe was paracetamol intravenous. The only scale to measure the pain available on department is a numeric scale, but because the patient had a low GCS I was unable to use it, the patient couldn’t verbalise or self report. NRS (Numeric Rating Scale) should be use if the patient is able to cooperate, the patient is asked to indicate on a scale from 0 to 10 where their pain is, with 0 being pain free and 10 being the worst pain you can imagine. (Mallett et al, 2013) I felt that on this situation pain was not consider at all, given a minimal importance. Pain is felt when sensory nerve endings are stimulated and neurones relay information to the brain. Specialized pain receptors, known as nociceptors, are found in free nerve endings close to mast cells and small bloods vessels that all work together to respond to pain. (Dolan and Holt, 2013) The physiological responses that occur when the nociceptors are stimulated are similar to those of the acute stress. The sympathetic nervous system is activated causing vasoconstriction, while dilating the arteries supplying vital organs such as the muscles. Tidal volume and alveolar ventilation may be reduced, as is gastric motility. Skeletal muscle spasm may occur and hormonal changes may cause electrolyte imbalances and hyperglycaemia. (Dolan al tal, 2013)Castledine and Close (2009) refer that acute pain it’s associated with well-defined cause, on this case was trauma, there was several haematomas on the patient’s body. It can range from mild to severe, it may become chronic if not treated effectively, due to sensitization of the nervous system. Stimulates the autonomic nervous system and stress related hormones, leads to protein breakdown and poor healing process. Has cardiovascular effects, hypertension, tachycardia, myocardial ischaemia, hypercoagulability, increases the risk of blood clots. Mr. X was with tachycardia even when given all the treatments for electrolyte imbalance, was never consider the possibility that could be from the pain. Decreases the respiratory function, more risk of chest infection. Unrelieved pain can increase the release of hormones and enzymes, such catecholamines, aldosterone, ADH, cortisol, angiotensin II, and prostaglandins, which help to regulate urinary output, and fluid and electrolyte balance, as well blood volume and pressure. This results in the retention of sodium and water, causing urinary retention. Increased excretion of potassium causes hypokalaemia. A decrease in extracellular fluid occurs as fluid moves into the intracellular compartments, causing fluid overload, increased cardiac workload and hypertension. The failure of clinicians to assess pain can lead to undertreated pain and serious medical complications in the acute pain patients, placing patients at risk of myocardial ischemia, stroke, bleeding and other complications. All this data shows how important is to assess pain, and how pain can aggravate the outcome of the patients when not treated appropriately.As describe above Mr. X GCS was 9, and unable to communicate, the verbal response was sounds only, but has Castledine (2009) describes to assess pain we should do physical assessment, head-to-toe review of the patient with includes looking for erythema, swelling, atypical body temperatures, tenderness, sweating, and deformities, on the case of Mr. X, sweating and haematomas were present. Observation of the patient body language, does the patient appear restless? And yes, Mr. X was constant verbalising sounds and moving is arms and legs. Uncontrolled acute pain is known to cause psychological distress, and it may also lead to adverse physiological changes in some organs and systems, like is describe above. (Dolan at al 2013) Pain should be anticipated in all patients and every action should be questioned for its potential to cause pain. However, nurses and doctors underestimate patient’s pain in 35-55% of patients. (Watt-Watson 2001, in Mallett et al, 2013) On the case that I described unfortunately is an example of this, was not given the importance that it should, and there wasn’t a scale that could accurately assess the pain for this patient. Anticipation of pain allows alternative strategies to be considered or pre-emptive analgesics given. All patients requiring critical care should be assess for pain on regular basis. Mr. x was a patient that require critical care, a multicentred observational pain study compared critical care units where patients pain was routinely scored compared with those units where it was not, this demonstrated both reduction in duration of mechanical ventilation and length of critical care unit stay where scoring took place. (Mallett et al, 2013) This demonstrates the importance that assessing and managing pain correctly can do on the recovery of the patients. Mr. X like I stated before, was unable to communicate or interact with the staff, on this circumstance the best way to assess pain in a patient that is unconscious is using behavioural and physiological indicators, this involves looking for behavioural changes such as facial grimacing, ventilator dyssynchrony and limb flextion, along with physiological changes associated with pain, such as hypertension, tachycardia, tachypnoea and lacrimation. Critically ill patients may suffer excessive pain from their life-threatening illnesses, injuries, or nursing care and/or procedures. Often are unable to effectively communicate to their caregivers, making difficult to assess and manage their pain effectively. One must assume that all critically ill patients are in pain or are at high risk for pain. (Mallett et al, 2013)My proposition is to use scales that we can use behavioural and physiological indicators, because these patients are unable to self-report, the use of scales like numeric scale, is inappropriate. I’m going to talk about the two more common ones used already on some hospitals in Europe, Australia and United States. Marmo and D’Arcy (2013) states that CPOT (Critical Care Pain Observation Tool) measures a patient’s pain level by looking at four behavioural dimensions, facial expression, body movements, muscle tension, and ventilator compliance or vocalization for patients who were never intubated but who are nonverbal. The tool also includes a picture of facial expressions and directions for use of the tool. The French and English version of the CPOT were tested with cardiac surgery and ICU adults with various diagnoses (trauma, postoperative and medical cases). It demonstrated moderate to high interrater reliability. Bases upon the results, the CPOT seems to be beneficial tool for critically ill nonverbal patients. Gelinas et al (2006) conduct a study to validate CPOT, it demonstrates that no matter the patient level of consciousness, critical ill adults patients react to a noxious stimulus by expressing different behaviours that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for management of pain. In the absence of a patient’s self-report, observable behavioural and physiological indicators become important indices for the assessment of pain. On Australian Critical Care Journal (2018), a study was published that presented the results when CPOT was implemented on 441 adult ICU patients unit, the results were an increase of pain assessments, particularly for non-communicative patients, appropriate observational assessments were also more frequently used for these patients, analgesia administration increased as well. (Phillips et al, 2018) Another study conduct by Mascarenhas et al (2017) came to the same result, that using the CPOT improved the pain assessments of patients unable to self-report, nursing staff stated that the CPOT increased accountability and aided decision-making of administration of opioid-based relief. The authors also said that the learning gained with this experiment may be relevant to other critical care areas. Another tool that can be use for patients will low GCS is BPS (Behavioural Pain Scale), was developed by Payen et al (2001), is used in patients who are sedated and mechanically ventilated and is based on three dimensions, facial expression, movements of upper limbs and compliance with mechanical ventilation. The nurse selects the descriptor in each dimension that best describes the behaviour displayed by the patient. Mr. X was not intubated but I think is relevant to present this tool as well, because when working Resuscitation area we come across with intubated patients, but also like I will explain later, both tools can complete each other. Aissaoui et al (2005) assessed the accuracy of BPS, on the study this tools demonstrated has a good psychometric properties when used with critically ill patients. Validity of the BPS was proven by a significant increase in BPS scores during painful procedures and exhibited an excellent responsiveness, suggesting that this is a powerful tool to detect the impact of painful stimulation in ICU patients. This analysis has shown that behavioural indicators can be valid and reliable measure of pain. In addition BPS has a good feasibility, the average time of assessment was only four minutes. The short time required will make this tool useful in critical care settings, not only ICU.Recent study shows the accuracy of using both scales for pain evaluation in critical care settings, CPOT and BPS, the aim of the study was to identify the best combination of scales for evaluation of pain in patients unable to communicate. The results showed a good criterion and discriminant validity, BPS was found to be more specific, 91.7% that CPOT, 70,8%, but less sensitive (BPS 62.7%, CPOT 76.5%). The combination of BPS and CPOT resulted in better sensitivity 80.4%. Facial expression was the main parameter to determine pain scales changes. In critically ill, mechanically ventilated patients, both tools can be used for assessment of pain intensity, the combination of both BPS and CPOT might result in improved accuracy to detect pain compared to scales alone. (Severgnini et al, 2016) I going to present on appendix II and III both tools. In conclusion, the case of Mr. X, the use of this tools would had a impact on his care, this assessments tools can improve the care that Emergency Departments give to their critical ill patients and there’s enough date already that sustain this premise. Sometimes this patients like Mr. X wait long periods of time to have a bed in ICU departments, and staff from Resuscitation areas should be trained to use this tools to assess the pain for their patients unable to communicate or self-report. I felt a lot of frustration when Mr. X was during my care, because I felt the Medical staff ignore the signs and discarded completely the pain factor.