Pain

I will attach my PICO assignment and the rubric and the articled I used. They have to be used in this paper.Assignment InstructionsIn this assignment, students will be asked to create the initial steps of an evidence based practice project using your topic and the article you found in Finding a Quantitative Nursing Research Article II (so long as it was approved).  You will also need your PICO(T) question that was approved in the Topic and PICO(T) Question assignment. The student will locate several additional resources to answer their PICO question, and write this information into a paper using APA style. Please click on the link below for more information, and watch your due dates and times carefully. For additional help, use the Module 4 discussion board. There is a six page limit to this paper, but that does not include the cover page or references. Finding the Evidence Paper Instructions v2-1.docxActionsBe very careful not to plagiarize in this assignment. Remember, if you use a source and do not cite it, that is plagiarism. If you have a direct quote from any source and it is not clearly indicated as a quote in your paper, then even if you cite it that is plagiarism. IF SEVEN OR MORE WORDS ARE THE SAME AS ANY SOURCE THAT IS A QUOTE AND MUST BE MARKED AS SUCH. If you only change one or two words from the source but keep the order of the ideas the same as in the original, that is plagiarism. Go back to the plagiarism tutorial or ask a librarian if you have any questions. Any instances of plagiarism detected will result in your failing the course and being referred to the Office of Community Standards.Submit your EBP Project – Finding the Evidence assignment and your nursing quantitative research article to the link above. LATE PAPERS ARE NOT ACCEPTED AFTER THE SUBMISSION LINK CLOSES ON MONDAY OF WEEK #5 AT 2359.IF YOU DO NOT SUBMIT A PAPER, YOU CANNOT RECEIVE CREDIT FOR THE SHARING THE EVIDENCE ASSIGNMENT IN MODULE FIVE.RubricEvidence Based Practice Project:Finding the EvidenceEvidence Based Practice Project:Finding the EvidenceCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeInitial PICO question completed / nursing research article selected.5 to >3.0 ptsAccomplishedResearch article is a quantitative article, nursing focused, and is 5 years or less from current publication date. Article must be uploaded as a pdf file. Please note: if you forget to upload your nursing quantitative research article, a 5 point penalty will be applied to your paper3 to >2.0 ptsProficientResearch article is a quantitative article that is nursing focused but is greater than 5 years old.2 to >0 ptsNeeds ImprovementResearch article is not nursing focused or is a qualitative article, systematic review, meta-synthesis, meta-analysis, meta-summary, integrative review, clinical information article or “how-to” article. No article uploaded.5 ptsThis criterion is linked to a Learning OutcomeOpening Paragraph(Paragraph #1)10 to >8.0 ptsAccomplishedIntroduction statement(s) present. PICO question with all elements present. Statement of importance with two facts such as costs, morbidity, mortality, safety. Include related statistics with citation and is 5 years or less from current publication date.8 to >3.0 ptsProficientNo introduction statement(s). PICO statement is incomplete. Statement of importance incomplete or missing. Citation is incomplete or missing.3 to >0 ptsNeeds ImprovementNo introduction statement(s). PICO statement grossly incomplete or missing. Statement of importance missing. No citation10 ptsThis criterion is linked to a Learning OutcomeGeneral Format5 to >4.0 ptsCompletely metPaper is six pages or less. Paper includes the following headings: Summary of Research Article, Major Variables, Strengths and Weaknesses, Practice Guideline, Fourth Resource, Conclusion 5 points4 to >0.0 ptsPartially metPaper more than six pages, headings missing, or incorrect headings. 4 – 1 points0 ptsNot metPaper greater than six pages and headings missing or incorrect.5 ptsThis criterion is linked to a Learning OutcomeSummary paragraph for your nursing quantitative research article. (Paragraph #2)15 to >14.0 ptsAccomplishedCorrectly identified design, sampling method, and setting of study. Identified major findings of study. Major findings include information from the Results and / or Discussion sections. Major findings clearly tied to PICO question. Facts connected to your nursing practice.14 to >3.0 ptsProficientDesign, sampling method, or setting incorrect. Identified findings are not the most important findings. Only one finding includes results or discussion sections. Major findings not clearly tied to PICO question. Facts not clearly connected to your nursing practice.3 to >0 ptsNeeds ImprovementDesign, sampling method, and setting not identified. No major findings clearly identified from the article. No findings from the results or discussion sections No attempt to connect the major findings from the article back to the PICO question. No attempt to connect the major findings from the article back to your nursing practice.15 ptsThis criterion is linked to a Learning OutcomeMajor research variables (Paragraph #3)10 to >9.0 ptsAccomplishedAll major research variables included. Conceptual definition for each variable mentioned or its absence noted. Operational definition for each variable mentioned. Correct level of measurement given for each variable.9 to >0.0 ptsProficientSome major variables missing or variables included that are not actually major research variables. Incorrect or missing conceptual or operational definitions. Incorrect or missing levels of measurement.0 ptsNeeds ImprovementParagraph missing.10 ptsThis criterion is linked to a Learning OutcomeTwo additional strengths or weaknesses from your nursing quantitative research article. (Paragraph #4)10 to >8.0 ptsAccomplishedTwo strengths or two weaknesses or one strength and one weakness are specifically identified from your nursing quantitative research article. The student choices for strengths / weaknesses must focus on the methods used by the authors for sampling, measurement methods used (ex. a questionnaire), or how the data was collected (data collection) with examples from the student’s research article.8 to >3.0 ptsProficientOnly one strength / or weakness explained well with second strength / weakness only identified. Strengths / weaknesses not based on sample, measurement methods, or data collection.3 to >0 ptsNeeds ImprovementStrength / weaknesses identified are not based on these three critique skills. No strengths / weaknesses identified.10 ptsThis criterion is linked to a Learning OutcomeClinical practice guideline summary.(Paragraph #5)10 to >8.0 ptsAccomplishedName and specific website of the clinical practice guideline and specific website identified. Guideline is the most recent version or published within the past five years. Three facts clearly identified that were found within the guideline and relate to the practice of a BSN. Facts clearly tied to PICO question. Facts connected to your nursing practice.8 to >3.0 ptsProficientName of the clinical practice guideline or website not clearly identified. Fewer than three facts clearly identified that were found within the guideline or facts not specifically related to the practice of the nurse. Facts vaguely tied to PICO question. Facts vaguely connected to your nursing practice.3 to >0 ptsNeeds ImprovementName of the clinical practice guideline and website not stated. What is given is not a clinical practice guideline. No clearly identified facts from the guideline. Facts not tied to PICO question or nursing practice.10 ptsThis criterion is linked to a Learning Outcome“Fourth resource” summary.(Paragraph #6)10 to >8.0 ptsAccomplishedThree facts clearly identified from the fourth resource which is 5 years or less from current publication date. Facts clearly tied to PICO question. Facts connected to your nursing practice.8 to >3.0 ptsProficientLess than three facts clearly identified from the fourth resource. Facts not clearly tied to PICO question. Facts not clearly connected your nursing practice.3 to >0 ptsNeeds ImprovementNo facts clearly identified from the fourth resource. Fourth resource is not an academic source. No attempt to connect facts from the fourth resource back to the PICO question. No attempt to connect facts from the fourth resource back to your nursing practice.10 ptsThis criterion is linked to a Learning OutcomeClosing Paragraph(s)(Paragraph #7, and #8 if needed)10 to >8.0 ptsAccomplishedPICO question is restated. A summary of what was learned (from all sources) is present. Sources are cited. Recommendations for practice are offered.8 to >3.0 ptsProficientMissing one or more of the following elements: PICO question. A summary of what was learned. Recommendations for practice.3 to >0 ptsNeeds ImprovementNo PICO question. Poor or no attempt to summarize information from the resources. No / vague recommendations for practice are offered.10 ptsThis criterion is linked to a Learning OutcomeAPA Style and Formatting15 to >0.0 ptsAccomplishedAPA formatting for this paper will follow the guidelines for general formatting, in text-citations, margins, headings (if desired) alignment and line spacing, font type and size, paragraph indentation, page headers, and the reference page as explained in the 7th edition of the APA Manual. Helpful Hints: • Do not use 1st person in a formal paper. • Do not use direct quotes, instead summarize and paraphrase what you are reading. Multiple quotes (more than two) will receive multiple point deductions. These deductions are separate from the 15 points for APA. In other words, there is no limit to the number of points that can be deducted for excess direct quotes. • Please do not forget to use the approved CONHI cover page. • Check your references format before submitting your paper. A ten-point deduction will be applied to your paper if the References page is omitted. The first time an APA error is discovered, it will be pointed out to you and a point will be deducted from your paper. Maximum number of points deducted for APA errors: 15 points0 ptsNeeds ImprovementAPA formatting for this paper will follow the guidelines for general formatting, in text-citations, margins, headings (if desired) alignment and line spacing, font type and size, paragraph indentation, page headers, and the reference page as explained in the 7th edition of the APA Manual. Helpful Hints: • Do not use 1st person in a formal paper. • Do not use direct quotes, instead summarize and paraphrase what you are reading. Multiple quotes (more than two) will receive multiple point deductions. These deductions are separate from the 15 points for APA. In other words, there is no limit to the number of points that can be deducted for excess direct quotes. • Please do not forget to use the approved CONHI cover page. The first time an APA error is discovered, it will be pointed out to you and a point will be deducted from your paper. Maximum number of points deducted for APA errors: 15 points0 ptsProficientAPA formatting for this paper will follow the guidelines for general formatting, in text-citations, margins, headings (if desired) alignment and line spacing, font type and size, paragraph indentation, page headers, and the reference page as explained in the 7th edition of the APA Manual. Helpful Hints: • Do not use 1st person in a formal paper. • Do not use direct quotes, instead summarize and paraphrase what you are reading. Multiple quotes (more than two) will receive multiple point deductions. These deductions are separate from the 15 points for APA. In other words, there is no limit to the number of points that can be deducted for excess direct quotes. • Please do not forget to use the approved CONHI cover page. The first time an APA error is discovered, it will be pointed out to you and a point will be deducted from your paper. Maximum number of points deducted for APA errors: 15 points15 ptsThis criterion is linked to a Learning OutcomeExcessive Direct Quotes0 ptsMore Than Two Direct QuotesFive points will be deducted for each direct quote in excess of two.0 ptsNo More Than Two Direct Quotes0 ptsTotal Points: 100Module 4 Evidence Based Practice: Finding the EvidenceSubmit by the due date and time listed in your syllabus.OverviewThis assignment will allow you to create an evidence-based practice project that includes the development of a PICO question and follows the initial steps of the Iowa Model.  You will share your findings using an APA formatted paper.Submitting your assignment Save this document to your desktop as a Word document. Open the document from your desktop and review the assignment instructions and grading rubric. Create a separate Word document for your paper. Return to the course and upload your paper and your approved nursing research article  to the assignment submission link.  Please note: if you forget to upload your nursing quantitative research article, a 5 point penalty will be applied to your paper.Grading Rubric Use this rubric to guide your work the assignment.  Points are awarded for each section based on content and clarity of expression.ParagraphAccomplished (Maximum points awarded)Proficient(Points awarded based on content)Needs Improvement(Minimum points awarded)Initial PICO question completed / nursing research article selected. Research article is a quantitative article, nursing focused, and is 5 years or less from current publication date.Article must be uploaded in pdf formatPlease note: if you forget to upload your nursing quantitative research article, a 5 point penalty will be applied to your paper5 to > 3 pointsResearch article is a quantitative article that is nursing focused but is greater than 5 years old.3 – >2 pointsResearch article is not nursing focused or is a qualitative article, systematic review, meta-synthesis, meta-analysis, meta-summary, integrative review, clinical information article or “how-to” article.No article uploaded.2 to >0 pointsOpening Paragraph(Paragraph #1)Introduction statement(s) present.PICO question with all elements present.  Statement of importance with two facts such as costs, morbidity, mortality, safety. Include related statistics with citation and is 5 years or less from current publication date.Facts must be from a source besides the primary research article, the guideline, or the fourth resource        10 – >8 pointsNo introduction statement(s).PICO statement is incomplete.  Statement of importance incomplete or missing.Citation is incomplete or missing.Facts are from the primary article, the guideline, or the fourth resource.9 – >3 pointsNo introduction statement(s).  PICO statement grossly incomplete or missing. Statement of importance missing.No citation3 – >0 pointsGeneral format.Paper is six pages or less. Paper includes the following headings: Summary of Research Article, Major Variables, Strengths and Weaknesses, Practice Guideline, Fourth Resource, Conclusion5 pointsPaper more than six pages, headings missing, or incorrect headings.4 – 1 pointsPaper greater than six pages and headings missing or incorrect.0 pointsSummary paragraph for your nursing quantitative research article.  (Paragraph #2)Correctly identified design, sampling method, and setting of study.Identified major findings of study.Major findings include information from the Results and / or Discussion sections.Major findings clearly tied to PICO question.Facts connected to your nursing practice.                     15  pointsDesign, sampling method, or setting incorrect.Identified findings are not the most important findings.Only one finding includes results or discussion sections.Major findings not clearly tied to PICO question.Facts not clearly connected to your nursing practice.         14 – >3 pointsDesign, sampling method, and setting not identified.No major findings clearly identified from the article.No findings from the results or discussion sectionsNo attempt to connect the major findings from the article back to the PICO question. No attempt to connect the major findings from the article back to your nursing practice.         3 – >0 pointsMajor research variables.(Paragraph #3)All major research variables included. Conceptual definition for each variable mentioned or its absence noted. Operational definition for each variable mentioned. Correct level of measurement given for each variable.10 pointsSome major variables missing or variables included that are not actually major research variables. Incorrect or missing conceptual or operational definitions. Incorrect or missing levels of measurement.9 – >1 pointsParagraph missing.0 pointsTwo additional strengths or weaknesses from your nursing quantitative research article. (Paragraph #4)Two strengths or two weaknesses or one strength and one weakness are specifically identified from your nursing quantitative research article.The student choices for strengths / weaknesses must focus on the methods used by the authors for sampling, measurement methods used (ex. a questionnaire), or how the data was collected (data collection) with examples from the student’s research article. 10 – >8 pointsOnly one strength / or weakness explained well with second strength / weakness only identified.Strengths / weaknesses not based on sample, measurement methods, or data collection. 8 – >3 pointsStrength / weaknesses identified are not based on these three critique skills. No strengths / weaknesses identified.            3 – >0 pointsClinical practice guideline summary.(Paragraph #5)Name of the clinical practice guideline and specific website identified.  Guideline is the most recent version or published within the past five years.Three facts clearly identified that were found within the guideline and relate to the practice of a BSN.Facts clearly tied to PICO question.Facts connected to your nursing practice.       10 – >8 pointsName of the clinical practice guideline or website not clearly identified. Fewer than three facts clearly identified that were found within the guideline or facts not specifically related to the practice of the nurse. Facts vaguely tied to PICO question. Facts vaguely connected to your nursing practice.           8 – >3 pointsName of the clinical practice guideline and website not stated. What is given is not a clinical practice guideline. No clearly identified facts from the guideline. Facts not tied to PICO question or nursing practice.          3 – >0 points“Fourth resource” summary.(Paragraph #6)Three facts clearly identified from the fourth resource which is 5 years or less from current publication date.Facts clearly tied to PICO question.Facts connected to your nursing practice.        10 – >8 pointsLess than three facts clearly identified from the fourth resource.Facts not clearly tied to PICO question.Facts not clearly connected your nursing practice.           8 – >3 pointsNo facts clearly identified from the fourth resource. Fourth resource is not an academic source. No attempt to connect facts from the fourth resource back to the PICO question. No attempt to connect facts from the fourth resource back to your nursing practice.3 – >0 pointsClosing Paragraph(s)(Paragraph #7 and #8, if needed)PICO question is restated.A summary of what was learned (from all sources) is present. Recommendations for practice are offered.           10 – >8 pointsMissing one or more of the following elements:PICO question.A summary of what was learned. Recommendations for practice.8 – >3 pointsNo PICO question.Poor or no attempt to summarize information from the resources.No / vague recommendations for practice are offered.3 – >0 pointsAPA Style and FormattingAPA formatting for this paper will follow the guidelines for general formatting, in text-citations, margins, headings (if desired) alignment and line spacing, font type and size, paragraph indentation, page headers, and the reference page as explained in the 7h edition of the APA Manual. Helpful Hints: Do not use 1st person in a formal paper. Do not use direct quotes, instead summarize and paraphrase what you are reading. Multiple quotes (more than two) will receive multiple point deductions. These deductions are separate from the 15 points for APA. In other words, there is no limit to the number of points that can be deducted for excess direct quotes.Please do not forget to use the approved CONHI cover page.Check your references format before submitting your paper. A ten-point deduction will be applied to your paper if the References page is omitted.The first time an APA error is discovered, it will be pointed out to you and a point will be deducted from your paper.  Maximum number of points deducted for APA errors:  15 pointsExcessive Direct QuotesNote! Five points will be deducted for each direct quote exceeding two in the paper. If the quotes exceed 10, then fifty points will be deducted. Instructions for Completing Your AssignmentStep one:  Using the topic you chose, identify a nursing clinical practice question that you would like to explore.   Step two: Use the PICO(T) question in the final form approved by your instructor or coach. Step three:  Search for a nursing quantitative research article (or two) that relates to your PICO question using Academic Search Complete, CINHAL, Pubmed, Google Scholar, or any other database that contains nursing research articles.  Please note: you can use the article that you submitted in Module Two to meet this requirement so long as it was approved.The article you will find must meet the following mandatory requirements:It must be based on the approved topic list unless other arrangements were made with your instructor or coach.It must be from a nursing research journal or have a nurse as an author.It must be no more than 5 years old from the current publication year.It must include implications and / or interventions that are applicable to nursing practice. It may not be a qualitative article, systematic review, meta-synthesis, meta-analysis, meta-summary, integrative review or a retrospective / quality improvement study. For more information on how to recognize these types of article see Grove & Gray (2019) pp. 21-23.It may not be a clinical information article or “how-to” article.Step Four: Collecting More Evidence (Do the research)Find a credible scholarly or government resource published within the past 5 years that provides you with at least two facts (ex. costs, morbidity, mortality, safety, or other related statistics) for why your clinical problem is important (provide statistics).  (The internet is a great place to get this information…just don’t forget to cite this information and add it to your reference page).Find a clinical practice guideline that relates to your question.  It must have information that relates to the role of the nurse.  Guideline is the most recent version or published within the past five years. (It is true that guidelines are not always updated within 5 years so you will need to discuss this.) There are several websites listed in your textbook that can help with searching for guidelines. The UTA library also has resources for clinical practice guidelines.Find a clinical “how-to” article, a nursing professional practice website, a systematic literature review, a meta-analysis, or some other credible academic resource published within the past 5 years that relates to your practice question. Hint: Did you notice that you will be finding a total of four different sources of information for your PICO question?  To re-cap, these four sources are:Statistics you are reporting in paragraph one.Nursing quantitative research article for paragraphs 2, 3, and 4Clinical Practice Guideline (paragraph 5)A source of your choosing (paragraph 6)Step Five: Write up your findings in APA format and submit them to assignment portal by the due date and time listed in your syllabus.  Here’s how to write up your findings:Start with a 7th edition APA cover page. An example is provided by the instructor.Paragraph #1: This is your opening paragraph. Start with an introduction statement. What is your PICO question? Describe why was it important (share the dollars, morbidity / mortality, statistics, safety stats you found with citation)?Paragraph #2:  What did your nursing quantitative research article add to your knowledge on this topic?  State the design (descriptive, correlational, predictive correlational, experimental, or quasi-experimental), sampling method, and setting of the study (this should only take one sentence: e.g. “Smith and Johnson conducted a predictive correlational study using a convenience sample from a psychiatric outpatient clinic.”). State the major findings of the study (maximum 3 findings). The findings you share should come from the results or discussion settings and should be relevant to your PICO question and your practice as a nurse. Paragraph #3. Mention the major research variables in your article. Do not include demographic variables unless they are important to the results of the study. For each major variable, give a conceptual and operational definition (if the authors did not give a conceptual definition you can say “not given”). Give the level of measurement for each variable (nominal, ordinal, interval, or ratio).Paragraph #4: Using the skills you have learned in your critique of a research article, describe two strengths or two weaknesses (or one strength and one weakness) that you found as you read this article.  Go back to what you learned in your article critique about sampling methods, measurement methods (ex. questionnaires), and data collection (how did they collect the data to make sure you are being thorough in your assessment. Be specific, so that your instructor, if reading the article, can find them too.  Do not re-state the limitations provided by the authors of your study unless they have to do with the study’s sampling, measurement methods, or data collection.  Do not discuss the research design or the descriptive or inferential statistics used by the authors as a strength or weakness of the study, as this is not related to with the study’s sampling, measurement methods, or data collection.Paragraph #5:  What is the name and website of the clinical practice guideline that you found?  Share at least three facts that you found within the guideline that is relevant to the PICO question and your practice as a BSN nurse and cite the guideline appropriately.Paragraph #6: Identify the fourth resource you found (clinical “how-to” article, a nursing professional practice website, a systematic literature review, or a meta-analysis) that relates to your practice question.  Share at least three facts that you found within this source that is relevant to the PICO question and your practice as a nurse, and cite appropriately. Paragraph #7 (and #8 if needed): re-state your PICO question and briefly summarize what you have learned through your search.  What would you recommend, if anything, as a change in practice for nurses?  Why?  Remember, this is your closing paragraph(s).Note to students about writing up your findings: This is a formal APA paper.  Look at the Rubric for more APA information for this paper.Your paper must be six pages (double spaced) or less. Use the following headings for paragraphs 2 through 7: Summary of Research Article, Major Variables, Strengths and Weaknesses, Practice Guideline, Fourth Resource, ConclusionTurn your paper (as a word document) and article (in pdf format) that you used for paragraphs 2, 3, and 4 in to the assignment submission link in Module Four at the due date and time listed in your syllabus.Possible points for this assignment: 100 pointsManaging Pain in  Critically Ill Adults: A Holistic ApproachA review of best practices from the current clinical guidelines. ABSTRACT:Nurses caring for critically ill adults are challenged to balance patient comfort with the risk of  complications associated with analgesic therapy. Evidence gathered since 2013, when the Society of Crit ical Care Medicine (SCCM) published the Clinical Practice Guidelines for the Management of Pain, Agita tion, and Delirium in Adult Patients in the Intensive Care Unit, known as the PAD guidelines, gave rise to  the SCCM 2018 publication of the Clinical Practice Guidelines for the Prevention and Management of Pain,  Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, known as the  PADIS guidelines. This article discusses how the PADIS guidelines go beyond the PAD guidelines, providing  specific guidance related to risk factors for pain, the assessment and management of pain in critical illness,  and the ways in which the experience of pain in critical illness is intertwined with that of agitation, delir ium, immobility, and sleep disruption. Tables summarize the key points in the PADIS guidelines, clarify the  distinctions between PADIS and PAD, and describe the implications for nurses.  Keywords: assessment, critical care nursing, pain, pain management Critically ill adults experience fluctuating lev els of pain intensity as a result of individual  characteristics, procedural interventions,  and underlying disease processes. By repeatedly  assessing patients for pain, anticipating sources  of discomfort, and adjusting pain management  strategies, nurses can address patient needs while  minimizing the risk of complications. In 2018, the Society of Critical Care Medicine  (SCCM) released Clinical Practice Guidelines for  the Prevention and Management of Pain, Agita tion/Sedation, Delirium, Immobility, and Sleep Dis ruption in Adult Patients in the ICU.1 Known as  the PADIS guidelines, this document was based on  evidence gathered since the 2013 SCCM publica tion of the Clinical Practice Guidelines for the  Management of Pain, Agitation, and Delirium in  Adult Patients in the Intensive Care Unit, known  as the PAD guidelines.2 Both guidelines are based  on extensive research and the consensus of expert  opinion. The most significant difference between  the two is that the 2018 guidelines added recom mendations addressing immobility and sleep dis ruption, acknowledging that these aspects of criti cal illness affect and are affected by the experience  of pain, the use of sedation, and the incidence of  delirium. A 2017 quality improvement study conducted by  Barnes-Daly and colleagues demonstrated that  compliance with the ABCDEF bundle of interven tions, which addresses critical illness holistically, is  associated with improved patient outcomes, includ ing hospital survival.3 Since the publication of that  study, the ABCDEF bundle was updated to incor porate the following key components, which are  reflected in the PADIS guidelines4: 34 AJN ▼ May 2020 ▼ Vol. 120, No. 5 ajnonline.com •  Assess, prevent, and manage pain •  Both spontaneous awakening trials and sponta neous breathing trials  •  Choice of analgesia and sedation •  Delirium: assess, prevent, and manage •  Early mobility and exercise •  Family engagement and empowerment This article focuses on PADIS recommendations  related to pain management in critically ill adults,  though the guidelines emphasize that the five phe nomena they address (pain, agitation/sedation,  delirium, immobility, and sleep disruption) are  interconnected.1 FROM PAD TO PADIS: WHAT’S NEW? While the PADIS guidelines do not change the rec ommendations made in the PAD guidelines, they  expand them, offering more specific guidance and  additional recommendations on managing proce dural pain and providing adjunctive pain manage ment, as well as ungraded statements related to  pain risk factors and assessment in critical illness  (see Table 11, 2).1 The guideline panel, which  included 32 international content experts, four  research methodologists, and four critical illness  survivors, followed the Grading of Recommenda tions Assessment, Development, and Evaluation  By Sarah A. Delgado, MSN, RN, ACNP-BC .htlaeH derflA © otohP(GRADE) system for clinical practice guideline  development.1 RISK FACTORS FOR PAIN IN CRITICAL ILLNESS The PADIS panel identified recent research demon strating that both pain at rest and procedural pain  in critically ill patients are influenced by patient specific psychological, demographic, and historical  factors, such as depression and anxiety; age, sex,  and ethnicity; comorbid conditions; and surgical  history. The intensity of procedural pain is further  affected by preprocedural pain intensity and the  type of procedure.1 The most painful procedures. A multinational  study of 3,851 critically ill adults undergoing one  or more of 12 diagnostic or therapeutic procedures  found that patients usually experienced mild pre procedural pain, which increased significantly dur ing procedures, more than doubling during three  such procedures: chest tube removal, wound drain  removal, and arterial line insertion.5 Positioning,  wound care, and mobilization were also signifi cantly associated with changes in pain intensity in  this study.  Such findings provide strong evidence supporting  preprocedural analgesia in critical illness. While the  PAD guidelines had suggested treating pain before  ajn@wolterskluwer.com AJN ▼ May 2020 ▼ Vol. 120, No. 5 35 Table 1. Comparing the PADIS and PAD Guidelines: Pain Risk Factors and Assessment in Critically Ill Adults1, 2 PADIS Key Points Quality of  Evidence Changes from PAD Application to  Nursing Practice Pain at rest is affected by both  psychological factors, such as  anxiety or depression, and  demographic factors, such as  age, comorbidities, and surgi cal history. Procedural pain is affected by  the nature of the procedure  itself; preprocedural pain inten sity; previous surgery or trauma;  underlying diagnoses; and  demographic factors, such as  age, sex, and ethnicity. The “reference standard” for  assessing pain in patients who  face no communication barriers  is self-report.  Both the 0–10 NRS-O and the  0–10 NRS-V are valid and feasi ble for assessing pain in critically  ill adults who can self-report  pain.  For monitoring pain in patients  who are unable to self-report  pain, the most valid and reliable  pain assessment tools are the  BPS in intubated patients, the  BPS-NI in nonintubated  patients, and the CPOT. When patients are unable to  self-report, clinicians can involve  family members in the pain  assessment process. Vital signs are not valid indica tors of pain in critically ill adults,  though changes in vital signs  can prompt pain assessment  with an appropriate, validated  pain assessment tool.Ungraded  statement  Ungraded  statement Ungraded  statement Ungraded  statement Ungraded  statement Ungraded  statement Ungraded  statementThis statement expands on the  PAD statement that critically ill  adults regularly experience  pain both at rest and with rou tine care.  This statement expands on the  PAD statement that procedural  pain is common among criti cally ill adults by more specifi cally describing influencing  factors. This statement echoes a  discussion in the PAD guide lines, which refers to self report as the “gold standard”  for pain assessment and sug gests clinicians ask patients  to rate their own pain, if  possible.  The PAD guidelines cited study  findings supporting the valid ity and feasibility of a 0–10  numeric rating scale, though it  did not suggest any specific  scale. The PAD guidelines advised  that both the BPS and CPOT  were valid and reliable tools in  patients who are unable to  self-report but did not include  the BPS-NI.  Family involvement in pain  assessment was not discussed  in the PAD guidelines. This statement is similar to but  stronger than a suggestion in  the PAD guidelines to not use  vital signs or pain scales that  include vital signs to assess  pain in critically ill adults,  though vital signs may prompt  further pain assessment.Assess patients for pain risk  factors and schedule rou tine assessments for pain at  rest. Assess patients for pain  before and during proce dures, providing preemp tive treatment before pro cedures if indicated. Assess pain in responsive  patients by asking them to  self-report its severity.  In patients who can self report, assess pain using  either the NRS-O in those  who can respond orally or  the NRS-V in those who  cannot respond orally.  In patients who cannot  self-report, assess pain  intensity using the BPS,  BPS-NI, or CPOT, and  document findings.  When patients are unable  to self-report pain, involv ing their family members in  pain assessment may be  helpful. When a change in hemo dynamic status is believed  to be related to a change  in pain intensity, ask the  patient to report pain  severity or use the BPS  or CPOT if the patient is  unable to self-report. BPS = Behavioral Pain Scale; BPS-NI = Behavioral Pain Scale in Nonintubated Patients; CPOT = Critical-Care Pain Observation Tool; NRS-O = Numeric  Rating Scale Oral; NRS-V = Numeric Rating Scale Visual; PAD = Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium  in Adult Patients in the Intensive Care Unit; PADIS = Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation,  Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.36 AJN ▼ May 2020 ▼ Vol. 120, No. 5 ajnonline.com procedures, they acknowledged that the benefits  were unclear.2 By contrast, the PADIS guidelines  specifically recommend the assessment and appro priate treatment of pain in advance of procedures to  prevent pain escalation during procedures.1 ASSESSING CRITICALLY ILL ADULTS FOR PAIN  Critically ill adults are often unable to interact ver bally because of a reduced level of consciousness or  dependence on mechanical ventilation. Nurses may  assess pain intensity in these patients using such  standardized tools as the Critical-Care Pain Obser vation Tool (CPOT)6 or the Behavioral Pain Scale  (BPS),7 which are both valid and reliable tools for  measuring pain in nonverbal critically ill adults.1 Both tools score specific observations about the  patients’ appearance and behavior in order to  determine their pain intensity. Patients who are  able to respond can report pain using the Numeric  Rating Scale Oral (scored from 0 to 10) or the  Numeric Rating Scale Visual (NRS-V; also scored  from 0 to 10). The PADIS guideline panel con cluded that the NRS-V is the best self-report pain  scale to use in critically ill adults. The PADIS guide lines also note that family members of nonverbal  patients may be helpful in providing input on the  patient’s level of comfort.1 with far fewer risks are equally effective in the  outpatient management of chronic pain.9 Despite  widespread concerns about opioid use, the PADIS  guidelines do not replace or change the PAD recom mendation regarding opioid use during critical ill ness. They do, however, describe the advantages of  minimizing the dosage and duration of opioid treat ment, particularly in postoperative patients, through  the application of multimodal pain management  strategies.1 As noted in the PAD guidelines, all iv opioids have similar efficacy when titrated appro priately, so no one opioid is generally preferred.2 Certain clinical factors, however, may influence the  choice. For example, in patients with renal impair ment, critical care teams may administer fentanyl  rather than morphine because the active metabolites  of morphine are cleared through the kidneys.10 Adverse effects of opioids and of pain. All anal gesics are associated with adverse effects. In opioid  analgesics, these include oversedation, respiratory  depression, bronchospasm, cough suppression, hypo tension, nausea, constipation, urinary retention, and  tolerance. However, uncontrolled acute pain also has  negative consequences. In addition to its well-known  association with agitation, immobility, and sleep dis ruption, uncontrolled acute pain in critical illness  may transition to chronic pain after recovery.11  The PADIS guideline panel concluded that  the NRS-V is the best self-report pain scale  to use in critically ill adults.The PADIS guidelines recommend against basing  pain assessment on vital signs alone.1 To date, no  studies have found a consistent relationship between  vital signs and pain presence or intensity. Vital sign  changes should be used only to prompt further pain  assessment using validated pain assessment tools.8 In  critically ill patients, factors such as comorbid condi tions, acute hemodynamic instability, and vasoactive  medications are likely to affect vital signs. USE OF OPIOIDS IN CRITICAL ILLNESS The PAD guidelines recommended the use of opi oids as first-line therapy for nonneuropathic pain in  critically ill adults.2 Since 2013, concern about opi oid use has increased dramatically, and current evi dence suggests that other interventions associated  Past use of opioids. Appropriate opioid use  requires critical care nurses to gather information  about patients’ opioid history. Although low doses  of an opioid often provide adequate analgesia to  opioid-naive patients without causing overseda tion, any previous opioid use, whether appropri ate or not, can lead to opioid tolerance, causing  low doses to be ineffective.12 Since critically ill  adults often face communication barriers and are  subject to multiple sources of pain, such as surgi cal incisions, invasive devices, bedside procedures,  transfer, and turning, these patients require close  monitoring and repeated assessment with a valid,  standardized pain assessment tool so that multi modal analgesic strategies may be administered as  indicated.12 ajn@wolterskluwer.com AJN ▼ May 2020 ▼ Vol. 120, No. 5 37 Table 2. Comparing the PADIS and PAD Guidelines: Managing Procedural Pain in Critically Ill Adults1, 2 PADIS Key Points Quality of  Evidence Changes from PADApplication to  Nursing PracticeUse the lowest effective  opioid dose to manage  procedural pain. For pain during discrete  and infrequent proce dures, use an iv, oral,  or rectal NSAID as an  analgesic alternative  to opioids.  Do not use either local  analgesia or nitrous  oxide to manage  pain during chest  tube removal. Do not use inhaled vola tile anesthetics. Do not use an NSAID  topical gel. Offer relaxation tech niques. Offer cold therapy. Conditional rec ommendation,  moderate level  of evidence Conditional rec ommendation,  low quality of  evidence Conditional rec ommendation,  low quality of  evidence Strong recom mendation, very  low quality of  evidence Conditional rec ommendation,  low quality of  evidence Conditional rec ommendation,  very low quality  of evidence Conditional rec ommendation,  low quality of  evidenceThis recommendation expands  on the strong PAD recommenda tion to preemptively manage pain  when chest tube removal is  planned and the weak suggestion  to provide preemptive pharmaco logical or nonpharmacological  analgesic interventions for other  invasive or potentially painful  procedures. This recommendation expands  on the PAD guidelines in endors ing a specific class of analgesics  to be used as an opioid alterna tive for discrete and infrequent  procedures. This is a new recommendation  based on evidence gathered  after 2013.  This is a new recommendation  based on evidence gathered  after 2013.  This is a new recommendation  based on evidence gathered  after 2013.  The PAD guidelines recom mended relaxation as one exam ple of a nonpharmacological  intervention that can be adminis tered preemptively for procedural  pain. The PAD guidelines recom mended nonpharmacological  interventions for procedural pain  but not specifically cold therapy.When potentially painful  procedures are sched uled, anticipate an  increase in pain and  preemptively treat the  patient with the lowest  effective dose of an opi oid or an iv, oral, or rectal  NSAID. When potentially pain ful procedures are  scheduled, anticipate  an increase in pain and  preemptively treat the  patient with the lowest  effective dose of an opi oid or an iv, oral, or rectal  NSAID. If local analgesia or  nitrous oxide is ordered  for chest tube removal,  discuss alternative  options with the ordering  provider. If volatile anesthetics are  ordered for procedural  pain, discuss alternative  options with the ordering  provider. Wait for more evidence to  emerge before integrat ing topical gel NSAIDs  into the management of  procedural pain. Encourage patients who  are able to follow com mands to use deep  breathing or guided  imagery during proce dures and ask the patient  or family about relaxation  techniques the patient  has used in the past.  Provide ice or cold  compress when possible  to relieve procedural pain.NSAID = nonsteroidal antiinflammatory drug; PAD = Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult  Patients in the Intensive Care Unit; PADIS = Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium,  Immobility, and Sleep Disruption in Adult Patients in the ICU.38 AJN ▼ May 2020 ▼ Vol. 120, No. 5 ajnonline.com Managing procedural pain. For procedural pain,  the PADIS guidelines, and others, recommend admin istering the lowest effective bolus dose of an opioid.1,  13, 14 For discrete and infrequent procedures, the guide lines suggest using a nonsteroidal antiinflammatory  drug (NSAID) as an alternative to opioids—though  NSAIDs are not recommended for routine use as an  opioid adjunct for nonprocedural pain during critical  illness. The risks of acute kidney injury and gastroin testinal bleeding as a result of NSAID use outweigh  the potential benefits NSAIDs confer in terms of  improved pain control.1 The PADIS guidelines  strongly recommend against using inhaled volatile  anesthetics to treat procedural pain in critically ill  adults and conditionally recommend against using  local analgesia, nitrous oxide, or topical NSAID gels  for this purpose in this population (see Table 21, 2).1 THE USE OF ANALGOSEDATION  Analgosedation is a strategy that combines the  goals of pain management and appropriate sedation  through the use of agents such as opioids, which  can achieve both effects.15 The PADIS guidelines  point out that analgosedation can refer both to  analgesia-based sedation, in which analgesics, such  as opioids, are used to treat pain and to achieve  adequate sedation, and to analgesia-first sedation,  in which sedatives such as propofol or dexmedeto midine are given after analgesics if the desired level  of sedation is not achieved. As noted in the guide lines, the role of sedatives in an analgesic-first  approach warrants further study.1 significant pain. Similarly, sedative agents can be  titrated to scores on a standardized tool, measured  after pain treatment. The recommendation is based  on a review of five studies that correlated the use  of assessment-based protocols with less exposure  to sedative and analgesic medication, lower pain  intensity scores, shorter duration of mechanical  ventilation, and fewer adverse events.1 In labeling  this a conditional recommendation, the guideline  authors note the need for more evidence to identify  the following1: •  patient populations most likely to benefit from  protocol-based analgosedation •  optimal analgesics to incorporate in the proto cols •  potential patient benefits •  potential patient safety concerns ADJUNCTIVE ANALGESIA As an adjunct to opioid therapy, the PADIS guide lines recommend administering acetaminophen for  nonneuropathic pain, unless contraindicated, to  critically ill adults to improve pain control while  reducing opioid consumption.1 In addition, both the  PADIS guidelines and the Guidelines on the Man agement of Postoperative Pain, commissioned by  the American Pain Society (APS), cite evidence sup porting the adjunctive use of a low-dose ketamine  infusion to manage pain in critically ill postsurgical  patients, qualifying the recommendation as condi tional or weak because the evidence is considered of  low or moderate quality.1, 13 Applying multiple strategies that affect  pain perception in different ways is likely to be more  effective than using a single modality.The PADIS guidelines endorse the routine  assessment and treatment of pain before sedation  is considered. (Sedatives administered before anal gesics can reduce a patient’s level of consciousness,  compromising pain assessment and resulting in  poor pain control.15) The guidelines conditionally  recommend that the management of pain and  sedation in critically ill adults be based on assess ment-driven protocols.1 Such protocols would call  for pain assessment at regular intervals with a valid  tool, such as the BPS or CPOT, as well as specific  interventions to be employed when scores indicate  The PAD guidelines had listed acetaminophen, iv ketamine, and cyclooxygenase (COX) inhibitors as  potential adjuncts to opioid therapy for managing  nonneuropathic pain.2 The PADIS guidelines, by  contrast, recommend against the use of COX-1– selective NSAIDs in critically ill adults and suggest  that the role of the COX-2–selective NSAID cele coxib in this population is unclear.1 For neuropathic  pain, the PAD guidelines recommended enteral  administration of gabapentin and carbamazepine  as adjuncts to opioid analgesia; the PADIS guide lines retained that recommendation, but added  ajn@wolterskluwer.com AJN ▼ May 2020 ▼ Vol. 120, No. 5 39 Table 3. Comparing the PADIS and PAD Guidelines: Adjunctive Pain Management in Critically Ill Adults1, 2PADIS Key Points Quality of Evidence Changes from PAD Application to  Nursing PracticeAcetaminophen can  be used as an adjunct  to opioid therapy to  reduce pain intensity and  opioid consumption.  If feasible, nefopam can  be used as an adjunct to  or a replacement for an  opioid to reduce opioid  consumption. To reduce opioid con sumption in postsurgical  patients, use low-dose  ketamine (a bolus fol lowed by a continuous  infusion) as an adjunct  to opioid therapy. For neuropathic pain  management, use a neu ropathic pain medica tion, such as gabapentin,  carbamazepine, or pre gabalin, as an adjunct to  opioid therapy. Do not use iv lidocaine  routinely as an adjunct  to opioid therapy. Do not routinely use  COX-1–selective NSAIDs  as an adjunct to opioid  therapy in this popula tion; the role of the  COX-2–selective NSAID  celecoxib is unclear. Do not offer cybertherapy  (virtual reality technology)  or hypnosis as nonphar macological adjuncts to  opioid therapy. Conditional recom mendation, very low  quality of evidence Conditional recom mendation, very low  quality of evidence Conditional recom mendation, very low  quality of evidence Strong recommenda tion, moderate qual ity of evidence Conditional recom mendation, low  quality of evidence Conditional recom mendation, low qual ity of evidence Conditional recom mendation, very low  quality of evidenceThe PAD guidelines had  similarly suggested that  nonopioids, including acet aminophen, could be used  in conjunction with opioids  to manage nonneuropathic  pain.  The PAD guidelines did not  specifically suggest nefo pam as an adjunct to or  potential replacement for  opioid therapy. The PAD guidelines had  included ketamine among  the nonopioids that could  be used as an adjunct to  opioid therapy to manage  nonneuropathic pain,  though it wasn’t a formal  recommendation.  This recommendation adds  pregabalin to the list of  adjunctive therapies, includ ing gabapentin or carba mazepine, the PAD guidelines  recommended to manage  neuropathic pain.  This is a new recommenda tion based on evidence  gathered after 2013.  This is a new recommenda tion based on evidence  gathered after 2013. The  PAD guidelines had included  oral, iv, and rectal COX selective NSAIDs among the  nonopioids they suggested  could be used as adjuncts to  opioid therapy.  Although the PAD guide linesrecommended the  adjunctive use of nonphar macological strategies for  controlling pain, they did  notspecify any interventions  to avoid.Unless contraindicated  by the patient’s condition  or allergy profile, admin ister acetaminophen as  ordered, along with an  opioid for nonneuro pathic pain.  Unless contraindicated  by the patient’s condition  or allergy profile, admin ister nefopam, if avail able, as ordered, along  with or instead of an  opioid.  Administer a continuous  ketamine infusion along  with opioid therapy to  postoperative patients,  as ordered, titrating the  opioid dose downward  asthe patient’s comfort  allows.  Unless contraindicated  by the patient’s condition  or allergy profile, use spe cific agents as ordered in  patients with neuro pathic pain.  If lidocaine is ordered as  an adjunct to opioid ther apy, discuss evidence based alternatives with  the ordering provider.  If a COX-1–selective  NSAID is routinely  ordered as an adjunct to  opioid therapy, discuss  evidence-based alterna tives with the ordering  provider. Wait for further evidence  to emerge before imple menting cybertherapy or  hypnosis as pain man agement strategies. 40 AJN ▼ May 2020 ▼ Vol. 120, No. 5 ajnonline.com Table 3. Continued PADIS Key Points Quality of Evidence Changes from PAD Application to  Nursing PracticeOffer massage as an  adjunct to pharmacolog ical pain management. Offer music therapy  to relieve both  nonprocedural and  procedural pain. Pain management  should be guided by  routine pain assessment,  administering analgesics  before considering a  sedative. Use an assessment driven, protocol-based,  stepwise approach for  pain and sedation  management.Conditional  recommendation,  low quality of  evidence Conditional  recommendation,  low quality of  evidence Good practice  statement Conditional recom mendation, moderate  quality of evidence.This is a new recommenda tion based on evidence  gathered after 2013.  This is a new recommenda tion based on evidence  gathered after 2013. This is a new statement based  on new evidence.  This is a new recommenda tion based on evidence  gathered after 2013.Ask patients or family  members about their  preferences for massage  and offer this as an  adjunct to pharmacologi cal and other nonphar macological strategies.  Play music and encour age family members and  patients to select music  based on their prefer ences to promote pain  control at rest and during  procedures.  Assess pain and  administer analgesics  if needed before  administering sedatives.  Collaborate with providers  to develop pain manage ment protocols. Gather  data before and after pro tocol implementation.COX = cyclooxygenase; NSAID = nonsteroidal antiinflammatory drug; PAD = Clinical Practice Guidelines for the Management of Pain, Agitation, and  Delirium in Adult Patients in the Intensive Care Unit; PADIS = Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/ Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.  pregabalin to the list of appropriate adjuncts for  neuropathic pain management.1, 2 NONPHARMACOLOGICAL INTERVENTIONS  There is a growing body of evidence that supports  the use of nonpharmacological interventions as  an adjunct to pharmacological interventions in  managing pain in critically ill adults. The PAD  guidelines did not recommend the use of specific  nonpharmacological interventions but noted their  use in the management of procedural pain.2 Based  on a review of clinical trials testing the efficacy of  nonpharmacological interventions to reduce pain  in critically ill adults, the PADIS guidelines condi tionally recommend music therapy, massage, and  such relaxation techniques as breathing exercises,  though they point out that implementation across  the studies that have tested these interventions has  been inconsistent.1 The PADIS guideline panel also issued a condi tional recommendation against both hypnosis  and cybertherapy (an intervention that uses vir tual reality technology to manage pain) because  current evidence does not suggest that these ther apies are sufficiently effective to warrant the sig nificant investment required to implement them  (see Table 31, 2).1 MULTIMODAL PAIN MANAGEMENT The preferred strategy for addressing pain in criti cally ill adults and others is multimodal manage ment, which includes both opioid and adjunctive  nonopioid analgesic medications, as well as non pharmacological strategies.1, 13, 14 This approach is  endorsed by the PADIS guidelines, the APS Guide lines on the Management of Postoperative Pain, the  American Nurses Association, and the American  Society for Pain Management Nursing.1, 13, 16, 17 Given  the complexity and diversity of patients’ pain expe riences, applying multiple strategies that affect pain  perception in different ways is likely to be more  effective than using a single modality, possibly  reducing the need for opioid medication and poten tial adverse effects.12ajn@wolterskluwer.com AJN ▼ May 2020 ▼ Vol. 120, No. 5 41 INTERDEPENDENT ASPECTS OF CRITICAL ILLNESS Although this article has focused on the management  of pain in critically ill adults, the perception and  response to pain is not a singular phenomenon and  is related to other aspects of critical illness. The  authors of the PADIS guidelines emphasize that the  five sections of the guideline—pain, agitation/ sedation, delirium, immobility, and sleep disruption— address interdependent aspects of critical illness.1 For instance, agitation and delirium affect patients’  ability to report pain, and untreated pain worsens  immobility and exacerbates sleep disruption. In  addressing these five problems within a single guide line, PADIS underscores the need for multimodal  strategies and recognizes that critical care teams  don’t focus on isolated conditions but rather address  patients’ pain in the context in which it occurs. Mul timodal approaches to pain management present an  opportunity to improve patients’ experience of criti cal illness as well as patient outcomes. ▼  For more than 90 additional continuing education activities on the topic of pain, go to www.nursing center.com/ce. Sarah A. Delgado is a clinical practice specialist at the American  Association of Critical-Care Nurses, Aliso Viejo, CA. Contact  author: sahdelgado@gmail.com. The author and planners have  disclosed no potential conflicts of interest, financial or otherwise.  REFERENCES 1. Devlin JW, et al. Clinical practice guidelines for the preven tion and management of pain, agitation/sedation, delirium,  immobility, and sleep disruption in adult patients in the ICU.  Crit Care Med 2018;46(9):e825-e873.  2. Barr J, et al. Clinical practice guidelines for the management  of pain, agitation, and delirium in adult patients in the inten sive care unit. Crit Care Med 2013;41(1):263-306.  3. Barnes-Daly MA, et al. Improving hospital survival and  reducing brain dysfunction at seven California community  hospitals: implementing PAD guidelines via the ABCDEF  bundle in 6,064 patients. Crit Care Med 2017;45(2):171-8.  4. Critical Illness, Brain Dysfunction, and Survivorship (CIBS)  Center. For medical professionals. ABCDEF (A2F) overview.  2020. https://www.icudelirium.org/medical-professionals/ overview.  5. Puntillo KA, et al. Determinants of procedural pain intensity  in the intensive care unit: the Europain study. Am J Respir  Crit Care Med 2014;189(1):39-47.  6. Gelinas C, et al. Validation of the critical-care pain obser vation tool in adult patients. Am J Crit Care 2006;15(4): 420-7.  7. Young J, et al. Use of a behavioural pain scale to assess pain  in ventilated, unconscious and/or sedated patients. Intensive  Crit Care Nurs 2006;22(1):32-9.  8. American Association of Critical-Care Nurses. Assessing  pain in critically ill adults. Crit Care Nurse 2018;38(6): e13-e16.  9. Agency for Healthcare Research and Quality. Noninvasive  nonpharmacological treatment for chronic pain: a systematic  review. Rockville, MD; 2018 Jun. AHRQ Publication No.  18-EHC013-EF. Comparative effectiveness review, number  209; https://effectivehealthcare.ahrq.gov/sites/default/files/ pdf/nonpharma-chronic-pain-cer-209.pdf.  10. Gelot S, Nakhla E. Opioid dosing in renal and hepatic  impairment. US Pharm 2014;39(8):34-8.  11. Kyranou M, Puntillo K. The transition from acute to  chronic pain: might intensive care unit patients be at risk?  Ann Intensive Care 2012;2(1):36.  12. Martyn JAJ, et al. Opioid tolerance in critical illness. N Engl  J Med 2019;380(4):365-78.  13. Chou R, et al. Management of postoperative pain: a clini cal practice guideline from the American Pain Society, the  American Society of Regional Anesthesia and Pain Medicine,  and the American Society of Anesthesiologists’ Committee  on Regional Anesthesia, Executive Committee, and  Administrative Council. J Pain 2016;17(2):131-57.  14. Herzig SJ, et al. Safe opioid prescribing for acute noncancer  pain in hospitalized adults: a systematic review of existing  guidelines. J Hosp Med 2018;13(4):256-62.  15. Wiatrowski R, et al. Analgosedation: improving patient out comes in ICU sedation and pain management. Pain Manag  Nurs 2016;17(3):204-17.  16. American Nurses Association. The ethical responsibility  to manage pain and the suffering it causes. Silver Spring,  MD; 2018 Feb 23. Position statement; https://www. nursingworld.org/~495e9b/globalassets/docs/ana/ethics/ theethicalresponsibilitytomanagepainandthesufferingit causes2018.pdf.  17. Pasero C, et al. American Society for Pain Management  Nursing position statement: prescribing and administering  opioid doses based solely on pain intensity. Pain Manag Nurs 2016;17(3):170-80.  Go to www.nursingcenter.com/ce/ajn and receive CE a certificate within minutes.Earn CE Credit online: TEST INSTRUCTIONS • Read the article. Take the test for this CE activity online at  www.nursingcenter.com/ce/ajn.  • You’ll need to create and log in to your personal CE Planner  account before taking online tests. Your planner will keep  track of all your Lippincott Professional Development (LPD)  online CE activities for you. • There is only one correct answer for each question. The  passing score for this test is 13 correct answers. If you pass,  you can print your certificate of earned contact hours and the  answer key. If you fail, you have the option of taking the test  again at no additional cost. • For questions, contact LPD: 1-800-787-8985. • Registration deadline is March 4, 2022. PROVIDER ACCREDITATION LPD will award 1.5 contact hours for this continuing nursing  education (CNE) activity. LPD is accredited as a provider of CNE  by the American Nurses Credentialing Center’s Commission on  Accreditation. This activity is also provider approved by the California  Board of Registered Nursing, Provider Number CEP 11749 for  1.5 contact hours. LPD is also an approved provider of CNE by  the District of Columbia, Georgia, Florida, West Virginia, South  Carolina, and New Mexico, #50-1223. Your certificate is valid  in all states. PAYMENT The registration fee for this test is $17.95. 42 AJN ▼ May 2020 ▼ Vol. 120, No. 5 ajnonline.com My topic:________Pain__________________My PICO(T) question___ In _adult patients with chronic pain, what is the effect of holistic medical approach on _controlling pain compared with talking oral medications for pain?____Upload this form on Canvas and be sure to upload your quantitative nursing research article as well.Delgado, S. (2020). Managing Pain in Critically Ill Adults: A Holistic Approach. The American Journal of Nursing., 120(5), 34–43.