RISK FACTORS FOR ACUTE PAIN RELATED TO NURSING CARE: A SCOPING REVIEWABSTRACT
Objective: to map the possible risk factors for acute pain related to nursing care in adults and the elderly in health services.
Method: scoping review using the JBI methodology and structured presentation according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was registered in the Open Science Framework: DOI 10.17605/OSF. IO/JCA9P. Studies with adults and older adults that explored risk factors for acute pain in the context of nursing care in all languages and without time constraint were included. The studies were independently selected by two reviewers between November 2023 and February 2024.
Results: 48 articles were included, and risk factors were organized into eight categories: management of invasive devices; patient mobilization and positioning; wound care management; administration of solutions or medications; body hygiene care; tracheal aspiration; immobilization; and infiltration/extravasation of solutions or medications.
Conclusion: the evidence found in the present review indicates the main risk factors for acute pain related to nursing care in adults and the elderly. Recognizing the nursing diagnosis of acute pain risk is fundamental for the development and implementation of nursing interventions aimed at preventing, minimizing or eliminating acute pain.
DESCRIPTORS:
Nursing; Nursing diagnoses; Acute pain; Risk factors; Nursing care
RESUMO
Objetivo: mapear os possíveis fatores de risco para dor aguda relacionados aos cuidados de enfermagem em adultos e idosos nos serviços de saúde.
Método: revisão de escopo utilizando a metodologia do JBI e apresentação estruturada conforme o checklist Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. O protocolo de revisão foi registrado no Open Science Framework: DOI 10.17605/OSF.IO/JCA9P. Foram incluídos estudos com adultos e idosos que exploravam os fatores de risco para dor aguda no contexto de cuidados de enfermagem em todos os idiomas e sem restrição temporal. Os estudos foram selecionados por dois revisores, de forma independente, entre novembro de 2023 e fevereiro de 2024.
Resultados: foram incluídos 48 artigos e organizados os fatores de risco em oito categorias: manejo de dispositivos invasivos; mobilização e posicionamento do paciente; manejo de cuidados com feridas; administração de soluções ou medicamentos; cuidados com higiene corporal; aspiração traqueal; imobilização e infiltração/extravasamento de soluções ou medicamentos.
Conclusão: as evidências encontradas na presente revisão indicam os principais fatores de risco para dor aguda relacionados aos cuidados de enfermagem em adultos e idosos. Reconhecer o diagnóstico de enfermagem de risco de dor aguda é fundamental para o desenvolvimento e implementação de intervenções de enfermagem que visem prevenir, minimizar ou eliminar a dor aguda.
DESCRITORES:
Enfermagem; Diagnósticos de enfermagem; Dor aguda; Fatores de risco; Cuidados de enfermagem
RESUMEN
Objetivo: mapear posibles factores de riesgo de dolor agudo relacionado con la atención de enfermería en adultos y ancianos en los servicios de salud.
Método: revisión de alcance utilizando la metodología JBI y presentación estructurada según la lista de verificación Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. El protocolo de revisión fue registrado en el Open Science Framework: DOI 10.17605/OSF.IO/JCA9P. Se incluyeron estudios con adultos y adultos mayores que exploraron los factores de riesgo del dolor agudo en el contexto de la atención de enfermería en todos los idiomas y sin restricciones de tiempo. Los estudios fueron seleccionados de forma independiente por dos revisores entre noviembre de 2023 y febrero de 2024.
Resultados: se incluyeron 48 artículos, con factores de riesgo organizados en ocho categorías: manejo de dispositivos invasivos; movilización y posicionamiento del paciente; manejo del cuidado de heridas; administración de soluciones o medicamentos; cuidado de la higiene corporal; aspiración traqueal; inmovilización; y infiltración/extravasación de soluciones o medicamentos.
Conclusión: la evidencia encontrada en esta revisión indica los principales factores de riesgo de dolor agudo relacionados con la atención de enfermería en adultos y ancianos. Reconocer el diagnóstico de enfermería de riesgo de dolor agudo es fundamental para el desarrollo e implementación de intervenciones de enfermería que tengan como objetivo prevenir, minimizar o eliminar el dolor agudo.
DESCRIPTORES:
Enfermería; Diagnóstico de Enfermería; Dolor Agudo; Factores de Riesgo; Atención de Enfermería
INTRODUCTION
Pain is considered to be the fifth vital sign by the American Pain Society. Due to its high prevalence and constant motivation to seek health services, it should be evaluated by health professionals along with other vital signs, so that the evaluation and recording can support the decision-making of nurses and other health professionals, for an effective intervention in pain control1.
Pain perception is individual and influenced by biological, psychological, and social factors. Physiologically, it arises in response to stimuli from peripheral nociceptors and is interpreted in the central nervous system2. Psychosocial aspects, such as the presence of anxiety, depression, and inclination to catastrophizing, play a significant role in modulating pain perception3.
Different methods are used to assess pain sensation, such as uni and multidimensional scales. Like one-dimensional scales, the numerical scale is the one in which the patient must express in numbers the intensity of pain from 0 to 10 (0 being "no pain", and 10, "maximum pain"). Nominal scales are well used, using adjectives such as "mild", "moderate" and "severe". The face scale is another example of a one-dimensional scale, being used for the patient to identify, through face drawings, the one who is closest to his painful experience4. The applicability of such scales has been tested in some studies in Brazil5-7.
Unlike the one-dimensional scales, the multidimensional scales assess pain in its complexity, contemplating psychic, social, spiritual, and physical characteristics4,6. Some multidimensional scales have been adapted to the Portuguese language and validated in studies in Brazil. The most popular are: McGill Pain Questionnaire8-9; Short-Form McGill Pain Questionnaire10; Brief Pain Inventory11; and Chronic Pain Self-efficacy Scale12.
The time criterion used to differentiate the type of pain is not consistent and may vary according to different specialists and bibliographic references. For the present study, the time standard adopted to define pain as acute was from the NANDA-I® taxonomy, which conceptualizes acute pain as “an unpleasant sensory and emotional experience associated with real or potential tissue injury (...), of sudden or slow onset, of mild to intense intensity, with early or predictable end and lasting less than three months”13.
The scales capture the evidence of pain, that is the signs/symptoms that characterize the presence of a real problem occurring at the moment. In other words, based on the evidence documented in the use of the scale, nurses select the nursing diagnosis that most accurately reflects the patient's health status and develop safe and effective care plans14, implementing appropriate nursing interventions15.
In addition to nursing interventions to resolve the diagnosis of acute pain16, evidence points to the use of various interventions for its prevention, when there are risk factors, such as before the administration of vaccines17, venipunctures18 and invasive procedures19-20. In other words, the nursing problem does not yet exist, but there is only the presence of risk factors; therefore, we are facing a possible nursing diagnosis of acute pain risk.
The International Classification of Nursing Interventions describes some non-pharmacological interventions for pain control, such as music therapy, distraction, application of heat/cold and massage, and are indicated for before, during, and after procedures considered to be painful16. Thus, there are interventions that can be applied before the painful experience, when we still have the "risk of acute pain".
Experiencing pain during care procedures can have adverse effects, such as the manifestation of intense anxiety in subsequent procedures and extreme physiological reactions during the current procedure. If pain is not managed correctly, the patient can avoid certain treatments and procedures18,21-22, such as refusal of vaccination due to fear of needles22-23.
In this context, knowing the risk factors for acute pain is essential to implementing nursing interventions focused on preventing or minimizing the painful experience. Thus, the nursing team should be aware of the possible risk factors for acute pain that may be present during invasive procedures, whether they be physical, chemical, or biological harmful agents17-18,20,24.
Thus, we understand that the risk of acute pain is considered a potential challenge in the nursing area, subject to interventions that may result in a new diagnosis of risk nursing. However, it is crucial for practitioners to be aware of the potential risk factors for acute pain in order to implement interventions that prevent or reduce it.
In this sense, the present study aimed to map the possible risk factors for acute pain related to nursing care in adults and the elderly in health services. In this sense, the following question arises: what are the risk factors for acute pain related to nursing care in adults and the elderly in health services?
It is hoped that the results found here may contribute to the identification of risk factors for acute pain.
METHODS
This scoping review was conducted in accordance with JBI’s25 recommendations, following five steps: (1) elaboration of the research question; (2) definition of relevant studies according to the inclusion/exclusion criteria; (3) selection of information sources and formulation of a research strategy for each database; (4) selection and extraction of studies; (5) compilation, synthesis and presentation of the results.
The presentation of the review was structured according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist26. The review protocol was registered in the Open Science Framework: DOI 10.17605/OSF. IO/JCA9P and published in the Online Brazilian Journal of Nursing27. The data collection period was between November 2023 and February 2024.
To formulate the research question, the mnemonic PCC (Participants, Concept and Context) was adopted, including studies carried out with adults over 18 years of age and the elderly, which explored the risk factors for acute pain in the context of nursing care.
In the selection of information sources, all types of studies were considered, such as observational, experimental, quasi-experimental, theses or dissertations, literature reviews, reports, among others, considered relevant to the review question.
Studies conducted in contexts other than nursing care, those that did not present results, were not available in full, and studies with animals were excluded.
The search strategy was carried out according to JBI’s recommendations25. In the first stage, a search was carried out in PubMed and in Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases in order to detect the main indexing terms associated with the articles of interest. Based on these keywords, search strategies for the other databases were elaborated with the help of a librarian, as shown in Chart 1. The selected databases, as they are of greater relevance in the research area, were the following: Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed; Excerpta Medica dataBASE (EMBASE); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Scopus; Web of Science; Latin American and Caribbean Literature in Health Sciences (LILACS); Cochrane Database of Systematic Reviews.
After searching the databases, the files were transferred to an online bibliographic reference manager (EndNote®), through which the analysis and deletion of duplicates was carried out during the selection stage of the studies.
Through the Rayyan® app, two reviewers independently analyzed all titles and abstracts to select those probable studies to be included for the next phase. In this stage, seven exclusion criteria were used, namely: 1) Studies that did not address acute pain; 2) Studies that did not address risk factors for acute pain; 3) Studies carried out with children under 18 years of age; 4) Studies that were not carried out in the context of nursing care; 5) Studies that did not present results; 6) Studies whose complete text was not available in full; and 7) Animal studies. In the end, the selection discrepancies were resolved with the help of a third reviewer. Once there was a consensus in the selections, the studies were read in full by each reviewer, independently, in order to exclude those that were not in accordance with the objective of the study and the guiding question of this research.
Microsoft Excel® was used to organize the selected articles for reading and facilitate the tabulation of the data for the extraction phase. Based on the model recommended by the JBI25, the data extracted were database, title, authors, year of publication, country, objective, keywords, population, context of collection, main findings related to the scoping review question, possible risk factors described in the study, and final considerations.
Thus, for the synthesis and presentation of the results, the studies found in the scoping review were categorized by databases with their search strategy and, subsequently, the studies were grouped according to the year of publication, author, country and context of the study. Next, the risk factors for acute pain were classified according to the terms found in the studies and the terms proposed by the research team for further validation.
FINDINGS
As shown in Figure 1, 9,674 studies were identified in the databases selected for the research, according to the search strategies adopted. The deletion of 1,279 duplicates was done through the EndNote® manager. The sample for reading titles and abstracts was 8,395 studies. From the study selection phase, 8,290 studies were excluded by the two independent reviewers, using Rayyan®. After the complete reading of the text of the articles, 57 articles were excluded because they did not answer the research question, leaving 48 articles for the final review (Figure 1).
According to Chart 2, regarding the year of publication, 2020 and 2023 stood out for representing together 25 % of the selected studies, with six studies each, followed by 2014, with 10.2 % (n=5), and 2012, with 8.3 % of the sample (n=4). Regarding the countries of origin of the studies, the United States of America was the most prevalent country (14.6 %; n=8), followed by Brazil (10.4 %; n=5), France and England (8.3 % each; n=4). Regarding the context of nursing care, most of the studies took place in the hospital environment (85.4 %; n=41), followed by Primary Health Care (4.2 %; n=2), in both Primary Health Care and hospital contexts (4.2 %; n=2), in nursing homes (4.2 %; n=2) and universities (2 %; n=1).
The types of study were described in Chart 2 according to the level of evidence28, with the highest evidence being level 1. No studies were classified as level 1; Most studies were classified as level 4 (33.3 %; n=16), level 6 and level 2 (29.2 % each; n=14).
Characterization of the studies according to author, year of publication, country, type of study, level of evidence and context of collection. Viçosa, MG, Brazil, 2025.
The risk factors for acute pain identified in the scoping review and the respective references are described in Chart 3 and were grouped with a single term by the investigators, with three identified with the highest percentage, such as "management of invasive devices", cited by 54.2 % of the authors (n=26), "patient mobilization and positioning", by 31.2 % of the authors (n=15), and "wound care management", by 29.2 % of the authors (n=14).
Risk factors for acute pain identified in the scoping and grouping review. Viçosa, MG, Brazil, 2025.
DISCUSSION
According to Cavalheiro19, 100 % of patients have pain during an invasive procedure, and this is the main risk factor for the occurrence of a serious adverse event associated with nursing care58.
In intensive care, the invasive procedures that cause the most pain are those related to the removal of a chest tube, the use of a urinary catheter, and the insertion of a central venous catheter49. Pain during peripheral venous catheter insertion and during arteriovenous fistula needle insertion was also evidenced in more than 50 % of patients in other studies41.
"Patient mobilization and positioning" was the second most cited risk factor by the authors. The change of the patient's decubitus is an essential practice that aims to ensure the well-being of individuals, mitigate the adverse effects of prolonged muscle inactivity, promote the effective removal of secretions from the lower airways, optimize the distribution of air and blood in the lungs, in addition to preventing the occurrence of pressure injuries. However, constant vigilance of hemodynamic parameters is necessary, as patient repositioning can generate hemodynamic instabilities, cardiorespiratory alterations, and pain, as evidenced in several studies related to patient movement/repositioning in bed or during intra-hospital transport58-59,66,69,-70,77.
On the other hand, immobilizing the patient can also cause pain. Approximately 30 % of the patients complained of pain during limb immobilization40. Physical restraint in bed, for example, is employed in some health services as a strategy to manage patients who are agitated, confused, or disoriented, and who present a potential risk of falling or attempting to remove essential health care devices for their treatment. However, they can result in injuries at the site of application of the restraint device, in addition to hyperemia, contusion, dislocation of the limbs, ischemic lesions in the hands and arms, decreased physical mobility, among other consequences that can cause pain in the patient78-80.
As part of nursing care, professionals should apply strategies that ensure the maintenance of patients' body hygiene in various conditions, adjusting these approaches according to the patient's degree of dependence and limitations in relation to autonomy in self-care. Hygiene care requires frequent movements, subjecting critically ill patients to a considerable risk of serious adverse events, such as hemodynamic instability and pain58,81.
According to Tegegne50 and Firmino33, about 93 % of patients reported pain during wound treatment. Pain may be associated with tissue injury or trauma, and may also be influenced by emotional reactions, such as anxiety50. In wound care management, several technologies are used for various purposes, with the aim of ensuring clinical improvement, obtaining efficient results, reducing risks for users and professionals, and contributing to promoting a better quality of life for those affected82.
Endotracheal suctioning was evidenced as the second cause of pain of greater intensity during study procedures in the Intensive Care Unit66. Tracheal aspiration is an invasive technique used to remove secretions in individuals who are not able to effectively eliminate pulmonary, tracheobronchial, and/or oropharyngeal secretions. It is understood that tracheal aspiration is an extremely annoying and uncomfortable procedure for patients, and should be performed when absolutely necessary83.
In the context of the administration of solutions or medications, such as chemotherapy treatment, inadvertent infiltration or extravasation of the drug from the blood vessel to the surrounding tissues may occur, which may induce significant tissue lesions, pain, discomfort, burning, irritation, inflammation, edema, erythema, induration, ulceration, and necrosis84-85.
Pain during the administration of acetaminophen with acetic acid was also documented by almost half of the patients in one study49. These drugs are composed of a combination of an active ingredient and an excipient, which is an additive. Generally, they are non-toxic and have no pharmacological effect, but some excipients may demonstrate effects or actions recognized in specific situations, such as allergies, intolerances, and skin reactions65,76.
It is important to highlight that pain sensitivity tends to decrease with age86-87. During the aging process, peripheral sensory neurons undergo structural and functional changes, resulting in a decreased response to nociceptive stimuli86. Thus, the manifestation of pain in elderly patients may be less evident compared to young adults, which requires health professionals to pay extra attention to identify subtle clinical signs and to adequately assess pain in this age group.
The exclusion of studies that were not available for reading in full may have left articles potentially relevant to the study out of this review. As this was a scoping review, there was no assessment of the quality of evidence of the studies for inclusion.
CONCLUSIONS
The evidence found in the present review indicates the main risk factors for acute pain related to nursing care in adults and the elderly, such as "invasive procedures", "patient mobilization and positioning", "wound care management", "tracheal aspiration", "administration of solutions or medications", "body hygiene care", "immobilization" and "infiltration/extravasation of solutions or medications". The compiled evidence reinforces the relevance of a multidimensional and integrated approach to pain management.
Future studies will be carried out by the research team to validate the risk factors found in this review, so that they can then serve as a basis for decision-making and care planning to prevent, minimize, or eliminate pain associated with health care in adults and the elderly.
Considering the limitations of the review study and increasing evidence on these risk factors for acute pain, a content validation study with nursing experts is underway to validate the risk factors identified in this scoping review and, subsequently, a clinical validation study.
Recognizing the nursing diagnosis of acute pain risk is fundamental for the development and implementation of nursing interventions aimed at preventing, minimizing, or eliminating acute pain.
Based on this review, we hope that health teams will be better prepared to identify risk factors early and implement preventive measures, thus contributing to excellence in care and reduction of adverse events associated with nursing care.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the dissertation - Risk factors associated with acute pain in adults and the elderly: a scoping review, to be presented to the Graduate Program in Health Sciences, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil, in 2025.
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FUNDING INFORMATION
Institutional Program for Scientific Initiation Scholarships (PIBIC) of the National Council for Scientific and Technological Development (CNPq). PIBIC-CNPQ 2022-23
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TRANSLATED BY
Spyros Daskaleas.
