Thunder Project ® II

Background: Diagnostic and treatment-related procedures are performed each day on millions of acutely and critically ill patients. Practice guidelines for the management of acute procedural pain are limited due to the lack of scientifically-based knowledge of the perceptions and responses of acutely and critically ill patients undergoing procedural pain.

Objectives: (1) to describe patients' pain perceptions and responses to turning, wound drain removal, tracheal suctioning, femoral line removal, central line insertion, and non-burn wound dressing change; (2) to compare patients' pain perceptions and responses across procedures.

Methods: a comparative, descriptive design was used. Descriptions and extent of pain intensity, pain quality, and procedural distress were obtained from 6201 patients from 4 to 94 years of age in 169 hospitals. Data were collected by hospital site nurses who used pretested valid and reliable data collection instruments and standardized procedure outlines and scripts. Chart reviews elicited demographic and procedure-specific information as well as information about analgesics administered before and during procedures.

Results: data were obtained from 91 children ages 4 to 12, 151 adolescents ages 13 to 17, and 5959 adults over 18 years of age. Children 4-12 years of age only underwent tracheal suctioning and turning. Mean pain intensity scores on a 0-5 scale for children 4-7 were 2.3 and 2.7 for the two procedures, respectively. Mean pain scores on a 0-100 scale for children 8-12 were 52.0 and 28.1, respectively. Patients 13 years of age and older used 0-10 numeric rating scales to rate pain intensity across the six procedures. Mean pain intensity scores ranged from 3 to 7, and mean procedural distress scores ranged from 2 to 6 across the six procedures. The most painful and distressing procedure for adults was turning, while adolescents found wound care to be the most painful and distressing. Procedural pain was most often described by those 18 years of age and older as sharp, stinging, stabbing, shooting, and bad, words that suggest an incisive quality to the pain and a negative experience for the patient. Patients undergoing turning, tracheal suctioning, wound care, and wound drain removal received less analgesics than patients undergoing femoral sheath removal or central line insertion, the two least painful procedures. The majority of patients in this descriptive study did not receive any form of analgesic, anesthetic, or sedative therapy prior to their procedure, including patients who had reported pain prior to the procedure.

Conclusions: Procedural pain intensity and its associated distress vary considerably, depending on the specific procedure performed. The variation in pain intensity and distress can depend on how patients are prepared for the procedure as well as the different stimuli that may occur with various procedures. Anticipatory preparation that includes analgesic administration and information about expected sensations may prepare patients better for the experience. Given the frequency with which procedures are performed on acutely and critically ill patients, more directed, individualized attention to proparation for and control of procedural pain is warranted.



Puntillo, K.A., White, C., Morris A., Perdue S., Stanik-Hutt J., Thompson C., Wild L. (2001). Patients’ perceptions and responses to procedural pain: Results from Thunder II Project. American Journal of Critical Care, 10(4), 238-251.

Thompson C.L., White C., Wild L.R., Morris A.B., Perdue S.T., Stanik-Hutt J., Puntillo K.A. Translating research into practice: Implications of Thunder Project II. Critical Care Clinics of North America, 2001 Dec;13(4):541-6.

Puntillo K.A., Wild L.R., Morris A.B., Stanik-Hutt J., Thompson C., White C. Practices and predictors of analgesic interventions for adults undergoing painful procedures. (In review, AJCC).


K. Puntillo, L. Wild, A. Morris, J. Stanik-Hutt, C. Thompson, C. White. “Practices and Predictors of Analgesic Interventions for Adults Undergoing Painful Procedures”. (Accepted, Society of Critical Care Medicine Annual Meeting, San Diego, January 2002).

Kathleen Puntillo RN, DNSc, FAAN. Nursing Specialty Award recipient for Thunder Project II poster abstract, titled "Practices and Predictors of Analgesic Interventions for Adults Undergoing Painful Procedures." SCCM Meeting Jan-Feb 2002. San Diego CA

Carol Thompson, Univ. TN; Cheri White, Sutter Roseville Med.Ctr.; Lori Wild, Univ. Washington; Ann Morris, Children’s Recovery Center of N. Cal.; Julie Stanik-Hutt, Johns Hopkins Univ.; Kathleen Puntillo, UCSF. "Pain and distress with adult tracheal suctioning. (Accepted: American Thoracic Society Annual Meeting, Atlanta GA, May 2002).

Kathleen A. Puntillo, Ann B. Morris, Carol L. Thompson, Julie Stanik-Hutt, Lorie R. Wild, Cheri White. Validity and Predictability of Pain Behaviors Observed During Six Common Procedures: Results From Thunder Project II. (Accepted: American Pain Society Annual Meeting, Baltimore, MD, March 2002).

Treating Pain in the Difficult Patient-AACN Thunder Project, Society for Critical Care Medicine, Annual MeetingSan Francisco, CA, February, 2001

Pain During Procedures: Lessons Learned from the AACN Thunder Project II, Washoe Medical Center, Trauma the Challenge, Reno, NV, August, 2001

Bernice Budz. Thunder from a site coordinator's perspective. Canadian Critical Care Nursing Annual Meeting, 2001.

Your Feedback