R E S E A R C H A R T I C L E
Vital signs: Valid indicators to assess pain in intensive care unit
patients? An observational, descriptive study
Sevilay Erden RN, PhD
1| Nevra Demir MSN, RN
2| Gulay A. Ugras RN, PhD
3|
Umut Arslan PhD
4| Sevban Arslan RN, PhD
11
Department of Nursing, Çukurova University, Adana, Turkey
2
Department of Nursing, Gazi University, Ankara, Turkey
3
Department of Nursing, Mersin University, Mersin, Turkey
4
Department of Public Health, Hacettepe University School of Medicine, Ankara, Turkey Correspondence
Sevilay Erden, Department of Nursing, Çukurova University, 01330 Sarıçam, Adana, Turkey.
Email: sevilaygil@gmail.com
Abstract
Pain is a stressor for intensive care unit (ICU) patients, and inadequate pain assessment has been linked to increased morbidity and mortality. One hundred and twenty patients were evaluated during three periods: (T1) 1 min before, (T2) during, and (T3) 20 min after the noci-ceptive procedure. For each patient, data were obtained through at least two nocinoci-ceptive pro-cedures. Conscious patients’ self-reports of pain were assessed using the Numerical Rating Scale and Visual Analog Scale. For unconscious patients, the Behavioral Pain Scale was used instead. Descriptive statistical methods, Friedman's test, and Spearman’s rank correlation coefficient were used for the data analysis. Significant changes were observed in heart rate (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2) during nociceptive
proce-dures. The HR, RR, and pain scores increased, while the SpO2decreased. Positive correlation
coefficients were observed between the pain intensity and HR and RR levels. According to our study findings, vital signs are not strong indicators for pain assessment in neurosurgery ICU patients. However, HR and RR can be used as cues when behavioral indicators are not valid in these unconscious patients.
K E Y W O R D S
neurosurgery intensive care unit, nociceptive procedure, pain, pain assessment, Turkey, vital signs
1 | I N T R O D U C T I O N
Pain has been considered as a leading stressor for intensive care unit (ICU) patients (Puntillo, Gélinas, & Chanques, 2017; Puntillo, Max, Chaize, Chanques, & Azoulay, 2016), and inadequate pain management has been related to increased morbidity and mortality (Stites, 2013). Each year, an estimated 71% of the nearly five million ICU patients recall having pain when in ICU (Stites, 2013). It has been suggested that approximately 50–71% of ICU patients have unrecognized or undertreated pain (Kotfis, Zegan-Baranska, Szy-dłowski, Żukowski, & Ely, 2017; Wongtangman, Suraseranivongse, & Sanansilp, 2017).
A systematic assessment of pain is difficult, and pain can be under-recognized due to non-communicative patients being unable to
self-report pain (e.g. being unconscious or mechanically ventilated) (Alderson & McKechnie, 2013; Puntillo et al., 2004). The literature reveals that systematic pain assessment has a pivotal role for minimiz-ing pain and analgesic consumption (Erden, Demir, Kanatlı, Danacı, & Carboga, 2017).
A previous study conducted in France indicated that no pain assessment was performed on approximately half of 1360 ICU patients on mechanical ventilation (Payen et al., 2001). Although sev-eral tools have been developed and tested among adult ICU patients to identify objective measures of pain, there is no perfect tool to eval-uate pain. Vital signs are easily accessible for nurses to assess the vari-ability of medical status and can be an important indicator for pain assessment. In one study, it was stated that more than 70% of ICU nurses used vital signs to assess pain (Rose et al., 2012). In particular, when ICU patients are unable to self-report their pain, effective pain assessments should require an objective evaluation through the observation of pain indicators by health-care professionals. In
This paper was presented at the 8th World Congress of the World Institute of Pain (New York, USA, 20–23 May 2016).
DOI: 10.1111/nhs.12543
unconscious and traumatic brain injury patients, pain can be assessed through an examination of the patient’s vital signs (Arbour & Gélinas, 2014). Multiple studies have noted that blood pressure (BP), respira-tory rate (RR), and heart rate (HR) are the most frequent physiological indicators of pain (Jafari, Courtois, Van den Bergh, Vlaeyen, & Van Diest, 2017; Middleton, 2003; Payen et al., 2001; Ye, Chuang, Tai, Lee, & Hung, 2017). Pain produces a physiological stress response that includes increased HR and BP to provide oxygen and other nutrients to vital organs (Middleton, 2003). These prompt the patient’s physio-logical responses to pain, such as tachycardia, tachypnea, or hyperten-sion (Alderson & McKechnie, 2013).
The pain assessment tools used for ICU patients, such as the PAIN algorithm, the Nonverbal Pain Assessment Tool, and the Nonverbal Pain Scale (NVPS), contain physiological dimensions (HR, BP, and RR) in addi-tion to behavioral dimensions (facial expression, activity, and guarding). The Numerical Rating Scale (NRS) is used to grade severity (Stites, 2013). Jafari et al. (2017) reported that two hemodynamic parameters (HR and BP) were the most frequent physiological indicators of pain. However, some studies found that vital sign assessments of patient pain in the ICU were inconsistent with patient reports of pain (Arbour & Gélinas, 2010; Gélinas, Tousignant-Laflamme, Tanquay, & Bourgault, 2011). Pain assessment can be unreliable, as ICU patients often experience many hemodynamic problems causing changes in their vital signs. Tachycardia could be due to pain, but could also be caused by fever or hypovolemia (Gélinas et al., 2011). If health-care professionals use vital signs as an indicator for pain, they should first ensure that there are no medical reasons (e.g. fever, hypoxia, shock, hypovolemia) that cause fluctuations of hemodynamic parameters. After eliminating medical reasons, vital signs could be considered as a cue for the presence of pain, especially for unconscious neurologi-cal patients. Although conflicting research results were reported, the literature recommends that the reliable and valid Behavioral Pain Scale (BPS) for ICU patients should be applied. If the objective scales cannot be used, the patient’s vital signs should be used as an indica-tor for pain assessment. A number of pain scales, such as the BPS and Critical Pain Observational Tool (CPOT), assess the facial expression or extremity responses; however, in some neurosurgery or brain injury patients who have difficulties with extremities or facial expressions, we need to use vital signs as an indicator for pain assessment. Thus, NVPS vital signs (HR, RR, BP) and peripheral oxy-gen saturation (SpO2) parameters are used addition to other
parame-ters (face, activity, guarding) in neurosurgery patients for a more appropriate assessment (Topolovec-Vranic et al., 2013; Kapoustina, Echegaray-Benites, & Gélinas, 2014).
In the present study, we aimed to examine the criterion validity of vital signs (mean arterial pressure [MAP], HR, RR, and SpO2) for pain
assessment in adults in the neurosurgery ICU.
2 | M E T H O D S
2.1 | Design, participants, and ethical considerations
A repeated measures design was chosen for the present study. A con-venience sample of 120 patients from a neurosurgery ICU in Ankara,
Turkey, was recruited. All participants were >18 years and admitted to the neurosurgery ICU. Patients were excluded if they were at high risk of increased intracranial pressure (ICP) (neurologically unstable ICP >25 mm Hg for 5 min after positioning, endotracheal suctioning etc.), were being treated for chronic pain, quadriplegic, receiving neu-romuscular blocking agents, being investigated for brain death, under-going continuous sedation and analgesia, had drugs or alcohol abuse problems, or had complications after surgery (e.g. hemorrhage or death). In the ICU, patients with increased ICP risk were implanted with an external ventricular drain (EVD) and were monitored. There-fore, nociceptive procedures, such as mobilization, were not per-formed in EVD patients. In addition, for improved ICP control (sedative drugs, osmotic diuretics etc.), these patients were excluded to avoid any bias. Patients with subdural hematoma/aneurysm were kept as hypervolemic and hypertensive (systolic blood pressure 140–160 mm Hg) to avoid postoperative vasospasm. As these proce-dures can affect vital signs, patients with aneurysms were excluded.
The study was approved by the Gazi University Research Ethics Committee of the Gazi University Hospital (no. 25901600-79). Eligible patients were met by a member of the research team the day before surgery to explain the study and to obtain consent. All conscious patients and relatives of unconscious patients were informed about the nature of the study, and informed consent was obtained. The study was conducted in accordance with the principles of the Declara-tion of Helsinki, 2002.
2.2 | Instruments
Data were collected using the patient information and vital signs follow-up forms. The patient information form included data about the patient's age, sex, neurosurgery ICU admission, chronic diseases, and analgesic medication use. The vital signs follow-up form con-tained a section to document MAP, HR, RR, SpO2, and pain scores
during the nociceptive procedures. While the MAP, HR, RR and SpO2
values were obtained from the ICU bedside monitor, pain scores were assessed by the ICU nurses. Conscious study participants’ self-reports of pain were assessed via the NRS and the Visual Analog Scale (VAS); for unconscious study participants, the BPS was used. The literature indicates that for patients able to self-report their pain (conscious and mechanically ventilated), the NRS and VAS are the gold standards (Haefeli & Elfering, 2006; Hjermstad et al., 2011; Kotfis et al., 2017). These scales were found to be reliable and valid tools for pain mea-surement, and patients were asked to rate their pain between 0 and 10 (0 indicating no pain, and 10 indicating the worst possible pain) (Tulunay & Tulunay, 2000; Eti Aslan, 2004). Yazıcı Sayın and Akyolcu (2014) reported that this scale could be used for Turkish patients, as it was simple and easy to understand. The sensitivity and selectivity of the VAS was also determined by Eti Aslan (2004), who stated that it could be used for measuring and monitoring pain for the Turkish pop-ulation. Many researchers have used the VAS and NRS among Turkish patient in the ICU to assess pain (Karahan et al., 2012; Beytut, Bas¸-bakkal, & Karapınar, 2016).
When self-report is impossible, observational pain scales, includ-ing the BPS, have been recommended for clinical use for critically ill adults (Hjermstad et al., 2011; Gélinas, 2016; Kotfis et al., 2017;
Severgnini et al., 2016). The BPS takes into consideration three behavioral dimensions: facial expression, movement/positioning of the upper limbs, and compliance with ventilation. Each behavior is scored from 1 (no response) to 4 (full response); the total score varies from 3 (no pain) to 12 (maximal pain). The BPS has good psychometric indices for the inter-observer agreement of assessments in trauma, surgical, and medical patients (Kotfis et al., 2017). The Turkish version of the BPS was found to be between .71 and .93 (Esen, Öntürk, Badır, & Aslan Eti, 2010). Thus, the BPS is considered to be a reliable and valid tool to assess pain among the Turkish population. We ana-lyzed the results according to the presence of pain. Thus, for the NRS and VAS, a score of >1 (Gélinas, 2016), and a score of >4 for the BPS, were indicative of the presence of pain (Severgnini et al., 2016).
In our study, inter-observer agreement was not performed, as data were obtained by one observer. Cronbach's alphas were calcu-lated as psychometric properties for both unconscious and conscious patients for the nociceptive procedures. Cronbach’s alpha for the BPS was .91, and .85–.88 for the NRS.
2.3 | Data collection
Two study participants groups were observed: (i) unconscious and mechanically ventilated; and (ii) conscious (mechanically ventilated or not). The nociceptive procedures, including endotracheal suctioning, mobilization (according to patient status: in bed, bedside, with wheel-chair, or walking with assistance in the ICU), positioning (supine in bed, right and left lateral) and wound care, were the most frequently performed and can cause pain in patients at ICU before (T1), during (T2), and 20 min after the procedure (T3). Vital signs and pain scores of patients were recorded. Data were obtained at least two different nociceptive procedures for each patient.
2.4 | Data analysis
Statistical analysis was performed using SPSS version 23. The normality of each quantitative variable was tested by using the Kolmogorov–Smirnov and Shapiro–Wilk tests. The Friedman test was used to evaluate the differences between repeated measures, including vital signs and pain scores during nociceptive procedures, and Dunn’s post-hoc test was used for multiple comparisons. Spearman’s rank correlation coefficient was used to assess the relationship between two quantitative variables. Descriptive statistics were expressed in fre-quency and percentage for categorical variables, and quantitative data were expressed in mean, standard deviation (SD) for normally-distributed variables, and median (minimum–maximum) values for non-normally dis-tributed data. A P-value of <.05 was considered statistically significant.
3 | R E S U L T S
3.1 | Characteristics of the samples
The mean age of the patients was 52.31 17.41 years, and half of the 120 patients were male (n = 60, 50%). The patients were admitted to the neurosurgery ICU, mostly due to intracranial tumor (n = 71, 59.2%) and intracerebral hemorrhage (n = 20, 16.6%). Data were
obtained from 36 (30%) of the 120 study participants who were unconscious and mechanically ventilated, and from 84 (70%) patients who were conscious. Nearly all of the study participants took an anal-gesic (n = 84, 70%), which was mostly a nonsteroidal anti-inflammatory drug (63.3%) (Table 1).
3.2 | Description of the nociceptive procedure
Of the 259 nociceptive procedures, 106 were positioning, 62 were wound care, 55 were mobilizations, and 36 were endotracheal suc-tioning during the study. Seventy two conscious and 34 unconscious patients were given position and 43 conscious and 19 unconscious patients received wound care. Mobilization was performed on all of the conscious participants, while endotracheal suctioning was per-formed on all of the unconscious patients.
3.3 | Discrimination of vital signs and pain results
Regardless of the level of consciousness and ventilation status of the patients at T1, they had lower baseline values for MAP, HR, and RR compared to T2 during all nociceptive procedures, but T3 values were similar to T1. While HR and RR increased significantly (P = .001 for HR, P < .001 for RR), MAP and SpO2fluctuations were not
signifi-cantly different (P > .05) during (T2) positioning (P = .820 for MAP,
TABLE 1 Characteristics of the samples
Characteristic Values Mean SD Minimum– Maximum Age (years) 52.31 17.41 20–90 Sex N % Female 60 50.0 Male 60 50.0
Diagnosis in neurosurgery intensive care unit
Intracranial tumor 71 59.2 Intracerebral hemorrhage 20 16.6 Other (hydrocephalus,
shunt infection, etc.)
29 24.2 Surgery/intervention No surgery 36 30.0 Tumor resection 59 49.2 Hematoma drainage 13 10.8 Other 12 10.0 Consciousness Yes 84 70.0 No 36 30.0
Analgesic medication intake
Yesa 84 70.0
No 36 30.0
Chronic disease
Yesb 37 30.8
No 83 69.2
aTenoxicam (i.v.) (63.3%), paracetamol (i.v.) (5%).
bHypertension (89.1%), atrial fibrillation (19.9%), coronary artery
dis-ease (3.3%). SD, standard deviation.
P = .960 for SpO2), wound care (P = .070 for MAP, P = .690 for
SpO2), and mobilization (P = .640 for MAP, P = .480 for SpO2)
com-pared to T1 and T3. During endotracheal suctioning (T2), HR increased (P = .002), whereas SpO2 decreased (P = .016), and MAP
and RR values were not significantly different compared to when they were at T1 or T3 (P = 0.100 for MAP, P = .410 for RR). Evaluation of the participants’ pain scores according to their state of consciousness revealed that the stage involving painful interventions (T2) was associ-ated with significantly higher pain scores in the groups compared to the other periods (T1 and T3, P < .001) (Table 2).
3.4 | Criterion validity of vital signs
Only the HR variability was found to be associated with pain during wound care (r = 0.317, P = .30). The fluctuation of RR was associated with pain during positioning (r = 0.316, P = .005), wound care (r = 0.358, P = .014), and mobilization (r = 0.532, P = .001). Positive correlation coefficients were found between HR and RR for the patient’s pain intensity (Table 3).
4 | D I S C U S S I O N
ICU patients are at greater risk for recognition and under-treatment of pain. This special population needs ongoing assessment,
appropriate treatment, and evaluation for effective pain management (Herr, Bursch, Ersek, Miller, & Swafford, 2010). Changes in vital signs’ responses to nociceptive procedures can be useful for assessing pain among ICU patients.
4.1 | Discriminant criterion validity of vital signs
To the detriment of the patient’s consciousness and ventilation status, patients’ MAP, HR, and RR values increased during all procedures (T2) for both conscious and unconscious patients. While HR and RR significantly increased during wound care, mobilization, and position-ing (T2), HR increased, whereas SpO2decreased during endotracheal
suctioning (T2) for both groups (Table 2). These results are consistent with some studies that found increased values of most of the vital signs in response to nociceptive exposure in critically ill ICU patients (Arbour & Gélinas, 2010; Arbour & Gélinas, 2014; Gélinas & Johnston, 2007; Payen et al., 2001). Arbour and Gélinas (2010) aimed to analyze the discriminant and criterion validity of vital signs for pain assess-ment conducted on 105 ICU patients. They found that MAP, HR, RR, and end-tidal carbon dioxide increased, and SpO2 decreased during
nociceptive procedures for both conscious and unconscious patients. Gélinas and Johnston (2007) and Gélinas et al. (2011) found increased values of MAP and HR in response to nociceptive procedures. Simi-larly, other ICU studies noted that BP and HR increased during
TABLE 2 Patient’s vital signs and pain scores during nociceptive procedures
Nociceptive procedures Values
Times
TestP-value
T1 T2 T3
Position (n = 106)
Median (minimum–maximum)
Vital signs MAP 87.0 (50.0–120.0) 90.0 (50.0–134.0) 89.0 (31.0–126.0) .820 HR 83.0 (39.0–153.0)a 86.0 (39.0–136.0)b 82.5 (42.0–136.0)a .001
RR 20.0 (12.0–34.0)a 22.0 (10.0–35.0)b 20.0 (11.0–34.0)a <.001
SpO2 96.0 (89.0–100) 96.0 (96.0–100) 96.0 (90.0–100) .960
Pain scores Conscious (n = 72) 0.0 (0.0–6.0)a 2.0 (0.0–9.0)b 0.0 (0.0–6.0)a <.001 Unconscious (n = 34) 3.0 (0.0–8.0)a,b 4.0 (0.0–12.0)a 3.0 (0.0–8.0)b <.001
Wound care (n = 62) Median (minimum–maximum)
Vital signs MAP 85.5 (49.0–106.0) 88.0 (54.0–126.0) 87.5 (44.0–120.0) .070 HR 81.5 (39.0–113.0)a 86.0 (39.0–120.0)b 80.0 (42.0–133.0)a <.001
RR 20.0 (12.0–28.0)a 22.0 (12.0–32.0)b 20.0 (12.0–30.0)a <.001
SpO2 97.0 (90.0–100.0) 96.0 (90.0–100.0) 96.0 (88.0–100.0) .690
Pain scores Conscious (n = 43) 0.0 (0.0–4.0)a 2.0 (0.0–8.0)b 0.0 (0.0–4.0)a <.001
Unconscious (n = 19) 4.0 (0.0–5.0) 4.0 (0.0–7.0) 4.0 (0.0–5.0) .052 Mobilization (n = 55)
Median (minimum–maximum)
Vital signs MAP 86.0 (34.0–112.0) 90.0 (52.0–124.0) 86.0 (52.0–123.0) .640 HR 77.0 (56.0–112.0)a 80.0 (54.0–125.0)b 76.0 (46.0–110.0)a .001
RR 22.0 (12.0–29.0)a 24.0 (11.0–34.0)b 20.0 (10.0–28.0)a <.001 SpO2 96.0 (90.0–99.0) 95.0 (90.0–99.0) 95.0 (89.0–99.0) .480
Pain scores Conscious (n = 55) 0.0 (0.0–6.0)a 1.0 (0.0–10.0)b 0.0 (0.0–6.0)a <.001
Unconscious (n = 0) Endotracheal suctioning (n = 36)
Median (minimum–maximum)
Vital signs MAP 86.5 (76.0–123.0) 91.5 (70.0–149.0) 86.5 (59.0–126.0) .100 HR 88.5 (58.0–160.0)a 91.0 (64.0–142.0)b 88.5 (54.0–130.0)a .002
RR 20.0 (12.0–31.0) 20.0 (12.0–34.0) 19.0 (12.0–30.0) .410 SpO2 98.0 (87.0–100)a 96.0 (64.0–100)b 98.0 (91.0–100)a .016
Pain scores Conscious (n = 4) 1.5 (0.0–3.0) 4.0 (1.0–7.0) 5.0 (0.0–3.0) —* Unconscious (n = 32) 3.0 (0.0–10.0)a 5.0 (0.0–12.0)b 3.0 (0.0–8.0)a <.001
*P-values were not calculated because of the small sample size. Superscript (a, b): Different letters show statistically difference between the groups. HR, heart rate; MAP, mean arterial pressure; RR, respiratory rate; SpO2, transcutaneous oxygen saturation; T1, before procedure; T2, during procedure; T3,
endotracheal suctioning and mobilization (Payen et al., 2001; Chen & Chen, 2015). However, in our study, during endotracheal suctioning, MAP and RR values were not significantly changed (Table 2). The ven-tilation mode (e.g. pressure control venven-tilation, synchronized intermit-tent mechanical ventilation) could inhibit the spontaneous ventilation of the patient. Chen and Chen (2015) also reported that aspiration did not change ventilation, even for conscious patients. Similarly, Altun Ugras¸ and Aksoy (2012) showed that some vital signs (e.g. MAP) immediately returned to baseline values 5 min after aspiration.
As previously mentioned, the current study, in line with the litera-ture, indicated that BP and HR are the most frequent physiological indicators of pain (Chen & Chen, 2015; Gélinas et al., 2011; Gélinas & Johnston, 2007; Middleton, 2003). The findings of these studies sup-port recommendations regarding the use of BPS when the patient is unconscious (Gélinas et al., 2011).
4.2 | Criterion validity of vital signs
According to the pain scores based on the consciousness examination, the study groups’ pain scores significantly increased during painful procedures (T2) compared to other times (T1 and T3) (Table 2). All vital signs (MAP, HR, and RR) were higher for participants who reported pain compared to pain-free patients, except for SpO2, which
was lower in patients who had pain. Nevertheless, only the variability of HR and RR was associated with pain during wound care, position-ing, and mobilization. Positive and weak correlation coefficients were found between HR and pain intensity. Positive and moderate correla-tion coefficients were also found between RR and pain. The study results are similar to those in the literature. Kapoustina et al. (2014) found that RR significantly changed between non-nociceptive and nociceptive procedures in neurosurgery patients. Similarly, Fowler et al.’s study (2011) of 2646 soldiers found relationships between the pain score and RR. Arbour and Gélinas (2010) found a correlation between HR, SpO2, and pain intensity. Other studies have also
reported that HR and BP have significantly moderate–high associa-tions with pain during a painful procedure (Al Sutari, Abdalrahim, Hamdan-Mansour, & Ayasrah, 2014; Rahu et al., 2015).
Although the current study and some of the literature showed a positive relationship between HR and RR values and pain, a few stud-ies indicated that changes in vital signs could be associated with a patient’s ventilatory status or diagnosis (Gélinas & Johnston, 2007;
Arbour & Gélinas, 2010). It has been indicated in previous ICU studies that during nursing interventions, vital signs of patients with pain did not change (Gélinas & Johnston, 2007; Nasraway Jr, Wu, Kelleher, Yasuda, & Donnelly, 2002; Siffleet, Young, Nikoletti, & Shaw, 2007), and can be clues in cases where behavioral pain assess-ment cannot be performed (Barr et al., 2013; Rahu et al., 2015). Nasraway Jr et al. (2002) explored objective indicators to assess pain, such as HR variability and changes in pupillary size. None achieved acceptable validity for pain assessment in the ICU (Nasraway Jr et al., 2002).
As described earlier, it is essential to jointly assess both vital signs and the pain-related behaviors of the patients when making clinical decisions to ensure valid and reliable pain assessment in the ICU. Nurses play a pivotal role in all phases of pain management and in closely evaluating patient status. Thus, for appropriate pain assess-ment in the ICU, nurses’ clinical judgement is important. Puntillo et al. (1997) indicated that there were moderate to strong correlations between nurses’ evaluations of vital sign changes and their assess-ments of patients’ pain scores.
An assessment of pain in critically ill patients at risk of non-treatment or under-non-treatment of pain and pain-related complications is required. Although reliable pain assessment is a pivotal part of effective pain management, fluctuations in vital signs are correlated with pain. The current study during nociceptive procedures, the HR and RR values should be used an indicator for pain assessment. Thus, the present study supports important data raising awareness of the nurses on vital signs may indicate the pain. The assessment of vital signs should be used with valid pain assessment tools. The American Association of Critical-Care Nurses indicated that assessing pain with validated tools when significant fluctuations in vital signs are noted (level C) (The American Critical Care Nurses, 2014). In neurosurgery patients, vital signs are easily accessible for nurses to assess the vari-ability of the medical/neurological status. For comprehensive pain assessments, validated pain scales should be used in combination with the assessment of vital signs. Using both tools and vital cues for pain assessment can have positive impact on ICU nurses' interventions about pain management and recording. Furthermore, ICU nurses using these instruments as a guide would help with more efficient decisions regarding pain management.
Thus, nurses and nurse educators should focus on valid indica-tors to collect reliable pain-assessment data. Considering that pain
TABLE 3 Correlations between vital signs and pain scores during nociceptive procedures
Vital signsa
Pain scores during nociceptive proceduresa
Position Wound care Mobilization Endotracheal suctioning r P-value r P-value r P-value r P-value MAP −.119 .306 −.061 .682 .056 .750 .305 .085 HR .184 .113 .317b .030 .218 .209 .274 .123
RR .316c .005 .358b .014 .532c .001 .106 .558
SpO2 .204 .078 .102 .494 .102 .560 .216 .228 aSpearman's rho values were used.
b
Correlation is significant at the .05 level.
cCorrelation is significant at the .01 level.
assessment has a key role in pain control, reliable and standart pain assessment provide regular anajgesia and pain relief. (Erden et al., 2017). Thus, standard pain assessment protocols for ICU patients should be formed and applied as a hospital protocol.
5 | L I M I T A T I O N S
The present study has some limitations. First, the sample size was homogeneous and small; therefore, the findings might not be general-izable. Second, the nociceptive procedure was unable to be standard-ized. While all participants were mobilized and turned, endotracheal suctioning was also performed in mechanically-ventilated patients. In addition, the patient’s hemodynamic parameters might have been altered by the procedure itself. Thus, HR and MAP could have been influenced more by the mobilization procedure than by painful proce-dures. Moreover, the use of analgesics could affect vital signs. How-ever, the analgesic administration was the routine of the clinic and out of our control. Also, one of the exclusion criterion was receiving con-tinuous analgesia, and nearly none of the patients were given different analgesics (opioids or strong analgesia). Thus, we consider the nono-pioids (tenoxicam and paracetamol) would not change the pain scores, neurological function, or values as much as strong analgesics. Finally, using a different assessment scale for pain for conscious and uncon-scious patients might cause variations in patients’ pain assessment. Further large-scale studies including homogeneous patient groups are required with variables affecting vital signs (particularly HR and RR) being adjusted.
6 | C O N C L U S I O N S
In conclusion, other findings (MAP and SpO2), except HR and RR, did
not support the criterion validity of vital signs in the pain-assessment process of this specific ICU group. The results highlighted that fluctua-tions in hemodynamic parameters are not always an accurate measure for the assessment of pain in critically ill patients. The absence of a change in vital signs does not indicate the absence of pain, and should only be used in combination with other reliable and validated pain assessment tools according to the conscious status of the patients, such as the NRS or BPS. Therefore, ICU nurses should continue the critical role they play in pain management and the evaluation of pain, and use vital signs only in cases where objective scales cannot be applied. In addition, teamwork is of utmost importance for pain man-agement. Thus, all health-care team members (e.g. doctors, nurses, physiotherapists) consider and monitor pain as a vital sign. They should know their key roles in pain management and interpret changes in vital signs in painful procedures and control pain effectively.
A C K N O W L E D G M E N T S
We would like to thank all the neurosurgery intensive care nurses and the patients participating in our study.
A U T H O R C O N T R I B U T I O N S
Study design: S.E.
Data collection: N.D., and S.E. Data analysis: U.A., and S.E.
Manuscript writing and revisions for important intellectual content: S.E., S.A., and G.A.U.
O R C I D
Sevilay Erden http://orcid.org/0000-0002-6519-864X
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How to cite this article: Erden S, Demir N, Ugras GA, Arslan U, Arslan S. Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study. Nurs Health Sci. 2018;1–7. https://doi.org/10.1111/ nhs.12543
