Received: 7 December 2017 Revised: 2 May 2018 Accepted: 20 May 2018

DOI: 10.1111/nhs.12543

RESEARCH ARTICLE

Vital signs: Valid indicators to assess pain in intensive care unit

patients? An observational, descriptive study
Sevilay Erden RN, PhD1 | Nevra Demir MSN, RN2 | Gulay A. Ugras RN, PhD3 |
Umut Arslan PhD4 | Sevban Arslan RN, PhD1

1
Department of Nursing, Çukurova University,
Adana, Turkey Abstract
2
Department of Nursing, Gazi University, Pain is a stressor for intensive care unit (ICU) patients, and inadequate pain assessment has
Ankara, Turkey been linked to increased morbidity and mortality. One hundred and twenty patients were
3
Department of Nursing, Mersin University, evaluated during three periods: (T1) 1 min before, (T2) during, and (T3) 20 min after the noci-
Mersin, Turkey
ceptive procedure. For each patient, data were obtained through at least two nociceptive pro-
4
Department of Public Health, Hacettepe
cedures. Conscious patients’ self-reports of pain were assessed using the Numerical Rating
University School of Medicine, Ankara, Turkey
Scale and Visual Analog Scale. For unconscious patients, the Behavioral Pain Scale was used
Correspondence
Sevilay Erden, Department of Nursing, instead. Descriptive statistical methods, Friedman's test, and Spearman’s rank correlation
Çukurova University, 01330 Sarıçam, Adana, coefficient were used for the data analysis. Significant changes were observed in heart rate
Turkey. (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2) during nociceptive proce-
Email: sevilaygil@gmail.com
dures. The HR, RR, and pain scores increased, while the SpO2 decreased. 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.

KEYWORDS

neurosurgery intensive care unit, nociceptive procedure, pain, pain assessment, Turkey, vital
signs

1 | I N T RO D UC T I O N self-report pain (e.g. being unconscious or mechanically ventilated)

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
(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, &
a, 2017).
Carbog
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-

been suggested that approximately 50–71% of ICU patients have eral tools have been developed and tested among adult ICU patients

ska, Szy- to identify objective measures of pain, there is no perfect tool to eval-
unrecognized or undertreated pain (Kotfis, Zegan-Baran
uate pain. Vital signs are easily accessible for nurses to assess the vari-
dłowski, Żukowski, & Ely, 2017; Wongtangman, Suraseranivongse, &
ability of medical status and can be an important indicator for pain
Sanansilp, 2017).
assessment. In one study, it was stated that more than 70% of ICU
A systematic assessment of pain is difficult, and pain can be
nurses used vital signs to assess pain (Rose et al., 2012). In particular,
under-recognized due to non-communicative patients being unable to
when ICU patients are unable to self-report their pain, effective pain

This paper was presented at the 8th World Congress of the World Institute of assessments should require an objective evaluation through the
Pain (New York, USA, 20–23 May 2016). observation of pain indicators by health-care professionals. In

Nurs Health Sci. 2018;1–7. wileyonlinelibrary.com/journal/nhs © 2018 John Wiley & Sons Australia, Ltd 1
2 ERDEN ET AL.
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 | METHODS
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, Baş -
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;
ERDEN ET AL. 3

Severgnini et al., 2016). The BPS takes into consideration three TABLE 1 Characteristics of the samples
behavioral dimensions: facial expression, movement/positioning of Values
the upper limbs, and compliance with ventilation. Each behavior is Minimum–
scored from 1 (no response) to 4 (full response); the total score varies Characteristic Mean  SD Maximum
from 3 (no pain) to 12 (maximal pain). The BPS has good psychometric Age (years) 52.31  17.41 20–90
indices for the inter-observer agreement of assessments in trauma, Sex N %
surgical, and medical patients (Kotfis et al., 2017). The Turkish version Female 60 50.0
of the BPS was found to be between .71 and .93 (Esen, Öntürk, Male 60 50.0
Badır, & Aslan Eti, 2010). Thus, the BPS is considered to be a reliable Diagnosis in neurosurgery intensive care unit
and valid tool to assess pain among the Turkish population. We ana- Intracranial tumor 71 59.2
lyzed the results according to the presence of pain. Thus, for the NRS Intracerebral hemorrhage 20 16.6
and VAS, a score of >1 (Gélinas, 2016), and a score of >4 for the BPS, Other (hydrocephalus, 29 24.2
shunt infection, etc.)
were indicative of the presence of pain (Severgnini et al., 2016).
Surgery/intervention
In our study, inter-observer agreement was not performed, as
No surgery 36 30.0
data were obtained by one observer. Cronbach's alphas were calcu-
Tumor resection 59 49.2
lated as psychometric properties for both unconscious and conscious
Hematoma drainage 13 10.8
patients for the nociceptive procedures. Cronbach’s alpha for the BPS
Other 12 10.0
was .91, and .85–.88 for the NRS.
Consciousness
Yes 84 70.0
2.3 | Data collection No 36 30.0
Two study participants groups were observed: (i) unconscious and Analgesic medication intake
mechanically ventilated; and (ii) conscious (mechanically ventilated or Yesa 84 70.0
not). The nociceptive procedures, including endotracheal suctioning, No 36 30.0
mobilization (according to patient status: in bed, bedside, with wheel- Chronic disease
chair, or walking with assistance in the ICU), positioning (supine in Yesb 37 30.8
bed, right and left lateral) and wound care, were the most frequently No 83 69.2
performed and can cause pain in patients at ICU before (T1), during a
Tenoxicam (i.v.) (63.3%), paracetamol (i.v.) (5%).
(T2), and 20 min after the procedure (T3). Vital signs and pain scores b
Hypertension (89.1%), atrial fibrillation (19.9%), coronary artery dis-
of patients were recorded. Data were obtained at least two different ease (3.3%).
nociceptive procedures for each patient. SD, standard deviation.

obtained from 36 (30%) of the 120 study participants who were

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
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

two quantitative variables. Descriptive statistics were expressed in fre- wound care, 55 were mobilizations, and 36 were endotracheal suc-

quency and percentage for categorical variables, and quantitative data tioning during the study. Seventy two conscious and 34 unconscious

were expressed in mean, standard deviation (SD) for normally-distributed patients were given position and 43 conscious and 19 unconscious

variables, and median (minimum–maximum) values for non-normally dis- patients received wound care. Mobilization was performed on all of

tributed data. A P-value of <.05 was considered statistically significant. the conscious participants, while endotracheal suctioning was per-
formed on all of the unconscious patients.

3 | RESULTS 3.3 | Discrimination of vital signs and pain results

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
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 SpO2 fluctuations were not signifi-
cantly different (P > .05) during (T2) positioning (P = .820 for MAP,
4 ERDEN ET AL.

TABLE 2 Patient’s vital signs and pain scores during nociceptive procedures

Times
Nociceptive procedures Values T1 T2 T3 Test P-value
Position (n = 106) Vital signs MAP 87.0 (50.0–120.0) 90.0 (50.0–134.0) 89.0 (31.0–126.0) .820
Median (minimum–maximum)
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) Vital signs MAP 85.5 (49.0–106.0) 88.0 (54.0–126.0) 87.5 (44.0–120.0) .070
Median (minimum–maximum)
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
a b a
Pain scores Conscious (n = 43) 0.0 (0.0–4.0) 2.0 (0.0–8.0) 0.0 (0.0–4.0) <.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) Vital signs MAP 86.0 (34.0–112.0) 90.0 (52.0–124.0) 86.0 (52.0–123.0) .640
Median (minimum–maximum)
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) Vital signs MAP 86.5 (76.0–123.0) 91.5 (70.0–149.0) 86.5 (59.0–126.0) .100
Median (minimum–maximum)
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,
20 min after procedure.

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).
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-

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 | DISCUSSION
ICU patients are at greater risk for under-recognition and under-
treatment of pain. This special population needs ongoing assessment,
ing (T2), HR increased, whereas SpO2 decreased 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
ERDEN ET AL.
TABLE 3 Correlations between vital signs and pain scores during nociceptive procedures
Pain scores during nociceptive proceduresa
Position Wound care
Vital signsa r P-value r P-value
MAP −.119 .306 −.061 .682
HR .184 .113 .317b .030
RR .316c .005 .358b .014
SpO2 .204 .078 .102 .494
a
Spearman's rho values were used.
b
Correlation is significant at the .05 level.
c
Correlation is significant at the .01 level.
HR, heart rate; MAP, mean arterial pressure; RR, respiratory rate; SpO2, transcutaneous oxygen saturation.
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 ventilation, 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
Ugraş 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;
5
Mobilization Endotracheal suctioning
r P-value r P-value
.056 .750 .305 .085
.218 .209 .274 .123
.532c .001 .106 .558
.102 .560 .216 .228
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-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
6 ERDEN ET AL.
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 | LIMITATIONS
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 | CO NC LUSIO NS
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.
ACKNOWLEDGMENTS
We would like to thank all the neurosurgery intensive care nurses and
the patients participating in our study.
A U TH 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.
ORCID
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