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Psychological Care 151

Research vignette, Continued
SpO 2 ) were associated with the patients’ self-reports of pain but specifically for use in the current study and has not been validated
were dependent on the patients’ status (mechanically ventilated outside this cohort. The limited validation of both these self-report
or not). Findings regarding the use of vital signs for pain assess- instruments represents a major methodological weakness in the
ment are not consistent and should be considered with caution. testing of criterion validity in the current study.
As recommended by experts, vital signs should only be used as A further limitation, as noted by the authors, was the inconsistent
a cue when behavioural indicators are no longer available in nature of the nocioceptive procedure. Although all patients
mechanically ventilated or unconscious patients.
were turned, approximately 3 of the patients also received endo-
2
Critique tracheal suctioning, while a minority received turning alone or
This study deals with an interesting and universal area of critical turning and hyperventilation. Further, the associated procedures
care nursing practice, that of pain assessment. Although in practice of endotracheal suctioning or hyperventilation may have been
many clinicians use vital signs as an indicator of pain, particularly more responsible for the changes in vital signs (particularly end-
citing the increase in parameters as an indicator of pain or the tidal CO 2 and SpO 2 ) than the turning and quantifying this influence
decrease as an indicator of the absence of pain, this practice is not is exacerbated by the inconsistent application of the procedure.
supported by the evidence. Inconsistent findings as to whether
vital signs are significantly related to the experience of pain have A strength of this study was the measurement of vital signs at three
been reported and this study is designed to help clarify any rela- points across the postoperative period including while the patient
tionship. The cohort enrolled in this study included 105 post- was unconscious and mechanically ventilated, conscious and
operative cardiac surgical patients, although those with significant mechanically ventilated and conscious after extubation. It is essen-
cardiac compromise or other comorbidities and complications tial that we have reliable markers of pain for critically ill patients at
were excluded. all these points in their illness continuum. This design strength was
somewhat compromised by the collection of data from only 33
The findings of this study suggest the vital signs that were tested patients in the first of these time periods when the patient was
do have discriminant validity, with MAP, HR, RR and end-tidal CO 2 unconscious and mechanically ventilated. A further strength was
all increasing significantly during the nocioceptive procedure and the measurement of a range of vital signs rather than focusing on
SpO 2 decreasing significantly. In contrast, criterion validity of the just one or two physiological parameters.
vital signs was not demonstrated, with only RR significantly associ- In summary, this study continues the theme of examining the value
ated with patient’s reports of pain.
of vital signs as an indicator of pain in the critically ill population.
Patients’ self-report of pain was achieved using the Verbal Descrip- The results further suggest that vital signs do not represent valid
tor Scale (VDS) and the Faces Pain Thermometer (FPT). The VDS was indicators of pain in this population. Further exploration of whether
developed in the early 1990s and has only been tested in a small vital signs can be used in conjunction with other indicators is
group of 30 post-anaesthetic care patients. The FPT was developed essential.

Learning activities
Activities 1–2 relate to the clinical case study ● Consider how family could help with the management of
1. Discuss possible strategies for assessing Brad’s pain levels, the patient’s anxiety.
including considering various pain assessment instruments 4. Critically ill patients who experience delirium require highly
that may have been used. You should particularly consider the skilled and informed nursing. The following exercises may
problems created by Brad’s variable response to the VAS being enhance your ability to manage delirium:
used to assess his pain. ● Identify nursing interventions which may reduce the poten-
2. Outline possible strategies that might be used to assist Brad to tial for delirium
fill in the gaps in his memory that appear to be causing him ● Describe the rationale for your selection of nursing interven-
some distress during his recovery after leaving ICU. Discuss the tions using current research
potential advantages and detrimental effects of each of these ● Outline the differences between delirium and dementia
strategies. ● Develop a nursing plan for a patient you cared for previously
3. The assessment of anxiety, sedation and pain intensity is inte- with delirium. Identify interventions you did not use but
gral to critical care nursing. would use in the future.
● Differentiate between each of these parameters and outline 5. Compare and contrast the various sedation assessment instru-
a method you would use to assess them. List any special ments, and discuss the relative merits and disadvantages of
considerations associated with your choices. using each of these instruments. Now repeat the exercise for
● Suggest a non-pharmacological strategy you could employ each of the pain assessment instruments and the delirium
to reduce anxiety and pain. assessment instruments.